Every finding on record at Graham Oaks Care Center

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 5 of 7 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #6) reviewed for care plans. The facility failed to ensure the staff developed the comprehensive care plan goals and interventions from the comprehensive assessment for Resident #1, Resident #2, Resident #3, Resident #4, and Resident #6. The facility failed to ensure the comprehensive care plans for Resident #1, Resident #2, and Resident #4 described the resident's preference and potential for future discharge. The facility failed to ensure the comprehensive care plans for Resident #1, Resident #2, and Resident #4 documented a desire to return to the community was assessed. This failure could place the residents at risk of inadequate care and services.Findings included: Record review of Resident #1's face sheet reviewed on 6/14/2026 revealed a [AGE] year-old female, admission date 11/20/2023, Diagnoses: chronic pain syndrome (pain that lasts for over 3 months), muscle weakness, lack of coordination (difficulty making precise physical movements), chronic obstructive pulmonary disease(restricted airflow and breathing difficulties), dysphagia following cerebral infarction(brain damage disrupts the neurological pathways that coordinate swallowing.), cerebral infarction (blood supply to part of the brain is blocked), aphasia following cerebral infarction(brain damage disrupts neurological pathways that coordinate speaking), dysarthria and anarthria(speech difficulty), cognitive communication deficit(underlying disruption in thinking impairs a person's ability to effectively speak, listen, read, write). Resident #1 had a BIMS of 11 (moderate cognitive impairment). Record review of Resident #1's MDS dated [DATE] revealed in the CAA summary indicated ADL function, pressure ulcer, and pain were triggered areas and these areas were to be addressed in the care plan. Record review of Resident #1's comprehensive care plan dated 6/5/2026 revealed no ADL function, pressure ulcers, or pain were addressed in the care plan. Record review of Resident #1's comprehensive care plan dated 6/5/2026 revealed no evidence of documented discharge plan or assessment. In an interview on 6/14/2026 at 12:30 P.M. with Resident #1, she stated she had no plans to leave the facility, and the staff are managing her pain. Resident #1 stated staff take care of her, and she had no wounds or sores. She stated she used to have pressure ulcers, but the facility got her healed up. Resident #1 stated if she needed anything, she could just ask facility staff and they addressed it. Record review of Resident #2's face sheet reviewed on 6/14/2026 revealed an [AGE] year-old male, admission date of 5/04/2026, Diagnoses: dementia (decline in mental ability severe enough to interfere with daily life), major depressive disorder (consistent feeling of sadness lasting and interrupting daily life), epilepsy (recurrent, unprovoked seizures), psychosis (symptoms that indicate a loss of contact with reality). Resident #2 had a BIMS of 4 (severe cognitive impairment). Record review of Resident #2's MDS dated [DATE] revealed in the CAA summary indicated vision, communication, psychotropic drugs, and pain were triggered areas and it further indicated these areas were to be addressed in the care plan. Record review of Resident #2's comprehensive care plan dated 6/3/2026 revealed no evidence that vision, communication, psychotropic drugs, or pain were addressed in the care plan. Record review of Resident #2's comprehensive care plan dated 6/3/2026 revealed no evidence of documented discharge plan or assessment. In an attempted interview on 6/14/2026 at 12:05 P.M., Resident #2 did not respond any questions. Record review of Resident #3's face sheet reviewed on 6/14/2026 revealed a [AGE] year-old female, admission date of 5/28/2026, with diagnoses: dementia (decline in mental ability severe enough to interfere with daily life), cardiac pacemaker (battery operated device that prevents the heart from beating too slow), depression (persistent sadness affecting daily life), violent behaviors (use of physical force or power to threaten, damage, or harm oneself, others, or property), dorsalgia (back pain), atherosclerotic heart disease of native coronary artery without angina (plague build up in original blood vessels that supply the heart restricting blood flow and oxygen). Resident #3 had a BIMS of 5 (severe cognitive impairment). Record review of Resident #3's MDS dated [DATE] revealed in the CAA summary indicated communication, psychosocial well-being, psychotropic drugs, and pain were triggered areas and it further indicated these areas were to be addressed in the care plan. Record review of Resident #3's comprehensive care plan dated 6/3/2026 revealed no evidence that communication, psychosocial well-being, psychotropic drugs, or pain were addressed in the care plan. In an attempted interview on 6/14/2026 at 11:28 A.M., Resident #3 did not respond to any questions. Record review of Resident #4's face sheet reviewed on 6/14/2026 revealed a [AGE] year-old-female, admission date of 5/13/2026 with diagnoses: rhabdomyolysis (rapid break down of damaged skeletal muscle), acute kidney failure (sudden loss of kidney ability to filter waste), palliative care (specialized medical care for someone living with a serious illness which focuses on pain relief and other symptoms), cerebral infarction (blood flow to brain blocked), myeloma (uncommon blood cancer within bone marrow), type 2 diabetes (resists insulin or doesn't produce enough), idiopathic neuropathy (nerve damage with no clear cause). Resident #4 had a BIMS of 7 (severe cognitive impairment). Record review of Resident #4's MDS dated [DATE] revealed in the CAA summary indicated urinary incontinence, psychosocial well-being, behavior, nutrition, pressure ulcers, psychotropic drugs, and pain were triggered areas and it further indicated these areas were to be addressed in the care plan. Record review of Resident #4's comprehensive care plan dated 5/27/2026 revealed no evidence that urinary incontinence, psychosocial well-being, behavior, nutrition, pressure ulcers, psychotropic drugs, or pain were addressed in the care plan. Record review of Resident #4's comprehensive care plan dated 5/27/2026 revealed Resident #4 was at risk for elopement and resided in the secured unit in the facility. In an observation on 6/14/2026 at 11:45 A.M., Resident #4 walked to LVN C and requested pain medication and LVN C assessed her for pain. LVN C retrieved Resident #4's pain medication and watched her take it. In an interview on 6/14/2026 at 11:50 A.M. with Resident #4, she stated she gets her medications correctly and can bring any concerns she has to staff and they will address them. Resident #4's only concern she had was that staff blow her off when she asked to get out the door. In an observation on 6/14/2026 at 12:15 P.M., LVN C reassessed Resident #4 for pain to ensure the pain medication was effective. Resident #4 revealed it was effective. Record review of Resident #6's face sheet reviewed on 6/14/2026 revealed an [AGE] year-old female, admission date of 5/30/2026 with diagnoses: displaced fracture of surgical neck of left humerus (common shoulder injury where upper arm bone breaks just below the ball of the shoulder joint and the bone fragments shift out of alignment), dementia without behavioral disturbance (decline in mental ability severe enough to interfere with daily life), cerebral infarction (blood flow to brain blocked), acute kidney failure (kidneys do not filter waste like normal). Resident #6 had a BIMS of 13 (cognitive intact). Record review of Resident #6's MDS dated [DATE] revealed in the CAA summary indicated communication, nutrition, and pain were triggered areas and it further indicated these areas were to be addressed in the care plan. Record review of Resident #6's comprehensive care plan dated 6/3/2026 revealed no evidence that communication, nutrition, or pain were addressed in the care plan. In an interview on 6/14/2026 at 12:16 P.M. with Resident #6, she stated she had no concerns with her care and received her pain medication timely and correctly. In an interview on 6/14/2026 at 11:36 A.M., LVN C stated Resident #2, Resident #3, Resident #4, and Resident #6 can make their needs known. LVN C stated Resident #2, Resident #3, Resident #4, and Resident #6 are newer residents that have adjusted well. She stated Resident #2, Resident #3, Resident #4, and Resident #6 needs were met and she had no concerns related to that. In an interview on 6/14/2026 at 12:08 P.M., CNA B stated that Resident #2, Resident #3, Resident #4, and Resident #6's needs are met and she had no concerns. In an interview on 6/14/2026 at 4:56 P.M., ADON A stated that MDS E and DON D were responsible for care plans. ADON A stated that MDS E took care of the initial care plans after the MDS assessment and DON D added changes to the care plan. An attempted was made to contact MDS E by telephone ion 6/14/2026 at 5:45 P.M., there was no answer or return the call recieved. In an interview on 6/14/2026 at 6:25 P.M., DON D stated MDS E was responsible for care plans after the MDS assessment and that she would add any change in condition. DON D stated Resident #2, Resident #3, Resident #4, and Resident #6's needs were being met and addressed. DON D stated a negative effect for CAA trigger areas not in the care plan was that something could be missed from their care DON D stated she tried to contact MDS E, and had not heard back from her. Record review of comprehensive care plan policy undated revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that includes measurable objectives and time frames to meet a residents' medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following-The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the residents' medical, physical, mental and psychosocial needs. Through the planning process, facility staff will work with the resident and his or her representative, if applicable, to understand and meet the residents' preferences, choices and goals during their stay at the facility. The facility will establish common documents and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. The policy further revealed, When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility's rationale for deciding whether or not to proceed with care planning for each area triggered will be recorded in the medical record. The comprehensive care plan policy undated further revealed, The comprehensive care plan will address a resident's preference for future discharge, as early as upon admission, to ensure the resident is given every opportunity to attain his/her highest quality of life.

Based on observation, interview, and record review, the facility failed to ensure the environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 of 77 resident rooms observed (Resident #8) reviewed for accidents and hazards. Facility staff failed to remove an extension cord from Resident #8's room. This deficient practice could place resident at risk of a fire hazard or tripping.The findings include: Record review of Resident #8's face sheet dated 04/07/26 revealed an [AGE] year-old female admitted to facility 09/23/25 with diagnoses including Chronic Obstructive Pulmonary Disease (lung disease) and Dementia (decline in cognitive function). Record review of Resident #8's MDS assessment dated [DATE] revealed the BIMS score was 7 of 15 reflective of severe cognitive impairment. Resident #8 ambulatory with wheelchair and partial assistance with transfers. Record review of Resident #8's Comprehensive Care Plan dated 04/01/26 the resident has impaired cognitivefunction/dementia or impaired thought processes. Observation on 04/08/26 at 1:12 PM revealed that Resident #8 had a white extension cord plugged into the electrical outlet located on the east wall of room by the foot of the resident's bed, and the white extension cord was laid between resident's mattress and bed frame towards head of bed and plugged into a lamp located on bedside nightstand. The white extension cord did not have surge protection. Interview on 04/08/26 at 1:16 PM, Resident #8 could not state who or when the white extension cord was placed in the room. Resident #8 states she did not know that extension cord was not allowed in resident rooms. Interview on 04/09/26 at 11:54 AM, the Maintenance Supervisor stated he was unaware of any extension cords being used in resident rooms. Maintenance Supervisor stated that extension cords are not allowed in resident rooms and are removed when found. Maintenance Supervisor stated that extension cords could be trip hazards or fire hazards. Interview on 04/09/26 at 2:20 PM, CNA A stated that extension cords are not allowed in resident rooms. Stated that extension cords are possible fire hazards. CNA A stated when extension cords are found in resident rooms it needs to be reported to Charge Nurse or Housekeeping Supervisor. Interview on 04/09/26 at 2:52 PM, the Housekeeping Supervisor stated that staff are to report to the Housekeeping Supervisor and her staff will remove any extension cords found in resident rooms. The Housekeeping Supervisor stated that they are always looking for hazards while they are cleaning and organizing rooms. Housekeeping Supervisor stated that extension cords are a trip and fire hazard. Interview on 04/09/26 at 4:10 PM, the Administrator stated that extension cords are not allowed in resident rooms, extension cords could be a fire hazard or trip hazard. The Administrator stated it is her expectation the if staff see any hazards such as extension cords in resident rooms they are to be removed. Record review of a Nursing Home List of Items Not Allowed in Resident Room Policy: dated January 6, 2026, Resident admission Packet. Does not list extension cords.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene including changing gloves while providing incontinence care to Resident #1 on 03/25/26. This failure could place residents at risk for the spread of infection.Findings included: Record Review of Resident #1's face sheet dated 03//25/26, revealed an 87- year- old female admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of bladder ( a condition that affects bladder function due to nervous system problems), Cellulitis of right lower limb (a common bacterial infection that occurs when it enters a crack or break in the skin), cutaneous abscess of right upper limb (a pus-filled cavity in the skin that may be caused by bacteria, fungi, viruses or foreign body), gangrene (a medical emergency that occurs when blood flow to a specific part of the body is lost, leading to tissue death), and diabetes mellitus ( a chronic condition that occurs when the body cannot properly use blood sugar leading to high blood sugar levels). Review of Resident 1's Annual MDS assessment dated [DATE]revealed Resident #1 required substantial/maximal assistance with most activities of daily living (ADLs) including toileting. Resident #1 was occasionally incontinent of bladder and frequently of bowels. Review of Resident #1's Care Plan dated 03/19/26 revealed she had bowel incontinence. Its goal stated Resident #1 will not have any complications related to bowel incontinence. Observation of incontinence care for Resident #1 on 03/25/26 at 11:20 a.m. revealed CNA A did not wash her hands prior to donning gloves. CNA A removed Resident #1's brief that was soiled with fecal matter. CNA A wiped the resident from front to back. She did not change gloves but continued to clean the resident with soiled gloves. Her gloves were visibly soiled with fecal matter. CNA A did not wash her hands, change gloves, or perform hand hygiene before placing the clean brief underneath the resident. CNA A applied skin protector with the same soiled gloves on Resident #1 before fastening the clean brief. She removed her gloves and picked up the trash. CNA A did not wash hands or perform hang hygiene before exiting Resident #1's room. In an interview on 03/25/26 at 11:26 a.m. with CNA A, she stated she should have changed her gloves and washed hands before retrieving a clean brief and placing it underneath Resident #1. CNA A stated she has been in the facility for about 6 months. She stated she has had in-services but did not receive complete infection control training with return demonstration. CNA A noted that hand washing was the most effective way of infection control but did not know she was supposed to wash hands before starting incontinent care. CNA A also said cross contamination was mixing clean with dirty which occurred while she was providing care. CNA A noted that the resident could acquire an infection when she did not follow good infection control practices including changing gloves before retrieving the clean brief. During an interview on 03/25/26 at 3:41 p.m. the DON stated she was aware of some of the concerns raised about infection control practice. She stated she was responsible for infection control in the facility. The DON stated employees received training on hire and annually. She noted she conducts random checks on employees and training with return demonstration periodically. The DON explained aides were expected to follow standard precautions including washing hands and changing gloves while providing care. Review of the facility's infection control policy revised undated reflected:Perineal Care Female(With or without catheter)Purpose: To clean the female perineum without contaminating the urethral area with germs from the rectal area.Procedural GuidelinesA. Beginning Stepsa) Gather needed supplies: Brief, Clean/Dry Linen, Wipes, Creamb) Knock on door and identify selfc) Greet resident by preferred named) Explain procedure and encourage resident's participation as appropriatee) Provide privacy as appropriate such as close doors/curtainsf) Provide safety as appropriate such as use good body mechanics; adjust bed to proper workingheight.B). If required, remove all items from the resident's bedside table, place a barrier towel on the table, and items required to perform care can be placed on the table.C) Lower head of bed and position resident on back with legs flexed and separated as able and as appropriateD) Expose the resident's perineal area.E) If heavy soiling is present, wear gloves and use tissues or wipes to remove heavy soiling prior to perineal care. DO NOT WIPE MORE THAN ONCE WITH THE SAME SURFACE OF THE TISSUE OR WIPESF) Place towel or extra incontinence pad under buttocksG) Wash hands and put on clean gloves for perineal careH) Gently wash perineal area, wiping from clean urethral area toward dirty rectal area to avoid contaminating urethral area with germs from the rectum. DO NOT WIPE MORE THAN ONCE WITH THE SAME SURFACE OF THE WASH CLOTH OR PRE-MOISTENED CLEANSING WIPES. IF AT ANYTIME YOUR GLOVES BECOME CONTAMINATED WITH FECES, CHANGE GLOVES.

Based on observation, interview, and record review the facility failed to provide written notice to the State Agency responsible for licensing the facility at the time of change, for a change in the facility's administrator for 1 of 1 facility. The facility failed to notify the State Agency of a change in the facilities administrator within 30 days. This failure could result in the lack of knowledge and inability to connect with the appropriate leadership of the facility. Findings included: In an observation on 11/07/2025 at 11:45 a.m., the investigator located the named administrator of the facility in TULIP during offsite preparation and documented the name for contact and accountability purposes. In an interview on 11/08/25 at 10:45 a.m., the facility Administrator introduced herself and indicated she started as the Administrator of the facility in May 2025. She was not the individual named in TULIP. In an interview on 11/08/25 at 3:02 p.m., CNA A stated that she started working at the facility in June 2025 and the ADM is the only administrator she had seen since she had worked there. CNA A stated that the ADM was who she reported to with any report of abuse or neglect, because the ADM was the abuse coordinator. In a follow-up interview on 11/08/25 at 7:58 p.m., the ADM stated she started as the AIT at the facility in December 2024 with another administrator. She stated he left, and she became full time administrator in March 2025. The ADM stated she is responsible for the day-to-day responsibilities and was in charge of the facility. The ADM stated it was her responsibility to contact the state agency about the administrator change but thought the previous administrator would do it when he left. The ADM stated she can make the change in TULIP, and she was aware it was to be done within 30 days. No corporate personnel were present to interview. In an observation on 11/8/25 at 10:10am of the facility posting in Hall C near the nurse's station, it revealed the Administrator, Abuse coordinator, named as the current ADM, not the name in TULIP. Record review of Facility Business card provided by ADM named her as the facility administrator. No policy provided.

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse and neglect for one (Resident #1) of 8 residents reviewed for neglect. On 9/2/25 the facility allowed Hospitality Aide A to perform a transfer on Resident #1 and failed to ensure she was trained and permitted per her job description to use Resident #1's personal medical transfer equipment to perform a transfer. No staff in the facility had been trained in the use of Resident #1's personal medical transfer equipment, and the Director of Therapy had asked the former DON to ensure her staff did not use the device. The transfer resulted in a fall during which Resident #1 received a fracture in her left knee. The noncompliance was identified as PNC. The IJ began on 9/2/25 and ended on 9/3/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for serious injuries, a decline in the resident's condition, hospitalization, or death. Findings included: Record review of Resident #1's admission Sheet, not dated, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her active diagnoses included Paraplegia (paralysis that affects the legs and not the arms), muscle weakness, unsteadiness on feet, osteomyelitis of vertebrate, and pain in thoracic spine. Record review of Resident #1's Annual MDS dated [DATE] reflected Resident #1 had a BIMS score of 15 (cognitively intact) and impaired range of motion in both lower extremities and section GG documented Resident #1 required partial to moderate assistance to transfer. Record review of Resident #1's comprehensive care plan, dated 7/14/25, reflected that she had a self-care performance deficit and required 1 staff to reposition and turn in bed, and to transfer from bed to chair. A revision of the care plan on 7/15/24 indicated that she used a sit to stand device, and it was discontinued on 9/3/25 Review of the Provider Investigation report dated 9/3/25 revealed: Resident had a fall during sit to stand transfer to the bathroom, resulting in left knee fracture . The Hospitality Aide that was assisting Resident #1 in the sit to stand transfer to the toilet was not trained or oriented to the sit to stand machine. The resident was sent to the emergency room for evaluation and pain medication was administered as ordered and as needed. There were no other negative findings at this time. Record review of a radiology report for Resident #1 dated 9/3/25 documented: There is a cortical discontinuity (interruption or fracture in the hard, dense, outer layer of bone that makes up most of the skeleton) in the lateral aspect of the left medial femoral condyle (the rounded, smooth end of the thigh bone that forms part of the knee joint), suggesting a fracture. Record review of the video evidence (Clip #1) date 9/2/25 at 6:56 PM provided by Resident #1 from her personal monitoring device located in her room, revealed Resident #1 was transferred by the Hospitality Aide A on 9/2/25 using her personal transfer equipment. The hospitality aide could not be heard in the video stating to Resident #1 that she had never used the sit to stand transfer device to perform a transfer. Resident #1 could be heard stating you have to learn when you're young. The Resident #1 is seen sitting on the transfer device while Hospitality Aide A pushed her into the bathroom after which the resident could not be viewed by the camera. Video clip #2 - Resident #1 is not in view, but Hospitality Aide A is seen standing in the doorway of the bathroom and is heard stating I I can't get in there. I'm sorry. She turned toward the resident's room door which was closed, opened the door and stated: Let me get some help. She then left the room. The resident could be heard groaning and calling out help!. She was not in view of the camera and the clip ended. Record review of the nurses note dated 9/2/2025 11:34 PM reflected the following information: Note Text: BP-146/94. T-97.5. P-101. R-18.Resident had a fall. Location: Resident Bathroom Fall information: Assisted, Legs gave out, .Cognition / Behavior at Time of Event: Oriented / no problem,This nurse was notified by the Hospital Aide that she had assisted residents to the ground via a gait belt from sit to stand device. The Hospitality Aide was assisting the resident to bathroom and during the transfer to toilet, resident could not get bearings on her legs, and they gave out. No injuries noted at the time of assisted fall. The Resident #1 did not hit her head, alert and oriented x4. resident complained of left knee discomfort. Resident assisted to w/c from floor by 3 staff members and placed in bed. Will continue to monitor for delayed injuries. Appears and/or states to be in pain. Describes the pain as: Intermittent, Location of pain: left knee Pain relieving intervention used at this time: routine oxycodone.Initial Treatment/New Orders:Resident Statement: resident stated legs gave out trying to transfer from sit & stand to toiletName of MD/NP notified: Medical Director/Primary Care PhysicianDate/time of notification: 09/02/2025 9:00 PM.Name of RP notified: husband Date/time of notification: 09/02/2025 9:00 PM.Interventions in place prior to fall: Scheduled toileting program, x2 assist when toiletingInterventions initiated in response to fall: Scheduled toileting program, x2 assist with transfers9/3/2025 01:52 Transfer Notification Note Text: Resident #1 was transferred to a hospital on [DATE] 1:30 AM related to resident had assisted fall in bathroom and hurt left knee, swelling noted in left knee, unable to manage pain or get x-ray until business hours, resident request to be sent to ER. Record review of the Hospitality Aide's job description stated in part: Knowledge base - ability to record information, good communication skills, genuine care for and interest in the elderly, ability to comply with company safety policies, provide support to the nursing department by assisting with non-nursing tasks, including but not limited to bed making, passing water and ice, answering call lights and gathering supplies. The Hospitality aide job description was signed on 8/27/25 by Hospitality Aide A. Record review of the facility incident logs for the months of July, August, and September 2025, revealed no other injuries related to transfers. Record review of the facility policy Transfers from Chair to Bed stated the following in part: .A gait belt should be used for all transfers and the resident supported by holding the gait belt. Record review of Hospitality Aide A's employee file revealed she was not trained for transfer skills and competency checked until 9/11/25 after which she was allowed to come back to work. Record review of the facility Policy titled Abuse/Neglect revealed the following in part: The resident has the right to be free from abuse and neglect, misappropriation, of resident property and exploitation as defined in this subpart. Neglect is the failure of the facility, its employees, or services providers to provide goods, and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. During an interview and an observation on 10/1/25 at 11:35 AM Resident #1 was sitting up in her electric wheelchair in her room with her left leg elevated. She stated she was non weight bearing to her left leg because of the fracture and she had to be transferred with a Hoyer lift. Resident #1 stated she did persuade Hospitality Aide A to use the transfer device despite Hospitality Aide A telling her she did not know how to us the transfer device. She stated she persuaded her to use the device because it was easier for her but stated some of the girls didn't like to use the device because it was difficult to maneuver in her small bathroom and she slid off the edge of the seat. She stated her leg was caught between the lift and the wall and it hurt. She stated they had to get the assistance of Hospitality Aide B to get her off of the floor and LVN C watched. Hospitality Aide A did not come back to the room. During an interview with Hospitality Aide A on 10/3/25 at 6:00 PM Hospitality A stated she didn't know how to use the sit to stand equipment, but she answered Resident #1's call light and Resident #1 kept telling her she needed to urinate. Hospitality Aide A stated she knew Resident #1's call light had been on for about 20 minutes before she went into the room to answer it. She then stated they were shorthanded that evening and she had been assigned by LVN C to work as a floater in 3 different halls. Hospitality Aide A stated she knew there was no one around to assist at that time because no one else answered the call light. Hospitality Aide A stated Resident # 1 asked her to use the sit to stand machine to transfer her to the toilet in the bathroom, so she did it anyway, knowing that she was not supposed to do a transfer. Hospitality Aide A stated she assisted Resident #1 to the toilet but was unable to get her lined up over the toilet seat. Hospitality Aide A stated Resident #1 then said her legs were giving way and she was unable stand. Resident #1 then fell to the floor. Hospitality Aide A stated she was unable to use a gait belt to aid in the support of Resident #1. Hospitality Aide A stated she realized after the incident that she should not have done the transfer because she had not been trained and that she had no training on the use of the transfer device before the incident. Hospitality Aide A stated the facility then told Resident #1 the device would have to be taken home because it did not belong to the facility and there was no manual for its use. Hospitality Aide A stated she was suspended after the incident and was allowed to come back after 9 days when the facility completed their investigation and that is when they had the training and check off skills for her. During an interview with Hospitality Aide B on 10/10/25 at 6:15 PM he was called to Resident #1's room after the fall on 9/2/25 to get her off the floor. He stated her leg was between the machine and the wall of the bathroom and he was unable to use a gait belt to lift her off the floor. He stated he lifted her underneath her arms and put her back into her chair. He then returned to the memory care unit where he was stationed that night. Hospitality aide B stated he had no training on use of the device by the facility. During an interview with the Administrator on 10/3/25 at 10:00 AM, she stated she was not aware that staff were not trained on the sit-to-stand machine until after the incident. She stated she thought the machine belonged to the facility; and that the DON that was no longer employed with the facility had trained them. She stated the prior DON had been in charge of training of Hospitality Aides and following through to ensure staff complete training for all equipment used for transfers and that they were tested and competency checked before using the equipment and all skills were performed. The Administrator stated that after the incident and during the time of the facilities investigation of the incident, that there was no policy manual for the use of the sit- to-stand device. The administrator stated she did not know Hospitality Aide A was performing transfers without training and competency checks. She stated that her expectation was that a Hospitality Aide does not perform transfers and duties that were not included in their job description and for which they had not been trained appropriately. The Administrator then stated she expected the DON to be responsible for monitoring and education of all staff. Attempted to interview LVN C on 10/8/25 and again 10/9/25 (Charge Nurse) regarding the incident with Resident #1, but she replied by text to the Administrator stating she was in the hospital, and she was unable to interview. During an interview on 10/9/25 at 11:00 AM The Administrator stated she was no longer employed by the facility effective today 10/9/25. During an interview with the Director of Therapy on 10/3/25 at 10:30 AM he stated Resident #1 was a one-person transfer prior to her fall, but she was now a 2 person Hoyer lift due to the non-weight bearing status to her left leg and her therapy had been put on hold. He stated he communicated to the former DON that the sit-to-stand lift did not belong to the facility and there was no manual for the equipment. He stated the residents had not been checked off to use the device and the staff were not trained. He stated he made it clear to the former DON that he was not qualified to do the training, because the use of the equipment was not a part of his curriculum in therapy school. He stated he assumed everyone in the facility knew the device was used by the resident because it was in her room and it was a large piece of equipment and hard to miss. He stated he did not recall the date that he relayed this information to the former DON, but he asked her to ensure staff did not use the device. During an interview with the former DON on 10/3/25 at 4:16 PM she stated her last day at the facility was 8/15/25. She stated she did not remember the Director of Therapy telling her that the staff should not use the device. She stated she did know that the device was being used by staff to do the transfers of Resident #1 without training and competency checks. During an interview with the Medical Director/Primary Physician on 10/6/25 at 4:00 PM he stated his expectation was that residents be transferred by staff that had been trained and the equipment used had been safely checked. Review of Hospitality Aide A's training record reflected that she had completed training on Position and Transfer Techniques and fall prevention on 9 /11/25. She had also signed an acknowledgment on 10/3/25 that she was to follow the resident's care plan to know who required a Hoyer lift or who was to be lifted by two people. During an interview on 10/3/25 with Hospitality Aide A, she stated if there were any questions about how a resident was to be transferred, she knew she was to clarify this with the nurse.During an Observation on 10/4/25 at 1:30 PM Hospitality Aide B and CNA 1 perform a Hoyer lift on 10/4/25 at 1:30 PM using 2 people on Resident #4 and proper procedure and all all-safety rules were followed, and no incidents were noted. In an interview with the Administrator on 10/8/25 at 9:00 A.M., she stated after the incident on 9/3/25 they immediately completed the following corrections/interventions. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance. Review of the Plan reflected: 1. Self-reporting protocol initiated on 9/3/25 and dated 9/3/23.2. Reported incident to the State within 2 hours of incident 9/3/25.3. Known perpetrator (Hospitality Aide A) suspended immediately pending investigation.4. Care plan for Resident #1 updated immediately and revised for injury.5. Skin assessments on all non-verbal residents and Safe Surveys of interviewable residents on halls A, B, C, D, were completed on 9/3/25 and 9/4/25.6. Interviews with staff members regarding whether they have seen a fellow staff member act in an abusive or neglectful manner toward a resident was completed on 9/3/257. Abuse and neglect Inservices started with all staff on 9/3/258. Ad HOC QAPI meeting held 9/3/25 for Inappropriate transfer by untrained staff.6. Audited all resident's Kardex/care plan on 09/3/25 to ensure all resident's level of care was updated and accurate.7. Educated and validated all staff understood the use of the Kardex/care plan system on 09/3/258. Review plan in QAPI monthly until resolved. Completed risk management entry 9/3/259. Medical director notified of this plan on 9/3/25 by the Administrator.10. The DON and Admin will monitor for potential neglect by reviewing incidents in stand up daily 9/3/2511. Monitor at least 10 of the following ADL Actions each week to ensure that the proper number of staff is providing assistance: bathing, bed mobility, transferring, walking initiated 9/3/25All monitoring above will continue for at least 4 weeks. The QAPI committee will review the findings and make revisions to the plan, as necessary. Verification 10/9/25 :Correction #1:In an Interview on 10/9/25 at 11:00 AM the Administrator stated that she received a call from the Charge Nurse notifying her of Resident #1's fall 0n 92/25. The resident was assessed and did not complain immediately. She did begin to complain of pain and the charge nurse notified her that the resident was requesting to go to the hospital. She was sent to the hospital and diagnosed with a fracture on her left knee. During the course of the investigation the administrator discovered that the resident was transferred by Hospitality Aide A that was performing duties such as transfer, that were not in her signed job description and was doing so without appropriate training on safety and operation. She stated she immediately filed a self-report and suspended the perpetrator pending the results of the investigation. She was informed by therapy staff that the mechanical lift device was not owned by the facility and no one in the facility had been trained to use the device. She stated she could see by viewing the video that Hospitality Aide A did perform the transfer with the device, and this was not a duty for which she was currently trained to do according to her job description. She notified Resident #1's family of the need to remove the device from the resident's room. The sit to stand device was no longer in the building as of 9/3/25. Record review of the facility reporting protocol template indicated all areas of the self-reporting protocol had been completed, dated, and signed by the staff. Correction #2. Record review of the nurses note dated 9/2/2025 11:34 PM Note Text: BP-146/94. T-97.5. P-101. R-18.Resident had a fall. Location: Resident Bathroom Fall information: Assisted, Legs gave out, .Cognition / Behavior at Time of Event: Oriented / no problem,This nurse was notified by the Hospital Aide that she had assisted residents to the ground via a gait belt from sit to stand device. The Hospitality Aide was assisting the resident to bathroom and during the transfer to toilet, resident could not get bearings on her legs, and they gave out. No injuries noted at the time of assisted fall. The Resident #1 did not hit her head, alert and oriented x4. resident complained of left knee discomfort. Resident assisted to w/c from floor by 3 staff members and placed in bed. Will continue to monitor for delayed injuries. Appears and/or states to be in pain. Describes the pain as: Intermittent, Location of pain: left knee Pain relieving intervention used at this time: routine oxycodone.Initial Treatment/New Orders:Resident Statement: resident stated legs gave out trying to transfer from sit & stand to toiletName of MD/NP notified: Medical Director/Primary Care PhysicianDate/time of notification: 09/02/2025 9:00 PM.Name of RP notified: husband Date/time of notification: 09/02/2025 9:00 PM.Interventions in place prior to fall: Scheduled toileting program, x2 assist when toiletingInterventions initiated in response to fall: Scheduled toileting program, x2 assist with transfers9/3/2025 01:52 Transfer Notification Note Text: Resident #1 was transferred to a hospital on [DATE] 1:30 AM related to resident had assisted fall in bathroom and hurt left knee, swelling noted in left knee, unable to manage pain or get x-ray until business hours, resident request to be sent to ER. Correction #3Record review of the Ad Hoc QAPI meeting revealed the meeting was conducted on 9/3/25 with the following members attending: Medical Director, Administrator, DON, ADON #1, ADON #2, MDS Nurse #1, MDS Director 1, MDS Director #2, Social Worker, Medical Records, Medical Director. Correction #4Record review of the Employee Disciplinary Report dated 9/4/25 revealed the Hospitality Aide A was suspended for investigation of Neglect and the improper transfer. Correction #5Record review of Skin assessments on all non-verbal residents and Safe Surveys of interviewable residents on halls A, B, C, D, completed on 9/3/25 and 9/4/25. Record review of Residents #5, #6 safe survey forms and interviews with Residents #2, #3, and #4 from 2 PM to 4 Pm on 10/9 /24 confirmed that they did feel safe in the facility, and all stated they were transferred properly. During interviews with Residents #2, # 3, #4, #5, and #6 from 2 PM to 4 PM they stated they could tell the difference between the Nurse's Aide, Hospitality Aides and Certified CNAs by their name badge. Correction #6Reviewed the Abuse and Neglect inservice signature page and content of training dated 9/3/25. All facility staff had been trained on abuse and neglect Immediately after the incident with Resident #1 before they were allowed to return to work. Correction #7 Interviews with 10 staff members Hospitality Aides A, B, C, K, E, D, F, G, H, I, J (formerly titled Hospitality aides but now classified as Nurses' Aides) between 2:00 PM and 4:00 PM on 10/9/25 reflected that they all attended a training skills lab on 9/3/25 and competed competency checks on 9/11/25. They stated hey were trained on Abuse and Neglect, Safe Transfers, an checked off on the Hoyer lift. Hospitality Aides A, B, C, K, E, D, F, G, H, I and J stated they were not allowed to operate the hydraulic controls and must transfer a mechanical lift with 2 people. Observed Hospitality Aide B and CNA 1 perform a Hoyer lift on 10/4/25 at 1:30 PM using 2 people on Resident #4 and proper procedure and all all-safety rules were followed, and no incidents were noted. Correction #8Reviewed QAPI minutes for meeting last held 10.3.25. Reviewed PIP dated 9/3/25 for incident. Meeting attended by medical director. Signed on 10/3/25. Correction # 9Interview with the Medical Director on 10/6/25 at 4:00 PM verified that he had been notified of the incident and the PIP on 9/3/25. Correction #10 Reviewed monitoring by the facility of ADL assistance initiated on 9/3/25 revealed that the monitoring was complete and current with evidence of monitoring from 9/3/25 to 10/9/25. Monitoring continues daily at the time of exit. During an Interview with the Administrator on 10/10/25 at 8:00 AM stated she only had 1 hospitality aide left in the building as of 10/9/25. She stated everyone else had completed training and skills checks and were ready to test. She stated scheduling was in process with herself and the new DON monitoring compliance During an Interview with Resident #1 on 10/9/25 at 4:00 PM she stated she had not been transferred by staff other than CNAs, and LVN, and that no Hospitality Aides had transferred her since the incident. She stated they always use 2 people to transfer. She stated she was transferred by the Hoyer lift and that her family member was asked by the administrator to remove the sit to stand device from the building. During an Interview with the current DON and the RNC on 10/9/25 at 4:10 PM both stated all Hospitality aides were checked off on transfer skills as of 9/19/25. Interviews with 7 Nurses' Aides (B, D, E, F, G, H, I, J) and one Hospitality Aide K on 10/9/25 between 9:00 and 10:00 AM were able to state their job description and duties they were allowed to perform. They stated they would go to the Kardex in the point of care to make sure what kind of care they needed. Hospitality Aide K stated she was told by the administrator that she cannot work on the floor until she passes her Texas Nurse's Aide Training requirement online and supervised clinical with competency checks. During Interviews with resident numbers 1,3,4,5,6,7 and 8 on 10/9/25 between 11:00 AM and 1:00 PM all stated that that they were transferred appropriately and had no transfer related incidents. Residents #1, #7 and #4 stated that were transferred by a Hoyer lift by two people, and never just by one person. Residents stated they could tell if a resident was a Hospitality Aide or CNA or a Nurse's Aide by looking at their employee's name badge. They stated Hospitality aides were not allowed to transfer residents. Record reviews of skills checklist and CNA online training revealed certificates of training and skills check lists for Nurses' Aides B, E, F, G, H, I, J and one Hospitality Aide K were in their employee files and dated before entrance. During Interviews on 10/9/25 between 11:00 and 1:00 PM Nurses' Aides B, D, E, F, G, H, I, J and one Hospitality Aide K stated they signed a nurse's aide job description stating their duties and name tags were updated to reflect their current job duties. Record review of Resident #1's care plan reflected that she was a Hoyer lift as of 9/3/25. Record review of Resident #'s 1, 2, 3, 4, 5, 6, and 7's care plan and Kardex reflected accuracy.

Based on observation, interview, and record review the facility failed to ensure 1 (Resident #1) of 8 residents reviewed for accident hazards were free from accident hazards in their environment. The facility failed to ensure Resident # 1's received adequate supervision and assistive devices to prevent accidents. The lift used by facility staff was not an adequate assistive device since there was no manual for proper staff training and the device was the personal property of Resident #1. This resulted in a fall during a transfer in which Resident #1 received a fracture on her left knee on 9/3/25. The noncompliance was identified as PNC. The IJ began on 9/2/25 and ended on 9/3/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for serious injuries, a decline in the resident's condition, hospitalization, or death. Findings included: Record review of Resident #1's admission Sheet, not dated, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her active diagnoses included Paraplegia (paralysis that affects the legs and not the arms), muscle weakness, unsteadiness on feet, osteomyelitis of vertebrate, and pain in thoracic spine. Record review of Resident #1's Annual MDS dated [DATE] reflected Resident #1 had a BIMS score of 15 (cognitively intact) and impaired range of motion in both lower extremities and section GG documented Resident #1 required partial to moderate assistance to transfer. Record review of Resident #1's comprehensive care plan, dated 7/14/25, reflected that she had a self-care performance deficit and required 1 staff to reposition and turn in bed, and to transfer from bed to chair. A revision of the care plan on 7/15/24 indicated that she used a sit to stand device, and it was discontinued on 9/3/25 Review of the Provider Investigation report dated 9/3/25 revealed: Resident had a fall during sit to stand transfer to the bathroom, resulting in left knee fracture . The Hospitality Aide that was assisting Resident #1 in the sit to stand transfer to the toilet was not trained or oriented to the sit to stand machine. The resident was sent to the emergency room for evaluation and pain medication was administered as ordered and as needed. There were no other negative findings at this time. Record review of a radiology report for Resident #1 dated 9/3/25 documented: There is a cortical discontinuity (interruption or fracture in the hard, dense, outer layer of bone that makes up most of the skeleton) in the lateral aspect of the left medial femoral condyle (the rounded, smooth end of the thigh bone that forms part of the knee joint), suggesting a fracture. Record review of the video evidence (Clip #1) date 9/2/25 at 6:56 PM provided by Resident #1 from her personal monitoring device located in her room, revealed Resident #1 was transferred by the Hospitality Aide A on 9/2/25 using her personal transfer equipment. The hospitality aide could not be heard in the video stating to Resident #1 that she had never used the sit to stand transfer device to perform a transfer. Resident #1 could be heard stating you have to learn when you're young. The Resident #1 is seen sitting on the transfer device while Hospitality Aide A pushed her into the bathroom after which the resident could not be viewed by the camera. Video clip #2 - Resident #1 is not in view, but Hospitality Aide A is seen standing in the doorway of the bathroom and is heard stating I I can't get in there. I'm sorry. She turned toward the resident's room door which was closed, opened the door and stated: Let me get some help. She then left the room. The resident could be heard groaning and calling out help!. She was not in view of the camera and the clip ended. Record review of the nurses note dated 9/2/2025 11:34 PM Note Text: BP-146/94. T-97.5. P-101. R-18.Resident had a fall. Location: Resident Bathroom Fall information: Assisted, Legs gave out, .Cognition / Behavior at Time of Event: Oriented / no problem,This nurse was notified by the Hospital Aide that she had assisted residents to the ground via a gait belt from sit to stand device. The Hospitality Aide was assisting the resident to bathroom and during the transfer to toilet, resident could not get bearings on her legs, and they gave out. No injuries noted at the time of assisted fall. The Resident #1 did not hit her head, alert and oriented x4. resident complained of left knee discomfort. Resident assisted to w/c from floor by 3 staff members and placed in bed. Will continue to monitor for delayed injuries. Appears and/or states to be in pain. Describes the pain as: Intermittent, Location of pain: left knee Pain relieving intervention used at this time: routine oxycodone.Initial Treatment/New Orders:Resident Statement: resident stated legs gave out trying to transfer from sit & stand to toiletName of MD/NP notified: Medical Director/Primary Care PhysicianDate/time of notification: 09/02/2025 9:00 PM.Name of RP notified: husband Date/time of notification: 09/02/2025 9:00 PM.Interventions in place prior to fall: Scheduled toileting program, x2 assist when toiletingInterventions initiated in response to fall: Scheduled toileting program, x2 assist with transfers9/3/2025 01:52 Transfer Notification Note Text: Resident #1 was transferred to a hospital on [DATE] 1:30 AM related to resident had assisted fall in bathroom and hurt left knee, swelling noted in left knee, unable to manage pain or get x-ray until business hours, resident request to be sent to ER.Record review of the Hospitality Aide's job description stated in part: Knowledge base - ability to record information, good communication skills, genuine care for and interest in the elderly, ability to comply with company safety policies, provide support to the nursing department by assisting with non-nursing tasks, including but not limited to bed making, passing water and ice, answering call lights and gathering supplies. The Hospitality aide job description was signed on 8/27/25 by Hospitality Aide A. Record review of the facility incident logs for the months of July, August, and September 2025, revealed no other injuries related to transfers. Record review of the facility policy Transfers from Chair to Bed stated the following in part: .A gait belt should be used for all transfers and the resident supported by holding the gait belt. Record review of Hospitality Aide A's employee file revealed she was not trained for transfer skills and competency checked until 9/11/25 after which she was allowed to come back to work. During an interview and an observation on 10/1/25 at 11:35 AM Resident #1 was sitting up in her electric wheelchair in her room with her left leg elevated. She stated she was non weight bearing to her left leg because of the fracture and she had to be transferred with a Hoyer lift. Resident #1 stated she did persuade Hospitality Aide A to use the transfer device despite Hospitality Aide A telling her she did not know how to us the transfer device. She stated she persuaded her to use the device because it was easier for her but stated some of the girls didn't like to use the device because it was difficult to maneuver in her small bathroom and she slid off the edge of the seat. She stated her leg was caught between the lift and the wall and it hurt. She stated they had to get the assistance of Hospitality Aide B to get her off of the floor and LVN C watched. Hospitality Aide A did not come back to the room. During an interview with Hospitality Aide A on 10/3/25 at 6:00 PM Hospitality A stated she didn't know how to use the sit to stand equipment, but she answered Resident #1's call light and Resident #1 kept telling her she needed to urinate. Hospitality Aide A stated she knew Resident #1's call light had been on for about 20 minutes before she went into the room to answer it. She then stated they were shorthanded that evening and she had been assigned by LVN C to work as a floater in 3 different halls. Hospitality Aide A stated she knew there was no one around to assist at that time because no one else answered the call light. Hospitality Aide A stated Resident # 1 asked her to use the sit to stand machine to transfer her to the toilet in the bathroom, so she did it anyway, knowing that she was not supposed to do a transfer. Hospitality Aide A stated she assisted Resident #1 to the toilet but was unable to get her lined up over the toilet seat. Hospitality Aide A stated Resident #1 then said her legs were giving way and she was unable stand. Resident #1 then fell to the floor. Hospitality Aide A stated she was unable to use a gait belt to aid in the support of Resident #1. Hospitality Aide A stated she realized after the incident that she should not have done the transfer because she had not been trained and that she had no training on the use of the transfer device before the incident. Hospitality Aide A stated the facility then told Resident #1 the device would have to be taken home because it did not belong to the facility and there was no manual for its use. Hospitality Aide A stated she was suspended after the incident and was allowed to come back after 9 days when the facility completed their investigation and that is when they had the training and check off skills for her. During an interview with Hospitality Aide B on 10/10/25 at 6:15 PM he was called to Resident #1's room after the fall on 9/2/25 to get her off the floor. He stated her leg was between the machine and the wall of the bathroom and he was unable to use a gait belt to lift her off the floor. He stated he lifted her underneath her arms and put her back into her chair. He then returned to the memory care unit where he was stationed that night. Hospitality aide B stated he had no training on use of the device by the facility. During an interview with the Administrator on 10/3/25 at 10:00 AM, she stated she was not aware that staff were not trained on the sit-to-stand machine until after the incident. She stated she thought the machine belonged to the facility; and that the DON that was no longer employed with the facility had trained them. She stated the prior DON had been in charge of training of Hospitality Aides and following through to ensure staff complete training for all equipment used for transfers and that they were tested and competency checked before using the equipment and all skills were performed. The Administrator stated that after the incident and during the time of the facilities investigation of the incident, that there was no policy manual for the use of the sit- to-stand device. The administrator stated she did not know Hospitality Aide A was performing transfers without training and competency checks. She stated that her expectation was that a Hospitality Aide does not perform transfers and duties that were not included in their job description and for which they had not been trained appropriately. The Administrator then stated she expected the DON to be responsible for monitoring and education of all staff. Attempted to interview LVN C on 10/8/25 and again 10/9/25 (Charge Nurse) regarding the incident with Resident #1, but she replied by text to the Administrator stating she was in the hospital, and she was unable to interview. During an interview on 10/9/25 at 11:00 AM The Administrator stated she was no longer employed by the facility effective today 10/9/25. During an interview with the Director of Therapy on 10/3/25 at 10:30 AM he stated Resident #1 was a one-person transfer prior to her fall, but she was now a 2 person Hoyer lift due to the non-weight bearing status to her left leg and her therapy had been put on hold. He stated he communicated to the former DON that the sit-to-stand lift did not belong to the facility and there was no manual for the equipment. He stated the residents had not been checked off to use the device and the staff were not trained. He stated he made it clear to the former DON that he was not qualified to do the training, because the use of the equipment was not a part of his curriculum in therapy school. He stated he assumed everyone in the facility knew the device was used by the resident because it was in her room and it was a large piece of equipment and hard to miss. He stated he did not recall the date that he relayed this information to the former DON, but he asked her to ensure staff did not use the device. During an interview with the former DON on 10/3/25 at 4:16 PM she stated her last day at the facility was 8/15/25. She stated she did not remember the Director of Therapy telling her that the staff should not use the device. She stated she did know that the device was being used by staff to do the transfers of Resident #1 without training and competency checks. During an interview with the Medical Director/Primary Physician on 10/6/25 at 4:00 PM he stated his expectation was that residents be transferred by staff that had been trained and the equipment used had been safely checked. Review of Hospitality Aide A's training record reflected that she had completed training on Position and Transfer Techniques and fall prevention on 9 /11/25. She had also signed an acknowledgment on 10/3/25 that she was to follow the resident's care plan to know who required a Hoyer lift or who was to be lifted by two people. During an interview on 10/3/25 with Hospitality Aide A, she stated if there were any questions about how a resident was to be transferred, she knew she was to clarify this with the nurse.Observed Hospitality Aide B and CNA 1 perform a Hoyer lift on 10/4/25 at 1:30 PM using 2 people on Resident #4 and proper procedure and all all-safety rules were followed, and no incidents were noted. In an interview with the Administrator on 10/8/25 at 9:00 A.M., she stated after the incident on 9/3/25 they immediately completed the following corrections/interventions. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance. Review of the Plan reflected: 1. Self-reporting protocol initiated on 9/3/25 and dated 9/3/25 by the Administrator . 2. Reported incident to the State within 2 hours of incident 9/3/25.3. Known perpetrator (Hospitality Aide A) suspended immediately pending investigation.4. Care plan for Resident #1 updated immediately and revised for injury.5. Skin assessments on all non-verbal residents and Safe Surveys of interviewable residents on halls A, B, C, D, were completed on 9/3/25 and 9/4/25.6. Interviews with staff members regarding whether they have seen a fellow staff member act in an abusive or neglectful manner toward a resident was completed on 9/3/257. Abuse and neglect Inservices started with all staff on 9/3/258. Ad HOC QAPI meeting held 9/3/25 for Inappropriate transfer by untrained staff.6. Audited all resident's Kardex/care plan on 09/3/25 to ensure all resident's level of care was updated and accurate.7. Educated and validated all staff understood the use of the Kardex/care plan system on 09/3/258. Review plan in QAPI monthly until resolved. Completed risk management entry 9/3/259. Medical director notified of this plan on 9/3/25 by the Administrator.10. The DON and Admin will monitor for potential neglect by reviewing incidents in stand up daily 9/3/2511. Monitor at least 10 of the following ADL Actions each week to ensure that the proper number of staff is providing assistance: bathing, bed mobility, transferring, walking initiated 9/3/25All monitoring above will continue for at least 4 weeks. The QAPI committee will review the findings and make revisions to the plan, as necessary. Verification 10/9/25 :Correction #1:In an Interview on 10/9/25 at 11:00 AM the Administrator stated that she received a call from the Charge Nurse notifying her of Resident #1's fall 0n 92/25. The resident was assessed and did not complain immediately. She did begin to complain of pain and the charge nurse notified her that the resident was requesting to go to the hospital. She was sent to the hospital and diagnosed with a fracture on her left knee. During the course of the investigation the administrator discovered that the resident was transferred by Hospitality Aide A that was performing duties such as transfer, that were not in her signed job description and was doing so without appropriate training on safety and operation. She stated she immediately filed a self-report and suspended the perpetrator pending the results of the investigation. She was informed by therapy staff that the mechanical lift device was not owned by the facility and no one in the facility had been trained to use the device. She stated she could see by viewing the video that Hospitality Aide A did perform the transfer with the device, and this was not a duty for which she was currently trained to do according to her job description. She notified Resident #1's family of the need to remove the device from the resident's room. The sit to stand device was no longer in the building as of 9/3/25. Record review of the facility reporting protocol template indicated all areas of the self-reporting protocol had been completed, dated, and signed by the staff. Correction #2. Record review of the nurses note dated 9/2/2025 11:34 PM Note Text: BP-146/94. T-97.5. P-101. R-18.Resident had a fall. Location: Resident Bathroom Fall information: Assisted, Legs gave out, .Cognition / Behavior at Time of Event: Oriented / no problem,This nurse was notified by the Hospital Aide that she had assisted residents to the ground via a gait belt from sit to stand device. The Hospitality Aide was assisting the resident to bathroom and during the transfer to toilet, resident could not get bearings on her legs, and they gave out. No injuries noted at the time of assisted fall. The Resident #1 did not hit her head, alert and oriented x4. resident complained of left knee discomfort. Resident assisted to w/c from floor by 3 staff members and placed in bed. Will continue to monitor for delayed injuries. Appears and/or states to be in pain. Describes the pain as: Intermittent, Location of pain: left knee Pain relieving intervention used at this time: routine oxycodone.Initial Treatment/New Orders:Resident Statement: resident stated legs gave out trying to transfer from sit & stand to toiletName of MD/NP notified: Medical Director/Primary Care PhysicianDate/time of notification: 09/02/2025 9:00 PM.Name of RP notified: husband Date/time of notification: 09/02/2025 9:00 PM.Interventions in place prior to fall: Scheduled toileting program, x2 assist when toiletingInterventions initiated in response to fall: Scheduled toileting program, x2 assist with transfers9/3/2025 01:52 Transfer Notification Note Text: Resident #1 was transferred to a hospital on [DATE] 1:30 AM related to resident had assisted fall in bathroom and hurt left knee, swelling noted in left knee, unable to manage pain or get x-ray until business hours, resident request to be sent to ER. Correction #3Record review of the Ad Hoc QAPI meeting revealed the meeting was conducted on 9/3/25 with the following members attending: Medical Director, Administrator, DON, ADON #1, ADON #2, MDS Nurse #1, MDS Director 1, MDS Director #2, Social Worker, Medical Records, Medical Director. Correction #4Record review of the Employee Disciplinary Report dated 9/4/25 revealed the Hospitality Aide A was suspended for investigation of Neglect and the improper transfer. Correction #5Record review of Skin assessments on all non-verbal residents and Safe Surveys of interviewable residents on halls A, B, C, D, completed on 9/3/25 and 9/4/25. Record review of Residents #5, #6 safe survey forms and interviews with Residents #2, #3, and #4 from 2 PM to 4 Pm on 10/9 /24 confirmed that they did feel safe in the facility, and all stated they were transferred properly. During interviews with Residents #2, # 3, #4, #5, and #6 from 2 PM to 4 PM they stated they could tell the difference between the Nurse's Aide, Hospitality Aides and Certified CNAs by their name badge. Correction #7 Interviews with 10 staff members Hospitality Aides A, B, C, K, E, D, F, G, H, I, J (formerly titled Hospitality aides but now classified as Nurses' Aides) between 2:00 PM and 4:00 PM on 10/9/25 reflected that they all attended a training skills lab on 9/3/25 and competed competency checks on 9/11/25. They stated hey were trained on Abuse and Neglect, Safe Transfers, an checked off on the Hoyer lift. Hospitality Aides A, B, C, K, E, D, F, G, H, I and J stated they were not allowed to operate the hydraulic controls and must transfer a mechanical lift with 2 people. Observed Hospitality Aide B and CNA 1 perform a Hoyer lift on 10/4/25 at 1:30 PM using 2 people on Resident #4 and proper procedure and all all-safety rules were followed, and no incidents were noted. Correction #8Reviewed QAPI minutes for meeting last held 10.3.25. Reviewed PIP dated 9/3/25 for incident. Meeting attended by medical director. Signed on 10/3/25. Correction # 9Interview with the Medical Director on 10/6/25 at 4:00 PM verified that he had been notified of the incident and the PIP on 9/3/25. Correction #10 Reviewed monitoring by the facility of ADL assistance initiated on 9/3/25 revealed that the monitoring was complete and current with evidence of monitoring from 9/3/25 to 10/9/25. Monitoring continues daily at the time of exit. During an Interview with the Administrator on 10/10/25 at 8:00 AM stated she only had 1 hospitality aide left in the building as of 10/9/25. She stated everyone else had completed training and skills checks and were ready to test. She stated scheduling was in process with herself and the new DON monitoring compliance During an Interview with Resident #1 on 10/9/25 at 4:00 PM she stated she had not been transferred by staff other than CNAs, and LVN, and that no Hospitality Aides had transferred her since the incident. She stated they always use 2 people to transfer. She stated she was transferred by the Hoyer lift and that her family member was asked by the administrator to remove the sit to stand device from the building. During an Interview with the current DON and the RNC on 10/9/25 at 4:10 PM both stated all Hospitality aides were checked off on transfer skills as of 9/19/25. Interviews with 7 Nurses' Aides (B, D, E, F, G, H, I, J) and one Hospitality Aide K on 10/9/25 between 9:00 and 10:00 AM were able to state their job description and duties they were allowed to perform. They stated they would go to the Kardex in the point of care to make sure what kind of care they needed. Hospitality Aide K stated she was told by the administrator that she cannot work on the floor until she passes her Texas Nurse's Aide Training requirement online and supervised clinical with competency checks. During Interviews with resident numbers 1,3,4,5,6,7 and 8 on 10/9/25 between 11:00 AM and 1:00 PM all stated that that they were transferred appropriately and had no transfer related incidents. Residents #1, #7 and #4 stated that were transferred by a Hoyer lift by two people, and never just by one person. Residents stated they could tell if a resident was a Hospitality Aide or CNA or a Nurse's Aide by looking at their employee's name badge. They stated Hospitality aides were not allowed to transfer residents. Record reviews of skills checklist and CNA online training revealed certificates of training and skills check lists for Nurses' Aides B, E, F, G, H, I, J and one Hospitality Aide K were in their employee files and dated before entrance. During Interviews on 10/9/25 between 11:00 and 1:00 PM Nurses' Aides B, D, E, F, G, H, I, J and one Hospitality Aide K stated they signed a nurse's aide job description stating their duties and name tags were updated to reflect their current job duties. Record review of Resident #1's care plan reflected that she was a Hoyer lift as of 9/3/25. Record review of Resident #'s 1, 2, 3, 4, 5, 6, and 7's care plan and Kardex reflected accuracy.

Based on interview, and record review the facility failed to maintain clinical records that were complete and/or accurate for 1 of 10 residents (Resident #1) reviewed for clinical records in that: The RN A did not document Resident # 1 was transferred to the ER on 5.12.25. This failure could place residents at risk of inaccurate and incomplete clinical records resulting in an inaccuracy in the care the resident received. The findings include: Record review Record review of Resident # 1's Face Sheet revealed she was a [AGE] year-old female originally admitted to the facility on 4.20.25 and readmitted on 5.20.25. She had diagnoses of fracture of hip, end stage renal disease (last stage of kidney failure) osteoporosis (porous brittle bone that breaks easily with spontaneous fractures common), and calciphylaxis (rare and life-threatening syndrome which involves calcium buildup in the skin and fat tissue leading to clotting and painful lesions). Record review of admission MDS dated 5.3.25 documented Resident #1 had a BIMS score of 7 (which indicated moderate cognitive impairment). Record review of Resident #1's Nursing progress Notes for 5.12.25 stated: Transfer Notification - Late entry Effective Date: 5/12/2025 10:38:0 Created By: DON Created Date : 5/23/2025 11:21:03 Resident was transferred to a hospital on [DATE] 10:38 AM related to AMS Hypoxia(low oxygen content in the blood) This is intended to serve as notice of an emergency transfer Record review of the nurses note dated 5.12.25 indicated Resident #1 returned to the facility with a diagnoses of urinary tract infection at 1:39 PM on 5.12.25 Resident #1 was nonresponsive and unavailable for an interview at the time of the investigation. In an interview on 5.22.25 at 2:30 PM, Resident # 1's family member said she was not aware of Resident #1's transfer to the emergency room on 5.12.25 @ 10:38 AM when she experienced an altered mental status. She stated she found out the resident had a UTI when she visited the resident at the nursing facility later that day. In an interview on 5.23.25 at 11.43 AM RN A stated she thought she did notify Resident #1's family member of the transfer on 5.12.25 but if it was not documented, and the family member stated she did not notify her she could not state with certainty that she did notify her. She stated she failed to follow proper procedure by not documenting the event when it occurred which could result in an inaccuracy in the care the resident received. In an interview on 5.23.25 at 11:50 AM the DON stated she was in the facility and she and another nurse were present and assisted with the transfer. She stated it was her expectation that resident information was documented in a resident's record at the time it occurred. She stated if documentation were not made a late entry could be made at a later date and identified as a late entry with the date and time the event occurred and the time and date the documentation was created. Record review of the facility's policy, Documentation not dated, revealed [in part]: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. The facility will maintain complete and accurate documentation for each resident. The facility will ensure that information is comprehensive and timely and properly signed. Complete documentation in the electronic health record in a timely manner.

Based on observation , interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 24 residents (Resident #4, Resident #44 and Resident #76) reviewed for comprehensive person-centered care plans. 1. The facility failed to ensure Resident #4's comprehensive care plan was person centered and measurable when addressing Resident #4's Tobacco use. 2. The facility failed to ensure Resident #44's comprehensive care plan contained the resident's use of Trapeze bar (medical device used to help patient move and positions themselves in bed) for bed mobility. 3. The facility failed to ensure Resident # 76's comprehensive care plan contained Resident #76's amputation . 4. The facility failed to ensure Resident #76's use of a fall mat was implemented as documented in the resident's care plan. These failures could place residents at risk for not receiving care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Findings include: 1. Record review of Resident #4's electronic face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Rhabdomyolysis (breakdown of muscle tissue causing chemical release) Syncope and collapse (brief loss of consciousness), Hypertension (high blood pressure), Congestive heart failure , and Unsteadiness on feet. Record review of Resident #4's Annual MDS, dated [DATE], revealed Section C cognitive Patterns BIMS score 05, which indicated severely impaired cognition. Section FF0115 Functional Limitation in range of Motion Upper Extremity impairment on one side. Lower extremity impairment on both sides. Section GG0120 Mobility Devices Wheelchair. Section J 1300 Current Tobacco use No. Record review of Resident #4's Care Plan, dated 12/23/2024, revealed no problem, goal or intervention related to Resident #4's use of smokeless tobacco. During an observation and interview on 01/20/2025 at 2:43 PM revealed Resident # 4 was sitting up in his bed. A brown ball of substance sat on his bedside table. Resident #4 stated it was his chewing tobacco. Resident #4 stated he took it out to eat and then put it back into his mouth. 2. Record review of Resident #44's electronic face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a previous admission on 09/23/2022. Resident #44 had diagnoses which included Encounter for orthopedic aftercare involving surgical amputation, Heart Failure, Nicotine Dependence, Pressure ulcer of sacral region, stage 4 and Acquired Absence of left leg below knee. Record review of Resident #44's Physician Orders, last reviewed 11/17/2024, revealed no orders for use of a Trapeze bar. Record review of Resident #44's Annual MDS, dated [DATE], Section C cognitive Patterns BIMS score 14, which indicated Intact cognition ). Section GG Functional Abilities-GG0130 Toileting Dependent, Lower body dressing setup or clean-up assistance, lying to sitting on bed Independent, Chair to bed transfer Independent. Section I Active Diagnosis Amputation. J1300 Current Tobacco Use Yes. Record review of Resident #44's Care Plan, dated 12/20/204, did not address use of a Trapeze Bar for bed mobility. No goals or interventions for use of a Trapeze Bar were addressed in the Care Plan, dated 12/20/2024. During an observation on 01/21/2025 at 09:03 AM revealed Resident #44 lying in bed and a trapeze bar attached to the bed frame . During an interview on 01/22/2025 at 12:05 PM, LVN A stated she was not sure how long Resident #44 had been using the trapeze bar. She stated she thought therapy recommended it. She stated she was not sure if he needed a physician order for the trapeze bar or if it should be on care plan. During an interview on 01/22/2025 at 1:30 PM with PTA D stated Resident #44 had a trapeze bar for a long time. PTA D stated he did not believe the therapy department recommended use of the trapeze bar. During an interview on 01/22/2025 at 2:40 PM with MDS Coordinator LVN B stated use of a trapeze bar should be care planned. LVN B stated if not care planned staff would not have known he needed the trapeze bar and how often he needed it. LVN B stated she did not know how long the resident had been using the trapeze bar. LVN B stated she was not sure who ordered the trapeze bar for this resident. LVN B stated if there was no order then it would not be triggered to be care planned . During an interview on 01/22/2025 at 2:45 PM, the DON stated use of trapeze bars should be care planned and did not need an order. The DON stated this could affect residents in that staff would not be able to monitor the effectiveness of the trapeze bar. The DON stated this could be a negative effect on the resident if trapeze bar use was not monitored and not being used correctly by the resident. The DON stated she did not know why this was not care planned and she monitored care plans for accuracy. The DON stated no one else at the facility monitored care plans . 3. Record review of Resident #76's electronic face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #76 had diagnoses which included Diabetes Mellitus, Acute Kidney Failure, Hypertension , Acquired Absence of Right Leg Below Knee (Amputation) Record review of Resident #76's Physician Orders, dated 01/21/2025, revealed: no orders for fall mat at bedside. Record review of Resident #76's Admission MDS, dated [DATE], Section C Cognitive status BIMS score 14, which indicated the resident was intact cognitively. Section GG0115 Functional Limitation in Range of Motion Upper extremity impairment on one side, Lower extremity impairment on one side. GG0120 Mobility Devices Walker, Wheelchair, Limb Prosthesis Section J Health Conditions J1300 Current Tobacco User No. Section J1 900 Number of falls since Admission/Entry two or more. Record review of Resident #76's Care Plan, dated 12/18/2024, reflected Focus: the resident is risk for fall. Date initiated: 12/06/2024 Revision on 12/182024 Goal: the resident will be free of falls through the renew date.12/17/2024. Intervention included fall mat while in bed. Amputation of right leg below knee was not addressed. Use of Prosthetic leg was not addressed. During an observation on 01/2025 at 10:30 AM and 01/21/2025 at 09:03 AM revealed no fall mat was observed by the bed in the room for Resident #76. During an interview on 01/22/25 at 09:20 AM, the DON stated she was responsible for entering fall risk assessments on care plans and MDS Coordinators entered items triggered on the CAA (Care Area Assessment)from the MDS. The DON stated care plans were reviewed weekly during the standard of care meeting. The DON stated she conducted quarterly audits to identify issues that had been resolved and needed to be cancelled. The DON stated equipment specified in the care plan must be in place for the resident such as a f all mat. The DON stated the expectations were interventions on the care plan were done and if not coaching/retraining was provided. The DON stated if a fall mat was noted in an intervention, a fall mat should be in place if the resident was in bed or in the room . During an interview on 01/22/2025 at 01:46 PM, LVN C stated she looked at care plans from time to time. LVN C stated the DON reviewed changes during the daily morning meeting. LVN C stated any equipment used for a resident should be on the care plan. LVN C stated the consequences for a resident if the equipment was not addressed on the care plan, a needed device could be missed by the caregiver and not be used. Record review of the facility's, undated, policy titled Comprehensive Care Planning, reflected: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. Record review of the facility's, undated, policy titled Uniform Smoke Free Policy reflected. Residents will be allowed to keep smokeless tobacco, i.e., chewing tobacco, snuff, in their room and in their possession. Residents may use smokeless tobacco at their own discretion. Residents will be educated regarding cleanliness and proper disposal of the smokeless tobacco. 44722 45216

Based on observation , interview and record review the facility failed to ensure the assessments accurately reflected the resident status for 2 of 11 residents (Residents #4 and #24) reviewed for assessments . 1. The Facility failed to ensure Resident #4's MDS was accurately completed with the residents tobacco use. 2. The facility failed to ensure Resident #24's MDS was accurately completed with Resident #24's anticoagulant. These failures could place residents at risk by decreasing the accurate information available to determine the care and services needed for each resident. The findings include: 1. Record review of Resident # 4's face sheet, dated 1/22/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Rhabdomyolysis (rare muscle injury where your muscles break down), high blood pressure and congestive heart failure. Record review of Resident #4's Annual MDS, dated [DATE], revealed Section C- Cognitive Patterns BIMS score of 5, which indicated Severely impaired cognition. Section J- Health Conditions revealed no evidence of current tobacco use. Record review of Resident #4's Care Plan, dated 12/23/2024, revealed no problem, goal or intervention related to Resident #4's use of smokeless tobacco. During an observation and interview on 01/202/2025 at 2:43 PM Resident # 4 was sitting up in his bed. A brown ball of substance was sitting on his bedside table. Resident #4 stated the substance was his chewing tobacco. Resident #4 stated he took it out to eat and then put it back into his mouth. 2. Record review of Resident #24's face sheet, dated 1/22/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. with a readmitted on 01/07/2025 with the following diagnosis of respiratory failure, dementia, high blood pressure, congestive heart failure and Cerebral Infraction (stroke). Record review of Resident #24's Physician order revealed a start date of 09/26/2024 Pradaxa oral capsule 150 MG (Dabigatran Etexilate Mesylate) Give 1 capsule by mouth two times a day related to Cerebral Infraction. Record review of Resident #24's Quarterly MDS, dated [DATE], revealed: Section C- Cognitive Pattern she had a BIMS score of 13, which indicated cognitively intact cognition. Section N- Medications documented no evidence of anticoagulant use. During an interview on 01/22/2025 at 3:18 PM, LVN B stated she was the MDS coordinator and the MDS should have included Resident #4's tobacco use and Resident #24's anticoagulant use. LVN B stated their cooperate monitored the MDS. LVN B stated the effect on residents could have affected residents' ability to receive outside resources. LVN B stated what led to the failure was oversight staff not looking at documentation completely. During an interview on 01/22/2025 at 3:33 PM, the DON stated her expectation was for MDS to be completed correctly and include all resident care needs. The DON stated the MDS was responsible to ensure MDS's were completed and their corporate monitored. The DON stated the effect on residents could have had interference with the resident's plan of care and what was being done to meet their goals. The DON stated they did not have a policy for the MDS, they followed the CMS Resident Assessment Instrument User's Manual. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf accessed on 01/22/2025) documented the following: J1300 Current Tobacco Use: Steps for Assessment 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes. DEFINITION TOBACCO USE Includes tobacco used in any form. CMS's RAI Version 3.0 Manual CH 3: MDS Items [J] October 2023 Page J-27 J1300: Current Tobacco Use (cont.) 3. If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period. Coding Instructions o Code 0, no: if there are no indications that the resident used any form of tobacco. o Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period. N0415: High-Risk Drug Classes: Use and Indication .Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). N0415E2. Anticoagulant: Check if there is an indication noted for all anticoagulant medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days) . N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days). N0415I2. Antiplatelet: Check if there is an indication noted for all antiplatelet medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days).

Based on interview and record review the facility failed to develop and implement written policies and procedures prohibited and prevented abuse, neglect, and exploitation, of residents and misappropriation of resident property for 1 of 4 employee files (Employee C) reviewed for abuse protocol. The facility failed to complete annual Criminal Background Checks for Employee C. This failure could place residents at risk for abuse, neglect, and exploitation. Findings include: In a record review of Employee C's personnel file reflected the facility did not complete annual Criminal History checks. The last check completed was date 12/2/22. In an interview on 10/16/24 at 4:45 PM, the Human Resource Specialist said the annual Criminal History checks for Employee C were not completed. He said it was the responsibility of the Human Resource Specialist to ensure reference checks were completed and documented during annual review. He said Criminal History checks helped prevent abuse . Human Resource Specialist stated he has worked for facility for only 3 weeks and has not completed reviews of all staff to see if background checks and training are up to date. Human Resource Specialist stated the former HRS must have missed the annual background check for Employee C. In an interview on 10/17/24 at 5:15 PM, the Administrator said Human Resources should be completing employee reference checks prior to employment and annually. The Administrator said Employee C's Criminal History was not checked or documented. The Administrator said a potential negative outcome of not checking employee Criminal History annually was to ensure the facility did not employ a person whose criminal history did not put the safety for the resident in jeopardy. A Criminal Background check was conducted for Employee C on 10/16/24, Employee C was employable. Record review of the facility's policy Criminal Background Checks , dated as revised 11/17/2017, reflected the following [in part]: Policy: It is the policy of the company to conduct criminal background checks of all applicants within 72 hours of employment . and complete annual Criminal History checks, Procedure: 6. The Criminal History Coordinator will be responsible for obtaining reference checks and licensure verification/registries prior to employment and annually. Written documentation of reference checks and licensure/verification will be maintained in the personnel file . Record review of the facility's Abuse and Neglect policy dated as revised 3/29/2018, reflected the following: The facility will conduct criminal background checks of all personnel in accordance with Texas Health and Safety Code, Chapter 250.

Based on interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 (Resident # 55) residents reviewed for quality of care. The facility failed to ensure Resident #55's pain was managed at a level that did not interfere with the resident's sleep or day to day activities This deficient practice could place residents at risk of pain, discomfort, and a diminished quality of life. Findings included: A review of Resident #55's Electronic Health Record (EHR) indicated her admitted was 05/31/2023 with relevant diagnoses of pain in left ankle and joints of left foot, abnormal gait, and mobility (difficulty walking and moving from place to place), muscle atrophy (decrease in size of the muscle tissue from not using the muscle). Review of Resident #55's routine medications indicated : Tylenol 500 mg 2 tablets every 6 hours for fever with a start date of 8/8/23, and Tylenol 500 mg 2 po every 6 hours as needed for pain/inflammation with a start date of 12/7/23. Review of Resident #55's quarterly MDS assessment dated [DATE] revealed Resident #55 experienced pain o at a level of an 8 constantly during the 5-day lookback period. Review of the MDS assessment dated [DATE] showed a Quarterly Assessment which revealed in the pain assessment the following: interview; Section J0300- Have you had pain or hurting at any time in the last 5 days? - Yes How much of the time have you experienced pain or hurting over the last 5 days? - Almost Constantly Please rate your pain over the last 5 days on a zero to ten pain scale, with zero being no pain and ten as the worst pain you can imagine. 08. Record Review of Resident #52's MAR revealed the resident had recieved Tylenol 500 mg caps 2 by mouth on 11/5/23 for a pain level of 5, on 11/9/23 for a pain level of 4, and on 11/27/23 and 11/28/23 for pa pain level of 5, and not again until 12/5/23 for a pain level of 3. In an interview with Resident #55 on 12/06/23 at 10:25 AM she said that she normally, constantly had pain since her admission in May 2023. She said that she had told someone that she needed a pain medication, the pain medication that had been given did not help and they were supposed to get her something else ordered for pain. She stated she did not remember who she told about her pain, or if it was a nurse. She stated that the pain limits her day-to-day activity and was constant. In an interview with the DON (Director of Nursing) on 12/07/23 at 2:28 PM She stated said she did not know the resident was having so much pain. She stated it was her expectation that the pain assessment information gathered on the 11/10/23 MDS would have resulted in the nurse communicating with the physician and getting her an order for pain medication She said that the RN MDS Coordinator signed the MDS, and the social worker did the actual interview for pain on the 11/10/23 quarterly MDS and it should have been addressed by nursing. The social worker did the MDS and did not notify her with her pain score. She said stated she would be contacting the physician to get a new order for pain. She stated it would be her expectation that a nurse completes the pain interview in section J of the MDS.A facility policy on pain management was not reviewed.

Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours for 2 of 5 residents (Residents #39 and #56) whose record were reviewed for recent admission to the facility, in that: 1. Resident #39 was admitted to the facility on [DATE] and a baseline care plan had not been developed within 48 hours of his admission. 2. Resident #56 was admitted to the facility on [DATE] and a baseline care plan had not been developed within 48 hours of her admission. This failure placed the residents at risk for not receiving care and services to meet their needs and to promote their physical and mental health and well-being within their new living environment. The findings included: 1. Resident #39 Review of Resident #39's Admission Record, dated 12/07/2023, revealed an [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included: Type 2 diabetes mellitus with foot ulcer; hyperlipidemia (high cholesterol); hypertension (high blood pressure); heart failure; end stage renal disease (kidney failure); dependence on renal dialysis; and dysphagia (difficulty swallowing). Review of Resident #39's Baseline Care Plan Acknowledgement form, dated 09/30/2023, revealed a copy of the baseline care plan was provided to the resident's representative. Review of Resident #39's Baseline Care Plan revealed it was dated as developed on 10/03/2023, later than 48 hours after admission. During an interview and record review on 12/07/2023 at 10:37 AM, the DON reviewed the Baseline Care Plan Acknowledgement form and the Baseline Care Plan for Resident #39. She stated the Baseline Care Plan dated 10/03/2023 was done late. She stated the Baseline Care Plan Acknowledgement had been done by the LVN charge nurse and she probably did the form as part of the nursing admission packet. The DON stated she was the one who initiated the baseline care plan within 48 hours and the LVN should not have completed the acknowledgement form. The DON stated the LVN would not have given the resident's representative a copy of a baseline care plan. 2. Resident #56 Review of Resident #56's Admission Record, dated 12/07/2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: iron deficiency anemia; depression; Alzheimer's disease; hypertension (high blood pressure); and cardiac arrhythmia (abnormal heartbeat). Review of Resident #56's Baseline Care Plan Acknowledgement form, dated 04/17/2023, revealed a copy of the baseline care plan was provided to the resident's representative. Review of Resident #56's Baseline Care Plan revealed it was dated as developed on 04/25/2023, later than 48 hours after admission. Review of the facility's policy and procedure for Base Line Care Plans, not dated, revealed the following [in part]: Completion and implementation of the baseline care plan withing 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan .

Based on interview, and record review, the facility failed to update the comprehensive care plan after the assessment for 1 of 6 residents (Resident #'s 53) reviewed for plan of care revision. The facility failed to include in the care plan, nutritional interventions for a significant weight loss for Resident #53 after the 11/26/2023 Comprehensive MDS . This failure could place the residents at risk of staff and providers not having the most current information for the Resident's plan of care. Findings included: Record review of Resident #53's electronic health record revealed a [AGE] year-old male with a, re-admitted [DATE], Diagnoses: dysphagia (difficulty swallowing), essential (primary) hypertension (high blood pressure), Alzheimer's disease (progressive memory loss), atrial fibrillation (the hearts upper chambers beat out of sequence with the lower chambers which can lead to poor blood flow, blood clots and stroke), anxiety disorder (feelings of worry and fear that interfere with daily activities), muscle weakness and muscle wasting and atrophy (decreased muscle mass resulting in weakness due to decreased physical activity, and nutritional deficiencies). Record review of Resident 53's electronic health record revealed the most recent Care Plan dated 3/21/23 listed a focus area for potential risk for malnutrition dated 3/1/23. The goal was for Resident #53 to maintain a stable weight and nutritional parameters. The Care Plan further revealed the interventions were last updated 5/16/23, the interventions were not reviewed or revised after the 31-pound weight loss in November 2023. Record review of Resident #53's electronic health record revealed he had a weight of 131.6 on 11/21/23 and a weight of 164.6 on 11/8/23 (a 31-pound weight loss loss). The weight documented on 11/21/23 was the last recorded weight for the resident. Record review of Resident #53's Admission MDS with an assessment reference date of 11/26/23, section K 0200 documented a weight of 132 pounds and a height of 72 inches. Section K0300 documented that Resident #53 had a weight loss of 5 percent or more in the last month and was not on a prescribed weight loss program. Section K0520 he had not received intravenous feeding, a feeding tube, mechanically altered diet, or a therapeutic diet while not a resident, or while a resident. Record review of the electronic health record revealed the physician orders, dated 12/6/23, for Resident #53 reflected that he was on a Regular diet with Regular consistency and thin fluids. In an interview on 12/06/23 at 10:52 AM Resident #53's wife stated that he did not eat as much due to his dementia. She stated she did not know that he had a significant weight loss . She stated she was here for every meal, and she cuts his meat. She stated he has dentures and has no trouble chewing. Interview on 12/07/23 at 3:32 pm with the DON revealed it would be her expectation that re-weight would happen if a large discrepancy in weight was discovered, and she would also expect the family and physician to be notified. She stated the care plan should be updated by the MDS nurse after the MDS was completed. She stated failure to update the care plan could result in the resident not receiving the care he needs. Interview on 12/07/23 at 4:03 pm with MDS Coordinator revealed she was responsible for updating the care plan with the MDS but if it is an acute problem then it was nursing that was to update the care plan. She stated failure to update the care plan and communicato the te the weight loss to the interdisciplinary team could result in the resident not receiving the care he needs. Review of the facilities undated policy titled: Comprehensive Care Planning revealed the following: The facility will establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives interventions are the specific services that will be implemented.

Based on interview and record review, the facility failed to ensure residents who have not used psychotropic drugs are not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record and gradual dose reductions were attempted for 1 of 5 residents (Resident #56) whose records were reviewed for unnecessary medications. Resident #56 was admitted to the facility on [DATE]. Her admission orders included an order for the antipsychotic medication Zyprexa 5 mg for a diagnosis of depression, with a start date on 04/18/2023. She did not have a diagnosis or indication of use for antipsychotic medication. The facility's failure placed the resident at risk for adverse side effects from receiving antipsychotic medication that was not indicated for use. The findings included: Review of Resident #56's Admission Record, dated 12/07/2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: iron deficiency anemia; depression; Alzheimer's disease; hypertension (high blood pressure); and cardiac arrhythmia (abnormal heartbeat). Review of Resident #56's Physician Order Summary revealed an order dated 04/17/2023 for Zyprexa 5 mg by mouth one time daily related to depression, with a start date on 04/18/2023. Review of the Consent for Antipsychotic Medication Treatment for Resident #56 revealed the physician documented the resident had been receiving Zyprexa since 04/17/2023 and the benefit was to help psychosis and agitation. The form was signed by the physician on 05/25/2023 and was signed by the resident's family member on 07/06/2023. The documented indication for use had not been clarified and added to the resident's list of diagnoses. Review of Resident #56's comprehensive care plan, dated as initiated on 07/06/2023 and last reviewed on 10/28/2023, revealed the care plan The resident requires anti-psychotic medications. Review of Resident #56's Quarterly MDS Assessment, dated 10/24/2023, revealed a BIMS score of 00 out of 15 (severe cognitive impairment); verbal behavioral symptoms on 1-3 days; other behavioral symptoms 4-6 days; wandering daily; selected Psychiatric/Mood disorder diagnosis of depression; and antipsychotic, antidepressant and anticoagulant medications received. There was no GDR attempted for antipsychotic medication. Review of the Pharmacist Consultant Medication Regimen Review Recommendation, dated 10/31/2023, revealed it was recommended a GDR be attempted for Zyprexa 5 mg by mouth daily. There was no documented physician follow-up to the Pharmacist Consultant's recommendation. During an interview and record review on 12/07/2023 at 6:31 PM, the DON reviewed Resident #56's physician order Zyprexa 5 mg daily for depression dated 04/17/2023 and the Consent for Antipsychotic Medication Treatment form. She stated the physician did document psychosis on the consent form. The DON stated there were several residents with antipsychotic medication orders that did not have the correct diagnosis for indication for use. The DON stated she would look for a policy and procedure for pharmacy services and psychotropic medications. A policy and procedure for pharmacy services and psychotropic medications was not provided at the time of the completion of the survey and exit from the facility on 12/07/2023.

Based on interview and record review the facility failed to implement their written policies and procedures to prohibit abuse, neglect, exploitation, and misappropriation of resident property for 1 of 8 employee files (Employee C) reviewed for abuse protocol. The facility did not complete reference checks on Employee C, with a hire date of 11/27/2023, prior to employment at the facility. This failure could place residents at risk for abuse, neglect, and exploitation. Findings included: In a record review of Employee C's personnel file revealed the facility did not complete reference checks with a hire date of 11/27/2023 prior to employment. In an interview on 12/07/23 at 11:30 AM, the Human Resource Specialist said the reference checks for Employee C were not completed. He said it was the responsibility of the Human Resource Coordinator to ensure reference checks are completed and documented prior to hire. He said reference checks helps prevent abuse. In an interview on 12/07/23 at 1:54 PM, the Administrator said Human Resources should be completing employee reference checks prior to employment. She said Employee C's references were not checked or documented. She said a potential negative outcome of not checking employee references would be the employee would not be a satisfactory hire. Review of the facility's policy Criminal Background Checks, dated as revised 11/17/2017, revealed the following [in part]: Policy: It is the policy of the company to conduct criminal background checks of all applicants within 72 hours of employment . Procedure: 6. The Criminal History Coordinator will be responsible for obtaining reference checks and licensure verification/registries prior to employment. Written documentation of reference checks and licensure/verification will be maintained in the personnel file. Review of the facility's policy Abuse/Neglect, dated as revised 03/29/2018, revealed the following [in part]: The resident has a right to be free from abuse, neglect, misappropriation of resident property, and exploitation . Procedure: 4. The facility will attempt to obtain at least one reference check on all new hires.

Based on interview and record review, the facility failed to report the results of investigations of allegations of abuse in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 4 (Resident #2, Resident #3, Resident #7and Resident #12) of 10 residents reviewed for abuse. The facility failed to report the investigations findings of abuse when Resident #3 attempted to remove Resident #2 from dinner table resulting Resident #2 receiving nail marks on her arm from Resident #3. The facility failed to report the investigation findings of abuse when Resident #12 slapped Resident #7 in the face while both residents were passing in the hall. This failure could place residents at risk for abuse. Findings include: Resident #2 Record review of Resident #2's, , MDS dated [DATE] indicated the resident was an [AGE] year-old female with a BIMS of 3 (severely cognitively impaired). The residents Medical Diagnoses were Dementia (a decline in cognitive abilities), and Psychotic Disturbances (a severe mental disorder that causes abnormal thinking and perceptions). The resident was a Hospice patient. Resident #2 resided in secure unit of facility. Resident #3 Record review of Resident #3's, MDS dated [DATE] indicated the resident was an [AGE] year-old female with a BIMS 1 (severely cognitively impaired). The residents Medical Diagnoses were Dementia (a decline in cognitive abilities) and Rhabdomyolysis (rare muscle tissue breakdown). Resident #3 resided in the secure unit of facility. Record review of incident report date 7/22/23, LVN A witnessed Resident #3 attempting to remove Resident #2 from dining room table. Resident #2 refused to move, and Resident #3 clawed her fingernails into Resident #2's inner left arm, leaving nail marks. LVN A immediately separated residents and de-escalated situation. LVN A assessed Resident #2, skin was not broken, red marks from nails were visible. Vitals taken. Resident #2 did not seem bothered by incident or upset. Resident #3 was placed on 1 on 1 supervision, social services provided. Resident #3 was assessed, no injuries, had no concerns moments after incident. Resident #3 has no history of aggressive behaviors towards others. LVN A notified the DON, physician, Hospice, and family of both residents. Interview on 8/8/23 at 10:30 am, the DON stated she reported the incident to HHSC on 7/22/23. The DON stated her investigation did not establish what caused the behavior of Resident #3 to try and remove Resident #2 from the table. Neither resident was interview-able and both residents had no concerns or any mental stress. The DON stated she provided in-service training to staff on 7/23/23, topics include Prevention of Physical abuse, Preventing and Recognizing Triggers of Behaviors and Dementia. The DON stated Resident #3 does not have any history of aggression and has not done anything like this before. The DON stated she performed an investigation on incident, but she must have forgotten to submit the PIR findings for incident on 7/22/23, on form (3613-A) to HHSC. Resident #7 Record review of Resident #7, [AGE] year-old female, discharged from facility 7/14/23 (moved closer to family) last MDS dated [DATE] BIMS 6 (severely cognitively impaired). Medical Diagnosis Alzheimer (a neurodegenerative disease), Resident # 7 resided in facilities secured unit. Resident #12 Record review of Resident #12, [AGE] year-old female, MDS dated [DATE] BIMS 00 (severely cognitively impaired), Medical Diagnosis Alzheimer (a neurodegenerative disease), Resident #12 resides in facility secure unit. Record review of incident report dated 5/30/23 indicated as Resident #12 and Resident #7 passed each other in the hall on the secure unit at 3:45 pm, Resident #12 slapped Resident #7 on the left side of face. CNA A witnessed incident. CNA B stated no words were exchanged between residents before or after the incident. CNA B stated both residents kept walking down the hall as if nothing happened. CNA A reported incident to LVN A. LVN A assessed both residents, Resident #7 did not have any marks or redness on left side of face or injuries anywhere on face or body. Resident #12 had no injuries. LVN A stated neither Resident #7 or Resident #12 had any clue or was aware of any incident. LVN A reported incident to the DON, resident's physicians, and families. Interview on 8/9/23 at 11: 00 am, the DON stated she reported incident to HHSC on 5/30/23, and an Intake Investigation Worksheet was assigned to incident. The DON stated her investigation did not establish what caused the behavior of Resident #12 to slap Resident #7, neither resident had any history of aggression towards anyone or each other. Neither resident suffered injury or mental destress over incident. Both residents are non-interview able. The DON stated she provided in-service training to staff on 5/31/23, topics include Tips and Strategies for De-Escalating Aggressive, Hostile, or Violent Patients. The DON stated she has been submitting incidents to HHSC for several months due to not having a permanent Administrator, (facility has been using interim Administrators for the past several months). The DON stated she performed an investigation on the incident, but she must have forgotten to submit the PIR findings for the incident on 5/30/23, on form (3613-A) to HHSC. Record review of facility's Resident-to-Resident Altercations policy Revised 9/2022 indicated the following: 4. If two residents are involved in an altercation: j. Report incidents, findings, and corrective measures to appropriate agencies as outlined in Abuse, Neglect-Reporting, and Investigation Record review of facility's Abuse/Neglect Policy Revised 3/29/18 Section F Investigation 3. G. Other pertinent information as available. The written report must be sent to HHSC no later than the Fifth working day after the initial report. The facility will use the designed state reporting form (3613-A).

41944 Based on observations, interviews and record review the facility failed to provide each resident with necessary respiratory care consistent with professional standards of practice, for 2 of 3 residents (Resident's #13 and #53) reviewed for respiratory care, by failing to ensure: Resident's #13 and #53 oxygen tubing was changed weekly as ordered by the Physician. This failure could place residents requiring oxygen at risk for respiratory infections due to the potential for microorganisms infiltrating their oxygen equipment and supplies causing a decline in physical health. The findings Include: Resident #13 Record Review of Resident #13's face sheet, dated 10/25/2022, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Diagnosis included chronic obstructive pulmonary disease, unspecified (primary). Observation and interview during initial rounds, on 10/23/2022 at 10:07 AM, revealed Resident #13's oxygen tubing was dated 10/10/2022. Resident said she uses oxygen at night or when needed. Record review of Resident #13's Order Summary Report, dated 10/25/2022, revealed Resident #13 had an order for: A) O2 2 LPM per nasal canula to maintain O2 status >90% every day and night shift; B) Change Respiratory Tubing, Mask, Bottled Water, clean filter every 7 days, PRN as needed with use every night shift every Sun. Resident #53 Record Review of Resident #53's face sheet, dated 10/25/2022, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Diagnosis included chronic obstructive pulmonary disease, unspecified (primary). Observation and interview during initial rounds, on 10/23/2022 at 10:30 AM, revealed Resident #53's oxygen tubing was dated 10/10/2022. Resident said she does not remember when her tubing was last changed. Record review of Resident #53's Order Summary Report, dated 10/25/2022, revealed Resident #53 had an order for: A) May have O2 2 LPM per nasal canula to maintain O2 states > 90% as needed; B) May use oxygen 2 LPM per nasal canula. every night shift; C) Change Respiratory Tubing, Mask, Bottled Water, 02 BAG, clean 02 MACHINE FILTER every night shift every 2 weeks on Sunday. In an interview with the DON, on 10/25/22 at 3:37 PM, when asked about the oxygen tubing being dated for 10/10/22, she said the facility policy had recently changed for oxygen tubing to be changed only when visible dirty or as needed. However, she did acknowledge the doctor orders were still active for oxygen tubing to be changed every 7 days and that doctor orders supersedes facility policy. Review of the facility's policy for Oxygen Administration (undated) revealed Oxygen tubing was to be changed when visibly soiled or as needed.

Based on interview and record review, the facility failed to act upon and notify the attending physician of the pharmacist consultant's recommendation for 2 of 5 residents (Resident #s 18 and 47) whose records were reviewed for pharmacist drug regimen review. A. The facility did not follow up with the attending physician on the Pharmacist Consultant's recommendation to add parameters to hold hypertensive medication for Resident #18. B. The facility did not follow up with the attending physician on the Pharmacist Consultant's recommendation to attempt a gradual dose reduction of Resident 47's order for Fluoxetine (Prozac) 60 mg daily. This failure placed residents at risk for receiving medication for an extended duration without monitoring and physician review for continuation and necessity of the medication. The findings include: Resident #18 Review of Resident #18's face sheet, not dated, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Additional diagnoses included cerebral infarction, hemiplegia and hemiparesis affecting right side, and hypertension. Review of Resident #18's active Physician Orders, dated 10/25/2022, revealed the following medication orders: Benazepril 10 mg, give 1 tablet by mouth one time a day for hypertension, related to the diagnosis essential (primary) hypertension, with an order start date of 6/14/2022; Propranolol 20 mg, give 1 tablet by mouth two times a day related to secondary hypertension, unspecified, with an order start date of 6/14/2022. Review of the Pharmacist Consultant Medication Regimen Review reports revealed a Director of Nursing Report, dated 7/29/2022. The report documented the Pharmacist Consultant had reviewed Resident #18's medication orders on 7/08/2022. The Pharmacist Consultant documented the resident was being treated for hypertension and recommended hold parameters be added to the hypertension medication orders. The DON documented her initials on the report that the recommendation had been followed-up on by her. Review of Resident #18's active Physician Orders, dated 10/25/2022, revealed no parameters for holding the medications had been added to the orders for Benazepril and Propranolol. Resident #47 Review of Resident #47's face sheet, not dated, revealed a [AGE] year-old male who was initially admitted to the facility on [DATE]. The form documented the resident's diagnoses included quadriplegia, other specified depressive episodes, anxiety disorder, and insomnia. Review of Resident #47's Physician Orders, dated 10/25/2022, revealed an order for Fluoxetine 20 mg, give 60 mg by mouth one time a day related to other specified depressive episodes. Review of the Pharmacist Consultant Medication Regimen Review reports revealed a Director of Nursing Report, dated 8/08/2022. The report documented the Pharmacist Consultant had reviewed Resident #18's medication orders on 8/02/2022. The Pharmacist Consultant had reviewed Resident #47's order for Fluoxetine 60 mg by mouth daily and inquired if a gradual dose reduction could be attempted. There was no documented evidence on the report that the recommendation had been followed-up on by the DON. In an interview on 10/25/22 at 6:32 PM, the DON stated the Pharmacist Consultant had not been here yet this month. She stated recommendations were made on the Director of Nursing Report and the Medical Director Report. She stated the Medical Director responded to recommendations. The DON stated she and the Medical Director sat down together sometimes and reviewed the Pharmacist Consultant's report and recommendations. She stated the Medical Director would initial on the Medical Director Report and she initialed on the DON report when recommendations had been followed-up. The DON stated she would add parameters to Resident #18's orders for blood pressure medication. She stated there were standing orders for some parameters. Review of the facility's policy for Consultant Pharmacist, dated as revised 10/25/2017, revealed the following [in part]: The facility will contract the services of a pharmacist to provide consultation on all aspects of pharmaceutical services. The facility and the pharmacist will collaborate for effective consultation regarding pharmaceutical services. The pharmacist reviews and evaluates the pharmaceutical services by helping the facility identify, evaluate, and address medication issues that may affect resident care, medical care, and quality of life . Procedure 6. The Consultant Pharmacist shall provide the facility with documentation that he has reviewed each patient's drug therapy. When potential irregularities are identified, the consultant pharmacist shall complete an individualized report detailing the potential irregularity 7. The pharmacist will provide a separate written report of irregularities to the attending physician, medical director, and director of nursing after their review. 8. The attending physician will be notified of irregularities within 2 business days . 9. If an irregularity requires immediate action by the physician, the facility will call the physician and notify them of the irregularity. 10. The attending physician will review the identified irregularity and will document what, if any, action is to be taken to address it. If there is no change in the medication, the attending physician should document his or her rationale . 12. The completed report will be filed in the resident's clinical record. 13. Any irregularities that do not require a physician's order will be initiated within a timely manner by the director of nurses and/or designee .

41871 41944 Based on interview and record review, the facility failed to ensure that residents with PRN orders for psychotropic drugs were limited to 14 days for 3 of 5 residents (Resident #s 14, 53 and 47) and a gradual dose reduction for a sedative/hypnotic medication was attempted for 1 of 5 residents (Resident #18) whose medication regimens were reviewed for unnecessary medications in that: A. Resident #14's order for PRN diazepam/Haldol gel was not discontinued after 14 days. B. Resident #53's order for PRN Lorazepam (antianxiety medication) was not discontinued after 14 days. C. Resident #47 had an order for the antianxiety medication Alprazolam (Xanax) 1 mg by mouth every 12 hours as needed (PRN) for anxiety, dated 8/25/22, which did not have an end/stop date. D. Resident #18 had an order for the sedative/hypnotic medication Zolpidem (Ambien) 10 mg by mouth at bedtime for difficulty sleeping, dated 7/02/2022, with no attempts of a gradual dose reduction. This failure could place residents administered PRN and routinely scheduled psychotropic medications at risk of adverse side effects from prolonged use of psychotropic medications including stroke and death. The findings included: Resident #14 Review of Resident #14's face sheet, dated 10/25/2022, revealed he was a [AGE] year-old male, admitted to the facility on [DATE] and was receiving hospice care services. Diagnosis included: senile degeneration of the brain; anxiety disorder; and other specified depressive episodes. Review of Resident #14's Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 1 out of 15 (Severe Cognitive Impairment). Review of Resident #14's Physician Orders, dated 10/25/2022, revealed Resident #14 was prescribed diazepam/Haldol gel 2mg/2mg, give 1 ml topically to inner wrist, rub in well, PRN every 4 hours as needed for anxiety, with a start date of 09/06/2022, and an end date of indefinite. Review of Resident #14's pharmacy consultant reviews for September 2022 revealed the consultant pharmacist had not recommended that the resident's order for diazepam/Haldol gel be discontinued because the 14-day maximum allowed prescribed length for prn psychotropic medications had been met. Resident #53 Review of Resident #53's face sheet, not dated, revealed she was admitted to the facility on [DATE] and was 82-years-old and had diagnoses including anxiety disorder, insomnia, Alzheimer's Disease, and major depressive disorder. Review of Resident #53's Quarterly MDS, dated [DATE], documented she had a BIMS score of 11 out of 15 (Moderate Cognitive Impairment). During the seven-day look-back period she had received an anti-anxiety medication for 7 days. No behavioral symptoms were documented. Review of Resident #53's pharmacy consultant reviews for September did not reveal the consultant pharmacist recommended that the resident's order for Lorazepam be discontinued because the 14-day maximum allowed prescribed length for PRN psychotropic medications had been met. Review of Resident #53's Physician Orders, dated 10/25/2022, revealed that the resident was to continue receiving Lorazepam 2 mg/ml 0.5 ml every 4 hours PRN and Lorazepam 2 mg/ml 1 ml every 4 hours PRN as needed for anxiety. The medication was ordered on 08/26/2021. The orders did not specify a stop date. Review of Resident #53's Medication Administration Records dated 10/1/2022 through 10/25/2022 did reveal documentation of PRN Lorazepam 2 mg/ml give 1 ml as given two times on 10/01/2022. In an interview on 10/25/22 at 3:32 PM, the Director of Nurses stated that PRN orders for psychotropic medications were to be discontinued after 14 days and that justification from the prescriber was required for PRN orders for psychotropic medications that extended beyond the 14-day limit. She stated the Lorazepam continued because the hospice staff refused to write a PRN order for 14 days duration. She stated the diazepam/Haldol gel continued because hospice refused to write a PRN order for 14 days duration. The DON stated she was responsible for seeing that PRN psychotropic medications were not administered PRN longer than 14 days. Resident #47 Review of Resident #47's face sheet, not dated, revealed a [AGE] year-old male who was initially admitted to the facility on [DATE]. The form documented the resident's diagnoses included quadriplegia, other specified depressive episodes, anxiety disorder, and insomnia. Review of Resident #47's Physician Orders, dated 10/25/2022, revealed an order for Alprazolam 1 mg by mouth every 12 hours as needed (PRN) for anxiety, with a start date of 8/25/2022. The order did not include and end/stop date. Review of Resident #47's quarterly MDS assessment, dated 10/05/2022, revealed the resident had received antianxiety medication 1 out of 7 days during the assessment review period. Resident #18 Review of Resident #18's face sheet, not dated, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Additional diagnoses included cerebral infarction, hemiplegia and hemiparesis affecting right side, diabetes mellitus type 2, epilepsy unspecified, insomnia, hypertension, gastro-esophageal reflux disease, and hypothyroidism. Review of Resident #18's active Physician Orders, dated 10/25/2022, revealed the following medication orders: Amitriptyline 75 mg by mouth one time daily related to insomnia, dated 6/14/2022 (Elavil - antidepressant medication); Zolpidem Tartrate 10 mg by mouth at bedtime for difficulty sleeping, dated 7/06/2022 (Ambien - sedative/hypnotic medication). The physician orders did not include a referral for mental health/psychological evaluation and services. The physician orders did not include orders for anti-anxiety medication. Review of Resident #18's quarterly MDS assessment, dated 10/21/22, revealed the resident had received antidepressant medication and hypnotic medication 7 out of 7 days during the assessment review period. The diagnosis section for psychiatric/mood disorder did not have any diagnoses selected. (The diagnoses of depression and anxiety were not selected.) Review of Resident #18's comprehensive care plan revealed a care plan, dated 9/09/2022, which documented The resident uses anti-anxiety/hypnotic medications - anxiety disorder - Zolpidem. The goal did address decreased episodes and signs/symptoms of sleep disturbance. The interventions/approaches included administering anti-anxiety medication as ordered by physician, monitoring for effectiveness and side effects of anti-anxiety medication. Review of the Pharmacist Consultant Medication Regimen Review reports revealed a Director of Nursing Report, dated 7/29/2022. The report documented the Pharmacist Consultant had reviewed Resident #18's medication orders on 7/08/22 - High Dose - Medication: Ambien tablet 10 mg (Zolpidem Tartrate) 1 po QHS (by mouth at bedtime). Recommendation: In geriatric patients, clearance of zolpidem is similar in men and women. The recommended dose of AMBIEN in geriatric patients is 5 mg regardless of gender per the FDA. Please consider reducing dose of Ambien to 5 mg QHS (at bedtime). There was no documented evidence on the report that the recommendation had been followed-up on by the DON. Review of the Pharmacist Consultant Medication Regimen Review report to Resident #18's physician, dated 9/30/2022, revealed the request for a response to the review date on 9/24/2022. The report documented High Dose - Medication: Ambien tablet 10 mg (Zolpidem Tartrate) 1 po QHS (by mouth at bedtime). Recommendation: In geriatric patients, clearance of zolpidem is similar in men and women. The recommended dose of AMBIEN in geriatric patients is 5 mg regardless of gender per the FDA. Please consider reducing dose of Ambien to 5 mg QHS (at bedtime). The physician response, dated 10/19/22, documented Disagree - Lots of anxiety regarding uterine cancer that is metastatic. Having difficulty sleeping. In an interview on 10/25/2022 at 6:32 PM, the DON stated the Medical Director was not Resident #18's physician. The DON stated Resident #18 had a lot of anxiety related to having cancer. Review of the facility policy titled Psychotropic Drugs, dated as revised 10/25/2017, revealed the following [in part]: The facility must ensure that . 1. Residents who have not psychotropic drugs will not be given psychotropic drugs unless the medication is used to treat a specific condition as diagnosed and documented in the clinical record. 2. Residents who use psychotropic drugs receive gradual dose reduction, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. 4. PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing physician believes that it is appropriate for the prn order to be extended beyond 14 days, he should document their rationale in the resident's medical record and indicate the duration for the prn order.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen. The facility failed to protect the 3 of 58 residents who are provided puree diets in the facility's only kitchen from bacterial contamination when Cook D assembled the puree machine processor touching the cutting blades post with his bare hands. This failure could place residents who are provided puree food at risk for food borne illness and compromise health status The findings included: Observation on 10/24/2022 at 11:00 AM during puree processing for 3 residents revealed Cook D processing puree food 3 times (clean and sanitized between food processing) for different food stuff, hamburger steak, green beans, and bread he assembled the food processor he touching the center post of the blades adjusting the seating of the blades with his bare hand. The center post was touched by the food pureed during processing potentially contaminating the food. During an interview on 10/24/2022 at 11:35 AM Dietary Manager said their expectation regarding touching food processor with bare hands she said Cook D should not have touched the inside of the food processor with bare hands. Review of the facility's policy and procedure dated 2012 titled Equipment Sanitation revealed the following: Will clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner. Review of the facility's policy and procedure dated 2012 titled, Infection Control revealed the following: Procedure: .2. Careful handwashing by personnel will be done in the following situations: .b. Between handling of dirty dishes boxes or equipment and handling clean food or utensils. .5. Equipment sanitation .d. Cups, glasses, and bowels must be handled so that fingers or thumbs do not contact inside surfaces.

Based on interview and record review, the facility failed to ensure that four of four residents reviewed on [MEDICATION NAME] therapy (Resident ID's #9, 13, 14 and 16) were free from unnecessary drugs due to inadequate monitoring. The facility failed to: A. Obtain a repeat blood test PT/INR ([MEDICATION NAME] time/international normalized ratio) to monitor [MEDICATION NAME] as ordered by the Physician for residents' (ID # 9 and 14); Resident ID #9 was hospitalized with hematuria (blood in the urine) and elevated PT/INR levels. She required Vitamin K and [MEDICAL CONDITION] of plasma and red blood cells. B. Obtain physician orders [REDACTED].#13 and 16). This failure could affect the 10 residents receiving [MEDICATION NAME] therapy and place them at risk for undetected health issues, overdosing, bleeding, delayed treatment and death. The findings included: Resident ID #9 Resident ID #9's March 2014 Physicians Orders, documented she was a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of resident ID #9's Nurses Notes, dated 12/18/13, documented resident ID #9 had non-[MEDICAL CONDITION] (swelling caused by fluid in your body's tissues) to right lower extremity. The physician was notified and resident was scheduled for a Doppler study on 12/18/13. On 12/19/13 resident ID #9 went to the hospital for a Doppler study and returned to the facility with two blood clots in the right leg, one blood clot in the mid-thigh and one in the ankle. New orders to start [MEDICATION NAME] 75mg. SQ every 12 hours and [MEDICATION NAME] 5mg. po everyday. An order to obtain a PT/INR on 12/23/13 and every month. Record review of resident ID #9's Telephone physician's orders [REDACTED]. 12/19/13 - [MEDICATION NAME] 75mg. SQ every 12 hours [MEDICATION NAME] 5mg. daily PT/INR on Monday 12/23/13 PT/INR every month 12/30/13 - PT/INR for 12/30/14 Discontinue [MEDICATION NAME] 80mg. Continue [MEDICATION NAME] 5mg. every day PT/INR 01/14/14 01/14/14 - Discontinue [MEDICATION NAME] 5mg. Increase [MEDICATION NAME] to 6mg. every day Re-check in 1 week Record review of resident ID #9's Nurses Notes, dated 02/08/14, documented resident ID #9 was having signs and symptoms of distress, slightly slumped over, pale and making verbal signals of having trouble breathing. Resident was transferred to the emergency room . Record review of resident ID #9's Telephone physician's orders [REDACTED]. 02/08/14 - Transfer via ambulance to emergency room for evaluation Record review of resident ID #9's Laboratory results from the local hospital, documented the following: -02/15/14 - PT: 23.2 (high) (10.8-12.9) seconds normal range INR: 3.72 (high) (2.5-3.5) therapeutic range -02/17/14 - PT: 17.3 (high) INR: 2.101 Record review of resident ID #9's Telephone physician's orders [REDACTED]. 02/17/14 - Returned from hospital - [MEDICATION NAME] 6 mg. one tab everyday 02/28/14 - PT and INR to be drawn on the 3rd Monday of each month. 04/09/14 - send to emergency room for evaluation. Record review of resident ID #9's Laboratory records did not document a PT/INR obtained for the month of March 2014. Record review of resident ID #9's Medication Administration Record, [REDACTED]. Record review of the Pharmacy Consultant medication regimen review for March and April 2014 documented No Recommendation for medication adjustment. Record review of resident ID #9's Nurses Notes, documented the following (in part): -12/28/13 through 12/29/14 - reported bruising to bilateral lower extremities. 01/03/14 - bruising to right upper forearm and to right upper wrist. Resident pulls arm back during lab draw. - 01/04/14 - bruising still present to right upper arm and to abdomen. - 01/05/14 - bruising on right upper abdomen from [MEDICATION NAME] injections. -04/01/14 - Foley catheter draining clear dark yellow urine. -04/03/14 thru 04/07/14 - Foley catheter patent and draining clear yellow urine to gravity. -04/08/14 - 6:30 PM - Blood noted on brief. When brief removed foley catheter lying out in brief with bulb filled intact large amount clotting blood noted to peri-area. Call place to doctor await return call. -04/08/14 - 8:00 PM - Foley catheter remains out. Resident voided two times with no blood noted. -04/09/14 - 2:00 AM - voiding no bleeding noted. -04/09/14 - 12:00 PM -Called to resident room by aides. Resident profusely bleeding from vagina, very large clots and complaints of abdominal pain. Physician and guardian notified. Vitals: Blood Pressure 130/81, Respirations 20, heart rate 70 and temperature 98 degrees. Transport to emergency room . Review of resident ID #9's admission record of the local hospital on [DATE] at 1:18PM, documented the following Diagnoses: [REDACTED]. -04/09/14 PT: 27.8 (high) INR: 5.272 (high) -04/09/14 PTT: 52.0 (high) (20.5-35.3) seconds Medications Administered: -04/09/14 at 4:23 PM administer Vitamin K 5mg IM *****(Reference NICL Laboratories, dated 1996-2013, documented the following (in part): "Properly anticoagulated patients INR values range between 2.0-3.0. However, if the patient is being treated for [REDACTED]. INR levels above 4.9 are considered critical values". *****(Reference WebMD 2005-2014) "A longer-than-normal PT can mean a lack of or low level of one or more blood clotting factors. A longer-than-normal PT can also mean that you have disseminated intravascular coagulation, a life-threatening condition in which your body uses up its clotting factors so quickly that the blood cannot clot and bleeding does not stop". *****(Reference WebMD 2005-2014) [MEDICATION NAME] is an anticoagulant medication. To decrease your risk for bleeding, your doctor will monitor you closely and check your lab results (INR test) to make sure you are not taking too much [MEDICATION NAME]. Tell your doctor right away if you notice any signs of serious bleeding. Review of the facility's Mosby's Nursing Drug Reference 2014, documented the following (in part): pg. 1250, [MEDICATION NAME] "Nursing considerations assess: Blood studies PT platelets INR 2nd or 3rd dose when in therapeutic range for 2 consecutive days, monitor 2-3 times a week for one to two weeks then less frequently, depending on stability of INR results, usually at least monthly". At 3:52PM on 04/09/14 resident ID #9 was transferred to another advanced healthcare hospital for further evaluation. Diagnoses: [REDACTED]. Record review of resident ID #9's Electronic Medical Record "Medication Tasks" from the advanced healthcare hospital, documented the following (in part): -04/09/2014 transfuse 4 units of Fresh Frozen Plasma; -04/10/2014 transfuse 3 units of Red Blood Cells. In an interview on 05/01/2014 at 6:30 PM, the DON stated resident ID #9's standing orders for PT and INR were dropped from the Lab's routine lab draw log after resident ID #9 discharged to the hospital in February 2014. She stated the facility did not have a log book or a check off list for routine lab orders at this time. The DON stated she was auditing resident charts for lab work, but had not completed every resident ' s records. She stated the facility missed getting resident ID #9's PT/INR lab work. She stated the facility does not have a policy for monitoring anticoagulant therapy; the facility follows doctor's orders. In an interview on 05/01/2014 at 6:50PM, the DON stated there are 10 residents in the facility on [MEDICATION NAME]. She stated she reviewed each of the residents' records and three of the 10 residents (ID #s 13, 14, and 16) did not have lab reports for PT and INR. She stated the medical director was notified and stat labs were ordered for the three residents On 05/02/14 review of resident ID #9's Hospital admission record from the advanced healthcare center dated 04/09/14, documented the following chief complaint: Gross hematuria. On 05/06/14 review of resident ID #9's Hospital Discharge Summary from the advanced healthcare center, documented resident's date of death : 04/19/2014. Cause of Death: Acute or chronic [MEDICAL CONDITION]. Resident ID #13 Resident ID #13's May 2014 Physicians Orders, documented she was a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of resident ID #13's PT/INR lab results documented the following: -09/23/2013 - PT: 22.4 (high) INR: 3.223 order documented on the lab result to continue current dose of [MEDICATION NAME] 2.mg on Sunday, Tuesday, Thursday and Saturday. [MEDICATION NAME] 5mg. on Monday, Wednesday and Friday; -12/19/2013 - PT: 19.7 (high) INR: 2.703 no orders. Record review of the May 2014 Physicians Orders, documented the following orders (in part): 04/02/2014 - [MEDICATION NAME] 2.5mg. one tab on Sunday, Tuesday, Thursday and Saturday. 04/02/2014 - [MEDICATION NAME] 5mg. one tab on Monday, Wednesday and Friday. There was not an order for [REDACTED]. In an interview on 05/01/2014 at 6:30 PM, the DON stated resident ID #13 did not have a standing order to obtain lab for a PT and INR. She stated the physician will order one when indicated. Review of resident ID #13's skin assessment notes or nurses' notes, dated January 2014 through May 2014, did not document any bruising or abnormal bleeding. Review of resident ID #13's stat lab dated 05/01/14 documented: PT 25.9 (high) and INR 4.596 (high). Order written on lab results to stop [MEDICATION NAME] for 3 days on 05/02/14 through 05/04/14. Resume [MEDICATION NAME] 2.5mg. every day on 05/05/14. Redraw PT and INR on 05/06/14. Resident ID #14 Resident ID # 14's May 2014 Physicians Orders, documented he was an [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of resident ID #14's May 2014 Physician Orders, documented the following orders (in part): 08/10/2013 - [MEDICATION NAME] 3mg. one tab every Sunday, Tuesday, Thursday and Saturday. 08/10/2013 - [MEDICATION NAME] 1.5mg. one tab every Monday, Wednesday and Friday. 08/10/2013 - PT and INR on the 1st day of every month. Record review of resident ID #14's PT/INR lab results documented the following: -05/23/2013 - PT 13.9 (high) INR 1.333 Review of resident ID #14's skin assessment notes from January 2014 through May 2014, did not document any bruising or abnormal bleeding. Review of resident ID #14's stat lab dated 05/01/14 documented: PT 12.8 (normal) and INR 1.171 (normal). Order written on the lab results to continue [MEDICATION NAME] as ordered and redraw PT and INR in one month. Resident ID #16 Resident ID #16s May 2014 Physicians Orders documented he was an [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of the May 2014 Physician Orders, documented the following orders (in part): 03/17/2014 - [MEDICATION NAME] 5mg. one tab every evening; There was not an order for [REDACTED]. Review of resident ID #16's skin assessment notes or nurses' notes for March 2014 through May 2014 did not document any bruising or abnormal bleeding. Review of resident ID #16's stat lab dated 05/01/14 documented: PT 16.9 (high) and INR 2.007 (normal). Order written on lab results to continue [MEDICATION NAME] as ordered and redraw PT and INR in one month. On 05/01/14 at 6:50 PM, the DON provided a list of 10 residents on [MEDICATION NAME].

Based on record review, and interview the facility failed to provide laboratory services to meet the needs of 4 of 4 sampled residents (ID #s 9, 13, 14 and 16) by failing to ensure: A. Obtain a repeat blood test PT/INR ([MEDICATION NAME] time/international normalized ratio) as ordered by the Physician for residents' (ID # 9 and 14); Resident ID #9 was hospitalized with hematuria (blood in the urine) and elevated PT/INR levels. She required Vitamin K and [MEDICAL CONDITION] of plasma and red blood cells; B. Obtain physician orders [REDACTED].#13, 14 and 16). This failure could affect the 10 residents receiving [MEDICATION NAME] therapy and could result in a delay of adjusting medications and ensuring treatment needs were identified and addressed. The findings included: Resident ID #9 Resident ID #9's March 2014 Physicians Orders, documented she was a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of resident ID #9's physician's orders [REDACTED]. every day, then was increased to 6mg. every day, and to re-check the PT/INR in 1 week. Resident ID #9 was transferred to a local hospital on 02/08/14 and returned to the facility on [DATE] and continued on [MEDICATION NAME] 6mg. every day. On 02/28/14 an order to draw PT/INR on the 3rd Monday of each month. Record review of resident ID #9's March 2014 Medication Administration Record, [REDACTED]. Record review of resident ID #9's Laboratory results from the local hospital, documented the following: -02/15/14 - PT: 23.2 (high) (10.8-12.9) seconds normal range INR: 3.72 (high) (2.5-3.5) therapeutic range -02/17/14 - PT: 17.3 (high) INR: 2.101 *****(Reference NICL Laboratories, dated 1996-2013, documented the following (in part): "Properly anticoagulated patients INR values range between 2.0-3.0. However, if the patient is being treated for [REDACTED]. INR levels above 4.9 are considered critical values". *****(Reference WebMD 2005-2014) "A longer-than-normal PT can mean a lack of or low level of one or more blood clotting factors. A longer-than-normal PT can also mean that you have disseminated intravascular coagulation, a life-threatening condition in which your body uses up its clotting factors so quickly that the blood cannot clot and bleeding does not stop". *****(Reference WebMD 2005-2014) [MEDICATION NAME] is an anticoagulant medication. To decrease your risk for bleeding, your doctor will monitor you closely and check your lab results (INR test) to make sure you are not taking too much [MEDICATION NAME]. Tell your doctor right away if you notice any signs of serious bleeding. Review of the facility's Mosby's Nursing Drug Reference 2014, documented the following (in part): pg. 1250, [MEDICATION NAME] "Nursing considerations assess: Blood studies PT platelets INR 2nd or 3rd dose when in therapeutic range for 2 consecutive days, monitor 2-3 times a week for one to two weeks then less frequently, depending on stability of INR results, usually at least monthly". Interview on 05/01/2014 at 6:30 PM, the DON stated resident ID #9's standing orders for PT and INR were dropped from the Lab's routine log after resident ID #9 discharged to the hospital in February. She stated they missed getting resident ID #9's lab work in March and she discharged to the hospital again in April. Record review of resident ID #9's Nurses Notes, documented the following (in part): -04/08/14 - 6:30 PM - Blood noted on brief. When brief removed foley catheter lying out in brief with bulb filled intact large amount clotting blood noted to peri-area. Call place to doctor await return call. -04/08/14 - 8:00 PM - Foley catheter remains out. Resident voided two times with no blood noted. -04/09/14 - 2:00 AM - voiding no bleeding noted. -04/09/14 - 12:00 PM -Called to resident room by aides. Resident profusely bleeding from vagina, very large clots and complaints of abdominal pain. Physician and guardian notified. Vitals: Blood Pressure 130/81, Respirations 20, heart rate 70 and temperature 98 degrees. Transport to emergency room . Review of resident ID #9's admission record of the local hospital on [DATE] at 1:18PM, documented the following Diagnoses: [REDACTED]. -04/09/14 PT: 27.8 (high) INR: 5.272 (high) -04/09/14 PTT: 52.0 (high) (20.5-35.3) seconds Medications Administered: -04/09/14 at 4:23 PM administer Vitamin K 5mg IM *****(Reference NICL Laboratories, dated 1996-2013, documented the following (in part): "Properly anticoagulated patients INR values range between 2.0-3.0. However, if the patient is being treated for [REDACTED]. INR levels above 4.9 are considered critical values". *****(Reference WebMD 2005-2014) "A longer-than-normal PT can mean a lack of or low level of one or more blood clotting factors. A longer-than-normal PT can also mean that you have disseminated intravascular coagulation, a life-threatening condition in which your body uses up its clotting factors so quickly that the blood cannot clot and bleeding does not stop". Review of the facility's Mosby's Nursing Drug Reference 2014, documented the following (in part): pg. 1250, [MEDICATION NAME] "Nursing considerations assess: Blood studies PT platelets INR 2nd or 3rd dose when in therapeutic range for 2 consecutive days, monitor 2-3 times a week for one to two weeks then less frequently, depending on stability of INR results, usually at least monthly". At 3:52PM on 04/09/14 resident ID #9 was transferred to another advanced healthcare hospital for further evaluation. Diagnoses: [REDACTED]. Record review of resident ID #9's Electronic Medical Record "Medication Tasks" from the advanced healthcare hospital, documented the following (in part): -04/09/2014 transfuse 4 units of Fresh Frozen Plasma; -04/10/2014 transfuse 3 units of Red Blood Cells. In an interview on 05/01/2014 at 6:30 PM, the DON stated resident ID #9's standing orders for PT and INR were dropped from the Lab's routine lab draw log after resident ID #9 discharged to the hospital in February 2014. She stated the facility did not have a log book or a check off list for routine lab orders at this time. The DON stated she was auditing resident charts for lab work, but had not completed every resident ' s records. She stated the facility missed getting resident ID #9's PT/INR lab work. Resident ID #13 Resident ID #13's May 2014 Physicians Orders, documented she was a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of the May 2014 Physicians Orders, documented the following orders on 04/02/14 an order for [REDACTED]. one tab on Monday, Wednesday and Friday. There was not an order in the record for a PT and INR to be drawn. In an interview 05/01/14 at 6:30 PM, the DON stated resident ID #13's physician will order a PT/INR as indicated. She stated resident ID #13 did not have a standing order for lab work. Resident ID #14 Resident ID # 14's May 2014 Physicians Orders, documented he was an [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of resident ID #14's May 2014 Physician Orders, documented the following an order on 08/10/13 for [MEDICATION NAME] 3mg. one tab every Sunday, Tuesday, Thursday and Saturday. The order also documented [MEDICATION NAME] 1.5mg. one tab every Monday, Wednesday and Friday and to draw PT/INR on the 1st day of every month. In an interview on 05/01/14 at 6:30PM, the DON stated resident ID #14's the dosage for [MEDICATION NAME] had not changed since admission. Resident ID #16 Resident ID #16 ' s May 2014 Physicians Orders, documented he was a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of the May 2014 Physician Orders, documented an order on 03/17/14 [MEDICATION NAME] 5mg. one tab every evening. There was not an order for [REDACTED]. Interview on 05/01/2014 at 6:30 PM, the DON stated the facility did not have a log book or a check off list for routine lab orders. She stated the facility does not have a policy for monitoring anticoagulant therapy; the facility follows doctor's orders. Interview on 05/01/2014 at 6:50PM, the DON stated there are 10 residents in the facility on [MEDICATION NAME]. She stated she reviewed each of the residents' records and resident ID #13, 14 and 16 did not have lab reports for PT and INR. She stated the medical director was notified and stat labs were ordered for the three residents. On 05/01/14 at 6:50 PM, the DON provided a list of 10 residents on [MEDICATION NAME].

Based on record review and interviews the facility failed to ensure 1 out of 19 residents (ID #14) who's medications regiment were reviewed was free of significant medication errors. The facility failed to transcribe, document and administer [MEDICATION NAME] 20mg. po Q.D. (diuretic treats fluid retention in people with [MEDICAL CONDITION] or a kidney disorder) to Resident #14 from 07/18/2013 through 07/21/2013 resulting in Resident #14 being admitted to local hospital on [DATE] with [DIAGNOSES REDACTED]. This deficient practice could place any of the current 76 residents at risk of a physical decline in health from not receiving their medications according to physician's orders [REDACTED]. The findings included: Resident ID #14 Resident ID #14's Physician orders, dated 07/01/2013, documented she was an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident ID #14's significant change in status assessment, dated 06/27/2013, documented she was severely impaired in her cognitive status, extensive assitance with the support of two staff for bed mobility, dressing and toileting. She was frequently incontinent of urine and bowel. Resident ID #14's active [DIAGNOSES REDACTED]. Resident ID #14's Comprehensive Plan of Care, dated 6/27/2013, documented the following( in part): Dehydration -1600 cc fluid restiction; diuretic therapy [MEDICATION NAME] and [MEDICATION NAME]; Risk for impaired gas exchange related to [MEDICAL CONDITION]; Oxygen at 2liters/minute and [MEDICATION NAME] (respiratory medication); History of [MEDICAL CONDITION] stage 3 or 4. monitor fluid restriction. Resident ID #14's Skilled Daily Nurses Notes, documented the following (in part): -07/18/2013 at 8:30 AM - resident's lower legs were red and warm to touch with 2+[MEDICAL CONDITION]. Message left for Physician notifying of residents change in condition; -07/18/2013 at 09:00 AM - Physician returned call and scheduled appointment to see resident at 10:45 AM that day at the emergency room . Resident ID #14's Discharge Instructions from the emergency room , dated 07/18/2013, documented the following orders: [MEDICATION NAME] (antibiotic-drug to treat infection) 300mg. tid; [MEDICATION NAME] (diurectic-to treat fluid retention) 20mg. qd. and [MEDICATION NAME] (drug to treat high blood pressure) 40mg. qd. Resident ID #14's Skilled Daily Nurses Notes documented the following (in part): -07/18/2013 not timed - resident returned from emergency room with new orders to begin [MEDICATION NAME] 300mg. tid for 7 days; [MEDICATION NAME] 20 mg. qd and to change [MEDICATION NAME] to 40mg. qd. Resident ID #14's Physician orders [REDACTED]. The order did not document the order for the [MEDICATION NAME]. Resident ID #14's MAR for July, documented [MEDICATION NAME] was not given from the July 18th through the July 21st as ordered. Resident ID #14's Skilled Daily Nurses Notes, at 7:45 AM, documented the following (in part): -07/21/2013 at 7:45 AM resident's respirations are labored and resident complaining not being able to breathe. Oxygen at 2L/min. administered. - 07/21/2013 at 8:00 AM resident was sent to E.R. - 07/21/2013 at 1:00 PM resident was admitted to the hospital [DIAGNOSES REDACTED]. Resident ID #14's Telephone Physician Orders, dated 07/21/13, documented send to emergency room for evaluation for shortness of breath, hematuria, and [MEDICAL CONDITION]. In an interview on 09/26/2013 at 11:45 AM, LVN B stated resident ID #14 returned from the E.R. on the 7/18/2013 on the 2pm to 10pm shift with orders to start the antibiotic and the changed dose of [MEDICATION NAME]. She stated she must have missed the order for the [MEDICATION NAME] and it was a documentation error. She stated resident ID #14 did not receive [MEDICATION NAME] from 7/18/2013 through 7/21/2013. In an interview on 09/26/2013 at 4:35 PM, the DON and the ADON were both present and both agreed that LVN B primarily works hall B. They stated any nurse can take orders for any resident on any hall. Policy and Procedure titled "Telephone Order Procedure", not dated, documented the following (in part): "To assure those physicians orders are carried out, to maintain optimum level of wellness for resident. Obtain telephone order from prescriber. Write telephone order on telephone order form. Record date and time order was received. Sign with first initial last name and tile of prescriber and your first initial, last name and title. Complete all resident identification information on telephone order form." CMS-672 Resident Census and Conditions of Residents, dated 09/23/2013, documented a census of 76.

Based on interview and record review, the facility failed to provide routine drugs and biologicals to residents in accordance with physician's orders for 1 of 19 residents (ID #14) reviewed for pharmacy services. The facility failed to administer the prescribed Lasix (diuretic-to treat fluid retention) to Resident #14. This deficient practice could place any of the current 76 residents at risk of a physical decline in health from not receiving their medications according to physician's orders. The findings included: Resident ID #14 Resident ID #14's Physician orders, dated 07/01/2013, documented she was an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident ID #14's significant change in status assessment, dated 06/27/2013, documented she was severely impaired in her cognitive status, extensive assitance with the support of two staff for bed mobility, dressing and toileting. She was frequently incontinent of urine and bowel. Resident ID #14's active [DIAGNOSES REDACTED]. Resident ID #14's Comprehensive Plan of Care, dated 6/27/2013, documented the following( in part): Dehydration -1600 cc fluid restiction; diuretic therapy lasix and zaroxolyn. Risk for impaired gas exchange related to chronic obstructive pulmonary disease; Oxygen at 2liters/minute and Xopenex (respiratory medication) History of chronic kidney disease stage 3 or 4. monitor fluid restrictin Resident ID #14's Skilled Daily Nurses Notes, documented the following (in part): -07/18/2013 at 8:30 AM - resident's lower legs were red and warm to touch with 2+edema. Message left for Physician notifying of residents change in condition; -07/18/2013 at 09:00 AM - Physician returned call and scheduled appointment to see resident at 10:45 AM that day at the emergency room . Resident ID #14's Discharge Instructions from the emergency room , dated 07/18/2013, documented the following orders: Clindamycin (antibiotic-drug to treat infection) 300mg. tid; Lasix (diurectic-to treat fluid retention) 20mg. qd. and Micardis (drug to treat high blood pressure) 40mg. qd. Resident ID #14's Skilled Daily Nurses Notes documented the following (in part): -07/18/2013 not timed - resident returned from emergency room with new orders to begin Clindamycin 300mg. tid for 7 days; Lasix 20 mg. qd and to change Micardis to 40mg. qd. Resident ID #14's Physician orders dated 07/18/2013, documented that the Clindamycin and Micardis were ordered. The order did not document theorder for the Lasix. Resident ID #14's MAR for July, documented Lasix was not given from July 18th through the July 21st as ordered. Resident ID #14's Skilled Daily Nurses Notes, at 7:45 AM, documented the following (in part): -07/21/2013 at 7:45 AM resident's respirations are labored and resident complaining not being able to breathe. Oxygen at 2L/min. administered. - 07/21/2013 at 8:00 AM resident was sent to E.R. - 07/21/ at 1:00 PM resident was admitted to the hospital [DIAGNOSES REDACTED]. In an interview on 09/26/2013 at 12:00 PM, the DON stated when a resident returns from hospital or doctors' appointments; the nurse transcribes the orders and then writes on the 24 hour nurses report by all three shifts Review of the Nurses' 24 hour report dated 07/18/2013, documented the medication's Micardis and Clindamycin to be given, but the Lasix was written to continue to hold for resident ID #14. Resident ID #14's Telephone Physician Orders, dated 07/21/13, documented "send to emergency room for evaluation for shortness of breath, hematuria, and edema". Resident ID #14's Transfer Form to E. R., dated 07/21/2013, documented "Lasix been on hold". In an interview on 09/26/2013 at 11:45 AM, LVN B stated resident ID #14 returned from the E.R. on the 7/18/2013 on the 2pm to 10pm shift with orders to start the antibiotic and the changed dose of Micardis. She stated she must have missed the order for the Lasix and it was a documentation error. She stated resident ID #14 did not receive Lasix from 7/18 through 7/21/2013. In an interview on 09/26/2013 at 4:35 PM, the DON and the ADON were both present and both agreed that LVN B primarily works hall B. They stated any nurse can take orders for any resident on any hall. Policy and Procedure titled "Telephone Order Procedure", not dated, documented the following (in part): "To assure those physicians orders are carried out, to maintain optimum level of wellness for resident. Obtain telephone order from prescriber. Write telephone order on telephone order form. Record date and time order was received. Sign with first initial last name and tile of prescriber and your first initial, last name and title. Complete all resident identification information on telephone order form." CMS-672 Resident Census and Conditions of Residents, dated 09/23/2013, documented a census of 76.

Based on observation, interview and record review the facility failed to ensure care was provided for its residents in a manner and in an environment that promoted maintenance or enhancement of each resident's quality of life by failing to: A. Identify the coffee was too hot resulting residents #10 and # 12 being burned by the coffee. B. Ensure residents were not left alone in the shower resulting in resident # 8 falling and fracturing 3 ribs. C. Identify the facility unlocked laundry exit door resulting in 2 residents (#9 and 11) wandering out the back door unattended; both residents fell and sustained injuries. D. Ensure residents did not develop new pressure sores (ID # ' s 14, 15 and19). E. Failed provide residents who entered the facility with pressure sores the necessary treatment and services to promote healing and prevent infection for 3 of 7 residents (ID #s 14, 15, and 19) reviewed for pressure sores by failing to ensure: This failure by the facility resulted in resident # ' s 8, 9, 10, 11 and 12 being harmed and residents # 14, 15 and 19 developing new pressure ulcers with resident # 14 and 19 developing infections [MEDICAL CONDITION]; and could affect any of the facilities 28 residents with a documented [DIAGNOSES REDACTED]. These deficient practices resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 02/26/2013. While the IJ was removed on 02/26/2013, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility did not have time to monitor the Plan of Removal for effectiveness or to train all staff. The findings include: In a confidential interview on 2/24/13 the complainant said there had been many falls, a lady fell in the shower while alone and there was not enough staff to monitor the residents. Resident # 8: Record review of the physician's order [REDACTED]. Her [DIAGNOSES REDACTED]. Record review for resident # 8 revealed nurse ' s notes dated 1/15/13 at 6:45 pm documenting resident # 8 had slipped and fell in the shower. The notes documented for resident # 8 was transferred to the hospital at 7:00 pm, by her daughter for x-rays, the daughter called back stating for resident # 8 had three fractured ribs. Record review of the physical therapy plan of care for resident # 8, dated 12/28/12, documented resident # 8 was a fall risk, and she had mild dementia. Her therapy was to include gait training and therapeutic exercises and activities. The current level of function was documented to be standing upright for 3 minutes without a rest break and use of a front wheeled walker and minimal assistance for 10 feet. Resident # 8 was documented to be unable to maintain a correct weight bearing status. Record review of the facility fall assessment for resident # 8, dated12/21/12, was incomplete and a reassessment, after the fall, could not be located. Record review for resident # 8 revealed a fall risk plan of care dated12/31/13, documenting resident # 8 could do touch weight bearing and her she had an unsteady gait. The careplan did not document any interventions for transfers. In an interview on 2/25/13 at 2:02 pm the ADON said resident # 8 had been alone in the shower, the CNA had stepped out to get washcloths or something and found resident # 8 in the floor when she returned. In a telephone interview on 2/25/13/at 2:07 pm resident # 8 ' s daughter said her mother had wanted to shower by herself and the staff had allowed it. Resident # 8 did have rib fractures from the fall. In a telephone interview on 12/26/13 at 1:59 pm resident # 8 ' s daughter said she had parked her mother by the shower, in her wheel chair. A CNA was going to put her mother in the shower, she did not know who took her mother to the shower. In an interview on 2/26/13 at 3:48 pm LVN H said she saw resident # 8 ' s daughter push resident # 8 in her wheelchair. LVN H said resident # 8 was then found in the shower room floor on the shower chair and a fixture was broke off the wall. Resident # 8 was complaining she could not breathe and asked for her daughter to be called at home; and resident # 8 was not dressed. Resident # 8 was observed in her home on 2/26/13 at 3:55 pm. Resident # 8 was using a walker and a wheel chair. In an interview on 2/26/13 at 3:03 pm CNA F said resident # 8 came to her asking for a shower on 01/15/13. CNA F said she told resident # 8 she would do it around 7:00 or 7:30, and then went on her break. CNA F said she heard a crash and went to look for it. CNA F said she found resident # 8 in the D hall shower floor. CNA F provided a written statement stating resident # 8 told her, her daughter had put her in the shower and left. In an interview on 2/26/13 at 3:55 pm resident # 8 said a facility staff had put her in the shower, then she told the staff to leave and the staff left. Resident # 8 said she showered, came out of the shower and fell . Resident # 8 said the pain from the fractured ribs slowed her improvement some; she went to another facility, completed her therapy, and then moved to where she now resides. Record review of the incident report for resident # 8, dated 1/15/13 at 6:45 pm, documented a crash and moaning was heard and resident # 8 was found sitting on the floor in the D Hall shower room. The administrative inquiry form dated 1/15/13 at 6:45 pm documented resident # 8 said she just slipped and fell . The recommendation area of the form was blank. In an interview on 3/26/13 at 11:15 am CNA G said residents were not to be left alone in the shower. In an interview on 2/26/13 at 11:35 am resident # 1 said the staff seldom left her alone in the shower but sometimes they had to. Staff would tell her to not move and would be gone for a few minutes. Resident # 1 said she had a bad knee that would give out on her. In an interview on 2/26/13 at 11:47 am resident # 2 said the staff left her alone in the shower chair, sometimes for a few minutes. Resident # 1 said she wanted somebody close by in the shower. Resident # 1 said her legs did not work well. Resident # 11: Record review of the physicians orders dated 01/31/13 for resident # 11, documented he was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. In an observation of resident # 11 on 2/26/13 at 11:37 am, resident # 11 was lying in his bed; he had a black right eye. He was alert and oriented. In an interview on 2/26/13 at 11:37 am resident # 11 said he had went out to the smoke area, through the back door. Resident # 11 said he then went through the open gate that had an employees only sign, he wanted to see what was behind the laundry. Resident # 11 said he went down the sidewalk, he didn't know it sloped and his wheelchair turned over. Resident # 11 said he called for help and was sent to the emergency room . Resident # 11 said his head was scratched up and he felt fuzzy for a couple of days. Clinical record review for resident # 11 revealed nurse ' s notes dated 02/09/12 at 7:45 am documenting a restorative aide called a nurse to the back facility where resident # 11 was found sitting up on the ground his face covered with blood. The note documented resident # 11 had an abrasion to his left knee, a laceration and an abrasion to the left forehead. He was documented to be alert and oriented. Resident # 11 was transferred to the hospital by ambulance. Resident # 11 was documented to have returned to the facility at10:00 am, he had sutures in his left forehead and was documented to be very confused. Continued clinical record review for resident #11 revealed nurse ' s notes dated 1/06/13 at 7:30 pm documented resident # 1 was confused, calling another resident by the wrong name and resident # 11 was going down the wrong hallway. Nurse ' s notes dated 2/02/13 at 10:00 am documented resident # 11 was found on the bathroom floor, head down. No injuries were noted. Record review of the incident/accident reporting log for October 2012 - February 2013 revealed there was not an incident report documenting the incident involving resident # 11 on 02/09/13. Record review of the care plan dated 8/28/12 documented resident # 11 had poor decision-making, the care plan did not document any concerns of wandering behaviors. Resident # 9: Record review of the physicians orders dated 1/30/13 for resident # 9 documented she was an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the nurse ' s notes dated 1/24/13 at 10:00 am resident # 9 had went out the back door, unsupervised to the smoking area and went around the laundry building; she was found sitting on the ground by the building, by the maintenance staff. The note documented a laceration and bruising of the left hand. No further assessment was documented at that time. On1/25/13 at 10:00 am resident # 9 was documented to be wandering around the nurse ' s station and documented bruises on both hands. The note also documented resident # 9 complained of a headache and medication was given. The nurse note ' s dated 1/25/13 documented resident # 9 continued to wander in and out of others rooms, she complained of a headache and no further assessment was documented. Record review of the care plan dated 10/21/12 for resident # 9 documented the fall risks for resident # 9 and she was to wear a wonder guard bracelet, resident # 9 was at risk for injury for wandering in an unsafe environment. The care plan had not been updated. Record review of the incident report dated 1/24/13 at 10:00 am had an addendum dated 1/25/13 at 10:20 am documenting a wonder guard was being placed on the back door. Observation on 2/26/13 at 3:03 pm of the exits to the back smoking area revealed the inside exit door did not lock and the outside exit door was not locked. This exit from the building was located on the " B " hall behind the chart area, the wall blocked vision of the doors. The dining room exit door had a wander guard alarm on it. In an interview on 2/26/13 at 3:48 pm LVN L said the laundry exit door did not have an alarm on it, the B hall LVN had to monitor the door. The facility had 3 residents on B hall, 4 residents on A hall and 2 residents on D hall who wandered. In an interview on 2/26/13 at 5:30 pm CNA M said the staff go and get the residents that get out the laundry exit door and remind them to not go out the door. In an interview on 2/26/13 at 5:39 pm CNA N said the staff tried to monitor the laundry exit door and other residents told them when residents got out; some resident did get out of the door. Resident # 10: Record review of the physician' s orders date 1/30/13 documented resident # 10 was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the incident accident log for October 2012 through February 2013 documented resident # 10 had spilled her coffee on her and sustained a red area to her right thigh. The report documented resident # 10 had decreased motor skills and were becoming worse with resident # 10 having a difficult time grasping objects. The report documented resident # 10 was instructed to be careful handling hot liquids. In an interview on 2/27/13 at 1:25 pm resident # 10 said she did spill her coffee, the staff put anti-burn cream on the burn and she was not sure if her family had been notified of the incident. Record review of the administrative inquiry dated 1/14/2013 documented resident # 10 said she spilled her coffee while trying to pick up the coffee cup and dropped it. The report documented the area to be 8 X 9 in size the report did not document centimeters or inches. Resident # 12: Record review of the physicians orders dated 1/30/13 for resident # 12 documented he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of the incident accident log for October 2012 through February 2013 documented resident # 12 had spilled his coffee on his self and sustained redness with blisters on his thighs on 10/07/2012. Record review of the incident report dated 10/07/2012 at 10:30 am documented a staff member found [MEDICAL CONDITION] notified the nurse. Resident # 12 stated he had spilled coffee on himself. The administrative inquiry dated 10/07/2012 documented resident # 12 said he spilled his coffee while getting it off his bedside table. Clinical record review of the nurse ' s notes for resident # 12, dated 10/03/2012 and 10/04/2012 documented resident #12 had increased difficulty with swallowing and had required assistance to eat. On 10/07/2012 the nurse note documented the right thigh and the inner left and right thigh had blister areas up toward the groin area. A note dated 10/08/2012 at an unknown time documented the kitchen staff were to start cooling the coffee down before serving it. A note dated 10/28/2012 at 11:00 am documented resident # 12 ' s treatment for [REDACTED]. In an interview on 3/04/2013 at 12:02 pm resident # 12 said he did spill his coffee and burn himself, resident # 12 denied any skin problems now. Record review of the careplan for resident # 12, dated 12/13/13 documented resident # 12 required extensive assistance with eating including tray set up and feeding. A. resident #14 did not develop new pressure ulcers or develop infection of the pressure ulcers he was admitted with. B. resident ID #15's physician's order [REDACTED]. C. resident #19 did not develop new pressure ulcers or infection of the pressure ulcers. This deficient practice could place 7 residents who had pressure sores or 61 residents who were dependent upon staff for mobility at risk of worsening pressure sores, new pressure sores, or infection and cause a physical decline in health. Resident # 14: Record review of the physicians order dated 1/30/2013 for resident # 14 documented he was a [AGE] year old male admitted to the facility on [DATE] and a re-admission date of [DATE]. His [DIAGNOSES REDACTED]. Observation on 2/25/13 at 10:12 am, resident # 14 was observed in his bed, he used a ventilator for breathing, and was on a pressure relieving air mattress. Resident # 14 was alert and oriented. Interview on 2/25/13 at 10:12 am, resident # 14 said he had a pressure ulcer that was healing, he was admitted with the pressure ulcer and it was the reason he came in. Resident # 14 said the night staff did not answer his call light or provide assistance. In a confidential interview on 3/05/2013 it was revealed residents were on their backs every morning and there were indications residents were not turned properly during the night. Record review of an admission nursing assessment dated [DATE], documented resident # 14 was admitted with the following pressure areas: 1 cm X 2 cm pressure area on his right hip, 8.5 cm X 6 cm area on his right thigh, 8 X 1 cm area on the right buttock, 2 cm X 2 cm X 2 cm area of the coccyx and an 7 cm X 7 cm area of the left buttock. Record review of the Braden scale assessment for predicting pressure sore risk dated 1/03/12 and 2/28/13 documented resident # 14 had a high risk for pressure ulcers with scores each time of 12. Record review of the skin assessment log for resident # 14 documented the development of new pressure ulcers on: ? 11/04/12 3.5 X 4.0 area right neck, ? 11/04/12 the left heel documented to have worsened to a stage II ulcer, ? 1/09/13 5 X cm area right heel, ? 2/07/13 11 X 8 cm size area on the left buttock. Record review of the nurse ' s notes dated 2/07/13 documented resident # 14 was very non-compliant with his care. The nurse ' s note did not document any interventions or teaching. In an interview on 3/05/2013 at 8:40 am CNA J said resident # 14 turned on one side at night and then turned on the other side the next morning; resident # 14 would allow his feet to be moved, so that ' s what we do. Record review of resident # 14 ' s physicians orders dated 11/01/12 documented the physician requested resident # 14 have a psychiatric consult for his refusal of care. Continued record review did not reveal any consult had been done. In an interview on 5/05/2013 at 3:00 pm the ADON said resident # 14 was last seen for a psychiatric evaluation in 2010. The ADON said there was no documentation of an evaluation since that time. In an interview on 5/05/2013 at 3:15 pm the facility Social Worker said she was not able to find any documentation of having done the psychiatric referral. Record review of the care plan for resident # 14, dated 10/03/12 documented resident # 14 ' s pressure ulcers and interventions, the care plan did not document resident # 14 ' s non-compliance with the recommendations and did not document interventions for the non-compliance. A care plan dated 10/15/12 for risk of skin breakdown did document resident # 14 as refuses to turn. There were no interventions for resident # 14 ' s not cooperating was documented. Record review of the physicians order dated 12/13/2012 for resident # 14 documented a physician's order [REDACTED].# 14 to hold the cloths in place. In an interview on 3/05/2013 at 9:34 am LVN A said resident # 14 had been using wet to dry dressings in the coccyx wound, then the physician changed to dry dressings and then changed to the cloths due to the large amount of drainage. LVN A said the towels were purchased by the facility; after use the towels were placed in a separate red biohazard bag with sugar sent to the laundry. Observation of the laundry room on 3/05/13 at 9:46 am revealed a note on the wall that read for biohazard put on a mask, gown, wash twice on F-3; make sure chemicals are hooked up to the washer. In an interview on 3/05/2013 at 10:00 am laundry staff " I " said resident # 14 ' s towels and bedding came to the laundry in a red biohazard sugar bag. The towels were washed with his linens, twice on the biohazard setting, then the towels were put on the laundry folding table, folded, placed in plastic trash bags and returned to resident # 14 ' s room. The bags were put in resident # 14 ' s closet. The staff did not wear gloves or do any other special precautions after the towels were washed. Observation of resident # 14 ' s room on 3/05/2013 at 10:04 am revealed open bags of towels in the closet. There were bags of briefs and boxes of gloves in the bottom of the closet with the towels bags; a bag of the towels was torn by a glove box. Record review of the nurses notes dated 2/26/2013 at 10:30 am documented resident # 14 stated he had chills the night before and had blurred vision. Resident# 14 ' s physician was contacted and labs were drawn. Resident # 14 was transferred to the hospital at 7:25 pm due to critical lab values. Record review of the emergency room record dated 2/26/2013 documented resident # 14 had a massive open coccyx wound. The physician ' s section documented resident # 14 had an extensive deep foul smelling decubiti of the entire buttocks and cultures were obtained. The physician documented [DIAGNOSES REDACTED]. Resident # 14 was then transferred to to a different hospital for more advanced care. Record review of the urine and wound cultures, dated as drawn 2/26/2013 documented the presence of e-coli in the wound and other bacteria in the wound and urine. Record review of the hospital record where resident # 14 was transferred documented resident # 14 had [DIAGNOSES REDACTED]. Resident # 14 was admitted to the ICU and antibiotics were started. Resident ID #15: Resident ID #15's February 2013 Record of Admission documented she was a [AGE] year-old female admitted to the facility on [DATE]. Resident ID #15's Admission Skin Assessment Form, dated 10/18/2012, documented she had no pressure ulcers. Resident ID #15's Braden Scale For Predicting Pressure Sore Risk form, dated 10/18/2012, documented she had a score of 12, indicative of high risk for developing pressure ulcers. Resident ID #15's admission MDS assessment, dated 10/30/2012, documented she was at risk for developing pressure ulcers and had no unhealed pressure ulcers. Resident ID #15's December 2012 physician's orders [REDACTED]. Resident ID #15's Skin Condition Report, dated 12/04/2012, documented the following: - unstageable pressure ulcer to right heel measuring 3 cm long by 3 cm wide; - unstageable pressure ulcer to inside right heel measuring 2 cm long by 1 cm wide - unstageable pressure ulcer to left heel measuring 3 cm long by 3 cm wide; - unstageable pressure ulcer to inside left heel measuring 3 cm long by 2 cm wide; - unstageable pressure ulcer to outside left heel measuring 4 cm long by 3 cm wide. Resident ID #15's Plan of Care, dated 12/04/2012, documented she had unstageable pressure ulcers to her right and left heels and was to have a pressure reducing mattress. Resident ID #15's quarterly MDS assessment, dated 01/20/2013, documented the following: she had severely impaired cognitive skills for daily decision making; she was totally dependent upon two or more persons for bed mobility, transfer, toileting, personal hygiene, and bathing; she had functional limitation in range of motion of her upper and lower extremities on both sides; she was at risk for developing pressure ulcers; she had two stage two pressure sores and one unstageable pressure sore; the dimension of her largest pressure sore was 3 cm long by 3 cm wide by 0 cm deep; the most severe tissue type for her pressure ulcers was eschar (necrotic tissue- black, brown, or tan tissue that adheres firmly to the wound bed); she was on a pressure reducing device for her bed, receiving pressure ulcer care and application of nonsurgical dressing, ointments/medications, and dressings to her feet. Resident ID #15's Skin Condition Report, dated 02/28/2013, documented she had a pressure ulcer to her right heel measuring 2.6 cm long by 2.9 cm wide by 0.1 cm deep. The report documented a pressure ulcer to her left heel measuring 3.5 cm long by 3.7 cm wide by 0.2 cm deep. Resident ID #15's March 2013 physician's orders [REDACTED]. Resident ID #15's March 2013 Nurse MAR indicated [REDACTED]. The nurses were initialing the task, documenting as completed, every shift. Resident ID #15's March 2013 Treatment Sheet documented the following treatment orders: - cleanse left heel with normal saline, apply Santyl ([MEDICATION NAME] ointment) and calcium alginate (absorbent dressing), cover with foam, and wrap with gauze daily and PRN; - cleanse open area to right ankle with normal saline or daily wound cleanser, apply triple antibiotic ointment and collagen (to aide in wound healing), and cover with dry dressing daily and PRN. In an observation on 03/04/2013 at 1:15 PM, during skin rounds with the ADON, resident ID #15 was lying in bed. Her heels were both wrapped. Resident ID #15's mattress was very firm and hard when pressure applied. In an interview on 0./05/2012 at 11:20 AM, LVN A stated resident ID #15's heel pressure ulcers developed in the facility. She stated upon dong the weekly skin assessment on 12/04/2012; she noticed resident ID #15's heels were both black with eschar. LVN A stated resident ID #15's skin was clear the week before. She stated resident ID #15 was contracted and hard to position. She stated the heel wounds were caused by pressure. LVN A stated the right heel was healing, and the left heel was still covered with eschar. She stated resident ID #15's heels should have been floated off the surface of the mattress to alleviate pressure. LVN A stated the pressure ulcers may have been caused by not repositioning resident ID #15 frequently enough. In an observation on 03/05/2013 at 11:45 AM, resident ID #15 was in bed with a pillow under her knees. Her heels were flat on the mattress surface. The mattress was very hard to touch. In an interview on 03/05/2012 at 11:46 AM, CNA C stated it was very hard to off-load resident ID #15's heels because of the way resident ID #15 was contracted. She stated she tried to keep them elevated. In an observation on 03/05/2012 at 12:00 PM, resident ID #15 was lying in bed. She was contracted, and her knees were touching her chest. Resident ID #15's heels were on the surface of the mattress. The mattress was hard to touch. In an observation on 03/05/2012 at 1:55 PM, resident ID #15 was lying in bed. Her heels were on the surface of the mattress. The mattress was hard to touch. In an interview on 03/05/2013 at 1:55 PM, LVN B stated she did not know if resident ID #15's mattress was a pressure reducing mattress. In an interview on 03/05/2013 at 2:20 PM, the ADON stated all mattresses in the facility were "Panacea" pressure reducing mattresses. She stated resident ID #15's mattress did not look familiar to her. The ADON stated the mattress resident ID #15 was lying on was not one of the mattresses ordered by the facility, and she did not know where it came from. The ADON stated the mattress was hard to touch. She stated resident ID #15's bed frame had broken a few weeks before, and she was put in a new bed. The ADON stated she suspected that may have been when resident ID #15 was put on the firm mattress. In an interview on 03/05/2013 at 2:30 PM, LVN B stated she thought all mattresses in the facility were pressure reducing mattresses. She stated she never felt the mattress or checked the label prior to documenting the pressure reducing mattress on the TAR. In an interview on 03/05/2012 at 2:35 PM, the ADON stated she did not know who changed out resident ID #15's bed. She stated the mattress was not the facility's product. The ADON stated the mattress looked like it came from a hospice agency. She stated when a hospice agency delivered a bed, the facility would switch the hospice regular mattress for one of the facility's pressure reducing mattresses. In an observation on 03/05/2012 at 2:35 PM, the ADON told the administrator resident ID #15's mattress was not a pressure reducing mattress. She told the administrator the mattress did not belong to the facility. In an interview on 03/05/2013 at 2:47 PM, the ADON stated the facility ordered the "Panacea" mattresses because they were pressure reducing mattresses and met standards for pressure ulcers stage three and below. She stated pressure ulcers could result from not using pressure reducing mattresses. In an interview on 03/05/2013 at 2:52 PM, LVN B stated without a pressure reducing mattress, residents were at higher risk of having skin breakdown form increased pressure. In an interview on 03/05/2013 at 2:55 PM, the ADON stated the firm mattress resident ID #15 was lying on was an "Invacare" mattress from hospice, and it was not a pressure reducing mattress. In an interview on 03/5/2013 at 2:56 PM, the DON stated when using a non-pressure reducing mattress, pressure resulted, then skin breakdown occurred. She stated she had done no in-service or training for the nurses on how to check the mattresses. In an observation on 03/05/2013 at 3:01 PM, during the provision of wound care, resident ID #15's left heel pressure ulcer was black and measured 3.5 cm long by 3.5 cm wide. In an interview on 03/05/2013 at 3:01 PM, during the provision of wound care, the DON and LVN A stated the firm mattress had a negative impact on resident ID #15's heel pressure ulcers healing. They stated she did not know resident ID #15 was on a non-pressure reducing mattress. In an interview on 03/05/2013 at 3:13 PM, LVN D stated she had not been trained on how to check mattresses. She stated when documenting for the pressure reducing mattresses, she just signed the MAR. LVN D stated if a resident was not on a pressure reducing mattress, skin breakdown would occur. In an interview on 03/05/2013 at 4:10 PM, the DON stated all of resident ID #15's skin documents were provided to the survey team, and there was no additional documentation anywhere else. Resident # 19: Record review of the physicians order dated 1/30/2013 for resident # 19 documented he was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Observation on 3/04/2013 at 12:22 pm revealed resident # 19 was lying in bed on his left side, he had a pressure relieving mattress, his feet were offloaded and he was not interviewable. Record review of the admission nursing assessment dated [DATE] for resident # 19 revealed the skin condition section of the assessment was blank. Record review of the physician ' s telephone orders for resident # 19 dated 1/23/13 documented orders for treatment to resident # 19 ' s heels, right outer foot and right lower extremity. Record review of the facility skin assessment log for resident # 19 documented new pressure ulcers on: ? 1/29/13 a red area 3 X @ cm on the left buttock with drainage, ? 1/29/18 a red area 9 X * cm on the right buttock with drainage. ? 2/19/13 a black area 2 X 3 cm on the bottom right foot, ? 2/19/14 a black area 4 X 3 cm on the outer left foot, Record review of the Braden scale dated 1/22/13 documented resident # 19 was a high risk for pressure ulcers with a score of 11. Record review of the care plan for resident # 19 dated 2/05/13 revealed a care plan for incontinence and an indwelling foley catheter. A care plan for risk of pressure ulcers could not be located. In an interview on 3/05/13 at 3:30 pm the ADON said there were no other care plans that were not in the residents charts. Record review of the physicians orders dated 2/20/13 documented an order for [REDACTED]. Resident # 19 was noted to have received orders for a urinary tract infection on 2/12/13. The facility submitted a Plan of Removal on 2/26/13 documenting the identification of concerns related to accident hazards involving elopement,[MEDICAL CONDITION] hot coffee and falls. THe plan documented the: a. Removal of coffee to the kitchen area, staff are to use ice cubes to cool the coffee before serving it to residents. b. The back door accessing the housekeeping service door has been locked with akey, only staff will have access to the key. The gate had a lock placed on it on 10/12/2012. c. The wonderguard system has bid placed on it as 1855 (6:55 pm)on 2/26/13 it had been ordered and is to be installed within 30 days. d. In-services on accidents, hazards, and detailed elopement measures with behavioral changes have immediately been put into effect with the staff on 2/26/2013 at 6:50 pm. e. The QA Committee meeting will be on

Based on observation, interview and record review the facility failed to ensure that five of eleven residents reviewed for accident hazards (Resident ID # ' s 8, 9, 10, 11 and 12) received adequate supervision and assistance to prevent accidents when: A. The facility failed to supervise Resident # 8 while she was in the shower, resident # 8 fell , while unattended in the shower and fractured 3 ribs. B. The facility failed to supervise or provide monitoring of the exit door behind the " B " hall nurses ' station that exits to the laundry and back of the facility, and failed to ensure the closure of the gate marked " employees only " , resulting in resident 11, going through the gate, losing control of his wheel chair on the slope and turning it over: Resident # 11 was treated in the emergency room for a head injury with facial lacerations, sutures and bruising. C. The facility failed to supervise or provide monitoring of the exit doors when resident # 9 went out to the smoking area and around the laundry building. Resident # 9 was found sitting on the ground with a laceration and bruising to her left hand fingers. D. The facility failed to monitor coffee temperatures and observe residents getting coffee resulting in resident # ' s 10 and 12 spilling coffee on themselves and were found to have red raised areas on the hip (#10) and legs and thighs (#12). These deficient practices resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 02/26/2013. While the IJ was removed on 02/26/2013, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility did not have time to monitor the Plan of Removal for effectiveness or to train all staff. This deficient practice could place: - 6 residents identified by the facility as having behaviors of wandering, at risk for wandering outdoors without supervision; - 14 residents that required minimal or no assistance with eating at risk for burns from coffee, and - 42 residents that required 1 or 2 person assistance with ADL ' s including bathing at risk for falls while bathing unsupervised. The findings include: In a confidential interview on 2/24/13 the complainant said there had been many falls, a lady fell in the shower while alone and there was not enough staff to monitor the residents. Resident # 8: Record review of the physician' s orders dated 12/31/12 documented resident # 8 was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review for resident # 8 revealed nurses ' notes dated 1/15/13 at 6:45 pm documented resident # 8 had slipped and fell in the shower. The notes documented for resident # 8 was transferred to the hospital at 7:00 pm, by her daughter for x-rays, the daughter called back stating for resident # 8 had three fractured ribs. Record review of the physical therapy plan of care for resident # 8, dated 12/28/12, documented resident # 8 was a fall risk, and she had mild dementia. Her therapy was to include gait training and therapeutic exercises and activities. The current level of function was documented to be standing upright for 3 minutes without a rest break and use of a front wheeled walker and minimal assistance for 10 feet. Resident # 8 was documented to be unable to maintain a correct weight bearing status. Record review of the facility fall assessment for resident # 8, dated 12/21/12, was incomplete and a reassessment, after the fall, could not be located. Record review for resident # 8 revealed a fall risk plan of care dated12/31/12, documenting resident # 8 could do touch weight bearing and her she had an unsteady gait. The careplan did not document any interventions for transfers. The careplan did document staff were to encourage resident to ask staff for assistance. In an interview on 2/25/13 at 2:02 pm the ADON said resident # 8 had been alone in the shower, the CNA had stepped out to get washcloths or something and found resident # 8 in the floor when she returned. In a telephone interview on 2/25/13/at 2:07 pm resident # 8 ' s daughter said her mother had wanted to shower by herself and the staff had allowed it. Resident # 8 did have rib fractures from the fall. In a telephone interview on 12/26/13 at 1:59 pm resident # 8 ' s daughter said she had parked her mother by the shower, in her wheelchair. A CNA was going to put her mother in the shower, she did not know who took her mother to the shower. In an interview on 2/26/13 at 3:48 pm LVN " H " said she saw resident # 8 ' s daughter push resident # 8 in her wheelchair. LVN " H " said resident # 8 was then found in the shower room floor on the shower chair and a fixture was broke off the wall. Resident # 8 was complaining she could not breathe and asked for her daughter to be called at home; and resident # 8 was not dressed. Resident # 8 was observed in her home on 2/26/13 at 3:55 pm. Resident # 8 was using a walker and a wheel chair. In an interview on 2/26/13 at 3:03 pm CNA " F " said resident # 8 came to her asking for a shower on 01/15/13. CNA " F " said she told resident # 8 she would do it around 7:00 or 7:30, and then went on her break. CNA " F " said she heard a crash and went to look for it. CNA " F " said she found resident # 8 in the " D " hall shower floor. CNA " F " provided a written statement stating resident # 8 told her, her daughter had put her in the shower and left. In an interview on 2/26/13 at 3:55 pm resident # 8 said a facility staff had put her in the shower, then she told the staff to leave and the staff left. Resident # 8 said she showered, came out of the shower and fell . Resident # 8 said the pain from the fractured ribs slowed her improvement some; she went to another facility, completed her therapy, and then moved to where she now resides. Record review of the incident report for resident # 8, dated 1/15/13 at 6:45 pm, documented a crash and moaning was heard and resident # 8 was found sitting on the floor in the " D " Hall shower room. The administrative inquiry form dated 1/15/13 at 6:45 pm documented resident # 8 said she just slipped and fell . The recommendation area of the form was blank. In an interview on 3/26/13 at 11:15 am CNA " G " said residents were not to be left alone in the shower. Resident # 1: Record review of the physicians orders for resident # !, dated 1/30/13 documented resident # 1 was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. In an interview on 2/26/13 at 11:35 am resident # 1 said the staff left her alone in the shower but sometimes they had to. Staff would tell her to not move and would be gone for a few minutes. Resident # 1 said she had a bad knee that would give out on her. Resident # 2: Record review of the physicans orders dated 2/28/13 for resident # 2 documented she was a [AGE] yearold female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident # 11: Record review of the physicians orders dated 01/31/13 for resident # 11, documented he was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. In an observation of resident # 11 on 2/26/13 at 11:37 am, resident # 11 was lying in his bed; he had a black right eye. He was alert and oriented. In an interview on 2/26/13 at 11:37 am resident # 11 said he had went out to the smoke area, through the back door. Resident # 11 said he then went through the open gate that said employees only on it, he wanted to see what was behind the laundry. Resident # 11 said he went down the sidewalk, he didn't know it sloped and his wheelchair turned over. Resident # 11 said he called for help and was sent to the emergency room . Resident # 11 said his head was scratched up and he felt fuzzy for a couple of days. Clinical record review for resident # 11 revealed nurse ' s notes dated 02/09/13 at 7:45 am documenting a restorative aide called a nurse to the back facility where resident # 11 was found sitting up on the ground his face covered with blood. The note documented resident # 11 had an abrasion to his left knee, a laceration and an abrasion to the left forehead. He was documented to be alert and oriented. Resident # 11 was transferred to the hospital by ambulance. Resident # 11 was documented to have returned to the facility at10:00 am, he had sutures in his left forehead and was documented to be very confused. Continued clinical record review for resident #11 revealed nurse ' s notes dated 1/06/13 at 7:30 pm documented resident # 11 was confused, calling another resident by the wrong name and resident # 11 was going down the wrong hallway. Nurse ' s notes dated 2/02/13 at 10:00 am documented resident # 11 was found on the bathroom floor, head down. No injuries were noted. Record review of the incident/accident reporting log for October 2012 - February 2013 revealed there was not an incident report documenting the incident involving resident # 11 on 02/09/13. Record review of the care plan dated 8/28/12 documented resident # 11 had poor decision-making, the care plan did not document any concerns of wandering behaviors. Resident # 9: Record review of the physicians orders dated 1/30/13 for resident # 9 documented she was an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the nurse ' s notes dated 1/24/13 at 10:00 am resident # 9 had went out the back door, unsupervised, to the smoking area and went around the laundry building; she was found sitting on the ground by the building, by the maintenance staff. The note documented a laceration and bruising of the left hand. No further assessment was documented at that time. On 1/25/13 at 10:00 am resident # 9 was documented to be wandering around the nurse' s station and documented bruises on both hands. The note also documented resident # 9 complained of a headache and medication was given. Record review of the care plan dated 10/21/12 for resident # 9 documented the fall risks for resident # 9 and she was to wear a wonder guard bracelet, resident # 9 was at risk for injury for wandering in an unsafe environment. The care plan had not been updated. Record review of a separate plan of care for resident # 9, dated 10/21/13 documented resident # 9 was a risk for elopement by actively trying to leave the facility. Record review of the MDS dated [DATE] for resident # 9 documented in section E0900 resident # 9 said there had been no episodes of wandering. Record review of the incident report dated 1/24/13 at 10:00 am for resident # 9 had an addendum dated 1/25/13 at 10:20 am documenting a wonder guard was being placed on the back door. Observation on 2/26/13 at 3:03 pm of the exits to the back smoking area revealed the inside exit door did not lock and the outside exit door was not locked. This exit from the building was located on the " B " hall behind the chart area, the wall blocked vision of the doors. The dining room exit door had a wander guard alarm on it. In an interview on 2/26/13 at 3:48 pm LVN L said the laundry exit door did not have an alarm on it, the B hall LVN had to monitor the door. The facility had 3 residents on B hall, 4 residents on A hall and 2 residents on D hall who wandered. In an interview on 2/26/13 at 5:30 pm CNA M said the staff go get the residents that get out the laundry exit door and remind them to not go out the door. In an interview on 2/26/13 at 5:39 pm CNA N said the staff tried to monitor the laundry exit door and other residents told them when residents got out; some resident did get out of the door. Resident # 10: Record review of the physician's order [REDACTED]. Her [DIAGNOSES REDACTED]. Record review of the incident accident log for October 2012 through February 2013 documented resident # 10 had spilled her coffee on her and sustained a red area to her right thigh. The report documented resident # 10 had decreased motor skills and were becoming worse with resident # 10 having a difficult time grasping objects. The report documented resident # 10 was instructed to be careful handling hot liquids. In an interview on 2/27/13 at 1:25 pm resident # 10 said she did spill her coffee, the staff put anti-burn cream on the burn and she was not sure if her family had been notified of the incident. Record review of the administrative inquiry dated 1/14/2013 documented resident # 10 said she spilled her coffee while trying to pick up the coffee cup and dropped it. The report documented the area to be 8 X 9 in size the report did not document centimeters or inches. Resident # 12: Record review of the physicians orders dated 1/30/13 for resident # 12 documented he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of the incident accident log for October 2012 through February 2013 documented resident # 12 had spilled his coffee on his self and sustained redness with blisters on his thighs on 10/07/2012. Record review of the incident report dated 10/07/2012 at 10:30 am documented a staff member found the burns and notified the nurse. Resident # 12 stated he had spilled coffee on himself. The administrative inquiry dated 10/07/2012 documented resident # 12 said he spilled his coffee while getting it off his bedside table. Clinical record review of the nurse ' s notes for resident # 12, dated 10/03/2012 and 10/04/2012 documented resident #12 had increased difficulty with swallowing and had required assistance to eat. On 10/07/2012 the nurse note documented the right thigh and the inner left and right thigh had blister areas up toward the groin area. A note dated 10/08/2012 at an unknown time documented the kitchen staff were to start cooling the coffee down before serving it. A note dated 10/28/2012 at 11:00 am documented resident # 12 ' s treatment for [REDACTED]. In an interview on 3/04/2013 at 12:02 pm resident # 12 said he did spill his coffee and burn himself, resident # 12 denied any skin problems now. The facility submitted a Plan of Removal on 2/26/13 documenting the identification of concerns related to accident hazards involving elopement, burns from hot coffee and falls. THe plan documented the: a. Removal of coffee to the kitchen area, staff are to use ice cubes to cool the coffee before serving it to residents. b. The back door accessing the housekeeping service door has been locked with akey, only staff will have access to the key. The gate had a lock placed on it on 10/12/2012. c. The wonderguard system has bid placed on it as 1855 (6:55 pm)on 2/26/13 it had been ordered and is to be installed within 30 days. d. In-services on accidents, hazards, and detailed elopement measures with behavioral changes have immediately been put into effect with the staff on 2/26/2013 at 6:50 pm. e. The QA Committee meeting will be on February 27, 2013 at 12:30 pm addressing the plan of correction dated 2.26.2013. f. Administrator and/or designee will review and monitor this plan of correction daily for the next 30 days then monthly for 4 months. The submitted plan of correction was reviewed and accepted on 2/26/2013 at 8:00 pm. The facility CMS 672 dated 2/25/2013 documented 14 residents ate independently and 52 residents required assistance; 42 residents required the assistance of 1 or 2 persons for bathing and 28 residents were diagnosed with [REDACTED].

Based on observation, interview and record review, the Administrator failed to ensure that the Nursing staff was adequate to supervise and monitored to assure the care and services were provided to attain or maintain the safety of the residents by failing to ensure that five of eleven (Resident ID # ' s 8, 9, 10, 11 and 12) received adequate supervision and assistance to prevent accidents when: A.The facility failed to supervise Resident # 8 while she was in the shower, resident # 8 fell , while unattended in the shower and fractured 3 ribs. B.The facility failed to supervise or provide monitoring of the exit door behind the " B " hall nurses ' station that exits to the laundry and back of the facility, and failed to ensure the closure of the gate marked " employees only " , resulting in resident 11, going through the gate, losing control of his wheel chair on the slope and turning it over: Resident # 11 was treated in the emergency room for a head injury with facial lacerations, sutures and bruising. C.The facility failed to supervise or provide monitoring of the exit doors when resident # 9 went out to the smoking area and around the laundry building. Resident # 9 was found sitting on the ground with a laceration and bruising to her left hand fingers. D.The facility failed monitor coffee temperatures and observe residents getting coffee resulting in resident # ' s 10 and 12 spilling coffee on themselves and were found to have red raised areas on the hip (#10) and legs and thighs (#12). These deficient practices resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 02/26/2013. While the IJ was removed on 02/26/2013, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility did not have time to monitor the Plan of Removal for effectiveness or to train all staff. This deficient practice could place: - 6 residents identified by the facility as having behaviors of wandering, at risk for wandering outdoors without supervision; - 14 residents that required minimal or no assistance with eating at risk [MEDICAL CONDITION] coffee, and - 42 residents that required 1 or 2 person assistance with ADL ' s including bathing at risk for falls while bathing unsupervised. The findings include: In a confidential interview on 2/24/13 the complainant said there had been many falls, a lady fell in the shower while alone and there was not enough staff to monitor the residents. Resident # 8: Record review of the physician's order [REDACTED]. Her [DIAGNOSES REDACTED]. Record review for resident # 8 revealed nurses ' notes dated 1/15/13 at 6:45 pm documenting resident # 8 had slipped and fell in the shower. The notes documented for resident # 8 was transferred to the hospital at 7:00 pm, by her daughter for x-rays, the daughter called back stating for resident # 8 had three fractured ribs. Record review of the physical therapy plan of care for resident # 8, dated 12/28/12, documented resident # 8 was a fall risk, and she had mild dementia. Her therapy was to include gait training and therapeutic exercises and activities. The current level of function was documented to be standing upright for 3 minutes without a rest break and use of a front wheeled walker and minimal assistance for 10 feet. Resident # 8 was documented to be unable to maintain a correct weight bearing status. Record review of the facility fall assessment for resident # 8, dated12/21/12, was incomplete and a reassessment, after the fall, could not be located. Record review for resident # 8 revealed a fall risk plan of care dated 12/31/13, documenting resident # 8 could do touch weight bearing and her she had an unsteady gait. The careplan did not document any interventions for transfers. In an interview on 2/25/13 at 2:02 pm the ADON said resident # 8 had been alone in the shower, the CNA had stepped out to get washcloths or something and found resident # 8 in the floor when she returned. In a telephone interview on 2/25/13/at 2:07 pm resident # 8 ' s daughter said her mother had wanted to shower by herself and the staff had allowed it. Resident # 8 did have rib fractures from the fall. In a telephone interview on 12/26/13 at 1:59 pm resident # 8 ' s daughter said she had parked her mother by the shower, in her wheel chair. A CNA was going to put her mother in the shower, she did not know who took her mother to the shower. In an interview on 2/26/13 at 3:48 pm LVN " H " said she saw resident # 8 ' s daughter push resident # 8 in her wheelchair. LVN " H " said resident # 8 was then found in the shower room floor on the shower chair and a fixture was broke off the wall. Resident # 8 was complaining she could not breathe and asked for her daughter to be called at home; and resident # 8 was not dressed. Resident # 8 was observed in her home on 2/26/13 at 3:55 pm. Resident # 8 was using a walker and a wheel chair. In an interview on 2/26/13 at 3:03 pm CNA " F " said resident # 8 came to her asking for a shower on 01/15/13. CNA " F " said she told resident # 8 she would do it around 7:00 or 7:30, and then went on her break. CNA " F " said she heard a crash and went to look for it. CNA " F " said she found resident # 8 in the " D " hall shower floor. CNA " F " provided a written statement stating resident # 8 told her, her daughter had put her in the shower and left. In an interview on 2/26/13 at 3:55 pm resident # 8 said a facility staff had put her in the shower, then she told the staff to leave and the staff left. Resident # 8 said she showered, came out of the shower and fell . Resident # 8 said the pain from the fractured ribs slowed her improvement some; she went to another facility, completed her therapy, and then moved to where she now resides. Record review of the incident report for resident # 8, dated 1/15/13 at 6:45 pm, documented a crash and moaning was heard and resident # 8 was found sitting on the floor in the " D " Hall shower room. The administrative inquiry form dated 1/15/13 at 6:45 pm documented resident # 8 said she just slipped and fell . The recommendation area of the form was blank. In an interview on 3/26/13 at 11:15 am CNA " G " said residents were not to be left alone in the shower. In an interview on 2/26/13 at 11:35 am resident # 1 said the staff seldom left her alone in the shower but sometimes they had to. Staff would tell her to not move and would be gone for a few minutes. Resident # 1 said she had a bad knee that would give out on her. In an interview on 2/26/13 at 11:47 am resident # 2 said the staff left her alone in the shower chair, sometimes for a few minutes. Resident # 1 said she wanted somebody close by in the shower. Resident # 1 said her legs did not work well. Resident # 11: Record review of the physicians orders dated 01/31/13 for resident # 11, documented he was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. In an observation of resident # 11 on 2/26/13 at 11:37 am, resident # 11 was lying in his bed; he had a black right eye. He was alert and oriented. In an interview on 2/26/13 at 11:37 am resident # 11 said he had went out to the smoke area, through the back door. Resident # 11 said he then went through the open gate that said employees only on it, he wanted to see what was behind the laundry. Resident # 11 said he went down the sidewalk, he didn't know it sloped and his wheelchair turned over. Resident # 11 said he called for help and was sent to the emergency room . Resident # 11 said his head was scratched up and he felt fuzzy for a couple of days. Clinical record review for resident # 11 revealed nurse ' s notes dated 02/09/12 at 7:45 am documenting a restorative aide called a nurse to the back facility where resident # 11 was found sitting up on the ground his face covered with blood. The note documented resident # 11 had an abrasion to his left knee, a laceration and an abrasion to the left forehead. He was documented to be alert and oriented. Resident # 11 was transferred to the hospital by ambulance. Resident # 11 was documented to have returned to the facility at10:00 am, he had sutures in his left forehead and was documented to be very confused. Continued clinical record review for resident #11 revealed nurse ' s notes dated 1/06/13 at 7:30 pm documented resident # 1 was confused, calling another resident by the wrong name and resident # 11 was going down the wrong hallway. Nurse ' s notes dated 2/02/13 at 10:00 am documented resident # 11 was found on the bathroom floor, head down. No injuries were noted. Record review of the incident/accident reporting log for October 2012 - February 2013 revealed there was not an incident report documenting the incident involving resident # 11 on 02/09/13. Record review of the care plan dated 8/28/12 documented resident # 11 had poor decision-making, the care plan did not document any concerns of wandering behaviors. Resident # 9: Record review of the physicians orders dated 1/30/13 for resident # 9 documented she was an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Observation of resident # 9 on 2/25/13 at 9:18 am resident # 9 was in her wheelchair in lobby going toward the D hall. Resident # 9 ' s room was observed to be on the A hall. Record review of the nurse ' s notes dated 1/24/13 at 10:00 am resident # 9 had went out the back door, unsupervised to the smoking area and went around the laundry building; she was found sitting on the ground by the building, by the maintenance staff. The note documented a laceration and bruising of the left hand. No further assessment was documented at that time. On1/25/13 at 10:00 am resident # 9 was documented to be wandering around the nurse ' s station and documented bruises on both hands. The note also documented resident # 9 complained of a headache and medication was given. The nurse note ' s dated 1/25/13 documented resident # 9 continued to wander in and out of others rooms, she complained of a headache and no further assessment was documented. Record review of the care plan dated 10/21/12 for resident # 9 documented the fall risks for resident # 9 and she was to wear a wonder guard bracelet, resident # 9 was at risk for injury for wandering in an unsafe environment. The care plan had not been updated. Record review of the incident report dated 1/24/13 at 10:00 am had an addendum dated 1/25/13 at 10:20 am documenting a wonder guard was being placed on the back door. Observation on 2/26/13 at 3:03 pm of the exits to the back smoking area revealed the inside exit door did not lock and the outside exit door was not locked. This exit from the building was located on the " B " hall behind the chart area, the wall blocked vision of the doors. The dining room exit door had a wander guard alarm on it. Resident # 10: Record review of the physician's order [REDACTED]. Her [DIAGNOSES REDACTED]. Record review of the incident accident log for October 2012 through February 2013 documented resident # 10 had spilled her coffee on her and sustained a red area to her right thigh. The report documented resident # 10 had decreased motor skills and were becoming worse with resident # 10 having a difficult time grasping objects. The report documented resident # 10 was instructed to be careful handling hot liquids. In an interview on 2/27/13 at 1:25 pm resident # 10 said she did spill her coffee, the staff put anti-burn cream on the burn and she was not sure if her family had been notified of the incident. Resident # 12: Record review of the physicians orders dated 1/30/13 for resident # 12 documented he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of the incident accident log for October 2012 through February 2013 documented resident # 12 had spilled his coffee on his self and sustained redness with blisters on his thighs on 10/07/2012. Record review of the incident report dated 10/07/2012 at 10:30 am documented a staff member found [MEDICAL CONDITION] notified the nurse. Resident # 12 stated he had spilled coffee on himself. The administrative inquiry dated 10/07/2012 documented resident # 12 said he spilled his coffee while getting it off his bedside table. Clinical record review of the nurse ' s notes for resident # 12, dated 10/03/2012 and 10/04/2012 documented resident #12 had increased difficulty with swallowing and had required assistance to eat. On 10/07/2012 the nurse note documented the right thigh and the inner left and right thigh had blister areas up toward the groin area. A note dated 10/08/2012 at an unknown time documented the kitchen staff were to start cooling the coffee down before serving it. A note dated 10/28/2012 at 11:00 am documented resident # 12 ' s treatment for [REDACTED]. In an interview on 3/04/2013 at 12:02 pm resident # 12 said he did spill his coffee and burn himself, resident # 12 denied any skin problems now. The facility CMS 672 dated 2/25/2013 documented 14 residents ate independently and 52 residents required assistance; 42 residents required the assistance of 1 or 2 persons for bathing.

Based on observation, interview, and record review, the facility failed to ensure residents did not develop new pressure sores and failed provide residents who entered the facility with pressure sores the necessary treatment and services to promote healing and prevent infection for 3 of 7 residents (ID #s 14, 15, and 19) reviewed for pressure sores by failing to ensure: A. resident #14 did not develop new pressure ulcers or develop infection of the pressure ulcers he was admitted with. B. resident ID #15's physician's order [REDACTED]. C. resident #19 did not develop new pressure ulcers or infection of the pressure ulcers. This deficient practice could place 7 residents who had pressure sores or 61 residents who were dependent upon staff for mobility at risk of worsening pressure sores, new pressure sores, or infection and cause a physical decline in health. The findings included: Record review of the physicians order dated 1/30/2013 for resident # 14 documented he was a [AGE] year old male admitted to the facility on [DATE] and a re-admission date of [DATE]. His [DIAGNOSES REDACTED]. Observation on 2/25/13 at 10:12 am, resident # 14 was observed in his bed, he used a ventilator for breathing, and was on a pressure relieving air mattress. Resident # 14 was alert and oriented. Interview on 2/25/13 at 10:12 am, resident # 14 said he had a pressure ulcer that was healing, he was admitted with the pressure ulcer and it was the reason he came in. Resident # 14 said the night staff did not answer his call light or provide assistance. In a confidential interview on 3/05/2013 it was revealed residents were on their backs every morning and there were indications residents were not turned properly during the night. Record review of an admission nursing assessment dated [DATE], documented resident # 14 was admitted with the following pressure areas: 1 cm X 2 cm pressure area on his right hip, 8.5 cm X 6 cm area on his right thigh, 8 X 1 cm area on the right buttock, 2 cm X 2 cm X 2 cm area of the coccyx and an 7 cm X 7 cm area of the left buttock. Record review of the Braden scale assessment for predicting pressure sore risk dated 1/03/12 and 2/28/13 documented resident # 14 had a high risk for pressure ulcers with scores each time of 12. Record review of the skin assessment log for resident # 14 documented the development of new pressure ulcers on: ? 11/04/12 3.5 X 4.0 area right neck, ? 11/04/12 the left heel documented to have worsened to a stage II ulcer, ? 1/09/13 5 X cm area right heel, ? 2/07/13 11 X 8 cm size area on the left buttock. Record review of the nurse ' s notes dated 2/07/13 documented resident # 14 was very non-compliant with his care. The nurse ' s note did not document any interventions or teaching. In an interview on 3/05/2013 at 8:40 am CNA J said resident # 14 turned on one side at night and then turned on the other side the next morning; resident # 14 would allow his feet to be moved, so that ' s what we do. Record review of resident # 14 ' s physicians orders dated 11/01/12 documented the physician requested resident # 14 have a psychiatric consult for his refusal of care. Continued record review did not reveal any consult had been done. In an interview on 5/05/2013 at 3:00 pm the ADON said resident # 14 was last seen for a psychiatric evaluation in 2010. The ADON said there was no documentation of an evaluation since that time. In an interview on 5/05/2013 at 3:15 pm the facility Social Worker said she was not able to find any documentation of having done the psychiatric referral. Record review of the care plan for resident # 14, dated 10/03/12 documented resident # 14 ' s pressure ulcers and interventions, the care plan did not document resident # 14 ' s non-compliance with the recommendations and did not document interventions for the non-compliance. A care plan dated 10/15/12 for risk of skin breakdown did document resident # 14 as refuses to turn. There were no interventions for resident # 14 ' s not cooperating was documented. Record review of the physicians order dated 12/13/2012 for resident # 14 documented a physician's order [REDACTED].# 14 to hold the cloths in place. In an interview on one3/05/2013 at 9:34 am LVN A said resident # 14 had been using wet to dry dressings in the coccyx wound, then the physician changed to dry dressings and then changed to the cloths due to the large amount of drainage. LVN A said the towels were purchased by the facility; after use the towels were placed in a separate red biohazard bag with sugar sent to the laundry. In an interview on 3/05/2013 at 10:00 am laundry staff " I " said resident # 14 ' s towels and bedding came to the laundry in a red biohazard sugar bag. The towels were washed with his linens, twice on the biohazard setting, then the towels were put on the laundry folding table, folded, placed in plastic trash bags and returned to resident # 14 ' s room. The bags were put in resident # 14 ' s closet. The staff did not wear gloves or do any other special precautions after the towels were washed. Observation of the laundry room on 3/05/13 at 9:46 am revealed a note on the wall that read for biohazard put on a mask, gown, wash twice on F-3; make sure chemicals are hooked up to the washer. Observation of resident # 14 ' s room on 3/05/2013 at 10:04 am revealed open bags of towels in the closet. There were bags of briefs and boxes of gloves in the bottom of the closet with the towels bags; a bag of the towels was torn by a glove box. Record review of the nurses notes dated 2/26/2013 at 10:30 am documented resident # 14 stated he had chills the night before and had blurred vision. Resident# 14 ' s physician was contacted and labs were drawn. Resident # 14 was transferred to the hospital at 7:25 pm due to critical lab values. Record review of the emergency room record dated 2/26/2013 documented resident # 14 had a massive open coccyx wound. The physician ' s section documented resident # 14 had an extensive deep foul smelling decubiti of the entire buttocks and cultures were obtained. The physician documented [DIAGNOSES REDACTED]. Resident # 14 was then transferred to to a different hospital for more advanced care. Record review of the urine and wound cultures, dated as drawn 2/26/2013 documented the presence of e-coli in the wound and other bacteria in the wound and urine. Record review of the hospital record where resident # 14 was transferred documented resident # 14 had [DIAGNOSES REDACTED]. Resident # 14 was admitted to the ICU and antibiotics were started. Resident ID #15 Resident ID #15's February 2013 Record of Admission documented she was a [AGE] year-old female admitted to the facility on [DATE]. Resident ID #15's Admission Skin Assessment Form, dated 10/18/2012, documented she had no pressure ulcers. Resident ID #15's Braden Scale For Predicting Pressure Sore Risk form, dated 10/18/2013, documented she had a score of 12, indicative of high risk for developing pressure ulcers. Resident ID #15's admission MDS assessment, dated 10/30/2012, documented she was at risk for developing pressure ulcers and had no unhealed pressure ulcers. Resident ID #15's December 2012 physician's orders [REDACTED]. Resident ID #15's Skin Condition Report, dated 12/04/2012, documented the following: - unstageable pressure ulcer to right heel measuring 3 cm long by 3 cm wide; - unstageable pressure ulcer to inside right heel measuring 2 cm long by 1 cm wide - unstageable pressure ulcer to left heel measuring 3 cm long by 3 cm wide; - unstageable pressure ulcer to inside left heel measuring 3 cm long by 2 cm wide; - unstageable pressure ulcer to outside left heel measuring 4 cm long by 3 cm wide. Resident ID #15's Plan of Care, dated 12/04/2012, documented she had unstageable pressure ulcers to her right and left heels and was to have a pressure reducing mattress. Resident ID #15's quarterly MDS assessment, dated 01/20/2013, documented the following: she had severely impaired cognitive skills for daily decision making; she was totally dependent upon two or more persons for bed mobility, transfer, toileting, personal hygiene, and bathing; she had functional limitation in range of motion of her upper and lower extremities on both sides; she was at risk for developing pressure ulcers; she had two stage two pressure sores and one unstageable pressure sore; the dimension of her largest pressure sore was 3 cm long by 3 cm wide by 0 cm deep; the most severe tissue type for her pressure ulcers was eschar (necrotic tissue- black, brown, or tan tissue that adheres firmly to the wound bed); she was on a pressure reducing device for her bed, receiving pressure ulcer care and application of nonsurgical dressing, ointments/medications, and dressings to her feet. Resident ID #15's Skin Condition Report, dated 02/28/2013, documented she had a pressure ulcer to her right heel measuring 2.6 cm long by 2.9 cm wide by 0.1 cm deep. The report documented a pressure ulcer to her left heel measuring 3.5 cm long by 3.7 cm wide by 0.2 cm deep. Resident ID #15's March 2013 physician's orders [REDACTED]. Resident ID #15's March 2013 Nurse MAR indicated [REDACTED]. The nurses were initialing the task, documenting as completed, every shift. Resident ID #15's March 2013 Treatment Sheet documented the following treatment orders: - cleanse left heel with normal saline, apply Santyl ([MEDICATION NAME] ointment) and calcium alginate (absorbent dressing), cover with foam, and wrap with gauze daily and PRN; - cleanse open area to right ankle with normal saline or daily wound cleanser, apply triple antibiotic ointment and collagen (to aide in wound healing), and cover with dry dressing daily and PRN. In an observation on 03/04/2013 at 1:15 PM, during skin rounds with the ADON, resident ID #15 was lying in bed. Her heels were both wrapped. Resident ID #15's mattress was very firm and hard when pressure applied. In an interview on 0./05/2012 at 11:20 AM, LVN A stated resident ID #15's heel pressure ulcers developed in the facility. She stated upon dong the weekly skin assessment on 12/04/2012; she noticed resident ID #15's heels were both black with eschar. LVN A stated resident ID #15's skin was clear the week before. She stated resident ID #15 was contracted and hard to position. She stated the heel wounds were caused by pressure. LVN A stated the right heel was healing, and the left heel was still covered with eschar. She stated resident ID #15's heels should have been floated off the surface of the mattress to alleviate pressure. LVN A stated the pressure ulcers may have been caused by not repositioning resident ID #15 frequently enough. In an observation on 03/05/2013 at 11:45 AM, resident ID #15 was in bed with a pillow under her knees. Her heels were flat on the mattress surface. The mattress was very hard to touch. In an interview on 03/05/2012 at 11:46 AM, CNA C stated it was very hard to off-load resident ID #15's heels because of the way resident ID #15 was contracted. She stated she tried to keep them elevated. In an observation on 03/05/2012 at 12:00 PM, resident ID #15 was lying in bed. She was contracted, and her knees were touching her chest. Resident ID #15's heels were on the surface of the mattress. The mattress was hard to touch. In an observation on 03/05/2012 at 1:55 PM, resident ID #15 was lying in bed. Her heels were on the surface of the mattress. The mattress was hard to touch. In an interview on 03/05/2013 at 1:55 PM, LVN B stated she did not know if resident ID #15's mattress was a pressure reducing mattress. In an interview on 03/05/2013 at 2:20 PM, the ADON stated all mattresses in the facility were "Panacea" pressure reducing mattresses. She stated resident ID #15's mattress did not look familiar to her. The ADON stated the mattress resident ID #15 was lying on was not one of the mattresses ordered by the facility, and she did not know where it came from. The ADON stated the mattress was hard to touch. She stated resident ID #15's bed frame had broken a few weeks before, and she was put in a new bed. The ADON stated she suspected that may have been when resident ID #15 was put on the firm mattress. In an interview on 03/05/2013 at 2:30 PM, LVN B stated she thought all mattresses in the facility were pressure reducing mattresses. She stated she never felt the mattress or checked the label prior to documenting the pressure reducing mattress on the TAR. In an interview on 03/05/2012 at 2:35 PM, the ADON stated she did not know who changed out resident ID #15's bed. She stated the mattress was not the facility's product. The ADON stated the mattress looked like it came from a hospice agency. She stated when a hospice agency delivered a bed, the facility would switch the hospice regular mattress for one of the facility's pressure reducing mattresses. In an observation on 03/05/2012 at 2:35 PM, the ADON told the administrator resident ID #15's mattress was not a pressure reducing mattress. She told the administrator the mattress did not belong to the facility. In an interview on 03/05/2013 at 2:47 PM, the ADON stated the facility ordered the "Panacea" mattresses because they were pressure reducing mattresses and met standards for pressure ulcers stage three and below. She stated pressure ulcers could result from not using pressure reducing mattresses. In an interview on 03/05/2013 at 2:52 PM, LVN B stated without a pressure reducing mattress, residents were at higher risk of having skin breakdown form increased pressure. In an interview on 03/05/2013 at 2:55 PM, the ADON stated the firm mattress resident ID #15 was lying on was an "Invacare" mattress from hospice, and it was not a pressure reducing mattress. In an interview on 03/5/2013 at 2:56 PM, the DON stated when using a non-pressure reducing mattress, pressure resulted, then skin breakdown occurred. She stated she had done no in-service or training for the nurses on how to check the mattresses. In an observation on 03/05/2013 at 3:01 PM, during the provision of wound care, resident ID #15's left heel pressure ulcer was black and measured 3.5 cm long by 3.5 cm wide. In an interview on 03/05/2013 at 3:01 PM, during the provision of wound care, the DON and LVN A stated the firm mattress had a negative impact on resident ID #15's heel pressure ulcers healing. They stated she did not know resident ID #15 was on a non-pressure reducing mattress. In an interview on 03/05/2013 at 3:13 PM, LVN D stated she had not been trained on how to check mattresses. She stated when documenting for the pressure reducing mattresses, she just signed the MAR. LVN D stated if a resident was not on a pressure reducing mattress, skin breakdown would occur. In an interview on 03/05/2013 at 4:10 PM, the DON stated all of resident ID #15's skin documents were provided to the survey team, and there was no additional documentation anywhere else. Resident # 19: Record review of the physicians order dated 1/30/2013 for resident # 19 documented he was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Observation on 3/04/2013 at 12:22 pm revealed resident # 19 was lying in bed on his left side, he had a pressure relieving mattress, his feet were offloaded and he was not interviewable. Record review of the admission nursing assessment dated [DATE] for resident # 19 revealed the skin condition section of the assessment was blank. Record review of the physician ' s telephone orders for resident # 19 dated 1/23/13 documented orders for treatment to resident # 19 ' s heels, right outer foot and right lower extremity. Record review of the facility skin assessment log for resident # 19 documented new pressure ulcers on: ? 1/29/13 a red area 3 X @ cm on the left buttock with drainage, ? 1/29/18 a red area 9 X * cm on the right buttock with drainage. ? 2/19/13 a black area 2 X 3 cm on the bottom right foot, ? 2/19/14 a black area 4 X 3 cm on the outer left foot, Record review of the Braden scale dated 1/22/13 documented resident # 19 was a high risk for pressure ulcers with a score of 11. Record review of the care plan for resident # 19 dated 2/05/13 revealed a care plan for incontinence and an indwelling foley catheter. A care plan for risk of pressure ulcers could not be located. In an interview on 3/05/13 at 3:30 pm the ADON said there were no other care plans that were not in the residents charts. Record review of the physicians orders dated 2/20/13 documented an order for [REDACTED]. Resident # 19 was noted to have received orders for a urinary tract infection on 2/12/13. In an interview on 2/25/13 at 10:20 am non-reviewed resident # 23 said the staff did not answer her call light at night and she was not turned. In a confidential interview on 2/26/13 it was said the night staff were not able to meet the resident ' s needs in a timely manner, it was difficult to complete tasks and residents had to wait. The CMS 672Resident Census and Conditions of Residents date 2/24/13 documented 7 residents with pressure ulcers and 61 residents who were dependent on staff for assistance with mobility.

Based on observation, record review and interview the facility failed to: maintain an Infection Control Program and provide a safe, sanitary and comfortable environment and to identify and prevent the development of infection for 4 of 5 residents (ID # ' s 6, 10,14,16) reviewed for indwelling foley catheters and urinary continence, and 3 of 7 (ID # ' s 13, 14 and 16) residents reviewed with pressure ulcers, by failing to: (1) Investigate, control, and prevent infections in the facility; (2) Maintains a record of incidents and corrective actions related to infections. This failure could affect any of the 12 resident with catheters, 38 residents with urinary incontinence and 7 residents with pressure ulcers. The findings included: Resident # 14: Record review of the physicians order dated [DATE] for resident # 14 documented he was a [AGE] year old male admitted to the facility on [DATE] and a re-admission date of [DATE]. His [DIAGNOSES REDACTED]. Observation on [DATE] at 10:12 am, resident # 14 was observed in his bed, he used a ventilator for breathing, and was on a pressure relieving air mattress. Resident # 14 was alert and oriented. Interview on [DATE] at 10:12 am, resident # 14 said he had a pressure ulcer that was healing, he was admitted with the pressure ulcer and it was the reason he came in. Record review of an admission nursing assessment dated [DATE], documented resident # 14 was admitted with the following pressure areas: 1 cm X 2 cm pressure area on his right hip, 8.5 cm X 6 cm area on his right thigh, 8 X 1 cm area on the right buttock, 2 cm X 2 cm X 2 cm area of the coccyx and an 7 cm X 7 cm area of the left buttock. Record review of the skin assessment log for resident # 14 documented the development of new pressure ulcers on: [DATE] 2 X 1 cm area to the right posterior calf, [DATE] 3.5 X 4.0 area right neck, [DATE] the left heel documented to have worsened to a stage II ulcer, [DATE] 5 X cm area right heel, [DATE] 11 X 8 cm size area on the left buttock. Record review of the nurse ' s notes dated [DATE] documented resident # 14 was very non-compliant with his care. The nurse ' s note did not document any interventions or teaching. Record review of the physicians order dated [DATE] for resident # 14 documented a physician's order [REDACTED].# 14 to hold the cloths in place. In an interview on one[DATE] at 9:34 am LVN A said resident # 14 had been using wet to dry dressings in the coccyx wound, then the physician changed to dry dressings and then changed to the cloths due to the large amount of drainage. LVN A said the towels were purchased by the facility; after use the towels were placed in a separate red biohazard bag with sugar and sent to the laundry. In an interview on [DATE] at 10:00 am laundry staff " I " said resident # 14 ' s towels and bedding came to the laundry in a red biohazard sugar bag. The towels were washed with his linens, twice on the biohazard setting, and then the towels were put on the laundry folding table, folded, placed in plastic trash bags and returned to resident # 14 ' s room. The bags were put in resident # 14 ' s closet. The staff did not wear gloves or do any other special precautions after the towels were washed. Observation of the laundry room on [DATE] at 9:46 am revealed a note on the wall that read for biohazard put on a mask, gown, wash twice on F-3; make sure chemicals are hooked up to the washer. Observation of resident # 14 ' s room on [DATE] at 10:04 am revealed open bags of towels in the closet. There were bags of briefs and boxes of gloves in the bottom of the closet with the towels bags; a bag of the towels was torn by a glove box. Record review of the nurses notes dated [DATE] at 10:30 am documented resident # 14 stated he had chills the night before and had blurred vision. Resident# 14 ' s physician was contacted and labs were drawn. Resident # 14 was transferred to the hospital at 7:25 pm due to critical lab values. Record review of the emergency room record dated [DATE] documented resident # 14 had a massive open coccyx wound. The physician ' s section documented resident # 14 had an extensive deep foul smelling decubiti of the entire buttocks and cultures were obtained. The physician documented [DIAGNOSES REDACTED]. Resident # 14 was then transferred to a different hospital for more advanced care. Record review of the urine and wound cultures, dated as drawn [DATE] documented the presence of e-coli in the wound and other bacteria in the wound and urine. Record review of the hospital record where resident # 14 was transferred documented resident # 14 had [DIAGNOSES REDACTED]. Resident # 14 was admitted to the ICU and antibiotics were started. Resident # 10: Record review of the physician's order [REDACTED]. Her [DIAGNOSES REDACTED]. In an observation on [DATE] at 9:30 am resident # 10 was observed in bed and requested to talk later. In an interview on [DATE] at 1:25 pm resident # 10 said she woke up cramping and went to the nurse ' s desk, they gave her a [MEDICATION NAME], her fever was 103 and she went to the emergency room . Record review of the physicians hospital note dated [DATE] for resident # 10 documented she had an acute urinary tract infection with sepsis and she was admitted to the hospital for treatment. She had a temperature of 102.7 in the emergency room . Resident # 13: Record review of the physicians orders dated [DATE] for resident # 13 documented he was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. In an observation on [DATE] at 9:50 am resident # 13 was observed in his bed, on his back. Resident # 13 was on a ventilator, he was not responsive. Resident # 13 was being fed by a tube and the feeding bag hung beside his bed. The bedrail, mattress and floor and a buildup of a white, sticky dried substance on them. Clinical record review for resident # 13 lab results from wound cultures dated [DATE]. The cultures documented infections of resident # 13 ' s perineal wound and scrotum wound. In an interview on [DATE] at 3:45 pm LVN K said staff was responsible for cleaning problems as they arose. Resident # 16: Record review of the physicians orders dated [DATE] for resident # 16 documented she was a [AGE] year old female admitted to the facility on [DATE] her [DIAGNOSES REDACTED]. Resident # 16 had an order for [REDACTED]. Observation of resident # 16 on [DATE] at 1:00 pm revealed she was lying in bed, she had an indwelling foley catheter with cloudy yellow urine draining from it. Record review for resident # 16 documented UA ' s were done on [DATE] and [DATE] and resident # 16 had a UTI each time. Resident # 7: Record review of the physician's order [REDACTED]. His [DIAGNOSES REDACTED]. Interview on[DATE] at 8:10 am resident # 7 said he had been septic and hospitalized twice for it. He just was not getting better. Record review for resident # 7 nurses notes dated [DATE] documented resident # 7 had complained generalized pain at 1:00 am. He was given Fexeril and no signs or symptoms of acute distress were noted. At 2:00 am resident # 7 complained of not being able to catch his breath, chest pain and nausea. Resident # 7 was transferred to the emergency room by ambulance at 2: 30 am. Record review of the hospital records dated [DATE] documented resident # 7 was diagnosed with [REDACTED]. Record review of hospital records dated [DATE]documented resident # 7 was brought to the emergency room for complaints of shortness of breath and hurting all over. Resident # 7 reported to the hospital staff the symptoms began about three days ago. Resident # 7 ' s oxygen saturation level was 78% as reported by the ambulance staff. Resident # 7 was placed on a ventilator, had CPR done to revive him and was transferred to another hospital. Record review from the history and physical from the second hospital documented resident # 7 had respiratory sepsis with pneumonia; family reported the same thing happened in December when resident # 7 had sepsis and pneumonia last December. The [DIAGNOSES REDACTED]. Record review of the facility nurse ' s notes for resident # 7, dated [DATE] and [DATE] documented resident # 7 had fever and a non-productive cough. On [DATE] the notes documented resident # 7 complained of having cold symptoms and wanting to see the doctor. The notes documented calling the physician ' s office for an appointment. There was no documentation of a respiratory assessment, the doctor ' s appointment being made or notification of family. Resident # 6: Record review of the physicians orders dated [DATE] for resident # 6 documented she was an [AGE] year old female admitted to the facility on [DATE]. Record review of the hospital history and physical for resident # 6, dated [DATE] documented her [DIAGNOSES REDACTED]. Resident # 6 was documented to have found by the nursing home staff that morning with a fever of 104 and the family brought resident # 6 to the emergency room . Resident # 6 was documented to have a fever of 107 degrees when she arrived, her respirations were shallow and labored; she had obvious urosepsis and appeared premorbid. Record review of the facility nurse ' s notes dated [DATE] documented at 6:50 am resident # 6 was found non-responsive, her respirations were rapid, and her temperature was 105.1. The nurse ' s notes dated ,[DATE], ,[DATE] and [DATE] documented resident # 7 had cloudy yellow urine in her catheter bag. The nurses notes dated [DATE] documented a clear yellow urine return. There was no documentation of the physician being notified and there was not any documentation of any further assessment or intervention for the change in her urine. Record review of the urine lab tests for resident # 6 documented a urine test on [DATE] revealing resident # 6 had a UTI and antibiotics were ordered. The follow up urine test dated [DATE] documented resident # 6 continued to have a UTI. Clincal record review did not reveal any further treatment or tests. Record review of the hospital discharged summary dated [DATE] for resident # 6 documented resident # 6 was admitted to the hospital with [REDACTED]. Record review of the facility infection control log for January through February 2013 revealed residents symptoms and dates were not documented; culture date, infection sites and results were not documented and other actions were not documented for one of 23 entries. The infection control log was incomplete, did not provide the identification, tracking or a means of prevention of resident infections and sepsis. In an interview on [DATE] at 2:00 pm the DON said she had been trying to get staff to document the [DIAGNOSES REDACTED]. Record review of the facility infection control log for [DATE] through February 2013 did not identfy residents with sepsis. The facility CMS 672, dated [DATE] documented 14 residents with catheters, 38 residents frequently incontinent of urine and 7 residents with pressure ulcers.

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent UTIs (urinary tract infection), restore as much normal bladder function as possible, and failed to ensure residents were not catheterized unless their clinical condition demonstrated catheterization was necessary for 3 of 7 residents sampled (ID #s 6, 16, and 17) for catheters (tube inserted into bladder to drain urine) by failing to ensure: A. resident ID #s 6, 16 and 17 had a clinical indication for a urinary catheter; B. resident ID #'s 6, and 16 did not develop multiple UTIs [MEDICAL CONDITION] (ID # 6) when the residents had a urinary catheter with no clinical indication. This deficient practice could place 14 residents with catheters at risk of infection, such as UTIs or urosepsis (septic poisoning from retained and absorbed urinary substances) and inability to restore normal bladder function, causing a physical and psychosocial decline in health. The findings included: Resident ID # 6: Record review of the physicians orders dated 12/31/12 for resident # 6 documented she was an [AGE] year old female admitted to the facility on [DATE]. Record review of the hospital history and physical for resident # 6, dated 1/28/13 documented her diagnoses of diabetes, pressure ulcers, hypertension, right [MEDICAL CONDITION], and left the knee amputation. Resident # 6 was documented to have found by the nursing home staff that morning with a fever of 104 and the family brought resident # 6 to the emergency room . Resident # 6 was documented to have a fever of 107 degrees when she arrived, her respirations were shallow and labored; she had obvious urosepsis and appeared premorbid. Record review of the facility's physicians orders for resident # 6 dated 11/13/12 documented an order to replace the indwelling foley catheter and obstain a UA. The order did not document a indication for the catheter to reamain in place. Record review of the facility nurse ' s notes dated 1/28/13 documented at 6:50 am resident # 6 was found non-responsive, her respirations were rapid, and her temperature was 105.1. The nurse ' s notes dated 1/25, 1/26 and 1/27/13 documented resident # 7 had cloudy yellow urine in her catheter bag on all shifts. The nurses notes dated 1/23/13 documented clear yellow urine return. There was no documentation of the physician being notified of the change in resident # 6 ' s urine and there was not any documentation of any further assessment or intervention. Record review of the hospital discharged summary dated 1/28/13 for resident # 6 documented resident # 6 was admitted to the hospital with [REDACTED]. Resident ID #16: Resident ID #16's Record of Admission documented she was a [AGE] year-old female admitted to the facility on [DATE], and re-admitted on [DATE], with the following Diagnoses: [REDACTED]. Resident ID #16's comprehensive MDS Assessment, dated 01/16/2013, documented the following: she had a short and long-term memory problem with severely impaired cognitive skills for daily decision making; she was totally dependent upon two or more persons for bed mobility, transfer, dressing, toileting, personal hygiene, and bathing; she had an indwelling catheter and was always incontinent of bowel. Resident ID #16's Admission Nursing Assessment, dated 01/28/2011, documented she had a Foley catheter upon admission to the facility. Resident ID #16's Care Plan, dated 01/31/2012, documented she a catheter for permanent use for a [DIAGNOSES REDACTED]. Resident ID #16's Admission Nursing Assessment, dated 05/31/2012, documented she had a Foley catheter upon re-admission to the facility. Resident ID #16's Laboratory Results, dated 06/24/2012, documented she had a UTI and was [MEDICATION NAME](antibiotic) 500 mg twice daily for 14 days. Resident ID #16's Laboratory Results, dated 09/15/2012, documented she had a UTI and was ordered [MEDICATION NAME] (antibiotic) one gram daily for ten days. Resident ID #16's February 2013 physician's orders [REDACTED]. In an observation on 03/04/2013 at 1:00 PM, during the provision of skin rounds with the ADON, resident ID #16 was lying in bed; her skin was clear, and she had a Foley catheter with cloudy yellow drainage in the bag. In an interview on 03/05/2013 at 11:15 AM, LVN B stated resident ID #16 was admitted to the facility with a catheter. She stated the catheter was had never been removed. LVN B no post-residual voids (test to check amount of urine left in bladder after urinating) were done to check resident ID #16's ability to void without catheterization. Resident ID #17 Resident ID #17's Record of Admission documented she was a [AGE] year-old female admitted to the facility on [DATE]. No diagnoses information was documented. Resident ID #17's February 2013 physician's orders [REDACTED]. Resident ID #17's Admission Nursing Assessment, dated 02/26/2013, documented the following: she required assistance of one person for transfer; she was full weight-bearing; she was able to ambulate independently and used a walker; she had adequate hearing, vision, and was able to communicate clearly; she was independent for grooming and required assistance for showering and dressing; she was alert, oriented, and cooperative; she answered questions readily and had quick comprehension; she was continent of bowel and had an indwelling Foley catheter. Resident ID #17's Interim Plan of Care, which was not dated, documented she had self-control of her bowel and bladder, as well as an indwelling catheter. Resident ID #17's Physician's Telephone Orders, dated 02/27/2013, documented an order for [REDACTED]. In an interview on 03/05/2013 at 11:36 AM, LVN E stated resident ID #17 was admitted to the facility with a catheter. LVN E stated she (LVN E) was planning on calling the physician to get an order to remove the catheter. LVN E stated resident ID #17 had a catheter for [MEDICAL CONDITION]. She stated resident ID #17 did not want a catheter when she was first admitted . LVN E stated it was at the discretion of the doctor to leave the catheter or give an order to remove it. She stated resident ID #17 should have been able to void on her own. In an interview on 03/05/2013 at 11:57 AM, resident ID #17 stated she was admitted to the facility from an assisted living facility and had a catheter there. Resident ID #17 stated she was unsure of why she was initially catheterized. She stated she never had a catheter prior to that, and she had no problems urinating on her own. Resident ID #17 stated no one had spoken to her about her catheter. She stated she did not like the catheter and did not need it. In an interview on 03/05/2013 at 4:10 PM, the DON stated catheters were used in the facility "100% on doctor's orders." She stated they could have been ordered for yeast infections or incontinence. The facility ' s CMS-672 Resident Census and Conditions of Residents, dated 02/25/2013, documented there were 14 residents with catheters.

Based on observation, interview, and record review, the facility failed to ensure nurse aides were able to demonstrate competency in skills and techniques for 1 of 1 resident (ID #18) reviewed for transferring using a hoyer lift, 2 of 4 residents (ID # s 3 and 4) observed for incontinent care, and 1 of 3 residents (ID #4) observed for catheter (tube inserted into bladder) care by failing to ensure: A. 2 of 2 CNAs (CNAs A and B) used the hoyer lift in accordance with the manufactures operating instructions and the facility policy when assisting resident ID #18 out of bed. Resident ID# 18 sustained a fall and was transported to the hospital for x-rays. X-rays revealed a suggestion of a fracture involving the proximal tibial metaphysis. Resident ID #18 was transported back to the facility with an immobilizer to the left knee, orders for pain medication, non-weight bearing, and a follow up x-ray to left knee in one month; B. 3 of 5 CNAs (CNAs C, D, and K) changed gloves after a dirty procedure and before a clean procedure while providing incontinent care to resident ID #s 3 and 4; C. 1 of 5 CNAs (CNA K) providing incontinent care cleansed the catheter tubing for resident ID #4; D. 1 of 5 CNAs (CNA K) performed hand hygiene after providing incontinent care for resident ID #4. This deficient practice could place the 4 residents requiring the hoyer lift for transfers at risk of avoidable injury, the 50 residents who were incontinent of urine, the 36 residents who were incontinent of bowel, and the 15 residents who had indwelling catheters at risk of infection. The findings included: Resident ID #18 Record review of resident ID #18's August Physician order [REDACTED]. Acute Venous Embolism and [MEDICAL CONDITION] of unspecified site. Record review of resident ID #18's Quarterly MDS Assessment, dated 08/13/2012, documented the following: he had no cognitive deficit; extensive assistance with the support of two persons for bed mobility, locomotion on the unit, dressing, toileting, and personal hygiene. She was totally dependent upon two or more persons for transfers and bathing. Record review of resident ID #18's Comprehensive Plan of Care for Activities of Daily Living, dated 08/13/2011, documented she was a total assist with the support of two staff for transfers using the Hoyer lift. In an interview on 09/28/2012 at 9:50 AM, resident ID #18 stated she was in bed and CNA A and B placed her on the hoyer lift pad and attached the pad to the hoyer to put her in a shower chair. She stated the hoyer lifts legs were under her bed and CNA A pulled the hoyer away from the bed. The legs of the lift were not spread out. She stated she could see the legs and the they were together. When CNA A turned the hoyer to place her in the shower chair, the hoyer tilted forward. She stated CNA A and B tried to stabilize the hoyer and held onto the lift pad. She stated her left knee came forward up against her chest when she hit the floor. Resident ID #18 stated it was supper time and the CNAs were trying to hurry. She also stated she has to be careful not to move her leg due to the pain. Resident ID #18 stated she has used the hoyer lift over the last two years, at least two times a day and now she is afraid to use the lift. In an interview on 09/28/2012 at 10:10 AM, the Administrator stated he was in the building when the incident occurred. He stated CNA A told him he wasn't sure what happened. The Administrator also stated CNA A told him he spread the base legs of the hoyer lift, pulled the lift away from the bed, turned the lift, and the lift tilted forward. Stated he did not have manufacturer's operating instructions for the lift but would try and locate the instructions. In an interview on 09/28/2012 at 10:15 AM, the maintenance supervisor stated the hoyer had recently been serviced. He stated one of the bars that assist with spreading the base legs of the hoyer needed to be replaced. He also stated the guy that replaced the bar that spreads the base legs of the hoyer, stated the bar may be too long and he would have to order one. In an interview on 09/28/2012 at 10:50 AM, CNA A stated CNA B approached him to assist her with resident ID #18 to get her out of bed and into the shower chair. He stated the lift pad wasn't the right size for resident ID #18 and they had to put another pad under the resident. He stated he pushed the hoyer lifts legs under the bed, spread the legs, and locked the wheels. He stated when he pulled the lift away from the bed and turned the lift with the resident, the lift tilted forward. He stated CNA B ran to help him stabilize the lift but the resident was too heavy and she fell forward and landed on the floor. CNA A stated he had been inserviced on how to use the hoyer lift. In an interview on 09/28/2012 at 10:58 A.M., CNA B stated she was going to take resident ID #18 to the shower room. She stated she asked CNA A to assist with getting the resident out of the bed. She stated the resident was on the lift pad and secured to the hoyer. She then stated CNA A raised the lift pad off the bed and pulled the hoyer away from the bed. She stated CNA A turned the hoyer to the left, the legs that stabilize the hoyer were closed and the hoyer tilted forward. She stated the resident fell forward and hit the floor. She stated she did not know why the legs of the hoyer were closed. CNA B stated she was inserviced on how to use the hoyer. Facility's Accident/Incident Report documented the incident occurred on 09/26/2012 at 4:40 PM. The incident involved resident ID #18 and the use of a hoyer lift. Recommended steps to prevent recurrence: replace the hoyer lift with more stable actuation arm and better leg stabilizer locks. Nursing Progress Notes documented the following: -09/26/2012 at 4:40 P.M.: resident fell while being transferred via hoyer lift. sent to the hospital for X-rays and evaluation. -09/27/2012 at 4:00 P.M.: resident returned from hospital, awake, alert, and oriented. Left leg in an imobilizer from ankle to thigh. physician's orders [REDACTED]. Resident is extremely sore and tearful due to left leg pain. Radiology Report, dated 09/26/2012 at 5:50 P.M., documented indication of knee injury and impression of suggestion of a fracture involving the proximal tibial metaphysis. Facility's Internal Investigation dated 09/26/2012, documented the following (in part): possible hoyer lift malfunction resulting in lift tilting over and resident falling, hoyer red tagged after maintenance assessed, and hospital reports fracture to left leg. Notification of State on 09/27/2012 at 1:55 P.M. Invoice record from American Scale Company dated 08/02/2012, documented the following (in part): adjustments made as necessary, tightened loose bolts, screws and handles. The lift is safe for patient use, as long as they are used by manufacturer's specifications. Hoyer lift needs new cross support for 450 pound lift. Facility's policy title "Transfer, Two Person Hoyer (Mechanical) Lift," not dated, documented the following (in part): "Position wheelchair so that you can maneuver the lift safely from the bed to over the chair. Roll resident on his/her side away from you and place the widest part of the sling under the resident's buttocks and thigh. Roll the resident onto the sling. Position lift over the bed, spread the legs of the lift to the widest open position to maintain a broad base of support. Attach the sling to the lift, and raise the sling off the bed until the resident is suspended over the bed. Slowly guide the lift away from the bed and position over the chair. One staff member holds the sling to help keep the resident's hips back in the chair as the lift is lowered." Manufacturer's operating instructions for the hoyer lift, not dated, documented the following (in part): "Spread the base legs to the widest position before lifting." Inservice record titled "Proper transfer using Hoyer Lift", dated 05/05/2009, documented CNA A's name on the attendance sheet. In an interview on 09/28/2012 at 12:00 P.M., the DON stated all staff were inserviced on how to use the hoyer lift. In an interview on 09/28/2012 at 11:50 AM, LVN J stated there were four residents including resident ID #18 in the facility who required the use of the hoyer lift for transfers. Non-harm findings: Resident ID #3 Resident ID #3's Admission Nursing Assessment documented she was admitted to the facility on [DATE]. Resident ID #3's History and Physical, dated 07/12/2012, documented she was an [AGE] year-old female with the following Diagnoses: [REDACTED]. Resident ID #3's 5-day MDS assessment, dated 09/25/2012, documented the following: she was totally dependent upon two or more persons for bed mobility and toileting; she had an indwelling catheter; she was frequently incontinent of bowel. In an observation on 09/25/2012 at 11:20 AM, during the provision of incontinent care, CNA C tucked feces soiled incontinent pads and linens under resident ID #3 and rolled resident ID #3 on her side. CNA D cleaned feces from resident ID #3's bottom with disposable wipes. CNA D placed clean linens under resident ID #3 and touched the tubing connected to her feeding tube without changing or removing her dirty gloves. CNA C and CNA D repositioned resident ID #3 in bed and covered the resident up without changing or removing their dirty gloves. CNA C positioned resident ID #3's catheter tubing under the resident's leg. In an interview on 09/25/2012 at 11:28 AM, CNA D stated gloves should be changed after a dirty and before a clean procedure. She stated she forgot to change her gloves while providing incontinent care to resident ID #3. CNA D stated foley catheters just had to be positioned below the bladder so urine would flow to gravity. In an interview on 09/25/2012 at 11:30 AM, CNA C stated gloves were supposed to be changed after a dirty and before a clean procedure. She stated foley catheter bags had to be positioned below the level of the bladder. When asked if resident ID #3's catheter tubing was compressed due to resident ID #3's leg applying pressure to it, she stated she did not know she couldn't place foley catheter tubes under a resident's leg. In an interview on 09/25/2012 at 3:10 PM, LVN E stated urinary catheter tubing was always supposed to be positioned over a resident's leg to prevent compression of the tubing. In an interview on 09/25/2012 at 3:15 PM, LVN F stated urinary catheter tubing should never be placed under a resident's body. Resident ID #4 Resident ID #4's Physician order [REDACTED]. Observation on 09/24/2012 at 2:00 P.M., CNA K rolled resident ID #4 on her right side and wiped bowel movement from the resident's buttocks. CNA K rolled the resident to her back and cleaned the perineum area without changing gloves and did not wipe around the resident ID #4's catheter. CNA K raised the resident's side rail, removed her gloves, and left the room without performing hand hygiene. In an interview on 09/24/2012 at 2:30 P.M. CNA K stated she has received in-servicing on incontinent care and on cleaning a catheter during incontinent care. CNA K stated she should change her gloves prior to touching clean from dirty care and wash her hands prior and post care. Resident ID #4's significant change in status MDS assessment, dated 08/30/2012, documented she was totally dependent on staff for toileting and she was always incontinent of bowel and had an indwelling catheter. In an interview on 09/26/2012 at 11:30 A.M., the DON stated staff were in-serviced monthly and they held an in-service on incontinent care last evening. The facility's policy and procedure, titled "Changing a Brief," which was not dated, documented the following: (in part) "Undo incontinent brief; clean resident; remove gloves and discard; wash hands; apply a second pair of gloves; replace gresh brief." The facility's In-service record titled, "Pericare Procedures," dated 09/25/2012, documented the following: (in part) "CNAs must follow correct procedures for pericare for residents. Clean from front to back, change gloves from dirty to clean areas, and wash hands before gloving." The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 09/21/2012, documented there were 50 residents incontinent of bladder, 36 residents incontinent of bowel, and 15 residents with indwelling catheters.

Based on observation, interview, and record review the facility failed to provided adequate supervision and assistance to prevent accidents for 1 of 1 resident (ID #18) reviewed for transferring using a hoyer lift, and 2 of 5 residents (ID #4 and 9) reviewed for use of side rails while in bed, by failing to ensure: A. 2 of 2 CNAs (CNAs A and B) used the hoyer lift in accordance with the manufacturer's operating instructions and the facility policy when assisting resident ID #18 out of bed. Resident ID# 18 sustained a fall and was transported to the hospital for x-rays. X-ray reports indicated a fracture involving the proximal tibial metaphysis. Resident ID #18 was transported back to the facility with an immobilizer to the left knee, orders for pain medication, non-weight bearing, and a follow up x-ray to left knee in one month. B. side rails were not used as a restraint to prevent attempts to get out of bed for Resident ID #4 and 9. The facility's failure could affect any of the 4 residents requiring the hoyer lift for transfers or the 36 residents with full side rails by placing them at risk for avoidable injury. The findings included: Resident ID #18 Record review of resident ID #18's August Physician Orders, documented she was an [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Acute Venous Embolism and Thrombosis of unspecified site. Record review of resident ID #18's Quarterly MDS Assessment, dated 08/13/2012, documented the following: She had no cognitive deficit; extensive assistance with the support of two persons for bed mobility, locomotion on the unit, dressing, toileting, and personal hygiene. She was total dependence with the support of two staff for transfers and bathing. Record review of resident ID #18's Comprehensive Plan of Care for Activities of Daily Living, dated 08/13/2011, documented she was a total assist with the support of two staff for transfers using the Hoyer lift. In an interview on 09/28/2012 at 9:50 A.M., Resident ID #18 stated she was in bed and CNA A and B placed her on the hoyer lift pad and attached the pad to the hoyer to put her in a shower chair. She stated the hoyer lifts legs were under her bed and CNA A pulled the hoyer away from the bed. The legs of the lift were not spread out. She stated she could see the legs and the they were together. When CNA A turned the hoyer to place her in the shower chair, the hoyer tilted forward. She stated CNA A and B tried to stabilize the hoyer and held onto the lift pad. She stated her left knee came forward up against her chest when she hit the floor. Resident ID #18 stated it was supper time and the CNAs were trying to hurry. She also stated she has to be careful not to move her leg due to the pain. Resident ID #18 stated she has used the hoyer lift over the last two years, at least two times a day and now she is afraid to use the lift. In an interview on 09/28/2012 at 10:10 AM, the Administrator stated he was in the building when the incident occurred. He stated CNA A told him he wasn't sure what happened. The Administrator also stated CNA A told him he spread the base legs of the hoyer lift, pulled the lift away from the bed, turned the lift, and the lift tilted forward. Stated he did not have manufacturer's operating instructions for the lift but would try and locate the instructions. In an interview on 09/28/2012 at 10:15 AM, the maintenance supervisor stated the hoyer had recently been serviced. He stated one of the bars that assist with spreading the base legs of the hoyer needed to be replaced. He also stated the guy that replaced the bar that spreads the base legs of the hoyer, stated the bar may be too long and he would have to order one. In an interview on 09/28/2012 at 10:50 AM, CNA A stated CNA B approached him to assist her with resident ID #18 to get her out of bed and into the shower chair. He stated the lift pad wasn't the right size for resident ID #18 and they had to put another pad under the resident. He stated he pushed the hoyer lifts legs under the bed, spread the legs, and locked the wheels. He stated when he pulled the lift away from the bed and turned the lift with the resident, the lift tilted forward. He stated CNA B ran to help him stabilize the lift but the resident was too heavy and she fell forward and landed on the floor. CNA A stated he had been inserviced on how to use the hoyer lift. In an interview on 09/28/2012 at 10:58 A.M., CNA B stated she was going to take resident ID #18 to the shower room. She stated she asked CNA A to assist with getting the resident out of the bed. She stated the resident was on the lift pad and secured to the hoyer. She then stated CNA A raised the lift pad off the bed and pulled the hoyer away from the bed. She stated CNA A turned the hoyer to the left, the legs that stabilize the hoyer were closed and the hoyer tilted forward. She stated the resident fell forward and hit the floor. She stated she did not know why the legs of the hoyer were closed. CNA B stated she was inserviced on how to use the hoyer. Facility's Accident/Incident Report documented the incident occurred on 09/26/2012 at 4:40 PM. The incident involved resident ID #18 and the use of a hoyer lift. Recommended steps to prevent recurrence: replace the hoyer lift with more stable actuation arm and better leg stabilizer locks. Nursing Progress Notes documented the following: -09/26/2012 at 4:40 P.M.: resident fell while being transferred via hoyer lift. sent to the hospital for X-rays and evaluation. -09/27/2012 at 4:00 P.M.: resident returned from hospital, awake, alert, and oriented. Left leg in an imobilizer from ankle to thigh. physician's orders [REDACTED]. Resident is extremely sore and tearful due to left leg pain. Radiology Report, dated 09/26/2012 at 5:50 P.M., documented indication of knee injury and impression of suggestion of a fracture involving the proximal tibial metaphysis. Facility's Internal Investigation dated 09/26/2012, documented the following (in part): possible hoyer lift malfunction resulting in lift tilting over and resident falling, hoyer red tagged after maintenance assessed, and hospital reports fracture to left leg. Notification of State on 09/27/2012 at 1:55 P.M. Invoice record from American Scale Company dated 08/02/2012, documented the following (in part): adjustments made as necessary, tightened loose bolts, screws and handles. The lift is safe for patient use, as long as they are used by manufacturer's specifications. Hoyer lift needs new cross support for 450 pound lift. Facility's policy title "Transfer, Two Person Hoyer (Mechanical) Lift," not dated, documented the following (in part): "Position wheelchair so that you can maneuver the lift safely from the bed to over the chair. Roll resident on his/her side away from you and place the widest part of the sling under the resident's buttocks and thigh. Roll the resident onto the sling. Position lift over the bed, spread the legs of the lift to the widest open position to maintain a broad base of support. Attach the sling to the lift, and raise the sling off the bed until the resident is suspended over the bed. Slowly guide the lift away from the bed and position over the chair. One staff member holds the sling to help keep the resident's hips back in the chair as the lift is lowered." Manufacturer's operating instructions for the hoyer lift, not dated, documented the following (in part): "Spread the base legs to the widest position before lifting." Inservice record titled "Proper transfer using Hoyer Lift", dated 05/05/2009, documented CNA A's name on the attendance sheet. In an interview on 09/28/2012 at 12:00 P.M., the DON stated all staff were inserviced on how to use the hoyer lift. In an interview on 09/28/2012 at 11:50 AM, LVN J stated there were four residents including resident ID #18 in the facility who required the use of the hoyer lift for transfers. Non-harm findings: Resident ID #4 Resident ID #4's Physician order [REDACTED]. Resident ID #4 ' s Physician order [REDACTED]. Resident ID #4's significant change in status MDS assessment, dated 08/30/2012, documented she required extensive assistance with support of two persons for bed mobility, transfers, dressing, toileting and personal hygiene. She did not ambulate and uses a wheelchair for mobility. Resident ID #4 ' s Comprehensive Care Plan dated and last reviewed on 08/30/2012, documented the following (in part): need for bed rails to increase bed mobility, assist with transfers and positioning and to establish bed boundaries. An observation on 09/26/2012 at 11:05 AM, resident ID #1 was sleeping in her bed with full side rails up on both sides. There was a measurement of 3.5/8 inches. between each side rail. From the headboard to the side rail measured 4.3/8 inches., from the footboard to the side rail measured 12 inches, and between the mattress and the rail measured 3.5 inches. In an interview on 09/25/2012 at 10:20 AM, CNA K stated resident ID #4 cannot use the side rails for positioning. In an interview on 09/26/2012 at 11:00 AM, LVN M stated resident ID #4 ' s side rails were the least restrictive due to resident ID #4 has a below the knee amputation and it was difficult to transfer and postion the resident. In an interview on 09/26/2012 at 11:15 AM, the DON stated resident ID #4 ' s side rails were the least restrictive because the resident tries to get out of bed. Resident ID #9 Review of the Record of Admission for Resident ID #9 revealed she was an [AGE] year old female who was initially admitted to the facility on [DATE]. Review of the monthly Physicians Orders, dated September 2012, revealed Resident ID #9's [DIAGNOSES REDACTED]. The monthly orders included an order for [REDACTED]. Review of the Fall Risk Assessments, dated 12/01/11, 3/12/12, 6/11/12, and 9/10/12 revealed Resident ID #9 had not had any falls, and had a total score of "8", which did not represent high risk for falling. Review of the Side Rail Assessment, dated 1/07/11, and most recently updated 9/10/12, revealed no changes had been made in the assessment. The assessment documented Resident ID #9 had used the side rails since admission to the facility, the resident had not expressed the desire to have the side rails on her bed, the resident did not have a history of falls, there was not evidence the resident may have a desire or reason to get out of bed, and alternative interventions to the use of side rails did not create more risk. Review of the Permission for Use of Restraints form, signed and dated 6/09/09 by Resident ID #9's daughter, revealed consent had been given for side rails to be used on two sides of the bed, at the time of the resident's admission to the facility. Review of the quarterly MDS assessment, dated 9/10/12, revealed Resident ID #9 was assessed as requiring extensive assistance with two or more persons physically assisting, with bed mobility. Review of the care plan, dated 12/14/11, revealed Resident ID #9 needed bed rails to increase bed mobility, assist with turning and repositioning, and to establish bed boundaries. The care plan documented the side rails were to be raised on both sides and secured while the resident was in bed, and the resident repositioned herself. The care plan updates on 3/15/12, 6/11/12, and 9/10/12 documented to continue the plan of care, with no further comments or revisions/changes. Observation on 9/26/12 at 1:35 PM revealed Resident ID #9 was seated in the recliner in her room. The resident's bed had the side rail raised on the side of the bed positioned against the wall. Upon raising the side rail on the side of the bed toward the inner area of the room, the side rail was observed to be "shaky" and not securely attached to the bed frame. The release knob was missing for lowering the side rail. CNA L entered the room and demonstrated how to lower the side rail, by pulling up on the threaded bolt/screw with the missing knob and pushing down on the side rail. In an interview on 9/26/12 at 1:40 PM, CNA L stated Resident ID #9 used side rails up on both sides of the bed while she was in bed. The CNA stated she thought the resident had used the side rails in bed "since she came here". CNA L stated the resident did not turn and reposition herself in bed. The CNA stated she usually turned the resident when she provided incontinent care and "cleans her up". Observation on 9/26/12 at 1:50 PM, accompanied by the CMM (Medicare Manager), revealed when the inner room side rail was raised on Resident ID #9's bed, it was not the full length of the bed mattress and bed frame. A gap of space approximately 11 inches long was measured between the end of the raised side rail and the foot board, and a gap of space approximately 5 inches long was measured between the end of the raised side rail and the head board. An approximate 2 inch wide gap of space was measured between the mattress and the side rail at the bottom half of the mattress, and an approximate 1-1/2 inch wide gap of space was measured between the mattress and side rail at the top half of the mattress. An approximate 5 inc gap of space was measured between the end of the mattress and the foot board. In an interview on 9/26/12 at 1:50 PM, the CMM stated she considered the raised side rails to be full length. She stated Resident ID #9 needed the side rails elevated, as she tried to get out of bed and had tried to put her leg over the side rail one time. The CMM stated the resident "rattles" the side rail sometimes. She stated the resident's family wanted her to have side rails, as they thought she tried to get up. The CMM stated Resident ID #9 had always had the same side rails, and no other type of side rail had been tried on her bed. She stated the resident may need a low bed with a scoop mattress and a bedside floor mat. In an interview on 09/28/2012 at 11:50 AM, LVN J stated there were four residents, including resident ID #18, who required the use of the hoyer lift for transfers. On 09/25/2012 at 3:15 PM, the administrator provided a list of 36 residents who had full side rails.

Based on observation, interview and record review, the facility failed to ensure 3 of 8 residents (ID #'s 2, 3 and 4) reviewed for pressure ulcers received the necessary treatment and services to prevent pressure ulcers from developing, promote healing and prevent infection. The facility failed to: A. ensure resident ID #3, who was admitted to the facility without pressure ulcers, did not develop pressure ulcers by failing to; - identify a pressure ulcer to the left hip until it was unstageable; and - obtain treatment orders for unstageable pressure sore to lower right buttock (posterior upper right thigh) that was identified on 6/11/11 until 6/13/11; and - provide treatments as ordered by the physician. B. ensure residents ID #2 and 4 received pressure ulcer treatments as ordered by their physicians and in a manner to promote healing and prevent infection. The facility's failures could affect any of the 11 residents residing on the respiratory unit by increasing their risk for developing pressure ulcers and infections. The findings included: Resident ID #3 Review of Record of Admission for Resident ID #3 revealed he was a [AGE] year old male admitted to the facility on [DATE]. Review of the Admission Nursing assessment dated [DATE] for Resident ID #3 revealed the resident was admitted to the facility with a [DEVICE] (gastrostomy tube for feeding), foley catheter, tracheotomy (for breathing), and an old scar to the right inner knee; required total assistance; non-weight bearing and on bedrest; and unresponsive. Review of the Daily Skilled Nurse's Notes dated 3/16/11 for Resident ID #3 revealed skin concerns were surgical wounds for a tracheotomy and a PEG (feeding tube) and no documented pressure ulcers. Review of the Braden Scale-For Predicting Pressure Sore Risk dated 3/16/11 for Resident ID #3 revealed the form was not completely filled out and was not scored. Review of the Nutritional Assessments performed for Resident ID #3 on 3/23/11, 4/19/11 and 5/24/11 revealed the assessments documented "NO WOUNDS REPORTED". Review of the admission MDS 3.0 dated 3/29/11 for Resident ID #3 revealed the following: - admitted from acute hospital - Short & Long-term memory problems - Severely impaired cognitive skills - bed mobility - total dependence on two + persons physical assist - ROM - impairment on both sides of the upper and lower extremities - Indwelling catheter - Incontinent of Bowel - Diagnosis - [MEDICAL CONDITION], Heart Failure, Diabetes Mellitus, [MEDICAL CONDITIONS] Disorder, Tracheotomy status and Dependence on Respirator status. - Height - 76 inches; Weight - 272 pounds - Feeding tube for nutrition - At risk for Pressure Ulcers - No unhealed pressure ulcers - Pressure reducing device for bed Review of the TAR for March, 2011 for Resident ID #3 documented skin barrier to buttocks prn preventative, the only initialed treatment was on 3/16/11. Review of the Physicians orders for May, 2011 for Resident ID #3 documented "SKIN BARRIER TO BUTTOCKS PRN AS PREVENTATIVE" with an order date of 3/16/11. Review of the orders revealed no other treatment orders for the buttocks. Review of the TAR for April, 2011 for Resident ID #3 documented a treatment which started on 4/13/11 for "Apply [MEDICATION NAME] to buttocks abrasion Q shift & prn", the only shift with documentation was the 7-3 shift. Review of the weekly skin condition reports for Resident ID #3 revealed the following: - Right & Left buttock (shearing or abrasion) 4/13/11 Size - no measurements, pink and red in color, serous exudate, scant amount, no odor, progress-new and [MEDICATION NAME] treatment 4/21/11 Size - 10 x 8 cm, red and pink in color, serous and serosanguinous exudate, small amount, no odor, progress - not changed, continue treatment 4/29/11 Size - 10 x 6 cm, red and pink in color, serous and serosanguinous exudate, scant amount, no odor, progress - improved, continue treatment - Right & Left Buttock (unstageable) 5/05/11 Size - 9 x 4.5 cm, red in color, serosanguinous exudate, small to moderate amount, no odor, and progress - improved, continue treatment 5/25/11 Size - 9 x 6 cm, red in color, serosanguinous exudate, small to moderate amount, odor present, deteriorated progress, continue treatment 6/04/11 Size - 10 x 6.2 cm, black, serous and foul purulent exudate, small to moderate amount, odor present, deteriorated, treatment santyl - Left Hip (Stage 4 - necrosis) 5/23/11 Size - 3 x 3 cm, black in color, no exudate, no odor, progress-new, treatment normal saline, and santyl. (Review of nurses notes dated 5/23/11 at 1400 (2 PM) for Resident ID #3 revealed the following: providing wound care at this time - approximately 1.5 inch x 1.5 inch eschar area to left hip noted - new/order to cleanse left hip with normal saline, pat dry- apply santyl ointment and dry dressing, change qd and prn.) 6/01/11 Size - 3.2 x 3 cm, black and pink in color, no exudate, no odor, progress - deteriorated, continue treatment 6/08/11 Size - 3.4 x 3.2 cm, black in color, no exudate, no odor, deteriorated, continue treatment In an interview with the ADON on 6/12/11 at 1:45 PM revealed the previous treatment nurse had left on 5/5/11 and the new treatment nurse had started after that. In an interview with LVN "A" on 6/12/11 at 3:00 PM the LVN stated she was the new treatment nurse for the facility. She stated she was unsure who performed the treatments or the measurements of pressure ulcers during the 2 week time period when the old treatment nurse left on 5/5/11 and when she started. Review of the TAR for May, 2011 for Resident ID #3 documented the following: - no treatments orders or documentation for the buttocks until 5/11/11 - 5/11/11 clean both buttock areas with normal saline or wound cleanser, apply [MEDICATION NAME], apply dry dressing, change qd and prn - 5/23/11 cleanse left hip wound with normal saline pat dry, apply santyl ointment and dry dressing, change qd and prn - Culture coccyx and send to lab for analysis on 5/26/11 Review of wound culture results for Resident ID #3 dated 5/28/11 documented the resident's wound had "ACINETOBACTER BAUMANNII" (resistant to most antibiotics, causes pneumonia, UTI's [MEDICAL CONDITION], enters through wounds, catheters and breathing tubes)organism and was susceptible to "TIGECYCLINE" and the lab results documented new/order received Tigecycline 50 mg IV every 12 hours x 10 days. Review of the Physicians orders for June, 2011 for Resident ID #3 documented "SKIN BARRIER TO BUTTOCKS PRN AS PREVENTATIVE" with an order date of 3/16/11 and "CLEANSE L. HIP WITH NS. PAT DRY. APPLY SANTYL AND APPLY DRY DRESSING. CHANGE Q DAY AND PRN" with an order date of 5/23/11. Review of the orders revealed no other treatment orders for the buttocks. Review of the facility weekly skin reports for Resident ID #3 revealed the following: 5/26/11 Right Buttock: in-house (no), stage II, 9 x 3 cm, stable wound, treatment orders-normal saline, [MEDICATION NAME], dry dressing; Left Buttock: in-house, unstageable, 11 x 6 cm, eschar, stable wound, treatment orders - normal saline, santyl and dressing; Left Hip: in-house, unstageable, 3 x 3 cm, eschar, stable wound, treatment orders - normal saline, santyl and dressing. 6/10/11 Right Buttock: in-house (no), stage II, 9 x 6 cm, stable wound, treatment orders-normal saline, [MEDICATION NAME], dry dressing; Left Buttock: in-house, unstageable, 11 x 6 cm, eschar, stable wound, treatment orders - normal saline, santyl and dressing; Left Hip: in-house, unstageable, 3 x 3 cm, eschar, stable wound, treatment orders - normal saline, santyl and dressing. Review of the TAR for June, 2011 on 6/11/11 for Resident ID #3 revealed the following: - cleanse left hip with normal saline, pat dry, apply santyl and apply dry dressing, change q day and prn - cleanse both buttock areas with normal saline or wound cleanser, apply [MEDICATION NAME], apply dry dressing q day and prn - pack the ulcer on buttock with 4 x 4, soaked with [MEDICATION NAME] every 8 hours and pack loosely with start date of 6/5/11. - Review of the TAR documentation revealed the pack dressing was only documented as done on the 7-3 shift from 6/8/11 thru 6/11/11. Review of the Doctor's progress notes for Resident ID #3 dated 6/5/11 revealed the following: - has developed deep stage 4 pressure ulcer in s.c. {sacral/coccyx} area with deep necrotic tissue - needs procedures: 1st - diverting [MEDICAL CONDITION], 2nd - deep debridement followed by wound vac Review of outpatient hospital record for Resident ID #3 dated 6/10/11 documented "[MEDICAL CONDITION]" return back to N.H. (nursing home). Observation of Resident ID #3 on 6/11/11 at 12:40 PM during wound care performed by LVN "B" and accompanied by CNA's "D" and "E" revealed the following: - Resident was on his back asleep, the head of bed was elevated, was on a bariatric size bed with a bariatric pressure-relieving mattress, had a tracheotomy to a ventilator, [DEVICE], [MEDICAL CONDITION] (collection bag for bowel movements), and a foley catheter to bedside drainage. - Skin observation revealed 4 pressure ulcers: right buttocks, left buttocks, left hip and right lower buttocks; all 4 areas were observed to have black-necrotic (dead skin) tissue. - CNA "D" was not observed to perform hand hygiene prior to leaving the residents room. - LVN "B" was observed to clean the right lower buttocks with normal saline, apply [MEDICATION NAME] ointment and was left open to air. Review of physicians orders for Resident ID #3 on 6/11/11 revealed there was not an order for [REDACTED]. In an interview with LVN "B" on 6/11/11 at 12:40 PM the LVN revealed Resident ID #3 was currently on antibiotics for a wound infection and all wounds were unstageable due to eschar. She stated she thought the buttock wounds had started as abrasions. She stated she was not responsible for measuring or staging of the residents wounds, that the facility had a treatment nurse. Review of physicians orders for Resident ID #3 on 6/13/11 revealed a telephone order written on 6/13/11 for right posterior thigh, 0.5 x 1 cm eschar, cleanse with wound cleanser, apply santyl, cover with dry dressing, change q day and prn. In an interview with the DON and ADON on 6/13/11 at 4:15 PM the interview revealed Resident ID #3 was admitted to the facility without any pressure ulcers. The DON stated the facility utilizes air mattresses on residents that have a Stage III or IV pressure ulcer or if a resident has multiple Stage II pressure areas. The DON stated she did not realize the pressure sore to Resident ID #3's hip was staged as a II on the skin reports but she was aware the pressure sores were necrotic. She stated she felt the pressure sores to the resident's buttocks had started from shearing. The DON stated the resident was not on an air mattress due to [MEDICAL CONDITION]. She stated the resident had been on an air mattress but he had been switched to a regular pressure relieving mattress after having a [MEDICAL CONDITION]. In an interview with the ADON on 6/15/11 at 10:10 AM she revealed Resident ID #3 had been on a regular size air mattress not a bariatric size air mattress. She stated the facility did utilize bariatric size air mattresses. The ADON stated she had not been able to find any documentation concerning when and how long the resident had been on an air mattress before he had a [MEDICAL CONDITION] and it was removed. In an interview with LVN "B" on 6/15/11 at 11:10 AM the LVN revealed while she was performing treatments to Resident ID #3 on 5/23/11 she found the wound to the left hip. She stated when she discovered the hip wound it already had eschar. In an interview with the medical director on 6/15/11 at 12:15 PM the physician revealed he had performed a [MEDICAL CONDITION] on Resident ID #3 to aid in wound healing. He stated the resident would benefit from a bariatric rotating air mattress. He also stated when the [MEDICAL CONDITION] was healed the resident would require debridement of his wounds. In an interview with the weekend treatment nurse LVN "C" on 6/15/11 at 12:30 PM the LVN revealed she was unsure why the treatment orders were not on the Treatment Sheets for Resident ID #3 until May 11, 2011. She stated on the 11th of May when she performed the treatments to the residents buttocks she realized he needed to have a covered dressing and wrote the new order. In an interview with the ADON on 6/15/11 at 12:35 PM the ADON revealed she was unsure why Resident ID #3's treatment orders were not on his TAR until 5/11/11. She stated several nurses are responsible for putting orders into the computer. The ADON stated the old treatment nurse was responsible for the order to the residents buttocks; however, she was unable to find a telephone order for the treatments until the treatment was changed on 5/11/11. She stated if a telephone order was not written then the order would not have been put into the computer and the treatments would not get printed onto the TAR. Review of the telephone orders on 6/15/11 for Resident ID #3 revealed the following clarification orders were written by LVN "C" and signed by the physician on 6/15/11: - 4/13/11 Apply [MEDICATION NAME] to buttocks abrasions q shift and prn - 5/11/11 Cleanse both buttocks areas with normal saline or wound cleanser, apply [MEDICATION NAME], apply dry dressing, change qd and prn. Resident ID #4 Review of Record of Admission for Resident ID #4 revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Skin Condition Report for Resident ID #4 dated 4/12/11 revealed the resident was admitted to the facility with an Unstageable/Stage IV Pressure Ulcer to the coccyx with measurements of 3.5 x 8.4 x 0.5 cm, red and yellow in color, serous exudate, small amount, no odor, with treatment of [REDACTED]. Review of telephone orders for Resident ID #4 revealed the following: - 4/12/11 Cleanse unstageable wound to coccyx (3.5 x 8.4 x 0.5) with normal saline, apply santyl, calcium alginate and cover with dressing - 5/26/22 Wound culture to coccyx - 5/27/11 [MEDICATION NAME] 500 mg per [DEVICE] bid x 10 days; febrile/wound healing - 5/30/11 DC [MEDICATION NAME] order; [MEDICATION NAME] 600 mg per [DEVICE] bid x 10 days; contact isolation, dx-MRSA/wound - 6/01/11 DC current treatment to coccyx with alginate - change to: cleanse coccyx wound with Normal Saline, pat dry - apply [MEDICATION NAME] and collagen, cover with dry dressing - change every day and prn. - 6/07/11 DC [MEDICATION NAME] order; change to [MEDICATION NAME] 100 mg per [DEVICE] bid x 7 days d/t (due to) adverse reaction to [MEDICATION NAME]. Review of facility skin report dated 6/10/11 documented Resident ID #4 had a Stage IV pressure ulcer to her coccyx with a size of 4 x 3.5 x 2.5 cm with treatment orders of cleanse with normal saline, santyl, calcium alginate, and dressing. (Telephone order dated 6/01/11documented to DC current treatment to coccyx with alginate - change to: cleanse coccyx wound with Normal Saline, pat dry - apply [MEDICATION NAME] and collagen, cover with dry dressing - change every day and prn.) Review of TAR for Resident ID #4 on 6/11/11, for the month of June, 2011, revealed a treatment to Stage IV to buttock/coccyx, cleanse with normal saline or wound cleanser, apply santyl, calcium alginate and cover with dressing every day and prn. Review of the TAR revealed the treatment was initialed as being performed on June 5, 7, 8, 9, 10 and 11 (June 1, 2, 3, 4 and 6 were blank). Observation of Resident ID #4 during incontinent care, provided by CNA's "D" and "E", on 6/11/11 at 10:27 AM revealed the following: - isolation equipment provided at the door entrance - both CNA's applied isolation equipment (gown and gloves) - Resident was on her back on a regular pressure relieving mattress. Had a tracheotomy to a ventilator, [DEVICE], and a foley catheter - Skin observation revealed the resident had a open pressure ulcer to the coccyx that was not covered with a dressing - Resident had bm on her buttocks and dried bm (bowel movement) on the bottom sheet and between her legs - CNA "D" utilized incontinent wipes from a package to perform incontinent care - CNA "D" performed incontinent care on the resident, then touched the package of wipes and the clean linens without removing her soiled gloves. In an interview with CNA's "D" and "E" on 6/11/11 at 10:27 AM, the aides revealed Resident ID #4 was on isolation [MEDICAL CONDITION] (methycillin resistant staph aureus) to her wound. They stated they had given Resident ID #4 her bed bath this AM between 7:45 AM and 8:00 AM and her wound did not have a dressing on it. The CNA's stated the resident's wound was usually covered with a dressing. In an interview with LVN "A" on 6/12/11 at 3:00 PM the LVN stated if a dressing came off it should be put back on as soon as possible after finishing whatever task was being performed. She also stated if a dressing became saturated with drainage it should be replaced. Interview with LVN "B" on 6/11/11 at 11:05 AM revealed she usually worked Monday thru Friday and not on the weekends. She stated the facility had a treatment nurse that performed treatments during the week and the weekend RN who usually performs treatments had called-in. She stated she would be responsible for the treatments. The LVN stated she was not aware Resident ID #4 did not have a dressing covering her pressure ulcer. In an interview with LVN "B" on 6/11/11 at 12:16 PM, the LVN revealed Resident ID #4's infection was in her pressure wound (that did not have a dressing on it). She stated she thought the wound was a Stage III but she was unsure because the treatment nurse was responsible for staging and measuring wounds (based on skin report wound was Stage IV). Observation of Resident ID #4, on 6/11/11 at 12:16 PM during wound care performed by LVN "B", revealed the pressure ulcer to the coccyx was cleaned with normal saline, santyl ointment applied, followed by "Colactive"collagen and the ulcer was covered with a dressing. In an interview with LVN "B" on 6/11/11 at 2:00 PM the LVN revealed she did not know why Resident ID #4 was not on an air mattress. In an interview with the DON on 6/13/11 at 4:15 PM the DON revealed she was unaware Resident ID #4 was not on an air mattress. Resident ID #2 Review of Record of Admission for Resident ID #2 revealed he was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of lab results for Resident ID #2 revealed the following: - 6/4/11 wound culture results were Providencia Stuartii organism (mostly found in urine first, also in stool, blood and can cause infectious endocarditis); Review of History and Physical dated 6/5/11 for Resident ID #2 revealed problems which included extensive Stage IV decubital ulcers, exposure of bone and chronic osteo[DIAGNOSES REDACTED]. Review of wound care evaluations with treatment interventions dated 6/6/11 for Resident ID #2 revealed the following for the residents right leg: - Stage III pressure ulcer to the right calf measuring 25.0 x 5.5 cm; clean with normal saline or wound cleanser apply Santyl to wound bed and apply [MEDICATION NAME] powder, calcium alginate to absorb excess drainage and cover with non-bordered foam, wrap with gauze and secure with tape; change daily. - Unstageable pressure ulcer to right outer knee measuring 2.50 x 2.50 cm; clean with normal saline or wound cleanser apply Santyl to wound bed and apply [MEDICATION NAME] powder, calcium alginate to absorb excess drainage and cover with non-bordered foam, wrap with gauze and secure with tape; change daily. - Stage III pressure ulcer to lower right calf measuring 4.0 x 1.5 cm; Clean with normal saline or wound cleanser, apply [MEDICATION NAME] to the wound bed, apply collagen to promote granulation tissue, cover with a bordered foam, change daily. - Stage III pressure ulcer to upper right calf measuring 3.5 x 3.5 cm; clean with normal saline or wound cleanser, apply [MEDICATION NAME] to the wound bed, apply collagen to promote granulation tissue, cover with a bordered foam, change daily. Review of telephone orders for Resident ID #2 revealed an order dated 6/10/11 for [MEDICATION NAME] (antibiotic) 1 GM IV q day x 10 days for wound healing and UTI. Review of facility skin report dated 6/10/11 documented Resident ID #2 was admitted to the facility with pressure ulcers to the following 15 areas: left outer ankle, right lumbar, lower right scapula, upper right scapula, left ischial tuberosity, right lower hip, right outer knee, lower right medial calf, upper right medial calf, sacrum, right heel, right calf, left lateral leg, right mid hip and right upper hip. Observation of Resident ID #2 receiving treatments performed by LVN "B" on 6/11/11 beginning at 10:52 AM and finishing at 12:05 PM, accompanied by the ADON and CNA's "D" and "E" revealed the following: - resident was in bed, on an air mattress, had a foley catheter to bedside drainage, tracheotomy to a ventilator, [DEVICE], [MEDICAL CONDITION], and an IV to the left arm - LVN "B" was finishing the dressing to the residents right leg, blood was noted to be soaking thru the [MEDICATION NAME] gauze; both lower legs were wrapped with [MEDICATION NAME] gauze from below the knees to above the ankles. - the coccyx dressing was soaked with bloody drainage, and the drainage had soaked thru the incontinent pad and onto the sheet below the pad; LVN "B" removed the coccyx dressing; - LVN "B" performed treatments to the resident's pressure ulcers by cleansing with normal saline, applying santyl ointment and calcium alginate, and covering with foam dressings; - LVN "B" removed the dressing to the right lower leg and cleansed it with normal saline, applied santyl ointment and calcium alginate and covered with ABD (abdomen) pads and wrapped with [MEDICATION NAME] gauze - LVN did not apply [MEDICATION NAME] powder, [MEDICATION NAME] and/or collagen as ordered. Review of facility Policy and Procedures for Treatment Nurse Responsibilities (undated) included: - the treatment nurse is responsible for completing the Braden Scale on all residents, weekly skin assessments on all residents, documentation of adverse skin problems, treatment of [REDACTED]. - the treatment nurse must complete the Braden Scale on all residents and ensure that all recommended preventative measures are put in place and being documented correctly - an individual skin sheet is required for each and every adverse skin condition site. The documentation on the skin sheet must include the date of assessment, the size of the area in centimeters, the stage of the wound (if it is pressure related), the color, the odor, presence of drainage, treatment order, progress of wound, special devices, and signature of assessor. - all treatments must have a Physician order [REDACTED]. In an interview with the ADON on 6/11/11 at 10:52 AM the ADON stated the facility had 11 residents that resided on the Respiratory Unit.