Every finding on record at Heritage Hall-Rich Creek

Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to ensure they had sufficient staff to attain the highest practicable well-being. The dining room was not being utilized for breakfast and was not used consistently at the evening meal due to staffing issues on 2 of 3 Units, Unit 1 and Unit 2. The findings included: The facility staff were not utilizing the dining room at breakfast and did not consistently use the dining room for the evening meal due to staffing issues. On 03/12/24 at 1:20 p.m., during an interview with Resident #11 this resident stated the facility did not use the dining room on Sunday morning's and sometimes it was not used because the facility did not have enough help. On 03/12/24 at 1:50 p.m., during an interview with the Administrator this staff stated that sometimes they had to close the dining room in the evenings if they did not have enough help, but it did not happen as much as it previously did. On 03/13/24 at 10:05 a.m., during an interview with the Director of Nursing (DON) this staff stated the dining room was not utilized at breakfast the residents eat breakfast in their rooms, and it has always been that way. On 03/13/24 2:40 p.m., during an interview with Licensed Practical Nurse (LPN) #6 this staff stated they did not use the dining room for breakfast. On 03/13/24 at 2:45 p.m., during an interview with Certified Nursing Assistant (C.N.A.) #4 this staff stated they did not use the dining room in the mornings and did not always use it in the evening. C.N.A. #4 stated some of the residents had stated they would use the dining room if it was available. On 03/13/24 at 2:50 p.m., during an interview with Resident #66 this resident stated the dining room was not used in the morning and the facility wouldn't have enough staff to use it. Resident #66 then stated when the dining room is closed later in the day they did not always know until the last thing, they would be in the dining room and then they had to pick everything up and take it to their room. On 03/13/24 at 4:00 p.m., during an end of the day meeting with the administrative staff the Administrator stated staffing has improved, they have never used the dining room for breakfast and when they tried, they had a low turnout. On 03/14/24 at 8:40 a.m., during an interview with Resident #21 this resident stated that they would use the dining room if it was open for breakfast, they did use the sitting room where they took other residents that required feeding assistance. Resident #21 stated the dining room had more light, was bigger, and more people could join in. On 03/14/24 at 11:20 a.m., the DON provided the survey team with a copy of a policy titled, Food Production. This policy read in part, The dietary department will provide accurate, efficient and consistent meal service .in a pleasant atmosphere .Nursing staff will be assigned to assist in the dining areas at all times . The facility dining room for Unit 1 and Unit 2 was not observed to be used for breakfast during the survey. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and clinical record review facility staff failed to maintain a medication error rate less than 5% during medication pour and pass observation. The surveyor observed medication pour and pass. On 3/13/2024, the surveyor watched three nurses pass medications to six residents for a combined total of 26 opportunities. Nurses' technique and hand hygiene were appropriate to the task. At 8:26 AM, the surveyor observed LPN #7 prepare morning medications for Resident #66. The resident had a physician order for a Lidoderm external patch 5% apply to posterior neck in the morning for pain. The nurse stated there was no tape on the medication cart, so would return to apply the patch later, after some tape had been found. Later in the day (2PM), LPN #7 informed the surveyor the resident had left the building for an appointment and a hold order was entered for the Lidoderm patch. The surveyor counted the Lidoderm patch as medication omission number one. At 8:35 AM, the surveyor observed LPN #7 prepare morning medications for Resident #11. The resident had physician orders for ICaps MV Oral Tablet (multiple vitamins with minerals) Give 1 tablet by mouth one time daily and cholecalciferol oral capsule 125 mcg Give 1 tablet by mouth one time daily. Neither medication was in the medication cart. The nurse stated she would check the storage room later for the 2 medications. Later in the day (2PM), LPN #7 informed the surveyor the medications were not in the storage room earlier, so a hold order had been entered. The surveyor counted these as medication omissions numbers two and three. The administrator, director of nursing, and assistant director of nursing were notified of the concern during a summary meeting on 3/13/2024.

Based on staff interview and clinical record review, the facility staff failed to ensure a minimum data set (MDS) assessment accurately reflected the resident's status for 1 of 23 residents in the survey sample, Resident #53. The findings included: For Resident #53, the facility staff coded the resident's side rails on the 1/17/24 MDS as a restraint when they were being used as an enabler for positioning. Resident #53's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Dementia, Generalized Muscle Weakness, Dysphagia, Aphasia, Other Specified Interstitial Pulmonary Diseases, and Type 2 Diabetes Mellitus. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/17/24 assigned the resident a brief interview for mental status (BIMS) summary score of 6 out of 15 indicating the resident was severely cognitively impaired. Resident #53 was coded as requiring supervision or touching assistance only with eating, and substantial/maximal assistance with rolling from left to right and moving from a lying position to a sitting position. Resident #53's current comprehensive person-centered care plan included a focus area stating in part that the resident required assistance for all activities of daily living related to weakness from a cerebral vascular accident (stroke) with an intervention dated 1/30/24 for 1/2 side rails at the head of bed to aid in turning and repositioning. Resident #53's clinical record included a Bed Rail assessment dated [DATE] which documented bilateral side rails were indicated and would serve as an enabler to promote independence. Resident #53's provider orders included an order dated 9/13/23 stating the resident May have 1/2 side rails at head of bed to aid in turning and repositioning per resident request. Resident is able to voluntarily reposition safely and use side rail controls. The resident's most recent MDS with an ARD of 1/17/24 coded the use of the bed rails as a daily restraint. On 3/13/24 at 9:53 AM, surveyor spoke with licensed practical nurse (LPN) #1 who stated Resident #53's side rails were not being used as a restraint and the coding was done in error. LPN #1 stated a modification should have been done and they will modify the MDS now. On 3/13/24 at 4:03 PM, the survey team met with the Administrator, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and Regional MDS Staff and discussed the concern of Resident #53's inaccurate MDS. No further information regarding this concern was presented to the survey team prior to the exit conference on 3/14/24.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to follow medical provider medication orders for two (2) of 23 sampled residents (Resident #88 and Resident #100). The findings include: 1. The facility staff failed to provide Resident #100's medications as ordered by the medical provider. Resident #100's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/18/24, was signed as completed on 2/20/24. Resident #100 was assessed as able to make self understood and as able to understand others. Resident #100's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact and/or borderline cognition. Resident #100 was assessed as requiring assistance with toileting hygiene, dressing, and bathing. Resident #100's medication administration records (MARs) indicated the following medications had not been provided for the 9:00 a.m. dose on 2/4/24 and on 2/6/24: - cyanocobalamin 500 mcg tablet, - folic acid 1 mg tablet, - Lasix 40 mg tablet, - multivitamin tablet, - sitagliptin 100 mg tablet, - spironolactone 25 mg tablet, - thiamine 100 mg tablet, - ferrous sulfate 325 mg tablet, - rifaximin 550 mg tablet, - lactulose 10 GM orally, and - midodrine 5 mg tablet. The documented reason these medications were not provided was that the resident was (a)bsent from home without meds. Resident #100 was out of the facility for dialysis at the time the aforementioned medications were scheduled to be administered. Resident #100's care plan included the intervention to administer ordered medications for the following focus areas: nutrition/dehydration/fluid maintenance, respiratory, dialysis, and cardiac/vascular. The facility's policy titled Administering Medications (with a revised date of December 2012) indicated: - Medications shall be administered in a safe and timely manner, and as prescribed. - Medications must be administered within one (1) hour of their prescribed time . This policy did not provide guidance to address when medications were scheduled to be administered when a resident is out of the facility for a dialysis treatment. On 3/13/24 at 3:45 p.m., the Director of Nursing (DON) reported the facility staff had an hour window before and after the medications were scheduled for the medications to be given. On 3/14/24 at 8:25 a.m., the DON reported the once-a-day medications could have been scheduled to be administered outside of the resident's dialysis times. On 3/13/24 at 4:03 p.m., the survey team met with the facility's Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Consultant, and Regional MDS Nurse. During this meeting, the failure of the facility's staff to administer Resident #100's medical provider ordered medications was discussed. 28567 2. For Resident #88, the facility staff failed to administer the IV antibiotic Ciprofloxacin per the providers orders. The provider ordered 112 doses of the antibiotic the resident received 111. Resident #88's diagnoses included, but were not limited to, rhadomyolysis, dementia, and stage 4 pressure ulcer of the sacral region. Section C (cognitive patterns) of Resident #88's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/07/24 included a Brief Interview for Mental Status (BIMS) score of 0 out of a possible 15 points. Resident #88's comprehensive care plan included the focus area at risk for skin impairment related to impaired physical mobility, and incontinence, is being treated for a Stage 4 to sacral area. Interventions included administer medications per current order. Resident #88's clinical record included an order for the antibiotic Ciprofloxacin 400 mg intravenously every morning and at bedtime for wound infection for 112 Administrations via picc line. The order date for this medication was documented as 01/12/24. On 01/12/24 Registered Nurse (RN) #2 documented a progress note that read in part, Ciprofloxacin .intravenously every morning and at bedtime for wound infection for 112 Administrations .Awaiting medication to be sent from pharmacy. MD [medical doctor] and RP [responsible party] made aware. A review of the clinical record revealed that Resident #88 received 38 doses of the Ciprofloxacin in January, 58 doses in February, and 15 doses in March for a total of 111 doses. On 03/13/24 at 11:17 a.m., the Director of Nursing (DON) and Nurse Consultant were made aware of the issue regarding Resident #88's antibiotic. On 03/13/24 at 4:00 p.m., during an end of the day meeting with the administrative staff the issue with the missing dose of the antibiotic was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure medications were available for administration for 1 of 20 current residents, Resident #29. The findings included: The facility staff failed to ensure the antibiotic Doxycycline was available for administration. Resident #29's diagnoses included, but were not limited to, methicillin resistant staphylococcus aureus infection (MRSA), history of urinary tract infection, and aphasia. Section C (cognitive patterns) of Resident #29's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/03/24 included a Brief Interview for Mental Status (BIMS) score of 0 out of a possible 15 points. Resident #29's clinical record included a provider order for the antibiotic Hyclate Oral Tablet 100 MG (Doxycycline Hyclate), give1 tablet two times a day for MRSA until 04/20/2024. A review of Resident #29's medication administration record for March 2024 revealed that for March 11, 2024, for both doses Licensed Practical Nurse (LPN) #4 documented a 5 for the administration of the Doxycycline. Per the MAR a 5=hold see progress note. When reviewing the progress notes the surveyor was unable to determine what the code of 5 represented. On 03/13/24 at 12:00 p.m., during an interview with LPN #4 this staff stated the medication was not available for administration and was not available in the stat box (cubex). On 03/13/24 at 4:00 p.m., during an end of the day meeting with the administrative staff the issue with the antibiotic not being administered on 03/11/24 was reviewed. On 03/14/24 at 8:10 a.m., the Director of Nursing provided the survey team with a copy of their policy regarding ordering medications from the pharmacy provider. This policy read in part, .The provider pharmacy is contacted if an emergency arises requiring immediate pharmacist consultation regarding medications ordered and needed prior to the next scheduled pharmacy delivery . On 03/14/24 at 9:23 a.m., during an interview with LPN #2 this staff stated the physician was in yesterday, was made aware of the missed day of antibiotics and the antibiotic was extended for 1 day to make up for the missed doses. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review and facility document review, the facility staff failed to act upon a medication regimen review for 1 of 23 residents in the survey sample, resident #95. The findings include: For resident # 95, the facility staff failed to act upon a physician approved pharmacist recommendation, generated by the December 11, 2023 medication regimen review. Resident # 95 's diagnoses included but were not limited to, unspecified dementia, unspecified mood disorder, major depressive disorder, psychotic disturbance, and anxiety. Resident # 95's significant change minimum data set (MDS), with an assessment reference date (ARD) of 2/28/24, assigned the resident a brief interview for mental status (BIMS) score of 4, indicating severe cognitive impairment. Resident # 95 was also coded as refusing care and wandering during the look back period. Surveyor reviewed Resident # 95's pharmacy drug regimen review dated 12/11/23 which read in part, This resident is receiving the atypical antipsychotic GEODAN (Ziprasidone) which carries a risk to cause adverse metabolic effects. Please consider checking a fasting lipid panel, fasting plasma glucose and A1C, at baseline, 3 months post initiation, and annually to monitor for potential adverse effects. Additionally, monitoring BMI and waste circumference is recommended at baseline, 1 month, 2 month, 3 month, 6 month, and then annually for all patients on atypical antipsychotics. The medical director had checked that they agreed with the recommendation and had signed the form. They did not date the form when they signed it. During further review of the clinical record this surveyor noted that Geodan therapy was initiated 11/27/23. The above lab work was obtained 1/15/24, more than a month after the recommendation was made and less than 3 months post initiation of therapy. Surveyor was unable to locate any waste circumference measurements in the record and only one note made 2/15/24 by the Registered Dietician (RD) addressing BMI, which was documented that day to be 26. On 3/14/24 at 9:46 AM this surveyor interviewed Licensed Practical Nurse (LPN) # 3, who is also the Unit Manager. When asked about the December 11, 2023 recommedation, they stated, yes, I remember this. Let me see what I can find. LPN # 3 returned at 10:43 AM and stated that there was only the 1/15/24 lab. I think when I looked at it, I just saw the part about 3 months. They indicated that there were no measurements of waste circumference done and that the RD had made notes about the BMI. This surveyor explained that there was only one note done February 15, 2024 that addressed the BMI located in the record, but I would look at other notes if they were able to produce them. On 3/14/24 at 10:57 AM this surveyor asked the Director of Nursing (DON) and the Regional Nurse Consultant for a policy regarding Medication Regimen Reviews. The Director of Nursing produced several policies. The first one entitled, Medication Utilization and Prescribing- Clinical Protocol with a revision date of December 2012, read in part, under the heading, Cause Identification, #3, The consultant pharmacist should use the monthly and interim drug regimen review to help identify potentially problematic medications. Under the heading Treatment/Management, # 3 The consultant pharmacist will advise the physician and staff about options to address medication-related issues such as food-drug interactions, effects of medication combinations, and drug-disease interactions. The next policy entitled, Psychoactive Medication with a created date of 3/14/24 read in part, Each resident's drug regimen will be evaluated and monitored by various members of the health care team as specified in this policy, to assure the regimen is free from unnecessary drugs i.e. excessive dose/duplicative therapy, for excessive duration, without adequate monitoring, without adequate indications for use or in the presence of adverse consequences which indicate the does should be reduced or discontinued or any combinations of these reasons. Under the heading Therapeutic Documentation # D. The consultant pharmacist will notify the Director of Nursing Services (DON) in writing of recommendations on a monthly basis. The DON will follow up with the physician as appropriate. A third policy entitled, Organization Aspects Consultant Pharmacist Services Provider Requirements read in part, Y. Provide a report of activities, findings and recommendations to the administrator and the director of nursing on a monthly basis. This includes a consolidation report of all resident reviews, and a summation of monthly findings. A copy of the monthly report will also be maintained by they pharmacy for reference. Individual resident recommendations are provided to prescribers, the facility's medical director and the director of nursing upon completion or following MRR. On 3/14/24 at 12:03 PM the survey team met with the Administrator, Director of Nursing, Regional Nurse Consultant, Assistant Director of Nursing and the Regional MDS Coordinator. This concern was discussed at that time. No further information was provided to the survey team prior to the exit conference.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide special eating equipment for 1 of 23 residents in the survey sample, Resident #8. The findings include: For Resident #8 (R8), the facility failed to utilize a two (2) handled cup with lid and straw for fluids on 3/12/24 and 3/13/24. R8's diagnosis list indicated diagnoses, which included, but not limited to muscle wasting and atrophy at multiple sites and cerebrovascular accident (stroke). On the most recent MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/27/23, R8 was coded as 10/15 on the BIMS (brief interview for mental status) indicating moderately impaired cognition for making daily decisions. She was coded as having functional limitations in range of motion to both upper extremities. R8 was also coded as requiring supervision or touching assistance with eating. On 3/12/24 at 1:25 PM, surveyor observed R8 sitting in wheelchair. Both hands were observed to be closed tightly. R8 stated, she has shaky hands She stated her cup is sometimes placed in a coffee cup to help her be able to take a drink better. On 3/13/24 at 8:16 AM, surveyor observed R8 sitting up in bed. She was drinking from a carton of milk with a straw. Surveyor asked R8 if a 2 handled cup was on her breakfast tray, she said, no. On 3/13/24 at 12:56 PM, surveyor observed R8 eating lunch. The tray was not observed to contain a 2 handled cup. Surveyor read tray-ticket and tray-ticket revealed, Feeding Assistance Devices 2 handled cup (with) w/lid and straw. A review of R8's clinical record revealed the following: A physician's order dated 9/7/23 with a start date of 10/1/23: Regular Diet Mechanical Soft w/(with) Pureed Meats .2 (two) handled cup (with) w/lid & straw . A Nutrition Care Area Assessment-Quarterly, dated 12/22/23, revealed in part: .C. Adaptive Devices, 2 (two) handled cup (with) w/lid and straw . A review of R8's current comprehensive care plan dated 12/22/23 revealed, in part: Provide and serve diet as ordered. On 3/13/24 at 1:22 PM, surveyor interviewed the dietary manager (DM), and asked the process for providing adaptive equipment to the residents. DM stated when adaptive equipment comes back to the kitchen, the dietary department washes it. Surveyor asked DM about R8's adaptive equipment and DM stated she (R8) is to get built-up utensils and 2 handled cup. Surveyor informed DM that R8 did not have the cup for the past two meal observations. DM stated she would look into it. On 03/13/24 at 4:03 PM, administrator, assistant director of nursing, director of nursing, regional nurse consultant, and regional MDS (minimum data set) nurse were informed of this concern. A review of the policy, Assistive Devices and Equipment, revealed in part: .1. Certain devices and equipment that assist with resident .independence are provided for residents. These may include (but are not limited to): a. specialized eating utensils and equipment .3. Recommendations for the use of devices and equipment are based on comprehensive assessment . No further information regarding this concern was presented to the survey team prior to the exit conference on 3/14/24.

Based on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 2 of 20 current residents, Resident #11 and #8. The findings included: 1. Resident #11's Durable Do Not Resuscitate (DDNR) was incomplete. Section #1 and #2 were left blank. Resident #11's diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction, dysphagia, muscle wasting and atrophy, anxiety, and depression. Section C (cognitive patterns) of Resident #11's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/07/24 included a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 points. Resident #11's clinical record included a DDNR dated for 02/13/23. Section #1 and #2 were incomplete. Section 1 of the DDNR read in part, I further certify [must check 1 or 2]: 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . The boxes beside #1 and #2 were blank. Section 2 read If you checked 2 above, check A, B, or C below: The three boxes below were blank. On 03/14/24 at 4:00 p.m., during an end of the day meeting with the administrative staff the incomplete DDNR was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 49622 2. For Resident #8, the facility staff failed to accurately document a physician's order for a LUE (left upper extremity) splint. The findings included: Surveyor made observations of Resident #8 (R8) on 3/12/24 and on 3/13/24. A splint was not visible on her left hand. Two blue splints were observed on R8's nightstand. A physician's order dated 1/8/24, revealed, RESTORATIVE NURSING PROGRAM- . (LUE splints 6 hours daily) 6 times per week. On 3/13/24 at 11:14 AM, surveyor interviewed licensed practical nurse #5 (LPN#5), who informed surveyor that she (R8), is to wear it (splint) every day for six hours. On 3/13/24 at 11:35 AM, surveyor interviewed certified nursing assistant #3 (CNA#3) and asked how often R8 is to wear splint. CNA#3 stated six days per week for six hours a day. CNA#3 stated she (R8) usually wears it from 9 am to 11 am. On 3/13/24 at 3:42 PM, surveyor interviewed assistant director of nursing (ADON). ADON agreed splint was to be worn six days per week for six hours per day. Surveyor informed ADON that CNA#3 stated R8 only wears the splint from 9 am to 11 am. On 03/13/24 at 4:03 PM, administrator, assistant director of nursing, director of nursing, regional nurse consultant, and regional MDS (minimum data set) nurse were informed of this concern. On 3/14/24 at 8:35 AM, ADON brought surveyor a new physician order for R8 dated 3/14/24. ADON informed surveyor the previous order had been entered wrong and it should have read, up to six hours. A review of the physician's order dated 3/14/24, revealed, Restorative Nursing Program .(LUE splints up to 6 (six) hours daily) 6 (six) times per week. ADON brought surveyor a Restorative Nursing Program Plan for R8 dated, 2/9/23 that revealed, .splint wearing up to 6 (six) hours to LUE (left upper extremity). A review of the policy, Medication Orders, revealed in part: .Recording Orders .6. Treatment Orders-when recording treatment orders, specify the treatment, frequency, and duration of the treatment. No further information regarding this concern was presented to the survey team prior to the exit conference on 3/14/24.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure the facility's arbitration agreement addressed residents' right to rescind the agreement within 30 calendar days of signing the agreement. The findings include: The facility's AGREEMENT TO ARBITRATE document did not address residents' right to rescind the agreement within 30 calendar days of signing the agreement. Review of the facility's AGREEMENT TO ARBITRATE document failed to reveal explicit language addressing residents' and/or residents' representatives' right to rescind the agreement within 30 calendar days of signing it. (A signed AGREEMENT TO ARBITRATE document for one (1) of the sampled residents was provided to the survey team.) On 3/13/24 at 9:24 a.m., the facility's Admissions Director reported they did not see language, in the document, addressing the right to rescind within 30 days of signing the facility's AGREEMENT TO ARBITRATE document. The Admissions Director reported the right to rescind within 30 days of signing the AGREEMENT TO ARBITRATE document is discussed when it is signed but isn't documented. The facility's Arbitration Policy (with an effective date of 10/24/22) included the following statement: Admissions personnel must explain to the Resident [sic] or their personal representative that if they sign the agreement, they have the explicit right to rescind the agreement within 30 calendar days of signing it. On 3/13/24 at 4:03 p.m., the survey team met with the facility's Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Consultant, and Regional MDS (Minimum Data Set) Nurse. During this meeting, the failure of the facility's AGREEMENT TO ARBITRATE document to explicitly include information about the right to rescind the agreement within 30 calendar days of signing it was discussed.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure the facility's arbitration agreement addressed the selection of a venue that would be convenient to both parties. The findings include: The facility's AGREEMENT TO ARBITRATE document did not address the selection of a venue. (A signed AGREEMENT TO ARBITRATE document for one (1) of the sampled residents was provided to the survey team.) On 3/13/24 at 10:38 a.m., the surveyor discussed the facility's AGREEMENT TO ARBITRATE document with the facility's Administrator and Admissions Director. The Admissions Director confirmed the agreement did not address selecting the location. The Administrator and Admissions Director reported the plan would be for a mutually agreed upon location to be selected. The facility's Arbitration Policy (with an effective date of 10/24/22) did not address the selection of a location. On 3/13/24 at 4:03 p.m., the survey team met with the facility's Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Consultant, and Regional MDS (Minimum Data Set) Nurse. During this meeting, the failure of the facility's AGREEMENT TO ARBITRATE document to address the selection of a location was discussed.

Based on observation, staff interview, and review of the manufacturer's instructions for the sanitizer, the facility failed to maintain the sanitizing solution used to sanitize food preparation counters and work surfaces at a level to effectively sanitize surfaces in accordance with the manufacturer's instructions. This had the potential to affect 112 of the 113 residents of the facility who receive food from the dietary department. The facility identified one resident who received nothing by mouth. Findings include: On 12/06/21 at 11:15 AM observation in the kitchen revealed there was a red container of sanitizing solution with a wiping cloth inside. The solution measured 50 parts per million (ppm) of Oasis 146 Multi-Quat Sanitizer. The Dietary Director verified the sanitizer was too low and stated it should have been between 150 to 400 ppm. On 12/08/21 at 10:45 AM observation of the Assistant Dietary Director obtaining the sanitizing level of the wiping cloth container of sanitizer, and it measured less than 50 ppm. She verified it was not strong enough to sanitize the food contact surfaces. Just prior to the solution being measured Dietary Employee (DE) 4 was observed using the wiping cloth from the container to wipe off the food counter. At 10:45 PM she stated she was using the solution to clean and sanitize the food preparation counters. The manufacturer's instructions for the Eco Lab Oasis 146 Multi-Quat Sanitizer revealed the sanitizer should be 150 to 400 ppm to sanitize food contact surfaces.

Based on observation, staff interview and facility policy review, the facility failed to ensure medication/drugs were secured to prevent residents from potentially gaining access to them. This had the potential to affect 49 ambulatory residents in the facility with a census of 113. Findings include: On 12/06/21 at 4:00 PM a large (gallon size) white bag with medications marked Omnicare Pharmacy was sitting on the floor behind the nursing station. The top of the bag was sealed shut except for a three-inch portion large enough for the surveyor to get her hand in the bag. The bag remained behind the nursing station with no staff present from 4:00 PM through 4:26 PM. On 12/06/21 at 4:26 PM a pharmacy employee arrived to pick the bag of medications up and three Licensed Practical Nurses (LPNs)1, LPN2, and LPN3 arrived at the nursing station to assist with giving the pharmacy employee the medications. Each of the LPNs verified the medications were behind the nursing station unlocked and with no staff present to supervise them. At 4:28 PM LPN1 and LPN3 stated the medications should have been locked in the medication storage room until the pharmacist arrived. The nursing station was located between Units A, B, and C and was open to the corridor on both ends of the nursing station. At 4:30 PM LPN2 provided a list of medications that were in the bag. Review of the medications revealed the bag contained 30 Mirtazapine (anti-depressant) F/C 15 milligrams (mg) tablets, 60 Trazadone (anti-depressant/sedative) 50 mg HCL tablets, 90 Omeprazole (for heartburn) 20 mg capsules, 23 Pantoprazole (for heartburn) Sodium tablets, and 13 Methenamine (for urinary tract infections) Hippurate 1-gram (gm)tablets. All the tablets were in blister packs. Review of the Storage of Medications policy with a revision date of April 2007 revealed it is the facility policy to keep all drugs and biologicals locked when not in use. A list of residents who were ambulatory, cognitively impaired and wander was requested from the Administrator. On 12/06/21 at 5:15 PM the Administrator provided a resident census sheet with the residents who were ambulatory, wanderers, cognitively impaired on Unit A, Unit B, and Unit C, on the 100 and 200 halls. Review of the list revealed the facility identified 49 ambulatory residents, of the 49 residents, five residents were identified as wanderers and seven residents were identified as having impaired cognition.

Based on Resident interview, staff interview, clinical record review, and facility document review the facility staff failed to follow professional standards of practice for the use of a NPWT (negative pressure wound therapy) device for 1 of 3 residents, Resident #1. The findings included: For Resident #1 the facility staff failed to follow manufacturer's guidelines for the placement of wound vac sponge. Merriam-Webster medical dictionary describes NPWT as a method of drawing out fluid and infection from a wound to help it heal. A special dressing is placed over the wound and a gentle vacuum pump is attached. Resident #1's face sheet listed an admission date of [DATE] and a readmission date of [DATE]. The [DIAGNOSES REDACTED]. Resident #1's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/10/19 assigned the resident a BIMS (brief interview for mental status) of 15 out of 15 in section C, cognitive status. Resident #1's comprehensive care plan was reviewed and contained a care plan for pressure ulcers: is at risk for skin breakdown related to DM (diabetes mellitus) and poor mobility, he was admitted with a surgical wound to left stump with sutures intact kerlix and ace bandage daily . This care plan was initiated on 07/02/19. Interventions for this care plan include 08/08/19 wound vac to left stump. This care plan was updated on 10/10/19 to read pressure ulcers: is at risk for skin breakdown related to DM and poor mobility, wound vac to left stump. Interventions updated to include wound vac as ordered. The orders section of the resident's paper clinical record was reviewed on 11/04/19. It contained a Doctor's Order Sheet dated 08/08/19, which read in part Wound was debrided today. SNAP VAC applied today. Please apply NPWT vac on Saturday (08/10/19). Setting should be continuous at 125 mmhg. Change 3 x week. SNAP VAC can be thrown away on Sat. Any questions call (phone number omitted) or if on weekend. Return in 2 weeks on 08/22/19 @ 10 AM. This order was signed by the wound care physician. According to WoundSource.com, a SNAP VAC is a mechanically powered, disposable NPWT system. Surveyor requested notes from the wound care clinic and was provided these notes on 11/05/18. The initial consultation note from the wound care clinic dated 08/08/19 read in part, Assessment and Plan: Left BKA (below knee amputation) residual limb wound, debridement today then placed Snap vac, then plan to begin KCI (brand of wound vac) vac ASAP (as soon as possible), changed thrice weekly RTC (return to clinic 2 weeks, sooner if concerns. The wound clinic note for 10/08/19 read in part, Assessment and Plan: . And yet again vac is applied poorly, with [MEDICATION NAME] directly to intact skin, about which the facility is contacted again . The wound clinic note for 10/29/19 read in part, Wound care orders are as follows per provider: clean wound with soap and water, rinse well, protect peri wound with na, wound is dressed from wound bed layer to outer dressing with: 1 piece black foam to wound bed drape, track pad, good seal obtained at 125 mmhg, dressing change 3 times a week. Comments: (name omitted) Ombudsman for the state of Virginia notified of continued failure of facility to place NPWT appropriately. Call was made to facility asking to speak with director of nursing or with administrator, we were told both were in a meeting and unavailable. Surveyor spoke with wound care physician on 11/04/19 at approximately 2:40 PM. Surveyor asked physician if he was currently treating Resident #1 at the wound clinic and he stated that he was treating resident for a BKA with non-healing wound. Physician stated that he had encountered some problems with the facility incorrectly placing the foam used in the wound vac, by placing on healthy skin, as well as the wound. Physician also stated that there had been some issues with the functioning of the wound vac pump. The physician stated that he had offered to have someone come to the facility to teach the staff about the wound vac, but the facility had denied this until 10/30/19. Surveyor asked to the physician if he had contacted the facility regarding these issues and he stated that he had contacted the director of nursing twice. Surveyor spoke with the wound care physician again on 11/05/19 at approximately 8:25 AM. Surveyor asked the physician how long he had been treating Resident #1 and the physician stated that he had been treating the resident for the current problem since 08/08/19. Physician stated that he specifically wanted the KCI brand wound vac to be used, but the facility had been using a Cardinal Health brand Surveyor spoke with Resident #1 on 11/05/19 at approximately 7:55 AM. Resident #1 stated they put a new wound vac on when he went to the wound clinic last time (10/30/19). Resident #1 stated he had experienced several issues with the previous wound vac not working correctly, but when he voiced concern to the facility staff they told him it was working right. Resident #1 stated that he had told the nurses doing his dressing changes that they were cutting the sponge for the wound vac too big, but they told him they knew what they were doing. Surveyor spoke with nurse from the wound clinic on 11/05/19 at approximately 9:30 AM. Wound clinic nurse stated Resident #1 was initially seen in the clinic on 08/08/19 for debridement of the wound and placement of the temporary SNAP vac. Surveyor asked the wound clinic nurse if there had been problems with the facility not doing the dressing changes as ordered, and wound clinic nurse stated that she had received a call from Resident #1, where he stated that the facility staff was not doing the dressing correctly. Wound clinic nurse also stated there was an ongoing issue with the wound dressing sponge not being placed correctly in the wound. Surveyor spoke with the DON (director of nursing) on 11/05/19 at approximately 11:10 am regarding Resident #1. Surveyor asked the DON if she was aware of any issues with Resident #1's wound vac. DON stated that she had been told the wound care clinic had said the sponge for the dressing had been cut too big. Surveyor asked DON if anyone from the wound care clinic had contacted her regarding ongoing problems with Resident #1's wound vac dressings. DON stated she had received a message last week (week of 10/28-11/01/19) to call the wound care physician. DON stated she returned the call, but never spoke with wound care physician. DON stated she called the clinic and spoke with a nurse. Surveyor asked the DON why the facility was using the Cardinal brand of wound vac system vs. the KCI system, and DON stated, That's just the provider we use. Surveyor spoke with the facility administrator on 11/05/19 at approximately 12:30. Surveyor asked the administrator if he was aware of any issues with Resident #1's wound care. Administrator stated that he was made aware from the local ombudsman that the wound clinic had reached out to her with concerns of the wound vac not being placed correctly. Administrator stated that he called the wound clinic on 10/31/19 and spoke with wound care nurse at the clinic. Administrator stated that wound care nurse said that there had been some issues with previous dressings, but current dressing (from appointment on 10/29/19) showed improvement/effort. The surveyor requested and was provided with the manufacturer's guidelines for the Cardinal Health wound vac system which read in part, 3.1 Applying the Dressing: 6. Take measurements of the wound dimensions and note wound type. Select the appropriate foam based on wound assessment. Cut the Cardinal Health NPWT foam dressing to a size that is appropriate for the wound. 7. Place the Cardinal Health NPWT foam dressing in the wound site taking care to avoid contact with the peri-wound skin. Note: The Cardinal Health NPWT foam dressing should cover the entire wound base, including tunneling and undermining. However, the Cardinal Health NPWT foam dressing should not be in contact with intact skin. The concern of the facility staff not following the manufacturer's guidelines for the placement of the wound vac sponge was discussed with the administrative staff (administrator, DON, regional nurse consultant) during a meeting on 111/0519 at approximately 3:45 PM. No further information was provided prior to exit. THIS IS A COMPLAINT DEFICIENCY.

Based on staff interview, Resident interview, clinical record review, facility document review and in the course of a complaint survey the facility staff failed to provide care and treatment to meet the needs of the resident for 1 of 3 residents, Resident #1. The findings included: For Resident #1 the facility staff failed to follow physician's orders [REDACTED]. Merriam-Webster medical dictionary describes NPWT as a method of drawing out fluid and infection from a wound to help it heal. A special dressing is placed over the wound and a gentle vacuum pump is attached. Resident #1's face sheet listed an admitted on 06/24/19 and a readmission date of [DATE]. The [DIAGNOSES REDACTED]. Resident #1's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/10/19 assigned the resident a BIMS (brief interview for mental status) of 15 out of 15 in section C, cognitive status. Resident #1's comprehensive care plan was reviewed and contained a care plan for pressure ulcers: .is at risk for skin breakdown related to DM (diabetes mellitus) and poor mobility, he was admitted with a surgical wound to left stump with sutures intact. Kerlix and ace bandage daily This care plan was initiated on 07/02/19. Interventions for this care plan include 08/08/19 wound vac to left stump. This care plan was updated on 10/10/19 to read pressure ulcers: is at risk for skin breakdown related to DM and poor mobility, wound vac to left stump. Interventions updated to include wound vac as ordered. The orders section of the resident's paper clinical record was reviewed on 11/04/19. It contained a Doctor's Order Sheet dated 08/08/19, which read in part Wound was debrided today. SNAP VAC applied today. Please apply NPWT vac on Saturday (08/10/19). Setting should be continuous at 125 mmhg. Change 3 x week. SNAP VAC can be thrown away on Sat. Any questions call (phone number omitted) or if on weekend. Return in 2 weeks on 08/22/19 @ 10 AM. This order was signed by the wound care physician. According to WoundSource.com, a SNAP VAC is a mechanically powered, disposable NPWT system. The orders section of the resident's paper clinical record also contained a handwritten physician's telephone order dated 08/13/19 at 2 pm, which read in part, 1) DC wound vac 125 mmhg 2) Wound vac to Left stump at 120 mmhg continuous. Change Tue-Thur-Sat and prn (as needed) 3) Monitor wound vac to left stump @ 120 mmhg continuous Q (every) shift. The orders section of the paper record also contained a handwritten physician's telephone order dated 08/13/19 at 3 pm, which read in part, 4) Hold wound vac until 8/20/19 then reapply wound vac to left stump. 5) Wet to dry NS (normal saline) dressing to left stump QD (every day) until 8/20/19. LPN (licensed practical nurse) #1 wrote both of these orders. The second of these orders indicated it was a voice order from the wound clinic nurse. The progress notes section of Resident #1's electronic clinical record was reviewed on 11/05/19. It contained a nurse's progress note dated 08/08/19, which read in part, 1:41 PM Resident returned from appointment with wound clinic at 1200 hours alert and verbal. Orders for wound vac at 125 mmhg settings continous (sic) and change 3 times a week . The electronic clinical record also contained a nurse's progress note dated 08/13/19, which read in part, 2:41 PM 10 AM new order received -1) DC (discontinue) wound vac 125 mmhg, 2) Wound vac to left tum at 120 mmhg continuous. Change Tue-Thurs-Sat and PRN (as needed), 3) Monitor wound vac to left stump at 120 mmhg continuous q (every) shift. New dressing applied to left stump, slough tissue noted in wound bed. Surveyor requested notes from the wound care clinic and was provided these notes on 11/05/18. The initial consultation note from the wound care clinic dated 08/08/19 read in part, Assessment and Plan: Left BKA (below knee amputation) residual limb wound, debridement today then placed Snap vac, then plan to begin KCI (brand of wound vac) vac ASAP (as soon as possible), changed thrice weekly RTC (return to clinic 2 weeks, sooner if concerns. The wound clinic note for 09/10/19 read in part, Wound care orders are as follow per above provider: clean wound with soap and water, rinse well. Protect peri wound with na, Wound is dressed from wound bed layer to outer dressing with: Dakins wet to dry applied today as facility did not supply wound VAC supplies. Wound VAC to be restarted upon return to facility at 125 mmhg, dressing change frequency: 3 times a week .The wound clinic note for 09/24/19 read as previous note. The wound clinic note for 10/08/19 read in part, Assessment and Plan: . And yet again vac is applied poorly, with [MEDICATION NAME] directly to intact skin, about which the facility is contacted again . The wound clinic note for 10/29/19 read in part, Wound care orders are as follows per provider: clean wound with soap and water, rinse well, protect peri wound with na, wound is dressed from wound bed layer to outer dressing with: 1 piece black foam to wound bed drape, track pad, good seal obtained at 125 mmhg, dressing change 3 times a week. Comments: (name omitted) Ombudsman for the state of Virginia notified of continued failure of facility to place NPWT appropriately. Call was made to facility asking to speak with director of nursing or with administrator, we were told both were in a meeting and unavailable. Surveyor spoke with wound care physician on 11/04/19 at approximately 2:40 PM. Surveyor asked physician if he was currently treating Resident #1 at the wound clinic and he stated that he was treating resident for a BKA with non-healing wound. Physician stated that he had encountered some problems with the facility incorrectly placing the foam used in the wound vac, by placing on healthy skin, as well as the wound. Physician also stated that there had been some issues with the functioning of the wound vac pump. The physician stated that he had offered to have someone come to the facility to teach the staff about the wound vac, but the facility had denied this until 10/30/19. Surveyor asked to the physician if he had contacted the facility regarding these issues and he stated that he had contacted the director of nursing twice. Surveyor spoke with the wound care physician again on 11/05/19 at approximately 8:25 AM. Surveyor asked the physician how long he had been treating Resident #1 and the physician stated that he had been treating the resident for the current problem since 08/08/19. Surveyor asked the physician what the setting on the wound vac were to be set on, and the physician stated that the setting is to be 125 mmhg, surveyor asked the physician if he had ever given the facility an order to decrease the wound vac setting to 120 mmhg, and he stated that he had not, and that he wanted the setting to be 125 mmhg for the duration of the treatment. Physician stated that he specifically wanted the KCI brand wound vac to be used, but the facility had been using a different brand. Surveyor asked the wound care physician if he was aware that the settings on the wound vac had been decreased to 120 mmhg, and he stated that he was not. Surveyor spoke with Resident #1 on 11/05/19 at approximately 7:55 AM. Resident #1 stated they put a new wound vac on when he went to the wound clinic last time (10/30/19). Resident #1 stated he had experienced several issues with the previous wound vac not working correctly, but when he voiced concern to the facility staff they told him it was working right. Resident #1 stated that he had told the nurses doing his dressing changes that they were cutting the sponge for the wound vac too big, but they told him they knew what they were doing. Surveyor spoke with nurse from the wound clinic on 11/05/19 at approximately 9:30 AM. Wound clinic nurse stated Resident #1 was initially seen in the clinic on 08/08/19 for debridement of the wound and placement of the temporary SNAP vac. Wound clinic nurse stated the facility was to replace the temporary vac on 08/11/19 with one supplied by the facility, but the facility had a problem obtaining a wound vac, so the SNAP vac was not replaced until 08/13/19. Surveyor asked wound clinic nurse if she gave the facility a telephone order to decrease the setting on the wound vac, and wound clinic nurse stated, Absolutely not, our standing orders are 125 mmhg. Surveyor then asked wound clinic nurse if she gave the facility an order to discontinue the wound vac and use wet to dry dressings, and wound clinic nurse stated since the facility was having an issue obtaining a wound vac, she obtained an order for [REDACTED].#1, where he stated that the facility staff was not doing the dressing correctly. Wound clinic nurse also stated there was an ongoing issue with the wound dressing sponge not being placed correctly in the wound. Surveyor spoke with LPN #1 on 11/105/19 at approximately 1:20 PM regarding Resident #1. Surveyor asked LPN #1 if she had written the order to change the settings on the wound vac from 125 mmhg to 120 mmhg, and she stated that she had because the settings on the wound vac being used by the facility did not have a setting for 125 mmhg. Surveyor then asked LPN #1 who gave her the order, and she stated that the order came from the wound care clinic. Surveyor then informed LPN #1 that she had spoken with the nurse from the wound care clinic and that wound clinic nurse had stated that she had not given the order to change the settings on the wound vac. LPN #1 stated to surveyor, Then why would I have numbered the orders 1, 2,3,4,5 if they didn't all come from the same place?. LPN #1 returned to speak with surveyor on 11/05/19 at approximately 2:10 PM. LPN #1 stated to surveyor that she was mistaken about who gave her the order to change the settings on the wound vac. LPN #1 stated to surveyor that the facility's medical director had given the order to change the setting on the wound vac, due to the wound vac system the facility was using did not have a 125 mmhg setting. LPN #1 stated to surveyor, I guess I shouldn't have numbered them that way. Surveyor spoke with the DON (director of nursing) on 11/05/19 at approximately 11:10 am regarding Resident #1. Surveyor asked the DON if she was aware of any issues with Resident #1's wound vac. DON stated that she had been told the wound care clinic had said the sponge for the dressing had been cut too big. Surveyor asked DON if anyone from the wound care clinic had contacted her regarding ongoing problems with Resident #1's wound vac dressings. DON stated she had received a message last week (week of 10/28-11/01/19) to call the wound care physician. DON stated she returned the call, but never spoke with wound care physician. DON stated she called the clinic and spoke with a nurse. Surveyor asked the DON why the facility was using the Cardinal brand of wound vac system vs. the KCI system, and DON stated, That's just the provider we use. Surveyor asked the DON if she was aware that the wound care physician had indicated he preferred the KCI system be used, and DON stated, No one from . (name omitted) office indicated to use the KCI vac. Surveyor spoke with the facility administrator on 11/05/19 at approximately 12:30. Surveyor asked the administrator if he was aware of any issues with Resident #1's wound care. Administrator stated that he was made aware from the local ombudsman that the wound clinic had reached out to her with concerns of the wound vac not being placed correctly. Administrator stated that he called the wound clinic on 10/31/19 and spoke with wound care nurse at the clinic. Administrator stated that wound care nurse said that there had been some issues with previous dressings, but current dressing (from appointment on 10/29/19) showed improvement/effort. Administrator stated that he spoke with a representative from the KCI company and that they are coming to do inservice with staff on the correct placement of the wound vac. Surveyor requested and was provided with a facility policy entitled Negative Pressure Wound Therapy which read in part General Guidelines: 3. Change dressings per physician orders [REDACTED]. Identify and size the wound to be treated. 6. Cut sponge dressing size: a. Using clean scissors or scalpel, trim the sponge dressing material to a size that is slightly smaller than the wound, and a shape that approximates the wound. The concern of the facility staff not following the physician's orders [REDACTED]. No further information was provided prior to exit. THIS IS A COMPLAINT DEFICIENCY.

Based on staff interview, clinical record review and in the course of a complaint survey the facility staff failed to ensure a complete and accurate clinical record for 1 of 3 residents, Resident #1. The findings included: For Resident #1 the facility staff failed to include the name of the prescribing physician on a handwritten telephone order. Resident #1's face sheet listed an admitted on 06/24/19 and a readmission date of [DATE]. The [DIAGNOSES REDACTED]. Resident #1's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/10/19 assigned the resident a BIMS (brief interview for mental status) of 15 out of 15 in section C, cognitive status. Resident #1's comprehensive care plan was reviewed and contained a care plan for pressure ulcers: .is at risk for skin breakdown related to DM (diabetes mellitus) and poor mobility, he was admitted with a surgical wound to left stump with sutures intact. Kerlix and ace bandage daily This care plan was initiated on 07/02/19. Interventions for this care plan include 08/08/19 wound vac to left stump. This care plan was updated on 10/10/19 to read pressure ulcers: is at risk for skin breakdown related to DM and poor mobility, wound vac to left stump. Interventions updated to include wound vac as ordered. The orders section of the resident's paper clinical record contained a handwritten physician's telephone order dated 08/13/19 at 2 pm, which read in part, 1) DC wound vac 125 mmhg 2) Wound vac to Left stump at 120 mmhg continuous. Change Tue-Thur-Sat and prn (as needed) 3) Monitor wound vac to left stump @ 120 mmhg continuous Q (every) shift. The orders section of the paper record also contained a handwritten physician's telephone order dated 08/13/19 at 3 pm, which read in part, 4) Hold wound vac until 8/20/19 then reapply wound vac to left stump. 5) Wet to dry NS (normal saline) dressing to left stump QD (every day) until 8/20/19. LPN (licensed practical nurse) #1 wrote both of these orders. The second of these orders indicated it was a voice order from the wound clinic nurse. Surveyor spoke with nurse from the wound clinic on 11/05/19 at approximately 9:30 AM. Wound clinic nurse stated Resident #1 was initially seen in the clinic on 08/08/19 for debridement of the wound and placement of the temporary SNAP vac. Wound clinic nurse stated the facility was to replace the temporary vac on 08/11/19 with one supplied by them. Surveyor asked wound clinic nurse if she gave the facility a telephone order to decrease the setting on the wound vac, and wound clinic nurse stated, Absolutely not, our standing orders are 125 mmhg. Surveyor then asked wound clinic nurse if she gave the facility an order to discontinue the wound vac and use wet to dry dressings, and wound clinic nurse stated the facility was having an issue obtaining a wound vac, therefore she obtained an order for [REDACTED]. Surveyor spoke with LPN #1 on 11/105/19 at approximately 1:20 PM regarding Resident #1. Surveyor asked LPN #1 if she had written the order to change the settings on the wound vac from 125 mmhg to 120 mmhg, and she stated that she had because the settings on the wound vac being used by the facility did not have a setting for 125 mmhg. Surveyor then asked LPN #1 who gave her the order, and she stated that the order came from the wound care clinic. Surveyor then informed LPN #1 that she had spoken with the nurse from the wound care clinic and that wound clinic nurse had stated that she had not given the order to change the settings on the wound vac. LPN #1 stated to surveyor, Then why would I have numbered the orders 1, 2,3,4,5 if they didn't all come from the same place?. LPN #1 returned to speak with surveyor on 11/05/19 at approximately 2:10 PM. LPN #1 stated to surveyor that she was mistaken about who gave her the order to change the settings on the wound vac. LPN #1 stated to surveyor that the facility's medical director had given the order to change the setting on the wound vac, due to the wound vac system the facility was using did not have a 125 mmhg setting. LPN #1 stated to surveyor, I guess I shouldn't have numbered them that way. The concern of the facility staff failing to include the name of the prescribing physician on a handwritten telephone order was discussed with the administrative staff (administrator, director of nursing, regional nurse consultant) on 11/105/19 at approximately 3:45 PM. No further information was provided prior to exit. THIS IS A COMPLAINT DEFICIENCY.

Based on, clinical record review, staff interview, observation, resident interview, and facility document review, the facility staff failed to ensure a hazard free environment for 1 of 29 residents, Resident #36. The findings included: The facility staff failed to ensure a hazard free environment while transferring Resident #36. Resident #36 sustained a skin tear to the left lower leg during a transfer from the wheelchair to the bed. Resident #36 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of Resident #36's most recent comprehensive MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/25/18 included a BIMS (brief interview for mental status) summary score of 10 out of a possible 15 points. Section G (functional status) had been coded to indicate extensive assistance with two persons physical assist (3/3) for transfer. Resident #36's comprehensive care plan included the focus area: ADL (activities of daily living) Function: Resident requires assistance from staff for daily ADL care ., has interventions that included but were not limited to, Encourage Resident to participate in ADL care as tolerated. The surveyor interviewed Resident #36 on 01/24/19 9:05 am. Resident #36 stated The CNA (certified nursing assistant) was trying to put me to bed and she did something that made the blood run out. It's been there for a month. The surveyor spoke to RN (registered nurse) #1 on 01/24/19 10:39 am. RN #1 voiced that Resident #36 acquired a laceration while being transferred to the bed from wheel chair. RN #1 stated, The foot rest on the wheel chair swung around and caught her left leg. The foot rest are off her wheel chair now. On 01/25/19 at 11:35am, the surveyor interviewed CNA #1 via phone. CNA #1 stated, Resident #36's wheelchair was locked. Resident #36 was assisted to standing and I was using the gait belt per policy. Resident #36 is a one person assist per CNA care plan. Resident #36 was standing with the back of her legs up against the wheelchair. Resident #36's blanket was wrapped around leg rest of wheelchair. She started shaking the wheelchair to loosen the blanket. When the blanket came loose the leg rest swung in, hitting Resident #36 in the left leg causing a skin tear. CNA #1 voiced that she sat Resident #36 on her bed and provided pressure to the wound with a clean towel. CNA #1 called the nurse to evaluate Resident #36 and provide treatment. CNA #1 stated I forgot to take the leg rest off of the wheelchair, but I didn't realize it until Resident #36 was standing to be transferred. I didn't want to leave her standing unsupported or lay the leg rest in the floor as that could be a potential hazard. CNA #1 voiced that she typically transfers Resident #36 without any issue. The surveyor reviewed a facility document titled Resident Incident Report, under the section titled Incident Witness Statement read in part: I was assisting Resident into the bed when the chair got stuck on her bed and blanket. Resident started to tug on her chair while I was holding her up and the chair had gotten free. That's when the leg of the wheelchair came around and knocked into her leg. Resident belted out a loud scream and when I checked her leg she had blood coming out and her leg had a deep skin tear. So I called for the LPN. I held a rag around the wound until the LPN arrived. The foretold statement was signed by CNA #1 and dated 12/15/18. The surveyor reviewed Resident #36's clinical record on 01/28/19 at 10:49am. A nursing note dated 12/15/18 at 10:14pm documented by LPN (licensed practical nurse) #1 read in part: 7:20 pm called to Resident's room. CNA was assisting Resident to bed. Her leg got caught on wheelchair. Place on left leg about 4 inches long and at one point an inch wide, ¼ inch deep. Bleeding from area. Pressure applied to stop bleeding. Steri-strips used to pull area together and triple antibiotic ointment applied. 4x4 applied and wrapped. Resting in bed. Took pain pill and all meds without difficulty .Doctor and responsible party (son) notified. Call light in reach. LPN #1 documented a nursing note dated 12/21/18 at 4:30pm that read in part: New order from doctor received to send Resident to ER (emergency room ) for evaluation of wound . ED (emergency department) summary dated 12/21/18 read in part under Diagnoses: [REDACTED]. skin tear though painful does not appear infected All labs fine .x-ray shows no deep infection . RN #2 documented a nursing note dated 12/22/18 at 1:13am that read in part: Resident returned back to facility .Orders received from doctor to start [MEDICATION NAME] 5/325 every 8 hours as needed .He also wants facility's wound care nurse to follow up on wound care . The administrative team was made aware of the above findings on 01/25/19 at 1:57pm. No further information regarding this issue was provided to the survey team prior to the exit conference on 01/28/19.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide appropriate treatment and services for care of a resident with a clinically justified indwelling catheter when the indwelling Foley catheters were not anchored for 3 of 29 residents (Resident #104, Resident #34, and Resident #69). The findings included: 1. The facility staff failed to anchor Resident #104's indwelling Foley catheter. The clinical record of Resident #104 was reviewed 1/23/19 through 1/28/19. Resident #104 was admitted to the facility 12/10/18 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #104's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/9/19 assessed the resident with a brief interview for mental status (BIMS) as 4/15. Section H Bladder and Bowel was coded for an indwelling catheter (H0100) and urinary continence (H0300) was coded as 9=not rated-resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for entire 7 days. Current comprehensive care plan initiated 1/10/19 identified urinary incontinency/Foley catheter. Resident is at risk for UTIs (urinary tract infections) r/t (related to) Foley placement. Approaches: change Foley catheter every month and as needed (prn), monitor for changes in urine. The (MONTH) 2019 physician orders read Change 16 F (16 French) Foley catheter month (every month). The surveyor observed Resident #104 on 1/23/19 at 2:37 p.m. Resident #104 was in bed. The surveyor observed a Foley drainage bag attached to the bed frame. Resident #104 was being attended to by licensed practical nurse #1. L.P.N. #1 asked if indwelling Foley catheters were anchored. L.P.N. #1 stated, They are supposed to be. When L.P.N. #1 checked the Foley for anchorage, the Foley was not anchored. L.P.N. #1 stated she would get a leg strap. The surveyor observed Resident #104 again on 1/24/19 at 8:36 a.m. Resident #104 was in bed. Licensed practical nurse #2 was attending to the resident. Foley catheter was observed to be unanchored. L.P.N. #2 stated Foleys were supposed to be anchor. The surveyor and L.P.N. # attempted to view the size of the Foley catheter. The only readable number was 10 ml (milliliter). The (MONTH) 2019 physician orders did not have a bulb size identified in the physician order. The surveyor informed the administrator, the director of nursing and the corporate registered of the above concern and requested the facility policy on Foley catheter care during the end of the day meeting on 1/24/19 at 4:14 p.m. The surveyor asked the DON if she would expect the staff to anchor indwelling Foley catheters. The DON stated she would expect staff to anchor Foleys. The surveyor reviewed the facility policy titled Catheter Care, Urinary on 1/25/19. The policy read in part 2. Ensure that the catheters remains secured with a leg strap to reduce friction and movement at the insertion site. (Catheter tubing should be strapped to the resident's inner thigh.) No further information was provided prior to the exit conference on 1/28/19. 2. The facility staff failed to anchor Resident #34's indwelling Foley catheter. The clinical record of Resident #34 was reviewed 1/23/19 through 1/28/19. Resident #34 was admitted to the facility 8/23/18 with [DIAGNOSES REDACTED]. Resident #34's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/21/18 assessed the resident with a BIMS (brief interview for mental status) as 13/15. Section H Bladder and Bowel was coded for an indwelling catheter (H0100) and urinary continence (H0300) was coded as 9=not rated-resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for entire 7 days. The (MONTH) 2019 physician orders read Change 18 F (French) Foley catheter q month (every month). The order did not contain the bulb size of the Foley catheter. The surveyor interviewed Resident #34 on 1/24/19 at 9:58 a.m. The resident was asked if the staff used a strap to hold the catheter to the leg. The resident stated he didn't think it was strapped. Certified nursing assistant #1 was attending to the resident's roommate and was asked to check for anchorage. C.N.A. #1 stated Foleys were supposed to be anchored. When checked, C.N. A. #1 stated the catheter was not anchored but they're supposed to be. The surveyor informed the administrator, the director of nursing, and the corporate registered nurse in the end of the day meeting on 1/24/19 at 4:14 p.m. The surveyor asked the DON if she would expect the staff to anchor indwelling Foley catheters. The DON stated she would expect staff to anchor Foleys. The surveyor reviewed the facility policy titled Catheter Care, Urinary on 1/25/19. The policy read in part 2. Ensure that the catheters remains secured with a leg strap to reduce friction and movement at the insertion site. (Catheter tubing should be strapped to the resident's inner thigh.) No further information was provided prior to the exit conference on 1/28/19. 3. For Resident #69 the facility staff failed to ensure Foley catheter tubing was anchored. Resident #69 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/10/18 coded the Resident 11 of 15 in section C, cognitive patterns. Resident #69's CCP (comprehensive care plan) was reviewed and contained a focus area of Urinary incontinence/foley catheter: Resident at risk for UTI (urinary tract infection) related to chronic foley catheter placement . Interventions included but were not limited to, Provide foley catheter care every shift and as needed. Resident #69's clinical record was reviewed on 01/28/18. It contained a physician's order summary which read in part, Provide foley catheter care every shift and as needed . Resident #69 was observed by the surveyor on 01/23/19 at approximately 1:13 pm. Resident was resting in bed. Surveyor asked Resident #69 if her catheter was anchored. Resident #69 pulled back her sheets and stated No. The surveyor observed the catheter tubing not anchored and was positioned across Resident #69's right thigh. The concern of the Foley catheter not being anchored was discussed with the administrative team during a meeting on 01/24/19 at approximately 4:36pm. The surveyor asked director of nursing (DON) if she expects urinary catheters to be anchored. The DON stated Yes. The surveyor requested a policy on catheter care at this time. The administrator provided the surveyor with said policy titled Catheter Care, Urinary on 01/25/19. This policy read in part under sectioned titled Steps in the Procedure18. Secure catheter utilizing a leg band. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services in accordance with professional standards of care, the resident's care plan and the resident's choice for 3 of 29 residents (Resident #37, Resident #108, and Resident #25). The findings included: 1. The facility staff failed to ensure the physician ordered oxygen amount was delivered to Resident #37 and failed to change the oxygen tubing weekly. The clinical record of Resident #37 was reviewed 1/23/19 through 1/28/19. Resident #37 was admitted to the facility 8/11/18 and readmitted [DATE]. [DIAGNOSES REDACTED]. Resident #37's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/23/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Section O Special Treatments, Procedures, and Programs was coded for oxygen use. Resident #37's current comprehensive care plan identified respiratory as a problem with an onset date of 1/24/19. Resident #37 was at risk for respiratory complications related to [MEDICAL CONDITION] and allergies [REDACTED]. Approaches: Administer meds (medications) as ordered, O2 per MD (medical doctor) order, monitor O2 sats (saturation levels) q shift (every shift), monitor for respiratory complications, monitor lung sounds qshift, and notify MD prn (as needed). The surveyor observed Resident #37 on 1/23/19 4:01 PM. Resident #37 was in bed with oxygen via nasal cannula at 3 liters. The oxygen tubing had a pink sticker that was dated 1/12/19. The surveyor observed Resident #37 again on 1/24/19 at 9:21 a.m. Resident #37 was in bed and finishing breakfast. O2 was at 3 liters and the tubing was dated 1/12/19 The surveyor interviewed licensed practical nurse #3 what oxygen amount was ordered for Resident #37. L.P.N. #3 stated Resident #37 was supposed to have 2 liters. L.P.N. #2 observed the oxygen at 3 liters/nc and changed the liter amount to 2. The surveyor reviewed the (MONTH) (YEAR) physician's orders [REDACTED].@ 2L/M (liters per minute) continuous. The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above concern during the end of the day meeting on 1/24/19 at 4:14 p.m. The surveyor requested the facility policy on respiratory care. The surveyor reviewed the facility policy titled Respiratory Therapy-Prevention of Infection on 1/25/19. The policy read in part Infection Control Considerations Related to Oxygen Administration 7. Change the oxygen cannulae and tubing every seven (7) days, or as needed. No further information was provided prior to the exit conference on 1/28/19. 2. The facility staff failed to ensure Resident #25 received the amount of oxygen ordered by the physician and failed to date oxygen tubing. The clinical record of Resident #25 was reviewed 1/23/19 through 1/28/19. Resident #25 was admitted to the facility 2/10/18 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #25's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/21/18 assessed the resident with a brief interview for mental status (BIMS) as 15/15. Section O Special Treatments, Procedures, and Programs was coded for oxygen use. Resident #25's current comprehensive care plan initiated 11/23/18 identified the resident to be at risk for respiratory complications related to hx (history) of [MEDICAL CONDITIONS], neb (nebulizer) treatments daily, wears O2 (oxygen) at all times and 1500 fluid restriction. Approaches: Administer meds (medications) per MD (medical doctor) order. The (MONTH) (YEAR) physician's orders [REDACTED]. The surveyor observed Resident #25 during the initial tour on 1/23/19 beginning at 12:26 p.m. Resident #25 was in bed. An oxygen concentrator was sitting to the left side of the bed and the amount of oxygen was set at 1 and ½ liters. There was no date on the oxygen tubing. The surveyor observed Resident #25 again on 1/23/19 at 2:41 p.m. Resident #25 was in bed with oxygen via the concentrator set on 1 and ½ liters. No date was observed on the oxygen tubing. The surveyor observed Resident #25 on 1/24/19 at 9:09 a.m. Resident #25 was in bed and eating breakfast. The oxygen concentrator was on 1 and ½ liters. No date was observed on the oxygen tubing. The surveyor informed licensed practical nurse #3 of the above observation at 9:30 a.m. L.P.N #3 observed the liter of oxygen setting and moved the concentrator to 2. L.P.N. #3 was asked if the nasal cannula was changed weekly. L.P.N. #3 stated usually done on 11-7 shift. The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above observation during the end of the day meeting on 1/24/19 at 4:14 p.m. The surveyor requested the facility policy on respiratory care. The surveyor reviewed the facility policy titled Respiratory Therapy-Prevention of Infection on 1/25/19. The policy read in part Infection Control Considerations Related to Oxygen Administration 7. Change the oxygen cannulae and tubing every seven (7) days, or as needed. No further information was provided prior to the exit conference on 1/28/19. 3. The facility staff failed to store a nebulizer mask in a plastic bag for Resident #108. Resident #108 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/15/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 12 out of a possible score of 15. Resident #108 was also coded as requiring limited supervision of 1 staff member for dressing, extensive assistance of 1 staff member for personal hygiene and being totally dependent on 1 staff member for bathing. During the initial tour of the facility on 1/23/19 at 12:33 pm, the surveyor observed Resident #108's nebulizer mask sitting on the table bedside of the bed. The mask was not stored in a plastic bag. The surveyor went back into the resident's room on 1/24/19 at approximately 11 am at which time the surveyor observed the nebulizer mask being stored in a plastic bag. At 4:15 pm on 1/24/19, the surveyor notified the administrative team of the above findings. The director of nursing stated, That mask should be stored in a plastic bag when not in use by the resident. The surveyor requested a copy of the policy concerning storage of a nebulizer mask when not in use. On 1/25/19 at 11 am, the surveyor was provided a copy of the facility's policy titled Departmental (Respiratory Therapy) Prevention of Infection. The policy read in part, .Store the circuit in plastic bag, marked with date and resident's name, between uses . No further findings were provided to the surveyor prior to the exit conference on 1/28/19.

Based on observation and staff interview, the facility staff failed to discard expired medications on 1 of 3 medication carts inspected. On 1/25/19 at 11:00 AM, the surveyor checked the medication cart on Side 2 for expired medications. The surveyor found 3 containers of artificial tears with expiration date 12/2018. The containers were labeled with the names of 3 unsampled residents. Medication administration records indicated that the 3 residents had received the medications daily in the 24 days after the expiration date. The nurse was informed of the concern and pulled the eye drops from the cart and went to the supply room for replacements. The director of nursing and administrator were notified of the issue on 1/25/19.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 1 of 29 residents (Resident #117). The findings included: The facility staff failed to ensure a registered nurse documented when Resident #117 was pronounced dead. The clinical record of Resident #117 was reviewed [DATE]. Resident #117 was admitted to the facility [DATE] and expired [DATE]. [DIAGNOSES REDACTED]. Resident #117's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] assessed the resident with a brief interview for mental status as ,[DATE]. The departmental note dated [DATE] 6:34 a.m. read Upon rounding, resident was observed in bed with no respirations, no apical pulse, no blood pressure, no oxygen saturation. Her skin is cool to touch and model (sic) up to her legs and hands. RN (registered nurse) notified and comfirmed (sic) findings time of death . Notified RP (responsible party) and Dr. (Doctor). RP stated to send body to ____ (name of nursing home omitted). Signed by licensed practical nurse #4. The surveyor was unable to locate documentation by the registered nurse of Resident #117's death in the clinical record. The surveyor informed the director of nursing (DON) of the above issue on [DATE] at 11:56 a.m. The DON was unable to locate documentation by the RN of Resident #117's death. The DON stated she would expect staff especially the RN on duty when Resident #117 expired to document their findings. The surveyor requested the facility policy on documentation from the director of nursing on [DATE]. The surveyor reviewed the facility policy titled Charting and Documentation on [DATE]. The policy read in part 2. The following information is to be documented in the resident medical record: d. Changes in the resident's condition. No further information was provided prior to the e exit conference on [DATE].

Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, it was determined the facility staff neglected to provide the appropriate supervision and devices for 1 of 3 Residents (Resident #3). The findings include: The facility staff neglected to assess a known wanderer Resident #3 for exit seeking behavior and provide adequate supervision and a wander guard device (an alarm that sounds at exit doors) to assist in preventing an elopement. The elopement on 10/20/10, that resulted in Resident #3 having an accident with facial and head trauma. Resident #3 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 1/10/11, Resident #3 ' s clinical record was reviewed. Located in the clinical record was a minimum data set (MDS) with an assessment reference date (ARD) of 10/20/10. In the section for memory, she was coded as having both long and short term memory problems. In the section for cognitive skills for daily living, she was coded as moderately impaired in decision making. She was coded as having 4 falls; 2 with injury and 2 without from her admission to the facility on [DATE]. The previous MDS with an ARD date of 9/11/10 indicated that the resident ' s decisions were poor, cues/supervision required. Resident #3 ' s clinical record review revealed that she had been seen wandering in the hall and other resident ' s rooms prior to her first documented exit seeking occurrence. In the CNA documentation, CNA # 1 wrote the following on 10/13/10: " Resident wheeling around the building going into people ' s rooms, going down the back doors, trying to go out. Went out the front doors going into other resident rooms- nurse aware. " The current director of nurses (DON) was asked who reviewed the clinical record. She stated, " We have paper nurses who review the clinical records. " She was asked if the unit manager (LPN #5) should have included wandering as a problem on the monthly summary. She responded, " Yes it should have been. " The director of nurses was asked to look at the comprehensive care plan to see if wandering/elopement had been added. She stated, " It is not here. " Resident #3 ' s Care Plan dated 9-22-10, indicated that the resident has cognitive loss and her comprehension is slow and that she has impaired decision making skills. Her care plan had no documentation for the risk of exit-seeking or wandering. An entry on 10-20-10 revealed the following: " Sent to emergency room for evaluation - fall with head injury. " This injury was due to the accident she had when she eloped from the building on the 10/20/10. On 1/10/11, the current director of nurses was asked if a facility report of the investigation (FRI) was done. The director of nurses provided a copy of the full investigation. In the report the following written statements were found. The activities assistant (on the survey staff list is other #4) documented the following: " On the afternoon of October 14th 2010, along with staff member Other #2, I observed Resident #3 strolling herself in the hallway. As she turned the corner, and headed down the hallway towards the time clock, other #2 and I watched her to see if she would stop and or turn around and come back. Resident #3 opened the door at the end of hall, and other #2 ran to get her. Other #2 and I discussed that someone needed to be informed of this. LPN #2 walked by at that time, and I told her what we had just observed with Resident #3. A wanderguard ankle bracelet was mentioned, and LPN #2 said, we need to look into it. That was the end of the conversation. " On 1/11/10, other #4 was interviewed by the survey team. She confirmed the above written statement as true repeating it verbatim. During an interview with other #2, she gave the same account of the October 14th incident as did other #4. The FRI report contained her written account of the exit seeking behavior. LPN #2 was on medical leave during this complaint survey and was not available for comment. However, the facility complaint investigation report read as follows: " LPN #2 states that she does not recall an incident in which Resident #3 attempted to exit the back door. LPN #2 states, that neither other #2 nor other #4 reported anything of this nature to her. LPN #2 states that she did recall an incident about a week ago when Resident #3 had wandered into another residents room and a volunteer had removed her from that room. " The surveyor did not find any documentation in Resident #3 ' s clinical record of either account. On 10/14/10, Resident #3 did elope from the building later in the evening. The following are the staff accounts of this incident. CNA #1 was interviewed on 1/10/11. Her statement is as follows: " On 10/14/10, CNA #2 and I were walking down the hall and CNA #2 saw Resident #3 outside from the nurse ' s lounge window. I came up to the front lobby to make sure she was okay and found that she was alone, still on the sidewalk facing sideways and pushing herself backwards. I immediately brought her back into the facility to the 100/200 hall and told LPN #1 where I found her. LPN #1 was doing a medication pass and told me to go tell the director of nurses who was in her office and asked her for a wanderguard. I told the director of nurses that Resident #3 had left the building and asked her for a wanderguard. The director of nurses told me to tell LPN #1 to look in the chart. She did not give me a wanderguard. I told this to LPN #1 and she said what am I looking for and told me to watch Resident #3 and if we didn ' t see her to find her. When I went back down the hall the director of nurses was gone. The wanderguards were locked in her office. " CNA #2 was not working during the survey and was not reached by telephone. However, her written statement in the facility report mirrored CNA #1 ' s account of the incident. LPN #1 had left the employment of the facility, but came by for her last paycheck on 1/11/11 at 12:10pm and agreed to an interview with the survey team. She was asked what had happened on 10/14/10 regarding Resident #3. She stated, " On the evening you all (referring to the survey team during the annual inspection) exited. Two CNA ' s came to me and said they had seen Resident #3 outside. I was passing medications and told CNA #1 to go to the director of nurse ' s office and get a wanderguard for Resident #3. When CNA #1 returned, she said the director of nurses said to look in the chart. I asked CNA #1 what was I looking for and if she had told her that we found Resident #3 outside. I told her to monitor Resident #3. " LPN #1 was asked why she did not chart the elopement. " She said, I did not chart it but we kept an eye on Resident #3. I did not chart it because I did not want to write that my director of nurses refused to give it to me. They have always been looked in the director of nurse ' s office. I had been here for 4 years and we always had to get them from her. " The previous director of nurses was not available for an interview but did provide a written statement of the occurrence on 10/14/10. The statement read as follows: " I am unable to recall exact details related to the conversation with CNA #1 on Thursday October 14th, 2010. I remember CNA #1 stopping outside my office door and reporting an incident of a resident attempting to exit the building. I recall telling the CNA to report this to her nurse and have her review her chart and let me know if she needed an alarm. I left the facility around 4:00pm, per my written calendar. I recall prior to leaving that I yelled calling down to nurse ' s station and reported to the nurse that I was leaving for the day. " LPN #3 and LPN #4 both were interviewed and asked what was the procedure for using a wanderguard. Both acknowledged the following: " When a demented resident becomes exit seeking the wander guard is placed on a resident. " On 10/20/10, Resident #3 exited the building, entered the parking lot and rolled down the hill into a graveled area beside a parked car. Her wheel chair turned over and Resident #3 suffered facial and head trauma. On 1/11/11 at 2:35pm, other #1 was interviewed. The following is her account of Resident #3 ' s elopement: " It was about 4:00pm when I heard someone say Resident #3 had gone out. When I heard she was outside the building I went right out but by the time I got outside to her she had already turned over. Her wheelchair wheels were still moving and I saw blood. " Other #1 was asked how long it took the nursing staff to get to her. She said, " About 30 seconds to a minute. " The surveyor obtained Resident # ' s medical record from the local hospital. She was admitted with the following Diagnoses: [REDACTED]. status [REDACTED]. MODERATELY SEVERE DEMENTIA.4. HYPERTENSION.5. [MEDICAL CONDITION] WITH HISTORY OF COMPRESSION FRACTURE.6. [MEDICAL CONDITION]. URINARY TRACT INFECTION. Resident # 3 was discharged from the facility on 1/11/10. Her [DIAGNOSES REDACTED]. DISCHARGE Diagnoses: [REDACTED]. status [REDACTED]. MODERATELY SEVERE DEMENTIA.4. HYPERTENSION.5. [MEDICAL CONDITION] WITH HISTORY OF COMPRESSION FRACTURE.6. [MEDICAL CONDITION]. URINARY TRACT INFECTION. On 1/10/11, the director of nurses was asked if the facility had an elopement policy in place before Resident #3 ' s accident and had she been assessed for elopement. She said, " We had a policy but there was no assessment tool used then. We are using one now. " The Policy and procedure given to the survey team on 1/10/11 contained a section titled " Wandering, Unsafe Resident. " It revealed the following information under policy interpretation and Implementation: 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctible risk factors related to unsafe wandering. 3. The resident ' s care plan will indicate the resident is at risk for elopement or other safety issues. 4. Interventions to try to maintain safety will be included in the care plan. 5. Nursing staff will document circumstances related to unsafe actions, including wander, by a resident. 6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Staff will notify the administrator and director of nursing immediately, and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility. The current director of nurses was the previous assistant director of nurses and she was asked on 1/11/11 where the wanderguards were kept prior to Resident #3 ' s accident on 10/20/10. She said, "They were kept in the director of nurse ' s office. They are now kept in the medication rooms. "The current director of nurses was asked if Resident #3 was assessed for wandering and she said, "No." Prior to exit on 1/11/11, the administrator told the survey team of plans to correct the elopement issues. He referred to the annual inspection and the deficiency where the facility failed to notify the office of licensure and certification of an elopement. He stated, "I knew this would come up and bite me in the butt." No further information was provided to the surveyor prior to exit. Reference: F279, F323, F514 This is a complaint deficiency.

Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, it was determined the facility staff fail to provide the appropriate supervision and assistive devices to prevent accident hazard and elopement for 2 of 3 Residents (Resident #3and #1 ). The findings include: 1. For Resident #3, the facility staff failed to ensure that she was assessed for exit seeking behavior and provided a wanderguard to prevent an elopement and an accident causing facial and head trauma. Resident #3 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 1/10/11, Resident #3 ' s clinical record was reviewed. Located in the clinical record was a minimum data set (MDS) with an assessment reference date (ARD) of 10/20/10. In the section for memory, she was coded as having both long and short term memory problems. In the section for cognitive skills for daily living, she was coded as moderately impaired in decision making. She was coded as having 4 falls; 2 with injury and 2 without from her admission to the facility on [DATE]. The previous MDS with an ARD date of 9/11/10 indicated the resident ' s decisions were poor, cues/supervision required. Resident #3 ' s clinical record was reviewed. It revealed that she had been seen wandering in the hall and other resident ' s rooms prior to her first documented exit seeking occurrence. In the CNA documentation, CNA #1 wrote the following on 10/13/10: " Resident wheeling around the building going into people ' s rooms, going out the back doors, trying to go out. Went out the front doors, going into other resident rooms- nurse aware. " On 1/10/11, the current director of nurses was asked if a facility report of the investigation (FRI) was done. The director of nurses provided a copy of the full investigation. In the report the following written statements were found. The activities assistant (on the survey staff list is other #4) documented the following: " On the afternoon of October 14th 2010, along with staff member Other #2, I observed Resident #3 strolling herself in the hallway. As she turned the corner and headed down the hallway towards the time clock. Other #2 and I watched her to see if she would stop and or turn around and come back. Resident #3 opened the door at the end of the hall, and other #2 ran to get her. Other #2 and I discussed that someone needed to be informed of this. LPN #2 walked by at that time and I told her what we had just observed with Resident #3. A wanderguard ankle bracelet was mentioned, and LPN #2 said, we need to look into it. " That was the end of the conversation. On 1/11/10, other #4 was interviewed by the survey team. She confirmed the above written statement as true repeating it verbatim. During an interview with other #2, she gave the same account of the October 14th incident as did other #4. The FRI report contained her written account of the exit seeking behavior. LPN #2 was on medical leave during this complaint survey and was not available for comment. However, the facility complaint investigation report read as follows: " LPN #2 states that she does not recall an incident in which Resident #3 attempted to exit the back door. LPN #2 states that neither other #2 nor other #4 reported anything of this nature to her. LPN #2 states that she did recall an incident about a week ago when Resident #3 had wandered into another resident ' s room and a volunteer had removed her from that room. " The surveyor did not find any documentation in Resident #3 ' s clinical record of either account. On 10/14/10, Resident #3 did elope from the building later in the evening. The following are the staff accounts of this incident. CNA #1 was interviewed on 1/10/11. Her statement is as follows: " On 10/14/10, CNA #2 and I were walking down the hall and CNA #2 saw Resident #3 outside from the nurse ' s lounge window. I came up to the front lobby to make sure she was okay and found that she was alone still on the sidewalk facing sideways and pushing herself backwards. I immediately brought her back into the facility to the 100/200 hall and told LPN #1 where I found her. LPN #1 was doing a medication pass and told me to go tell the director of nurses who was in her office and ask her for a wanderguard. I told the director of nurses that Resident #3 had left the building and asked her for a wanderguard. The director of nurses told me to tell LPN #1 to look in the chart. She did not give me a wanderguard. I told this to LPN #1 and she asked, ' What am I looking for? ' , and told me to watch Resident #3 and if we didn ' t see her to find her. When I went back down the hall the director of nurse was gone. The wanderguards were locked in her office. " CNA #2 was not working during the survey and was not reached by telephone. However, her written statement in the facility report mirrored CNA #1 ' s account of the incident. LPN #1 had left the employment of the facility, but came by for her last paycheck on 1/11/11 at 12:10pm and agreed to an interview with the survey team. She was asked what had happened on 10/14/10 regarding Resident #3. She stated, " On the evening you all (referring to the survey team during the annual inspection) exited. Two CNA ' s came to me and said they had seen Resident #3 outside. I was passing medications and told CNA #1 to go to the director of nurse ' s office and get a wanderguard for Resident #3. When CNA #1 returned she said the director of nurses said to look in the chart. I asked CNA #1 what was I looking for and if she told her that Resident #3 was found outside. I told her to monitor Resident #3. " LPN #1 was asked why she did not chart the elopement. She said, " I did not chart it but we kept an eye on Resident #3. I did not chart it because I did not want to write that my director of nurses refused to give it (a wanderguard) to me. They have always been locked in the director of nurse ' s office. I had been here for 4 years and we always had to get them from her. " The previous director of nurses was not available for an interview but did provide a written statement of the occurrence on 10/14/10. The statement read as follows: " I am unable to recall exact details related to the conversation with CNA #1 on Thursday October 14th, 2010. I remember CNA #1 stopping outside my office door and reporting and incident of a resident attempting to exit the building. I recall telling the CNA to report this to her nurse and have her review her chart and let me know if she needed an alarm. I left the facility around 4:00pm, per my written calendar. I recall prior to leaving that I yelled calling down to nurse ' s station and reported to the nurse that I was leaving for the day. " LPN #3 and LPN #4 both were interviewed and were asked what was the procedure for using a wanderguard . Both acknowledged the following: " When a demented resident becomes exit seeking the wander guard is placed on the resident. " On 10/20/10, Resident #3 exited the building, entered the parking lot and rolled down the hill into a graveled area beside a parked car. Her wheel chair turned over and Resident #3 suffered facial and head trauma. On 1/11/11 at 2:35pm, other #1 was interviewed. The following is her account of Resident #3 ' s elopement: " It was about 4:00pm when I heard someone say Resident #3 has gone out. When I heard she was outside the building I went right out but by the time I got outside to her she had already turned over. Her wheelchair wheels were still moving and I saw blood. " Other #1 was asked how long it took the nursing staff to get to her. She said, " About 30 seconds to a minute. " The surveyor obtained Resident #3 medical record from the local hospital. She was admitted with the following Diagnoses: [REDACTED]. status [REDACTED]. HEMORRHAGE.2. status [REDACTED]. ZYGOMATICOMAXILLARY FRACTURE OF THE ORBITAL FLOOR EXTENDING TO THE ANTERIOR MAXILLARY AREA INVOLVING THE ZYGOMA AS WELL AS A FRACTURE OF THE POSTERIOR WALLS OF THE MAXILLARY SINUS AND RAMUS OF THE MANDIBLE.3. MODERATELY SEVERE DEMENTIA.4. HYPERTENSION.5. OSTEOPOROSIS WITH HISTORY OF COMPRESSION FRACTURE.6. [DIAGNOSES REDACTED].7. URINARY TRACT INFECTION. Resident #3 was discharged from the facility on 1/11/10. Her [DIAGNOSES REDACTED]. DISCHARGE Diagnoses: [REDACTED]. status [REDACTED]. HEMORRHAGE.2. status [REDACTED]. ZYGOMATICOMAXILLARY FRACTURE OF THE ORBITAL FLOOR EXTENDING TO THE ANTERIOR MAXILLARY AREA INVOLVING THE ZYGOMA AS WELL AS A FRACTURE OF THE POSTERIOR WALLS OF THE MAXILLARY SINUS AND RAMUS OF THE MANDIBLE.3. MODERATELY SEVERE DEMENTIA.4. HYPERTENSION.5. OSTEOPOROSIS WITH HISTORY OF COMPRESSION FRACTURE.6. [DIAGNOSES REDACTED].7. URINARY TRACT INFECTION. On 1/10/11, the director of nurses was asked if the facility had an elopement policy in place before Resident #3 ' s accident and had she been assessed for elopement. She said, " We had a policy but there was no assessment tool used then. We are using one now. " The Policy and procedure given to the survey team on 1/10/11 contained a section titled " Wandering, Unsafe Resident. " It revealed the following information under policy interpretation and Implementation: 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctible risk factors related to unsafe wandering. 3. The resident ' s care plan will indicate the resident is at risk for elopement or other safety issues. 4. Interventions to try to maintain safety will be included in the care plan. 5. Nursing staff will document circumstances related to unsafe actions, including wander, by a resident. 6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Staff will notify the administrator and director of nursing immediately, and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility. The current director of nurses was the previous assistant director of nurses and she was asked on 1/11/11 where the wanderguards were kept prior to Resident #3 ' s accident on 10/20/10. She said, " They were kept in the director of nurse ' s office. They are now kept in the medication rooms. " The current director of nurses was asked if Resident #3 was assessed for wandering and she said, " No. " The current director of nurses was asked who reviewed the clinical record. She stated, " We have paper nurses who review the clinical records. " She was asked if the unit manager (LPN #5) should have included wandering as a problem on the monthly summary. She responded, " Yes it should have been. " The director of nurses was asked to look at the comprehensive care plan to see if wandering/elopement had been added. She stated, " It is not here. " Resident #3 ' s Care Plan dated 9-22-10, indicated that the resident has cognitive loss and her comprehension is slow and that she has impaired decision making skills. Her care plan had no documentation for the risk of exit-seeking or wandering. An entry on 10-20-10 revealed the following: " Sent to emergency room for evaluation - fall with head injury. " This injury was due to the fall she sustained when she eloped from the building on the 10/20/10. No further information was provided to the surveyor prior to exit. Reference: F279, F224, F514 This is a complaint deficiency. 2. The facility staff failed to provide adequate supervision and assistive devices to prevent an elopement which lead to Resident #1 elopement from the facility. Resident #1 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. A review of Resident #1's clinical record was performed by the surveyor on 1/10/11 and 1/11/11. Upon reviewing the nurses ' notes dated for 10/29/10 and timed for 11:00am which stated, "This nurse spoke to resident ' s POA (power of attorney) daughter _______ (name of daughter) regarding safety concern of Mr. _____ (name of resident) going outside without notifying staff. Discussion use of code alert system which would alert staff that resident was outside for monitoring and observation. _______ (name of daughter) requests to discuss this option with her father but declines at this time. States she feels this would compromise his independence and alter his mental status. Daughter well aware that her father goes outside in wheelchair without notifying staff." This entry in the nurses' notes was made by the former director of nursing dated 10/29/10. The next nurses ' was entry was dated and timed for 11/3/10 at 1:45 pm. The nurses ' note stated, " Exited the facility without notifying staff. Observed by visitor. Located on patio. Returned to facility (s with a line over it) without incident. Reminded and encouraged to notify staff prior to going outside. Risk of Elopement/Wandering Review completed. "At 2:45 pm on the same date, the following nurses ' note was noted by the surveyor, "Risk of Elopement/Wandering Review reviewed by ________(name of assistant director of nursing) and ______(name of former director of nursing). Decision was made to place wandergard on w/c (wheelchair) for safety due to risk for injury when resident if out of doors unsupervised." The next nurses' note was timed for 3:00 pm on 11/3/10 which stated, "Message left for _____ (name of daughter) concerning wanderguard. Alarm placed and explained to resident." No further attempts of elopement were noted as documented in the nurses' notes for this resident until 11/13/10. On 11/13/10 at 11:30 am the nurses ' note read in part, "Resident noted going out back doors, noted wanderguard in place but no alarm sounding ... " The surveyor interviewed the maintenance employee other #5 on 1/11/11 at 3:30 pm. The surveyor asked this employee before this incident how often the alarms on the doors checked concerning the wanderguard system were. The maintenance employee other #5 stated, " Weekly until the occurrence of the other resident leaving the facility in her wheelchair and getting hurt. Now we do it daily. "The maintenance other employee #5 was asked about his knowledge of a resident leaving thru a back door on 11/13/10 and the wander guard alert system failed to alarm when the resident left. The maintenance other employee #5 stated, " We checked the system and called the company. None of the antennas had been replaced since we had the system installed about six years ago. The company suggested that we replace the antennas. Antennas were ordered and replaced on the front and back doors. " According to documentation received from the maintenance other employee #5 and provided to the surveyor, on 11/20/10, the front door had 2 new antennas installed. No documentation was provided to the surveyor as to when the back door antennas were replaced. However, there was documentation provided to the surveyor that on 11/20/10, a key pad and push button was installed at the back door. The administrator and director of nursing sat in the conference meeting in which the maintenance employee other #5 was present as documented above. The administrator stated, " As soon as we found out that the alarm was not working, we designated a person to sit in the front lobby that could see the front and back doors and make sure that no residents were able to exit the building. This was done on the 3-11 pm shift." No further information was provided to the surveyor prior to the exit conference on 1/11/11.