Every finding on record at Heritage Manor of Slidell

Based on observations, record review and interviews, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion by failing to provide restorative therapy for 3 (#9, #71, and #88) of 21 residents reviewed in the final sample.Resident #9 Review of Resident #9's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Muscular Dystrophy, Right Hand Contracture, Left Hand Contracture, Right Foot Contracture, and Left Foot Contracture. Review of Resident #9's Quarterly Minimum Data Status (MDS) with Assessment Reference Date (ARD) of 07/21/2025 revealed a Brief Interview for Mental Status (BIMS) of 14, which indicated he was cognitively intact. Further review of Section GG, Functional Abilities, revealed Resident #9 had bilateral, upper and lower extremity impairment. Review of Resident #9's current Physician Orders revealed in part, the following: Restorative Nursing Program (RNP) for Dressing/Grooming, Order Date: 05/12/2025 RNP for Passive Range of Motion (PROM), Order Date: 02/19/2025 RNP for Assisted Active Range of Motion (AAROM), Order Date: 03/10/2025 Review of Resident #9's current Care Plan revealed, in part, the following: Focus: RNP: Dressing/Grooming- Resident to assist with activities of daily living (ADL) tasks with max assist. Focus: RNP: PROM to both hands for increased finger extension. Focus: RNP: AAROM to Bilateral Lower Extremities (BLEs) in supine or sitting position 10-15 reps with hip/knee exercise. Review of Resident #9's Tasks Report from 07/20/2025 to 08/19/2025, revealed staff did not document the following tasks as completed per current care plan and physician orders: Task: Restorative – AAROM Task: Restorative – Dressing/Grooming Training Task: Restorative – PROM On 08/19/2025 at 8:15 a.m., an interview was conducted with Resident #9. Resident #9 stated he felt his contractures were getting worse. Resident #9 further stated he received restorative nursing services for his contractures in the past, but did not recall receiving them in the past month. Resident #9 stated the previous, restorative employee had quit. Resident #9 stated his assigned CNA did not complete active or passive range of motion exercises with him. On 08/20/2025 at 10:42 a.m., an interview was conducted with S9CNA. S9CNA stated he was assigned to Resident #9's care. S9CNA stated he was not responsible for providing RNP services. S9CNA confirmed he did not provide range of motion exercises for Resident #9's hands or BLEs. On 08/20/2025 at 10:53 a.m., an interview was conducted with S4LPN. S4LPN stated she was assigned to Resident #9's care. S4LPN confirmed Resident #9 was on a RNP. S4LPN stated the previous restorative nursing assistant (RNA) had quit, and she was not aware of how RNP services were currently being handled. Resident #71 Review of Resident #71's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Dementia, Abnormalities of Gait and Mobility, Muscle Wasting and Atrophy of Left Lower Leg, Unsteadiness on Feet, History of Falling, and Generalized Muscle Weakness. Review of Resident #71's admission MDS with ARD of 04/28/2025 revealed she had a lower extremity impairment on one side and needed partial to moderate staff assistance with ADL's. Review of Resident #71's current Physician Orders revealed, in part, the following:RNP for Ambulation, Order Date: 05/23/2025RNP for AROM, Order Date: 05/23/2025 Review of Resident #71's current Care Plan revealed the following, in part:Focus: RNP: Ambulation- Resident to ambulate with hand held assist in facility hallway 200ft.Focus: RNP: AROM- Resident to do standing exercises holding onto a steady surface/parallel bars, working on heel raise/marching/hip abduction/straight leg raises. Review of Resident #71's Tasks Report from 07/20/2025 to 08/19/2025, revealed staff did not document the following tasks as completed per current care plan and physician orders: Task: Restorative – Assistive AROM Task: Restorative – Walking Training On 08/20/2025 at 10:55 a.m., an interview was conducted with S12CNA. S12CNA stated she was assigned to Resident #71's care. S12CNA stated she was not responsible for providing RNP services. S12CNA confirmed she had never completed any active or passive range of motion exercises, nor completed any standing exercises with Resident #71. Resident #88 Review of Resident #88's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Flaccid Hemiplegia Affecting Left Non-dominant Side, Age-Related Physical Debility, and Unspecified Sequelae of Cerebral Infarction. Review of Resident #88's Quarterly MDS with ARD of 07/18/2025 revealed a BIMS of 15, which indicated she was cognitively intact. Further review of Section GG, Functional Abilities, revealed Resident #88 had upper and lower extremity impairment on one side. Review of Resident #88's current Physician Orders revealed, in part, the following: Restorative Nursing Program (RNP) for Splinting, Order Date: 08/08/2024 RNP for Passive Range of Motion (PROM), Order Date: 08/08/2024 RNP for Active Range of Motion (AROM), Order Date: 08/08/2024Review of Physician Notes, dated April 2025 to current, revealed, in part, the following: Past Medical History: Brain aneurysm CVA History of Present Illness: [AGE] year old female with history of prior CVA with residual left hemiplegia. She is complaining today of left ankle pain. States her ankle rolled last night while being transferred into bed. Some swelling. Took Tylenol this morning with no relief. Plan: Functional quadriplegia: Requires Hoyer for transfers. Continue strict offloading, careful incontinence care. Continue restorative therapy. Signed, S6NP on 08/12/2025 at 12:19 P.M. Review of Resident #88's current Care Plan revealed, in part, the following: Focus: Resident requires restorative nursing program related to hemiplegia: Active Range of Motion to bilateral upper extremities (BUEs) with 2-3lb weight for 30 repetitions to all planes of motion, arm bike and rickshaw. Focus: Resident requires restorative nursing program related to hemiplegia: Passive Range of Motion to left upper extremity (LUE) for 15 minutes. Focus: Resident requires restorative nursing program: Resident has a splint/brace, apply splint to left lower extremity, Ankle-Foot Orthosis (AFO), in A.M. and remove in P.M. Check skin integrity Q2 hours and after removing. Review of Resident #88's Tasks Report from 07/20/2025 to 08/19/2025, revealed staff did not document the following tasks as completed per current care plan and physician orders: Task: Restorative –AROM Task: Restorative – Brace/Splint Task: Restorative – PROM On 08/19/2025 at 1:58 p.m., an interview was conducted with Resident #88. Resident #88 stated she did not wear a brace today. Resident #88 stated she was supposed to wear a brace on her left lower leg, during the day. Resident #88 stated she had not refused the brace and she did not recall the last time anyone applied the brace. Resident #88 stated the therapist had been putting on her brace but quit. Resident #88 stated no other facility staff had attempted to put the brace on her. On 08/20/2025 at 10:41 a.m., an observation was made of Resident #88 without a brace on her left lower extremity. On 08/20/2025 at 10:53 a.m., an interview was conducted with S7LPN. S7LPN stated she was assigned to Resident #88's care. S7LPN confirmed Resident #88 was on a RNP. S7LPN confirmed Resident #88 did not have on her brace today. S7LPN stated she was not responsible for applying Resident #88's brace. S7LPN stated the RNA would apply Resident #88's brace in the morning and the nurse would remove and check her skin in the evening. On 08/20/2025 at 10:55 a.m., an interview was conducted with S8CNA. S8CNA stated she was assigned to Resident #88's care. S8CNA stated she was not responsible for providing RNP services. S8CNA confirmed she had never applied a brace to Resident #88's left leg, completed any active or passive range of motion exercises with Resident #88, nor completed any exercises utilizing a 2-3 pound weight with Resident #88. On 08/20/2025 at 11:03 a.m., an interview was conducted with S3CN. S3CN stated the facility certified nursing assistants should provide coverage for RNP services when the contracted therapy department did not employee a RNA. S3CN confirmed any residents with orders and care plans to include RNP services should have received those services and been documented as complete in the electronic health record. On 08/20/2025 at 11:41 a.m., an interview was conducted with S6NP. S6NP stated she provided care to the aforementioned residents. S6NP confirmed if the resident had RNP services ordered, she expected those services to be provided. S6NP further confirmed she expected Resident #88's AFO brace to be applied in the morning and removed at night. On 08/20/2025 at 2:35 p.m., an interview was conducted with S5TD. S5TD stated the therapy department was a contracted company and responsible for the facility's RNP. S5TD stated the aforementioned residents were not currently receiving skilled therapy services. S5TD stated the aforementioned residents should have received RNP services and were not. S5TD stated her company had not employed a RNA since 07/19/2025. S5TD stated the facility was responsible for providing those services when her company did not employ an RNA. S5TD confirmed there were no restorative progress notes for Resident #9 from 07/20/2025 to 08/19/2025.

Based on observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff routinely disinfected shared resident care equipment for 4 (#33, #95, #104 and #108) of 4 (#33, #95, #104 and #108) sampled residents observed during medication administration. Review of a Center for Disease Control and Prevention (CDC) article dated 2008, updated 06/12/2024, and titled Recommendations for Disinfection and Sterilization in Healthcare Facilities revealed the following, in part:Guideline for Disinfection and Sterilization in Healthcare Facilities A. RationaleThe ultimate goal of the Recommendations for Disinfection and Sterilization in Health-Care Facilities is to reduce rates of health-care associated infections through appropriate use of both disinfection and sterilization. Each recommendation is categorized according to scientific evidence, theoretical rationale, applicability, and federal regulations. 4. c. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly). Resident #33Review of Resident #33's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Essential Hypertension and Chronic Obstructive Pulmonary Disease.Review of Resident #33's Medical Record Administration (MAR) dated August 2025 revealed resident's vital signs were obtained every day shift.Resident #95Review of Resident #95's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Essential Hypertension and Atherosclerotic Heart Disease.Review of Resident #95's MAR dated August 2025 revealed resident's vital signs were obtained every day shift.Resident #104Review of Resident #104's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Essential Hypertension.Review of Resident #104's MAR dated August 2025 revealed resident's vital signs were obtained every day shift.Resident #108Review of Resident #108's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Essential Hypertension.Review of Resident #108's MAR dated August 2025 revealed resident's vital signs were obtained every day shift.An observation was made on 08/19/2025 at 8:43 a.m. of an automatic wrist blood pressure monitor cuff made of a soft porous cloth fabric.An observation was made on 08/19/2025 at 8:45 a.m. during residents' medication administration with S4LPN. S4LPN entered Resident #104's room and obtained Resident #104's blood pressure with an automatic wrist blood pressure monitor and pulse oxygen saturation with the fingertip pulse oximeter. Then, Resident #104 touched the automatic wrist blood pressure monitor cuff with her other hand and contacted her shirt. S4LPN returned to the medication cart with the above equipment. S4LPN entered Resident #33's room and obtained Resident #33's blood pressure with the same automatic wrist blood pressure monitor and pulse oxygen saturation with the fingertip pulse oximeter and returned to the medication cart with the above equipment. Further observation revealed, S4LPN entered Resident #108's room and obtained Resident #108's blood pressure with the same automatic wrist blood pressure monitor and pulse oxygen saturation with the fingertip pulse oximeter and returned to the medication cart with the above equipment. S4LPN entered Resident #95's room and obtained Resident #95's blood pressure with the same automatic wrist blood pressure monitor and pulse oxygen saturation with the fingertip pulse oximeter. The blood pressure cuff came in contact with the bedside table as Resident #95 rested his arm. S4LPN returned to the medication cart with the above equipment. S4LPN did not sanitize the above equipment used to obtain residents' vital signs between each resident's use.An interview was conducted on 08/19/2025 at 9:10 a.m. with S4LPN. S4LPN stated the wrist blood pressure monitor and the fingertip pulse oximeter were to be sanitized with the facility's disposable disinfectant cloth wipes between each resident. S4LPN confirmed she did not sanitize the wrist blood pressure monitor and the fingertip pulse oximeter in between and/or after the above residents' vital signs were obtained and should have.An interview was conducted on 08/20/2025 at 4:45 p.m. with S2DON. S2DON confirmed she did not expect the nursing staff to sanitize the automatic wrist blood pressure monitor and the fingertip pulse oximeter in between each resident. S2DON further confirmed the automatic wrist blood pressure monitor and the fingertip pulse oximeter should only be sanitized if the equipment became visibly soiled. An interview was conducted on 08/20/2025 at 4:45 p.m. with S3CN. S3CN confirmed she did not expect the nursing staff to sanitize the automatic wrist blood pressure monitor and the fingertip pulse oximeter in between each resident. S3CN stated there was no scheduled routine cleaning for the automatic wrist blood pressure monitor and the fingertip pulse oximeter. S3CN further confirmed per individual nurses' judgement the automatic wrist blood pressure monitor and the fingertip pulse oximeter should only be sanitized if the equipment became visibly soiled.

Based on record review, observations, and interviews, the facility failed to ensure electrical equipment was maintained in safe operating condition for 1 of 1 (#97) sampled residents reviewed for call light safety.Findings: Review of the maintenance log from April 2025 to present revealed no documented request for repair as it related to Resident #97's call light electrical wires being exposed. On 08/18/2025 at 9:30 a.m., an observation was made in Resident #97's room of the call light pulled off the wall with multiple electrical wires exposed. On 08/19/2025 at 11:20 a.m., an observation was made in Resident #97's room of the call light pulled off the wall with multiple electrical wires exposed. On 08/20/2025 at 9:30 a.m., an observation was made in Resident #97's room of the call light pulled off the wall with multiple electrical wires exposed. On 08/20/2025 at 11:35 a.m., an observation was made in Resident #97's room of the call light enclosure box and it had been repaired. On 08/20/2025 at 11:50 a.m., an interview was conducted with S11MS. He stated no staff member had reported to him the need for Resident #97's call light repair. On 08/20/2025 at 12:20 p.m., an interview was conducted with S1ADMIN. He stated while assisting a staff member in Resident #97's room, he observed the call light enclosure box being pulled away from the wall with multiple wires exposed. He stated he repaired the call light and secured the call light enclosure box against the wall. S1ADMIN was informed of the numerous observations made of the call light being unsecured with wires exposed. He stated he would have expected his staff to recognize the need for repair and place a request for repair in the maintenance binder. S1ADMIN stated the call light should have been secured to the wall, and should not have been hanging with wires exposed.

Based on record review, observation, and interviews, the facility failed to ensure nurse staffing data requirements were documented on daily postings. This deficient practice had the potential to affect any of the 103 residents residing in the facility.Findings:Review of the facility's policy titled Posting of Nurse Staffing Information, dated 04/2006, revealed the following:The facility must post the following information on a daily basis.4. Resident Census Posting Requirements: The facility shall post nurse staffing information on a daily basis at the beginning of each shift. At the beginning of the day shift, the facility will initiate by entering the facility name, date, resident census, and shift times. An observation was made on 08/18/2025 at 4:00 p.m. of the nurse staffing data sheet dated 08/18/2025. Review of the nurse staffing data sheet revealed no documentation of the facility census. An interview was conducted on 08/18/2025 at 4:05 p.m. with S3CN. She reviewed the nurse staffing data sheet dated 08/18/2025. She confirmed the facility census was not documented on the nurse staffing data sheet and should have been. An interview was conducted on 08/20/2025 at 9:30 a.m. with S10CNAS. She stated she was responsible for completing the nurse staffing data sheet. She reviewed the nurse staffing data sheet dated 08/18/2025 and confirmed the facility census was not documented and should have been.

Based on record review and interviews, the facility failed to ensure nursing staff notified the resident representative when a resident had a significant change in condition for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed. Findings: Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses that included, Drug Induced Subacute Dyskinesia, Type 2 Diabetes Mellitus, Dysphagia, Essential Hypertension, Primary Generalized Osteoarthritis, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Stage 2, Schizophrenia, Unspecified, and Peripheral Vascular Disease Review of Resident # 1's MDS Assessment, with an ARD of 10/29/2024, revealed a BIMS Score of 01, indicating the facility assessed him to be severely cognitively impaired. Further review revealed he required extensive one person assistance for bed mobility/transfers. Review of Resident #1's Initial wound assessment completed 07/07/2025 at 12:30 p.m. by S2RN revealed the following, in part: Open lesion to left medial thigh, acquired in-house, new wound, wound measurements 12.0 cm x 8.7 cm x 2.0 cm, depth not applicable, tunneling not applicable, 100% of wound covered, surface intact, no evidence of infection, no exudate, edges attached, no induration, no edema, no pain. Treatment-generic wound cleanser, dry dressing, Practitioner notified, Responsible Party notified. On 02/04/2025 at 1:50 p.m., an interview was conducted with S2RN, wound care nurse. S2RN confirmed she documented she notified the Responsible Party for Resident #1 on 01/07/2025 regarding left upper thigh wound discovered but confirmed she did not notify the Responsible Party. On 02/04/2025 at 10:20 a.m., an interviewed was conducted with S1ADM. S1ADM confirmed S2RN had documented she had contacted Resident #1's Responsible Party after the initial wound assessment. S1ADM further confirmed it was the S2RN responsibility to notify Resident #1's Responsible Party of the change in condition and she did not.

Based on interviews and record review, the facility failed to ensure alleged injuries of unknown origin were reported to the State Agency within the required time frame for 1 (#1 ) of 3 (#1, #2, and #3) sampled residents. The facility failed to report Resident #1's injury of unknown origin to the state agency within 24 hours of being made aware. Findings: Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses that included, Type 2 Diabetes Mellitus, Dysphagia, and Peripheral Vascular Disease. Review of Resident # 1's MDS Assessment, with an ARD of 10/29/2024, revealed a BIMS Score of 01, indicating the facility assessed him to be severely cognitively impaired. Review of Resident #1's Nurses Notes dated 01/06/2025 to 01/11/2025 revealed the following: On 01/11/2025 at 9:33 p.m., S3RN wrote: I was summoned to resident #1's room by S5CNA, stating that Resident #1's family was there and wanted to know what happened to his leg. Before speaking with the family, I reviewed the residence medical record to ascertain the origin of his injuries. I was unable to find any supportive data to the origin of injury to the left thigh. Family member stated Resident #1 stated that he spilled hot coffee on his leg. S1ADM was notified of my findings and series of events. Multiple attempts were made during survey to contact S3RN, without success. On 02/03/2025 at 10:09 a.m., a telephone interview was conducted with Resident #1's Responsible Party. She stated she was at the facility the evening of 01/11/2025 and during Resident's #1 incontinent care she saw he had a wound to his inter left thigh. She stated she questioned Resident #1 and he stated it was a coffee spill. On 02/04/2025 at 12:17 p.m., a telephone interview was conducted with S5CNA. He stated on 01/11/2025, during incontinent care, he notice a wound to Resident #1's left inner thigh. He stated skin was missing from the leg. He stated he immediately reported to S3RN. On 02/03/2025 at 3:45 p.m., an interview was conducted with S2RN wound care. She stated on 01/07/2025 she was notified of a small dry lesion to Resident #1's upper left thigh. She stated at the time of the initial assessment the lesion did not appear to be a burn or skin injury. She stated two days later when she assessed the wound, skin had sluffed off of the wound. She stated the wound care nurse practitioner was notified and treatments were continued. She stated she documented the wound as a burn on 01/13/2025 after family claimed Resident #1 alleged spilling coffee on his leg. She stated on 01/13/2025 she questioned the resident multiple times about how he obtained his wound and each time Resident #1 stated I don't know. She stated Resident #1 has a low BIMS and was unable to tell her exactly what happen. She stated she then ask if he had spilled coffee on himself and Resident #1 stated no, I wasted it. She stated the wound could have been a burn but she was unsure due to no witnesses. She stated she did not notify administration of Resident #1's injury of unknown origin. On 02/04/2025 at 3:25 p.m., an interviewed was conducted with S1ADM. S1ADM confirmed he was the person responsible for filing self-reported incidents to the state for the facility. S1ADM stated he was made aware of Resident #1's injury on 01/11/2025. S1ADM further confirmed no self-reported incident to the state was filed regarding injury of unknown origin involving Resident #1 and should have.

Based on observation, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to affect 93 residents who were served from the kitchen. Findings: Review of the facility's policy titled Food Storage Labeling dated 05/2018 revealed in part, the following: Policy: The facility will ensure the safety and quality of food by following good storage and labeling procedures. Procedure: 1. Labeling a. All temperature controlled foods will be labeled. Information included on the label: name of food and date of storage. Review of the facility's policy titled Storage of Refrigerated Food dated 09/2022 revealed in part, the following: Policy: The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedure: 4. No food is left uncovered. An initial tour of the kitchen was conducted on 08/05/2024 at 8:15 a.m., with S5DS. An observation was made of 2-open to air, unlabeled bags of shredded cheddar cheese located in the facility's refrigerator. An interview was conducted on 08/05/2024 at 8:15 a.m., with S5DS. She confirmed the aforementioned items were unsealed, unlabeled, and should have been. An interview was conducted on 08/06/2024 at 2:30 p.m. with S1ADM. He was notified of the aforementioned findings. S1ADM confirmed opened food items should be sealed and labeled.

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 4 (#2, #28, #43, #149) of 20 resident's reviewed in the final sample. The facility failed to ensure: 1. Staff wore proper Personal Protective Equipment (PPE) while in the room of Resident's #2 and #149, who were on Droplet Precautions; 2. Staff wore proper PPE while providing care to Resident #43, who was on Enhanced Barrier Precautions; 3. Resident #43's urinary catheter bag remained off the floor; and 4. Staff performed proper infection control practices while performing wound care for Resident #28. Findings: 1. Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE], and was diagnosed with Covid-19 on 07/30/2024. On 08/05/2024 at 9:15 a.m., an interview was conducted with Resident #2. She stated she currently had Covid-19. On 08/05/2024 at 1:35 p.m., an observation was made of S9CNA providing incontinence care to Resident #2. After care was provided, S9CNA removed her gown, gloves, and mask while in the resident's bathroom. S9CNA disposed of the PPE, performed hand hygiene, and exited back across the resident's room, passing the resident without a mask in place. Resident #149 Review of Resident #149's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Covid-19. On 08/05/2024 at 11:07 a.m., an observation and interview was conducted with Resident #149. There was PPE on the outside of the door with a sign indicating she was on Droplet Isolation. Resident #149 stated she currently had Covid-19. On 08/05/2024 at 1:45 p.m., an observation was made of S9CNA providing incontinence care to Resident #149. After care was provided, S9CNA removed her gown, gloves, and mask while in the resident's bathroom. S9CNA disposed of the PPE, performed hand hygiene, and exited back across the resident's room, passing the resident without a mask in place. On 08/06/2024 at 1:34 p.m., an interview was conducted with S16CNA. She stated she was assigned to Resident #149, who was Covid-19 positive. S16CNA stated before exiting Resident #149's room, she removed all PPE in the restroom, then walked passed the resident with no PPE, including a mask, to exit the room. She stated this was the facility's process. On 08/06/2024 at 2:50 p.m., an interview was conducted with S1ADM. He stated all staff removed PPE, including their mask, in the Covid-19 positive resident's bathroom, washed their hands, and then exited back across the resident's room without a mask in place. He stated this was the facility's process. 2. & 3. Review of the facility policy titled Enhanced Barrier Precautions with a revision date of 03/2024, revealed the following, in part: Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized and infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). Enhanced Barrier Precautions are indicated for residents with any of the following: Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. Review of the Enhanced Barrier Precautions sign posted on resident doors revealed the following, in part: Enhanced Barrier Precautions: Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: urinary catheter. Resident #43 Review of Resident #43's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Neuromuscular Dysfunction of Bladder. Review of Resident #43's Care Plan revealed the following, in part: Problem: 04/21/2024-Resident has a catheter and requires Enhanced Barrier Precautions. On 08/05/2024 at 11:30 a.m., an observation was made of Resident #43 sitting in a recliner chair in her room. Resident #43's urinary catheter bag was observed on the floor by her left foot. On 08/05/2024 at 11:44 a.m., an observation was made with S7LPN of Resident #43's urinary catheter bag on the floor. She confirmed the resident's catheter bag was on the floor and should not have been. On 08/06/2024 at 11:38 a.m., an observation was made of Resident #43 sitting in her recliner chair in her room. Resident's urinary catheter bag was observed on the floor by the left wheel of her chair. On 08/06/2024 at 11:40 a.m., an observation was made with S10CNA of Resident #43's urinary catheter bag on the floor. She confirmed the resident's catheter bag was on the floor and should not have been. On 08/06/2024 at 2:15 p.m., an observation was made of S11CNA and S12CNA performing catheter care on Resident #43. S11CNA and S12CNA did not don a gown prior to performing catheter care on Resident #43. Immediately following Resident #43's catheter care an interview was conducted with S11CNA and S12CNA. S11CNA stated Resident #43 was on Enhanced Barrier Precautions. S11CNA confirmed she should have been wearing a gown while performing catheter care to Resident #43 and confirmed she had not. S12CNA confirmed she did not wear a gown and stated she was not aware she had to wear a gown when providing catheter care to Resident #43. Upon exiting Resident #43's room, two signs were observed on Resident #43's door which read: Enhanced Barrier Precautions Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: urinary catheter. On 08/06/2024 at 2:54 p.m., an interview was conducted with S4DON. She stated the expectation for urinary catheter position was the catheter bag should be hanging on the chair or bed off of the floor, and below the level of the waist. She stated at no point in time should the catheter bag be on the floor. She stated if a resident was on Enhanced Barrier Precautions, staff were to dress out with gloves, masks, and a gown when providing resident care, including catheter care. 4. Review of the facility's Dressing Change policy, last reviewed on 08/2021, revealed the following, in part: Steps in the Procedure: 7. Place all items to be used during procedure on the clean field. Arrange the supplies so that they can be reached. 9. Put on disposable gloves. 10. Position resident. 11. Remove dressing. Pull gloves over dressing and discard into appropriate plastic waste bag. 12. Perform hand hygiene. Put on disposable gloves. 13. Cleanse the area as ordered. Review of Resident #28's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Peripheral Vascular Disease, Venous Insufficiency, Type 2 Diabetes Mellitus, and Cutaneous-Vesicostomy Status. On 08/07/2024 at 8:30 a.m., an observation was made of S14WC performing supra pubic catheter care for Resident #28. Prior to entering room, S14WC and S15CNA sanitized hands and donned a clean gown and gloves. S14WC removed blankets from Resident #28 and continued to touch the right side rail and remote to lower residents head. Using the same gloves, S14WC began cleansing Resident # 28's supra pubic catheter site with wound cleansing saturated gauze and the catheter itself. On 08/07/2024 at 8:45 a.m., an observation was made of S14WC performing wound care to Resident #28's left leg. An observation was made of S14WC placing xeroform, ABD dressing and gauze to Resident #28's left leg. Without changing gloves or using hand sanitizer, S14WC grabbed clean tape from bedside table with soiled gloves and secured the gauze, then placed the tape back on bedside table. During the dressing change process of the resident's left leg, an unopened ABD dressing pack fell on the floor.S15CNA picked up the unopened ABD dressing pack from the floor and placed it on the television stand. S14WC retrieved the unopened ABD dressing pack from the television stand with clean gloves and placed the dressing on the clean bedside table. After the wound to the right leg was cleansed, S14WC applied the ABD dressings on Resident #28's right leg wounds. S14WC never sanitized her hands after opening the ABD pad that had fallen on the floor. S14WC used the soiled tape from the bedside table and taped the gauze wrap. S14WC placed soiled roll of tape on top of her wound care cart and then back in the drawer. On 08/07/2024 at 8:15 a.m., an interview was conducted with S14WC. She confirmed she touched Resident # 28's blankets, side rails and remote prior to supra pubic catheter care and did not change her gloves or use hand sanitizer after touching the above mentioned items. She stated this was not a sterile procedure and it was ok to do the above. S14WC stated she was unaware she touched the tape with soil gloves. She stated if she touched the tape with soiled gloves, she should have disposed of the roll of tape. She stated it was routine to keep extra supplies on the television stand in the residents' room and she was unaware the ABD dressing package fell to the floor. She stated after she picked up the ABD dressing package from the television stand she went to the wound cart and retrieved a second ABD pad to use. She stated she then took both ABD pads and placed them on the clean bedside table. She confirmed she used the both ABD pads on Resident #28's right leg wounds. On 08/07/2024 at 11:00 a.m., an interview was conducted with S14CNA. She confirmed the ABD dressing package dropped to the floor and she picked it up and placed on the television stand. On 08/07/2024 at 9:35 a.m., an interview was conducted with S4DON. She was made aware of the above findings. She stated she expected the wound care nurse to change gloves and use hand sanitizer after touching Resident #28's blankets, side rails and remote prior to cleansing the supra pubic site and catheter. S4DON confirmed tape should not be touched with soiled gloves and placed back on the clean bedside table, on the wound care cart, and then back in the drawer. She stated extra wound care supplies should not be placed on the television stand. She confirmed the ABD dressing that was dropped on the floor should have been discarded, not placed on the bedside table and used on Resident #28's wound. 46981 47173 49343

Based on interviews and record review, the facility failed to ensure residents' assessments accurately reflected the residents' status by failing to ensure a resident's Minimum Data Set was accurately coded for PASRR (Pre-admission Screening and Resident Review) for 2 (#21 and #54) of 6 (#21, #30, #47, #54, #76, and #91) residents reviewed for PASRR. Findings: Resident #21 Review of Resident #21's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Paranoid Schizophrenia, Bipolar Disorder, Schizoaffective Disorder, and Major Depressive Disorder. Review of Resident #21's 142 Form Notification of Medical Certification revealed an approval for admission by the state Level II Authority from 06/01/2023 through 05/30/2024. Review of Resident #21's PASRR Level II Evaluation dated 05/17/2023 revealed the resident had a serious mental illness. Review of Resident #21's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/2024 revealed Section A1500: Resident evaluated by PASRR was coded 0. No. Section A1510: Serious Mental Illness was blank. Resident #54 Review of Resident #54's clinical record revealed he was admitted to the facility on [DATE] with a diagnosis of Schizophrenia. Review of Resident #54's 142 Form Notification of Medical Certification revealed an approval for admission by the state Level II Authority from 07/10/2023 through 07/08/2024. Review of Resident #54's PASRR Level II Evaluation dated 07/13/2023 revealed the resident had a serious mental illness. Review of Resident #54's Annual MDS with an ARD of 06/05/2024 revealed Section A1500: Resident evaluated by PASRR was coded as 0. No. Section A1510: Serious Mental Illness was blank. On 08/07/2024 at 12:30 p.m., an interview was conducted with S6MDS. She verified Resident #21's Form 142 indicated Resident #21 was approved for nursing home admission by Level II authority effective 06/01/2023 through 05/30/2024. She reviewed Resident #21's Annual MDS assessment dated [DATE] and confirmed Section A1500 should have been coded as 1-Yes, and was not. She verified Resident #54's Form 142 indicated he was approved for nursing home admission by Level II authority effective 07/10/2023 through 07/08/2024. She reviewed Resident #54's Annual MDS assessment dated [DATE] and confirmed Section A1500 should have been coded as 1-Yes, and was not. On 08/07/2024 at 1:05 p.m., an interview was conducted with S4DON. She reviewed the aforementioned findings for Resident's #21 and #54. She confirmed the resident's Annual MDS assessments should have been coded correctly and were not.

Based on observation, record review, and interview, the facility failed to provide appropriate and sufficient services, treatment and care according to standards of professional practice for 1 (#43) of 1 (#43) residents that were reviewed for urinary catheter. The facility failed to ensure Resident #43's urinary catheter bag was below the level of the resident's bladder. Findings: Review of Resident #43's record revealed, in part, Resident #43 was admitted to the facility on [DATE] with diagnosis of Neuromuscular Dysfunction of Bladder. Review of Resident #43's Care Plan revealed the following, in part: Problem: 02/21/2024 Resident has an indwelling catheter: for diagnosis of Neurogenic Bladder. Interventions: Position urine catheter bag below bladder. On 08/06/2024 at 2:15 p.m., an observation was made of S11CNA and S12CNA performing catheter care on Resident #43. Resident #43 was lying in bed with the catheter bag secured to the left side of her bed frame, above waist level horizontally. Immediately following Resident #43's catheter care an interview was conducted with S11CNA and S12CNA. Both S11CNA and S12CNA confirmed Resident #43's catheter bag should not be positioned above the level of her waist. On 08/06/2024 at 2:54 p.m., an interview was conducted with S4DON. She stated the expectation for urinary catheter position was for the catheter bag to be hanging below the level of the waist.

Based on record review, observation, and interview the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 (Cart A) of 2 (Cart A and Cart B) medication carts observed. The facility failed to ensure Insulin pens were discarded 28 days after the date opened. Findings: Review of the revised 10/2023, NovoLog injection package insert provided by the facility revealed, in part: Until first use: Unused NovoLog FlexPen stored at room temperature should be thrown away after 28 days. In-use: The NovoLog FlexPen you are using should be thrown away after 28 days, even if it still has insulin left in it. On 08/05/2024 at 9:15 a.m., an observation was made of Cart A with S8LPN who confirmed Resident #13 and Resident #53's Novolog insulin FlexPens were observed to have an opened date of 06/24/2024. On 08/05/2024 at 9:17 a.m., an interview was conducted with S8LPN. She stated all insulin pens should be dated when first opened, and the pen should be discarded 28 days after the opened date written on the insulin pen. S8LPN confirmed both insulin pens observed had a written open date of 06/24/2024 labeled on the insulin pens. She confirmed the Novolog insulins pens for Resident #13 and Resident #53 were available on Cart A for resident use and shouldn't have been. On 08/05/2024 at 2:45 p.m., an interview was conducted with S4DON. She was made aware of the above observations. She stated insulin pens should be labeled with an open date and discarded 28 days after that date. She confirmed the Novolog insulin pens dated 06/24/2024 should have been discarded and not available for resident use.

Based on interviews and record review, the facility failed to ensure nurse staffing data was posted on a daily basis. This deficient practice had the potential to affect any of the 94 residents residing in the facility. Findings: Review of the facility's policy dated 06/2024 and titled Posting of Nurse Staffing Information revealed in part, the following: The facility must post the following information on a daily basis. 1. Facility name. 2. Current date. 3. The total number and actual hours worked by Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants that are directly responsible for resident care per shift. 4. Resident census. Posting Requirements: The facility shall post nurse staffing information on a daily basis at the beginning of each shift. Review of the facility's staffing data sheet binder on 08/05/2024 at 8:50 a.m. with S2AADM revealed the last completed staffing data sheet was dated 07/29/2024. Further review revealed no documentation of completed staffing data sheets dated 07/30/2024 - 08/04/2024. An interview was conducted on 08/05/2024 at 08:50 a.m. with S2AADM. She stated she was responsible for posting staffing data sheets. She stated the last daily staffing data sheet fully completed was 07/29/2024. She confirmed staffing data sheets should have been completed on a daily basis. An interview was conducted on 08/05/2024 at 09:00 a.m. with S1ADM. He stated he was aware the last staffing data sheet fully completed was 07/29/2024. He confirmed staffing data sheets should have been completed on a daily basis.

Based on record reviews and interviews, the facility failed to ensure the residents remained free of accident hazards for each resident who required transfer by facility's hoyer lift for 1 (#3) of 6 (#1, #3, #R1, #R2, #R3 and #R7) residents reviewed. The facility failed to secure resident's safety during transfer. This deficient practice resulted in a harm on 04/01/2024 when staff transferred Resident #3 from a Geri Chair to her bed without using a mechanical lift. Resulting in Resident #3 sustaining commuted, displaced, angulated fractures distal shafts of both the tibia and fibula and portable mildly displaced intra-articular fracture of the distal aspect of the proximal phalanx of the great toe. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's Lifting Policy with review date of 05/2023 revealed: 1. Resident will be screened for the need of manual assist for transferring and /or type of mechanical lift needed. This screening will be done on admission/readmission and in the observation prior of each MDS. 2. Staff will follow the documented lifting protocol deemed appropriate for each resident as noted in their ADL Resident Care Information. This information is documented in the resident's clinical record and via a color coded sticker system. This information should be referred to prior to lifting/transferring or assisting each resident. This documentation will also include which sling type and sling size is appropriate for each resident. RED-Total lift - 1 or more person transfer Resident #3 Review of Resident#3's clinical records revealed she was admitted to the facility on [DATE] with diagnosis: Alzheimer's disease, unspecified, Repeated Falls. Review of Resident #3's MDS, with an ARD of 04/02/2024, revealed the facility assessed her as requiring two-person mechanical lift for transfers. Review of facility's incident report dated 04/01/2024 at 4:40 p.m. revealed: Incident Type: Injury Unknown Origin Type of Injury: Fracture, Other Report prepared by: S10LPN Narrative: At 1:43 p.m., S11CNA reported to S10LPN that Resident #3's foot looked like it was broken. S11CNA did not state or make aware that she transferred resident by herself without a mechanical lift. Resident is a two-person transfer via mechanical lift. S10LPN observed Resident #3's right ankle dangling, blue discoloration, and swollen. Review of the Hospital Records dated 04/01/2024 revealed the following: Chief complaint: right lower leg injury. Right foot X-Ray Results: Commuted, displaced, angulated fractures distal shafts of both the tibia and fibula, portable mildly displaced intra-articular fracture of the distal aspect of the proximal phalanx of the great toe. On 04/09/2024 at 12:10 p.m., an interview was conducted with S11CNA. She stated she was working on 04/01/2024 and assigned to Resident #3. She stated she physically lifted Resident#3 out of her Geri chair and transferred her to bed without using a mechanical lift or staff assistance. She stated she was aware Resident #3 required two-person mechanical lift for transfers. She stated Resident #3 was a small person and she felt she could transfer the resident without assistance. S11CNA stated after she transferred Resident #3 back into the bed, she noticed the resident's right foot was deformed. On 04/09/2024 at 11:19 a.m., an interview was conducted with S10LPN. She stated on 04/01/2024, S11CNA reported something was wrong with Resident #3's ankle. She stated she assessed Resident #3's right foot and it was swollen, bruised, and deformed. She stated Resident #3 was transferred to a local hospital. She stated S11CNA told her she transferred the resident to bed without assistance. S10LPN confirmed Resident #3 was assessed to be a two-person mechanical lift for transfers. On 04/09/2024 at 1:26 p.m., an interview was conducted with S2DON. She confirmed Resident #3 was assessed to be a two-person mechanical lift for transfers. She stated S11CNA admitted she transferred Resident #3 to her bed without the mechanical lift or assistance. The facility has implemented the following actions to correct the deficient practice: 1. Director of Nurses and Assistant Director of Nurses in-serviced all nursing staff on lift policy/lift status/lift equipment. 2. Lift dot audit to ensure accuracy according to Plan of care. See facility's policy above. 3. Nursing Facility Administrator viewed cameras for visual evidence. 4. Nursing Facility Administrator suspended S11CNA immediately during investigation. 5. Continued in services on lift policy/lift status/lift equipment by who? How often? 6. Director of Nurses or designee monitored 5 random sampled total lift transfers though out the facility to ensure proper technique was implemented. 7. Director of Nurses or designee will continue to monitor 5 transfers a week and record on monitoring tool, interview staff during transfer and continue to in-service nursing staff weekly and monitor 5 lift transfers x 4 weeks. 8. 04/04/2024 S12CNA was terminated. 9. Competition date 04/08/2024.

Based on interviews and record review, the facility failed to notify the resident's physician and representative of changes in condition for 1 (#1) of 6 (#1, #2, #3, #R1, #R2, and #R3) residents reviewed for notification of change. The facility failed to: 1. Notify the resident's physician and family after identifying a new sacral wound for Resident #1; and 2. Notify the physician when Resident #1 did not have a bowel movement beyond 3 days. Findings: 1. Review of the facility's policy dated 09/2017 and titled, Change in Resident Medical Status revealed, in part: A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s), when there is- 1. A significant change in the resident's physical, mental, or psychosocial status; (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications.) 2. A need to alter treatment significantly; (that is a need to discontinue or change and existing treatment due to adverse consequences, or to commence a new form of treatment.) Review of the clinical record for Resident #1 revealed the resident was readmitted to the facility on [DATE] with diagnoses that included Pressure Ulcer of Sacral Region and Constipation. Review of Resident #1's Nurse's Notes revealed, in part: 12/24/2023 at 1:12 p.m., this nurse was notified by CNA that resident had a skin breakdown on sacral area. This nurse assessed along with S4RNS. S4RNS performed wound care to sacral area. 12/25/2023 at 6:28 a.m., treatment done to sacral wound. At 6:02 a.m., Responsible Party was notified. At 6:04 a.m., S9MD was notified. Review of the medical record for December 2023 revealed Resident #1's body audit on 12/23/2023 revealed no changes in skin and no skin breakdown. Further review revealed on 12/24/2023, Resident #1 had an Unstageable Sacral Ulcer. On 04/09/2024 at 12:40 p.m., a telephone interview was conducted with S13CNA. She said she was working on 12/24/2023 when she noticed a small quarter size reddened area with no break in skin. She stated she notified the nurse on the hall. On 04/09/2024 at 1:23 p.m., a telephone interview was conducted with S4RNS. S4RNS stated he could not recall the wound on Resident #1, but if he notified the MD or the family of a new wound, it would have been documented. On 04/09/2024 at 4:30 p.m., an interview was conducted with S5LPN. She said she was assigned to Resident #1 on 12/24/2023, the day her new sacral wound was found. She said S13CNA reported the wound to her and she and S4RNS assessed the wound. She said S4RNS conducted the skin assessment and performed wound care. She said she didn't notify the family or physician because it was the responsibility of the RN. On 04/11/2024 at 9:40 a.m., an interview was conducted with S3ADON. She said Resident #1's family and physician should have been notified on 12/24/2024, the day the new sacral wound was identified. On 04/11/2024 at 3:15 p.m., an interview was conducted with S2DON. She said staff should have notified Resident #1's family and the physician the day her wound was identified. 2. Review of the facility's policy dated 05/2011 and titled, Bowel Movement Monitoring revealed, in part: Policy: Bowel movements will be monitored on a daily basis in order to help prevent constipation and impaction. Procedure: 1. All residents will be monitored daily for bowel movements. 2. The nurse will review the documentation to determine if a resident has not had a bowel movement in 3 days, then a laxative will be given after notifying the physician and obtaining an order if there is no standing order. 3. Nursing observation of resident's condition and/or symptoms, as well as outcomes, must be documented in the Nurse's Notes. Review of nursing documentation for Resident #1 including Bowel Movement Records and Nurse's Notes revealed Resident #1 did not have a bowel movement between 03/08/2024 and 03/22/2024. Further review of records revealed the physician was not notified. On 04/11/2024 at 3:15 p.m., an interview was conducted with S1DON. She confirmed there was no documented bowel movements for Resident #1 between 03/08/2024 and 03/22/2024 and no documentation the physician had been notified. She confirmed the nurse's should have notified the physician when there was no bowel movement after 3 days. On 04/11/2024 at 4:10 p.m., an interview was conducted with S9MD. He stated he knew Resident #1's health had declined, her appetite was poor, she was not drinking much, and she had become bedbound. He verified he was not notified of Resident #1 not having a bowel movement between 03/08/2024 and 03/22/2024. He said he expected the nurses to notify him if the resident hadn't had a bowel movement for more than 3 days.

Based on record review and interviews the facility failed to develop a residents' plan of care for 1 (#1) out of 10 total sampled residents reviewed. The facility failed to develop a person-centered care plan for constipation for Resident #1 when she returned from a hospital stay on 01/19/2024. Findings: Review of the clinical record for Resident #1 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident had diagnoses that included Traumatic Subdural Hemorrhage, Rhabdomyolysis and Constipation. Review of Resident #1's Quarterly MDS with ARD 01/25/2024 revealed her BIMS was blank, which meant unable to complete an interview. Review of Resident #1's hospital discharge records dated 01/19/2024 revealed, in part: New medications: Senna-docusate 8.6-50 take 1 tablet by mouth 2 times daily as needed for constipation. Active diagnosis: Constipation Review of Resident #1's care plan revealed no care plan developed for her new diagnosis of constipation. On 04/11/2024 at 1:00 p.m., an interview was conducted with S12CPN. She reviewed Resident #1's care plan. She verified Resident #1 was not care planned for constipation and should have been when she returned from the hospital on 01/19/2024 with a new diagnosis of constipation. On 04/11/2024 at 1:35 p.m., an interview was conducted with S2DON. She reviewed Resident #1's care plan and confirmed she should have been care planned for constipation when she returned from the hospital on 01/19/2024 with a new diagnosis of constipation.

Based on interviews and record reviews, the facility failed to implement a comprehensive person-centered care plan by failing to follow physician's orders for 2 (#6 and #67) of 32 sampled residents reviewed for care plans. Findings: Review of the facility's policy titled Physician Orders revealed, in part: It is the policy of this facility that all physician's orders will be implemented timely and carried out in a professional manner. Verbal or telephone orders are considered to be in writing when dictated or given by the attending physician and later signed or initialed by him/her. Telephone orders are to be received/transcribed by a nurse. When the nurse receives a verbal (or telephone) order after the initial admit/readmit order, the nurse will transcribe the order to for NS-664-New Physician's Orders or enter the order electronically. The order shall in a timely manner be signed and dated by the nurse receiving the order. The order shall be transcribed on the MAR or other appropriate form. Licensed nurses are responsible for following physician orders. Resident #6 Review of Resident #6's clinical record revealed she was admitted to the facility on [DATE] with diagnosis to include Type 2 Diabetes Mellitus. Review of Resident #6's Weight Change History from 08/15/2023 to present revealed: 08/16/2023 Weight 173.00 lbs. 09/06/2023 Weight 185.20 lbs. An interview was conducted on 09/26/2023 at 1:55 p.m. with S4ADON. She stated she was responsible for entering resident's weights into the care plan. She confirmed she received an order from S5MD in August 2023 for Resident #6 to receive weekly weights. She confirmed she did not implement the order. She confirmed Resident #6 did not receive weekly weights in August or September 2023. An interview was conducted on 09/27/2023 at 9:34 a.m. with S5MD. He confirmed ordering weekly weights for Resident #67 in August 2023. He confirmed the weekly weights were not completed as ordered and should have been. He confirmed the nursing staff should follow physician orders. Resident #67 Review of Resident #67's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included the following; Type 2 Diabetes Mellitus with Diabetic Neuropathy. Review of Resident #67's most recent Minimum Data Set (MDS), indicated the resident had a Brief Interview of Mental Status (BIMS) of 15, which indicated she was cognitively intact. Review of Resident #67's current Physician Orders revealed an order dated 08/16/2023 for Novolog 70/30 flex pen 40 units subcutaneous every evening. Review of Resident #67's Physician's Progress Notes dated 08/16/2023 revealed Novolog 70/30 40 units subcutaneously at dinner time was added due to Type II Diabetes. Review of the facility's in-service document dated 08/22/2023 revealed the following, in part: Medication error education in-service was completed with S8LPN regarding the missed order written on 08/16/2023 for Novolog 70/30 40 Units subcutaneous every evening. An interview was conducted on 09/25/2023 at 9:01 a.m. with Resident #67. The resident stated she did not receive insulin the first week after she was admitted to the facility. An interview was conducted on 09/27/2023 at 1:04 p.m. with S6NP. She stated on 08/16/2023, she wrote an order for Resident #67 to receive Novolog 70/30 40 units every evening. She stated the facility failed to implement the order until 08/22/2023 and the resident did not receive insulin during that time. She stated she expected the nurses to follow physician orders. An interview was conducted on 09/27/2023 at 1:51 p.m. with S8LPN. He stated he was responsible for admitting Resident #67 to the facility during the night shift on 08/15/2023. He stated during the admission, he noted she did not have an order for insulin and should have. He stated he notified S6NP the morning of 08/16/2023 that Resident #67 did not have an order for insulin. He stated S6NP came to the facility on [DATE] and wrote insulin orders for the resident. He stated he should have implemented the order by entering it into the computer system right away. He confirmed he failed to input the order for Resident #67's insulin and the resident did not receive the medication from 08/15/2023 to 08/21/2023. An interview was conducted on 09/27/2023 at 1:54 p.m. with S7PDON. She stated on 08/22/2023 S10LPN completed a routine chart audit and noted Resident #67 had an order for Novolog 70/30 insulin in the chart that had not been entered into the computer system. She stated S6NP was notified and the order was implemented. She confirmed Resident #67 did not receive insulin from 08/15/2023 to 08/21/2023 and should have. An interview was conducted on 09/27/2023 at 2:18 p.m. with S10LPN. She stated she was auditing Resident #67's chart on 08/22/2023 and noticed an order for Novolog 70/30 insulin that hadn't been placed into the computer system. She stated she notified S9LPN about the missed order. An interview was conducted on 09/27/2023 at 2:22 p.m. with S9LPN. She stated S10LPN notified her of a missed insulin order for Resident #67 on 08/22/2023. She confirmed Resident #67 did not receive insulin from 08/15/2023 to 08/21/2023 and should have. 48872

Based on observations, record review, and interviews, the facility failed to ensure medications were properly stored in 1 (Med Room A) of 2 (Med Room A and Med Room B) Medication Storage Rooms observed for medication storage. Findings: Record review of the facility's policy titled Medication Rooms revealed in part: Procedure: 1. Refrigerators d. Check for discontinued and expired medications. 2. Locked Medication Room: d. Check for discontinued and expired medications and supplies. An observation was conducted on 09/25/23 at 1:50 p.m. of Med Room A. Two Daptomycin 500mg/50ml Eclipse IV devices were observed with expiration dates of 09/21/2023 in the locked Medication refrigerator. An interview was conducted on 09/25/2023 at 1:51 p.m. with S3LPN. She confirmed two Daptomycin Eclipse IV devices present in Med Room A's Medication refrigerator were expired and should have been discarded. An interview was conducted on 09/25/23 at 2:05 p.m. with S2DON. She confirmed two Daptomycin Eclipse IV devices present in Med Room A's Medication refrigerator were expired and should have been discarded.

Based on observations, interviews, and record review, the facility failed to provide respiratory care consistent with professional standards by failing to ensure oxygen tubing was properly labeled and/or changed in a timely manner for 7 (#46, #64, #70, #77, #89, #192, and #343) of 9 residents reviewed in the initial screening for oxygen therapy. Findings: Review of Facility Policy titled: Infection Control Oxygen Equipment Cleaning, revealed in part: Use disposable tubing, masks, and cannulas for patients receiving oxygen therapy. This equipment is to be discarded as this procedure dictates. 7. Tubing should be replaced every 7 days. 8. Masks should be replaced every 7 days. 9. Cannulas should be replaced every 7 days. 10. When not in use, store the mask/ cannula in a plastic bag clearly labeled with the resident's name and date. Resident #46 Review of Resident #46's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, [CONDITION(S)] ([CONDITION(S)]) and Asthma. Review of Resident #46's MDS with an ARD of 08/19/2022 revealed the facility assessed her to require the use of oxygen therapy. Review of Resident #46's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If less than 92%, administer as needed oxygen at 2 liters/minute via nasal cannula with follow up to evaluate effectiveness. Review of Resident #46's most recent Care Plan revealed, in part, resident has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident's #46's MAR for October 2022 revealed, in part, the following task: Check oxygen saturation every shift, if less than 92% administer as needed oxygen at 2 liters per minute via nasal cannula. Oxygen saturation to be documented at 6:00 a.m., 2:00 p.m. and 10:00 p.m. Further review revealed oxygen saturations below 91% and documented supplemental oxygen in use on the following dates/times: 10/01/2022 at 10:00 p.m., 10/02/2022 at 2:00 p.m., 10/03/2022 at 6:00 a.m., 10/04/2022 at 6:00 a.m., 10:00 p.m., 10/05/2022 at 6:00 a.m., 10/06/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/07/2022 at 6:00 a.m., 2:00 p.m., 10/08/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/09/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/10/2022 at 6:00 a.m., 10:00 p.m., 10/11/2022 at 6:00 a.m., 2:00 p.m., and 10/12/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m. On 10/10/22 at 9:45 a.m., an observation was made of Resident #46's oxygen tubing with no date present. On 10/10/22 at 12:43 p.m., an observation was made of Resident #46 with oxygen in use via nasal cannula. No date noted on oxygen tubing. On 10/11/22 at 10:05 a.m., an observation was made of Resident #46 with oxygen in use via nasal cannula. No date noted on oxygen tubing. On 10/12/2022 at 10:45 a.m., an interview was conducted with S6LPN. She confirmed there was no date present on Resident #46's oxygen tubing but should have been. Resident #64 Review of Resident #64's Clinical Record revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #64's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/11/22 at 10:48 a.m., an observation was made of Resident #64 with oxygen in use via nasal cannula. No date noted on oxygen tubing On 10/11/22 at 10:11 a.m., an interview was conducted with S4LPN. She stated the oxygen tubing should be changed weekly. She confirmed Resident #64's oxygen tubing was not dated but should have been. Resident #70 Review of Resident #70's Clinical Record revealed resident was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #46's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/10/2022 at 11:51 a.m., an observation was made of Resident # 70 lying in bed with oxygen in use via nasal cannula. No date noted on oxygen tubing. Resident #77 Review of Resident #77's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #77's MDS with an ARD of 09/20/2022 revealed the facility assessed her to require the use of oxygen therapy. Review of Resident #77's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If less than 92%, administer as needed oxygen at 2 liters/minute via nasal cannula with follow up to evaluate effectiveness. Review of Resident's #77's MAR for October 2022 revealed, in part, the following task: Check oxygen saturation every shift, if less than 92% administer as needed oxygen at 2 liters/minute via nasal cannula. Oxygen saturation to be documented at 6:00 a.m., 2:00 p.m. and 10:00 p.m. Further review revealed oxygen saturations below 91% and documented supplemental oxygen in use on the following dates/times: 10/01/2022 at 6:00 a.m., 10:00 p.m., 10/02/2022 at 10:00 p.m., 10/03/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/04/2022 at 2:00 p.m., 10/05/2022 at 6:00 a.m., 2:00 p.m., 10/06/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/07/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/08/2022 at 10:00 p.m., 10/09/2022 at 10:00 p.m., 10/10/2022 at 6:00 a.m., 2:00 p.m., 10/11/2022 at 6:00 a.m., 2:00 p.m., 10/12/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., and 10/13/2022 at 6:00 a.m. On 10/10/22 at 10:20 a.m., an observation was made of Resident #77 in her wheelchair with oxygen in use and oxygen tubing dated 09/30/2022. On 10/10/22 at 12:49 p.m., an observation was made of Resident #77 in her wheelchair with oxygen in use and oxygen tubing dated 09/30/2022. On 10/11/22 at 10:05 a.m., an observation was made of Resident #77 in her wheelchair with oxygen in use and oxygen tubing dated 09/30/2022. An interview was conducted on 10/12/2022 at 10:45 a.m. with S6LPN. She confirmed Resident #77's oxygen tubing was dated 09/30/2022 and out of date. Resident #89 Review of Resident #89's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included, in part: [CONDITION(S)] ([CONDITION(S)]); Acute on Chronic Respiratory Failure; Shortness of Breath and Wheezing. Review of Resident #89's MDS with an ARD of 09/14/2022 revealed the facility assessed her to have a BIMS of 15, which indicated she was cognitively intact. Further review revealed she was assessed to require the use of oxygen therapy. Review of Resident #89's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If less than 92%, administer as needed oxygen at 2 liters/minute via nasal cannula with follow up to evaluate effectiveness. Review of Resident #89's most recent Care Plan revealed, in part, resident has impaired gas exchange and should receive oxygen as ordered. Review of Resident's #89's MAR for October 2022 revealed, in part, the following task: Check oxygen saturation every shift, if less than 92% administer as needed oxygen at 2 liters/minute via nasal cannula. Oxygen saturation to be documented at 6:00 a.m., 2:00 p.m. and 10:00 p.m. Further review revealed oxygen saturations below 91% and documented supplemental oxygen in use on the following dates/times: 10/01/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/02/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/03/2022 at 2:00 p.m., 10:00 p.m., 10/04/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/05/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/06/2022 at 2:00 p.m., 10:00 p.m., 10/07/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/08/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/09/2022 at 2:00 p.m., 10:00 p.m., 10/10/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/11/2022 at 6:00 a.m., 2:00 p.m., 10/12/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., and 10/13/2022 at 6:00 a.m. On 10/10/22 at 10:20 a.m., an observation was made of Resident #89 in her wheelchair with oxygen in use via nasal cannula. No date noted on oxygen tubing. On 10/10/22 at 12:45 p.m., an observation was made of Resident #89 in her wheelchair with oxygen in use via nasal cannula. No date noted on oxygen tubing. On 10/11/22 at 10:05 a.m., an observation was made of Resident #89 lying in bed with oxygen in use via nasal cannula. No date noted on oxygen tubing. An interview was conducted on 10/12/2022 at 10:45 a.m. with S6LPN. She confirmed Resident #89's oxygen tubing was not dated but should be. Resident #192 Review of Resident #192's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included, in part: [CONDITION(S)] ([CONDITION(S)]); Heart Disease with Heart Failure and [CONDITION(S)]. Review of Resident #192's MDS with an ARD of 08/03/2022 revealed the facility assessed him to have a BIMS of 15, which indicated he was cognitively intact. Further review revealed he was assessed to require the use of oxygen therapy. Review of Resident #192's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If less than 92%, administer as needed oxygen at 2 liters/minute via nasal cannula with follow up to evaluate effectiveness. Review of Resident #192's most recent Care Plan revealed, in part, resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident's #192's MAR for October 2022 revealed, in part, the following task: Check oxygen saturation every shift, if less than 92% administer as needed oxygen at 2 liters/minute via nasal cannula. Oxygen saturation to be documented at 12:00 p.m. and 8:00 p.m. Further review revealed oxygen saturations below 91% and documented supplemental oxygen in use on the following dates/times: 10/03/2022 at 12:00 p.m., 8:00 p.m., 10/04/2022 at 8:00 p.m., 10/05/2022 at 8:00 p.m., 10/06/2022 at 8:00 p.m., 10/07/2022 at 8:00 p.m., 10/08/2022 at 8:00 p.m., 10/10/2022 at 12:00 p.m., and 8:00 p.m. On 10/10/22 at 10:20 a.m., an observation was made of Resident #192 in bed with oxygen in use via nasal cannula. The oxygen tubing was dated 09/30/2022. On 10/10/22 at 12:40 p.m., an observation was made of Resident #192's oxygen tubing dated 09/30/2022. On 10/11/22 at 10:05 a.m., an observation was made of Resident #192's oxygen tubing dated 09/30/2022. An interview was conducted on 10/12/2022 at 10:45 a.m. with S6LPN. She confirmed Resident #192's oxygen tubing was dated 09/30/2022, which was outdated. Resident #343 Review of Resident #343's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part: Pulmonary Hypertension, Chronic; Heart Failure, Personal history of COVID-19 and Personal history of Bilateral Pneumonia. Review of Resident #343's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 343's Care plan dated 9/23/22 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/10/22 at 9:00 a.m., an observation was made of Resident#343 with oxygen in use via nasal cannula. The oxygen tubing was dated 09/30/2022. On 10/11/22 at 9:06 a.m., an observation was made of Resident #343 with oxygen in use via nasal cannula. The oxygen tubing was dated 09/30/2022. On 10/11/22 at 10:11 a.m., an interview was conducted with S2LPN. She confirmed Resident #343's oxygen tubing was dated 09/30/2022 but should have been changed on or before 10/07/2022. On 10/12/22 at 9:40 a.m., an interview was conducted with S2LPN. She confirmed she had been educated on the facility's policy regarding oxygen therapy. She stated policy is to change oxygen tubing and/or the oxygen mask every 7days and confirmed all oxygen supplies should be dated when changed. On 10/13/2022 at 10:30 a.m., an interview was conducted with S2DON. She confirmed all oxygen tubing and masks should be changed every 7 days with the date it was changed written on the equipment. She further confirmed any oxygen equipment dated 09/30/22 should have been changed on or before 10/07/2022 and any undated equipment should have been changed immediately.

Based on record review and interviews, the facility failed to ensure each resident remained free from verbal and physical abuse by another resident for 2 (#89 and #46) of 26 residents reviewed in the initial screening for abuse. Findings: Review of the facility's policy Resident Abuse revealed in part: Policy: Conduct detrimental to resident care that results in neglect or abuse of any resident is strictly prohibited. Review of the facility's policy Resident Rights revealed in part: All residents in a long-term care facility have rights guaranteed to them under Federal and State law. Residents residing at this facility will be guaranteed a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. These rights include: 31. To be free from abuse, neglect, misappropriation of resident property and exploitation. Resident #89 Review of Resident #89's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #89's MDS with an ARD of 09/14/2022 revealed the facility assessed her to have a BIMS of 15, which indicated she was cognitively intact. Review of Resident #89's signed written statement, dated 08/10/2022, regarding the physical altercation with Resident #46 on 08/07/2022 revealed in part: Resident #89 was sitting at the nurses' station corner waiting on the nurse to give morning medications when Resident #46 passed her and bumped into her with her wheelchair. Resident #89 stated Excuse me at which point Resident #46 stated move you fat f****** cow. Resident #89 then told Resident #46 not talk to her that way and called her an old hag. Resident #46 then stated what are you gonna do about it?. Resident #46 then came up behind Resident #89 and started swinging. Resident #89 turned to block her but Resident #46 hit her in the face and arm. Resident #89 stated she then began yelling for help from staff. Resident # 46 Review of Resident #46's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #46's MDS with an ARD of 08/19/2022 revealed the facility assessed her to have a BIMS of 8, which indicated she was moderately cognitively impaired. Further review revealed Resident #46 was assessed by the facility to have a BIMS of 14 on 06/08/2022, which indicated she was cognitively intact. Review of Resident #46's signed written statement, dated 08/10/2022, regarding the physical altercation with Resident #89 on 08/07/2022 revealed in part: Resident #46 stated Resident #89 said, Hit me! Hit me! I was angry. She is always in the way. Review of Resident #46's Nurses Notes indicated on 08/07/2022 around 6:10 p.m., Resident #46 and Resident #89 were in the same area near the nurses station where they began a verbal altercation with each other. The situation escalated rapidly as each began to shout profanities and insults to the other. Before staff could separate the residents, Resident #89 shouted for Resident #46 to punch her, at which time, Resident #46 stood and punched Resident #89 in the face. An interview was conducted on 10/12/2022 at 10:45 a.m. with S6LPN. She confirmed she was caring for both residents at the time of the physical altercation. She stated Resident #89 was seated in her wheelchair drinking coffee at the nurse's station when Resident #46 bumped into her with her own wheelchair when trying to get by. She stated Resident #89 then made a rude remark to her about not being able to see well and bumping into her. She stated Resident #46 then spun around towards Resident #89 and they began to exchange rude remarks to each other. She stated Resident #46 hit Resident #89 in the face with her hand. She confirmed staff heard the altercation start but were not able to get them separated before Resident #46 hit Resident #89. An interview was conducted on 10/12/2022 at 2:10 p.m. with S2DON. She confirmed a physical altercation took place on 08/07/2022 between Resident #89 and Resident #46. She confirmed the facility determined Resident #46 wheeled herself behind Resident #89 but could not get through because Resident #89's wheelchair was blocking the path. She stated some words were exchanged between the two residents. She stated Resident #46 stood from her wheelchair, walked over to Resident #89 and hit her in the face. Resident #89 then pushed Resident #46 away.

Based on observations and interviews, the facility failed to implement appropriate infection control practices during the provision of resident care as evidenced by failing to ensure staff appropriately changed gloves and performed hand hygiene for 3 of 3 (#5, R1, and R2) residents observed for incontinence care. According to the Resident Census and Conditions of Residents, 32 out of 87 residents received incontinent care. Findings: Review of the facility's Policy title Perineal Care revealed the following steps for procedure. Preparing For Care 6. Perform hand hygiene and apply gloves 9. With a new washcloth or pre-moistened wash wipe, clean the anal area from front to back using a clean area of washcloth or pre-moistened wash wipe after each stroke. 10. When soap is used, rinse genital area moving front to back using a clean potion of the wash cloth or pre-moistened wash wipe for each stroke. 11. Dry area using same method. 14. Remove gloves and perform hand hygiene. Resident With Catheter Follow the instructions above for male or female resident, with the following additions: 4. Using clean washcloth or wash wipe, start at meatus and wash the tubing in a circular motion away from the body about 4-5 inches. Rinse using same method. 8. Remove gloves. Perform hand hygiene. 9. Place resident in a comfortable position and adjust bed height and linens. Resident #5 was a [AGE] year old male admitted on [DATE] with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/27/2022 at 12:31 p.m., an observation was made of S13CNA perform incontinent care for Resident #5. S13CNA was observed to place a towel at the end of Resident #5's bed and place dirty linens on top of the towel. S13CNA used soap and water rinsed towel to perform catheter care. S13CNA did not removed gloves and perform hand hygiene. After she performed catheter care, S13CNA pulled Resident #5's sheet and blanket down using soiled gloves and placed them on top of the stack of soiled linens. S13CNA cleaned bowel movement and placed new brief on Resident #5 without changing gloves or performing hand hygiene. S13CNA then repositioned Resident #5 in bed, adjusted bed controls, and pulled sheets and blankets from bottom of bed back up to Resident #5's chest while using soiled gloves. On 04/27/2022 at 01:45 p.m., an interview was conducted with S13CNA. She verified she did not remove gloves nor perform hand hygiene after performing pericare on Resident #5, prior to applying new brief to resident, repositioning resident in bed, touching the bed controls, and touching the resident's sheets. She stated she should have changed her gloves and used hand sanitizer or washed her hands after she was finished with pericare and before pulling sheets back up onto Resident #5. Resident R1 was an [AGE] year old male admitted to facility on 04/26/2022 as a new admission with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/27/2022 at 02:58 p.m., an observation was made of S15CNA perform incontinent care for R1. After preforming catheter care and pericare using pre-moistened wash wipe, S15CNA did not remove soiled gloves and did not perform hand hygiene. S15CNA touched R1, adjusted his sheets and draw sheets, moved the bed with bed controls, and placed new brief on R1 while using soiled gloves. Resident R2 was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/27/2022 at 03:20 p.m., an observation was made of S15CNA perform incontinent care for R2. S15CNA used pre-moistened wash wipes to perform catheter care and incontinent care. After she performed catheter care and pericare, S15CNA did not remove soiled gloves and did not perform hand hygiene. S15CNA placed new brief on R2, adjusted R2's sheets and repositioned resident in bed while using soiled gloves. On 04/27/2022 at 03:45 p.m., an interview was conducted with S15CNA. She verified she did not remove her gloves nor perform hand hygiene after performing pericare on R1 and R2, prior to applying new brief to both residents, repositioning both residents in bed, touching the bed controls for R1, and touching both residents' sheets. She stated she should have changed her gloves and used hand sanitizer after she was finished with pericare with both residents. On 04/28/2022 at 12:58 p.m., an interview was conducted with S3ADON. She was notified of the above observations made during incontinent care provided by S13CNA and S15CNA. She verified she would have expected S13CNA and S15CNA to change gloves and perform hand hygiene after pericare and catheter care, prior to placing clean brief on a resident and prior to touching resident's bed and linens.

Based on interviews, observations, and record reviews, the facility failed to ensure a resident was free from neglect for 1 (#1) of 5 sampled residents (#1, #2, #3, #4, and #5) who required 2 person transfer with a mechanical lift. This deficient practice resulted in an actual harm for Resident #1, a [CONDITION(S)], on 05/11/2021 at 12:32 p.m., when S4CNA transferred the resident with the mechanical lift, from the shower gurney to the resident's bed. Resident #1 slipped out of the lift's sling and landed on the floor. Resident #1 was transferred to the hospital on 5/11/2021 and diagnosed with a non-displaced fracture to the right medial tibial plateau. The resident was placed in a right leg immobilizer and admitted for pain control and orthopedic evaluation. S4CNA neglected to follow the resident's care plan of using two-person staff assist to transfer the resident via mechanical lift. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of medical record for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's MDS, with an ARD of 04/21/2021, revealed in part: BIMS (Brief Interview for Mental Status) of 13 indicating the resident was cognitively intact; Bed mobility- extensive assistance/2 person assist; Transfer- extensive assistance/2-person assist. Review of Resident #1's Care Plan revealed in part: Smart Chart I- Transfer: RED-STOP- Total Lift- (Large Sling)- Assist X 2 (CNA). Onset 10/02/17- Resident is at risk for falls related to impaired mobility, incontinence, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Requires total lift for transfers; Goal: Resident will be free of injury and complications through the next review date; Interventions: Ensure resident wears the proper footwear and clothing, Place call light within reach, provide assistive/supportive devices, assist with ADL's as needed, anticipate needs, Cues/reminders as needed for safety, Transfer- STOP-Total Lift-Large Regular- Assist X 2, wheel chair for mobility, A review of Resident #1's Nursing Notes revealed in part: 05/11/2021 at 12:32 p.m. - CNA (S3CNA) reported to this nurse that this resident fell . This nurse arrived to resident's room to assess resident and S4CNA who is in the room with resident and witnessed fall, told this nurse that the resident slipped out of shower mat from the lift and landed on the ground on her behind. This nurse found resident sitting straight up with a slight right lean on the ground with legs extended out in front of her with hands crossed in lap. Upon arrival resident immediately complained of right side pain, in both her arms and legs. This nurse asked resident did you hit your head? Resident stated No, I didn't hit my head. This nurse took immediate VS: BP- 149/77, P- 112, O2 Sat on RA- 98%, RR- 16, Temp- 98.3F. Notified Nurse Practitioner of findings and NP immediately came and assessed resident. NP then made the decision to send resident out for further pain evaluation. A review of hospital records for Resident #1 revealed in part: Emergency Department Final Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] Fall Closed fracture of right tibial plateau, initial encounter (Primary) Patient has sustained a tibial plateau fracture, there is no other apparent bony. We placed patient in an immobilizer and will admit patient for pain control and orthopedic evaluation. X-Ray Reports: Right femur 2 views CLINICAL DATA: Trauma FINDINGS: Note is made of a nondisplaced fracture of the medial tibial plateau which appears to be new compared to April 2019 and is likely acute. IMPRESSION: 1. Nondisplaced fracture of the medial tibial plateau newly identified when compared to April 2019 and likely acute. A review of the facility's investigative report revealed in part: 05/11/21: Resident was brought to her room via shower gurney after completing her shower. Bath aide walked out of the room upon the accused aide coming into the room. The accused aide utilized a total lift to initiate a transfer from the shower gurney to her bed. The resident slipped out of the lift sling; falling onto the floor next to the resident's bed. The resident was sent to the hospital for evaluation and treatment. X-ray results indicated a nondisplaced fracture of the medial tibial plateau newly identified when compared to April 2019, and likely acute. Findings: Shower Aide, S3CNA, gave the resident a bath on the shower gurney. Brought resident to resident's room and called for aide. When the resident's aide came into the room, the shower aide exited. The floor aide, S4CNA, lifted the resident via total lift. The resident slipped out of the pad, landing on the floor next to the bed. The resident was care planned as a total lift X 2 persons due to impaired mobility, bedbound, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The floor aide S4CNA failed to secure a second person for the transfer. A finding of neglect is substantiated as this aide failed to follow the resident's care plan. The shower aide failed S3CNA to assist the floor aide. A review of the facility's Mechanical Lift Policy revealed in part: Residents will be screened for the need of manual assist for transferring and/or type of mechanical lift needed. Staff will follow the documented lifting protocol deemed appropriate for each resident as noted on their ADL information. This information should be referred to prior to lifting/transporting or assisting each resident. Plan of Care for lifting will be developed for each resident in need of a mechanical lift and followed per all staff. Have co-worker stabilize the resident and assist in moving the resident's legs as the lift is in operation. Resident #1 was Care Planned for use of a mechanical lift with 2 persons required. On 06/03/2021 at 12:30 p.m., an interview was conducted with S3CNA, Shower Aide, who stated she had worked at the facility for 5 years. She stated it was her responsibility to pick up residents and take them to the shower room, complete the shower/bath, and return the resident to their room. She stated the hall CNAs would have the resident ready on a shower sling to use with the Hoyer lift and the hall CNAs lift the resident and place them on the shower stretcher. She stated she then takes the resident to the shower room. She stated when she returned with the resident, she alerted the hall CNA the resident was back and the hall CNAs used the Hoyer lift to return the resident back to bed. She stated she recalled the incident involving Resident #1 on 05/11/2021. She stated she returned the resident to her room and called for her CNA to come to the room. She stated after she alerted the hall CNA that the resident was back in her room, she went on to the next shower. She heard about the incident after it happened. She stated she received education on the lift and lift policy when she was hired, each year, and more often if needed. She stated she received education after the incident which included review of policy and procedure, watching the lift manufacture's video, and return demonstration on use of the Hoyer lift. On 6/03/2021 at 1:10 p.m., a telephone interview was conducted with S4CNA, who stated she has worked for the facility for 10 months. She stated it was her responsibility to get a resident ready for a shower including placing the shower sling under the resident and then lifting the resident with use of the Hoyer lift onto the shower stretcher. She stated she should always have a second CNA or Nurse available to help with the use of the Hoyer lift. She recalled the incident on 05/11/2021 involving Resident #1. She stated after the shower aide returned Resident #1 to her room, she left and was not available to help put the resident back to bed. She stated she did not request assistance from anyone else and proceeded to put the resident back to bed by herself. She stated after lifting the resident into the air and moving her towards the bed, the resident slipped out of the sling and landed on the floor. She stated she immediately called for assistance and the resident was sent to the hospital. She stated she made a poor decision not to call for assistance before she started transferring the resident with the lift. She stated she was educated during her orientation about use of the lifts in the facility. She stated this education included a return demonstration. She stated after the incident occurred, she was suspended while an investigation was performed. She stated when she returned to work she received inservices X 2 concerning the lifts used in the facility, the policy and procedure for lifts, always use 2 persons when operating a lift and also watching the manufacture's video about the lifts. She stated the DON and other nurse managers performed spot checks monitoring staff using the total lift and that she was asked to use the total lift to lift a resident and was monitored by a nurse manager on one of her shifts. On 06/03/2021 at 1:40 p.m., an interview was conducted with S2DON, who stated she was aware of the incident that occurred concerning the use of a lift and Resident #1. She verified S4CNA was the CNA involved in the incident. She stated S4CNA failed to call for assistance when using the lift which resulted in the resident falling out of the lift with injury. She stated all staff were trained upon hire and annually with a skills evaluation and return demonstration of the use of the Hoyer and standing lifts. She stated the S4CNA was hired in August of 2020, was a brand new certified CNA who took her CNA course in high school. She stated S4CNA was oriented and trained upon hire that included training and return demonstration of use of the lifts (Hoyer, Standing). She stated S4CNA was signed off with a competency check that included use of the lifts in August of 2020. She stated an inservice was offered to staff about the use of and policy and procedure of lifts in March of 2021. She stated after the incident, S4CNA was suspended while the investigation was performed. She stated when the S4CNA returned to work, she was inserviced x 2 with return demonstration of the use of lifts, watched a manufactures video about the lifts and was included in a spot check that included a return demonstration of the use of lifts. She stated as part of a QA follow up to the incident, spot checks concerning use of the lifts were done throughout the facility on all shifts and included a return demonstration. On 06/04/2021 at 2:00 p.m., an interview was conducted with S1Admin, who stated he was well aware of the incident involving Resident #1. He stated he was part of the investigation, including writing an incident report and an investigative report and confirmed the evidence substantiated neglect had occurred. He verified S4CNA was the CNA who performed the use of the lift by herself and S4CNA was immediately suspended during the investigation and S4CNA went through multiple trainings when returning to the facility. He stated all staff members who gave direct resident care were trained on the proper use of a lift and the policies and procedures that are used with the lift. He stated spot checks continue and the situation will be monitored through the QA program indefinitely. Multiple Nurses and CNA's were interviewed about the use of the mechanical lift. All staff interviewed were knowledgeable about the facility's policy that 2 trained staff members should be present when lifting a resident using the mechanical lift. All staff members stated they had received multiple trainings on the proper use of mechanical lifts. Multiple random residents, who required use of a mechanical lift for transfers, were interviewed with all responding that 2 or more staff members are present when the mechanical lift is used on them. Observations were made on 06/03/2021 and 06/04/2021by surveyors of nursing staff operating the mechanical lift. No issues were noted. Training documents including content (policy review and proper use of mechanical lifts with sufficient staff) and sign-in records were reviewed. Training conducted in February 2021, March 2021, and May 2021 addressed mechanical lift use. The May 2021 training also included a return demonstration monitored by the Therapy Department. The facility has implemented the following actions to correct the deficient practice: PLAN OF CORRECTION: 05/12/2021 Completion Date: 06/01/2021 1.) Resident was assessed immediately by the nurse on duty and sent to the hospital via EMS for evaluation and treatment. 2.) Residents identified as being potentially affected by the deficient practice were identified as those residents that are completely dependent on mechanical lift for transfers. 3.) Immediate actions: a. The aide involved in the incident was suspended pending further investigation and was counseled for not following company lift policy. She was inserviced on the lift policy and assigned to watch the lift's manufactures training video. Staff member worked one-on-one with DON for hands on training with return demonstration. Aide was placed on a 30-day probation during which time she will be randomly audited on proper use of the lifts, including use of a second person. Any further noted issues will result in progressive discipline, up to and including termination. b. Shower aide was counseled for not offering her assistance in the transfer and inserviced on the facility lift policy. c. All residents' lift statuses were audited by the assessment office to ensure accuracy of care plan, smart charting, and color dot in room were consistent. d. Facility nursing staff inserviced on facility lift policy and utilization of the buddy system for 2 person transfers. e. Therapy team and nursing administration to conduct return demonstration training with nursing staff to ensure proper use of total lift and placement of lift sling. All new aides and nurse hires will continue to be trained on the lift policy including return demonstrations. 4.) QA measures initiated to ensure continued compliance are: a. DON/designee to visualize 2 transfers weekly x 4 weeks to ensure proper use of lifts/slings and competency of facility lift policy. b. Audit of all residents lift status to be completed weekly x 4 weeks to ensure proper coding and transfer status. c. The results of these audits will be brought to QA weekly and reviewed for compliance. Any issues identified will be addressed immediately and a revised plan of correction initiated.

Based on observation, interview, and record review, the facility failed to ensure each resident's environment remained free of accident hazards by failing to ensure that a resident, identified by the facility as a non-compliant smoker (Resident #2), did not smoke while actively utilizing oxygen (O2). The facility identified 17 residents in the facility as smokers. Three (# 2, #6, #7) of the 17 residents identified as smokers utilized oxygen. The facility was aware Resident #2 continued to smoke with her O2 in progress. This had the potential to affect 101 residents in the facility. The Immediate Jeopardy situation began on 5/12/14 when facility documentation revealed Resident #2 was observed by staff "outside smoking, constantly requiring O2 at 3 liters per minute (LPM) for her [DIAGNOSES REDACTED]." S1Administrator was notified of the Immediate Jeopardy situation on 7/23/14 at 4:12 p.m. The Immediate Jeopardy ended on 7/23/14 at 6:40 p.m. when the facility's Administrator provided a plan of removal. The Plan of Removal was listed as: 1. Upon notification that Resident #2 was witnessed as smoking with her PRN (as needed) O2 in use, the following was implemented: a. The facility's Smoking Assessment for Resident #2 was updated to reflect that she is not safe to have an O2 etank and lighters in her possession. b. The O2 etank for Resident #2 was removed from her wheelchair to prevent her from smoking outdoors with oxygen in use. The SSD (social service director) and NFA (nursing facility administrator) reviewed the facility's policy with targeted Resident #2 relating to designated smoking areas and lighters being kept at the nursing station. c. The plan of care for Resident #2 has been reviewed and updated to reflect current interventions and staff in-serviced on the use of oxygen and safety hazards associated with oxygen usage. 2. Those residents who have the potential to be affected by the deficient practice will be identified as any resident within the facility's population or visitor. 3. Measures put into place to ensure the deficient practice will not reoccur are: a. The DON (director of nurses) and the NFA have immediately implemented the facility's policy for designated smoking areas and lighters kept at the nursing station. Designated smoking areas are: Patio at station two and (other than during meal time) the patio outside the restorative dining room. b. The DON immediately in-serviced all staff currently working in the facility at this time on the above plan. c. The facility's smoking policy was discussed with each resident in the facility's population that currently smokes. d. Residents who had been previously assessed as smokers have had their Smoking Assessment and Plan of Care updated to reflect the facility's smoking policy. e. Other staff will be in-serviced each shift until after all staff have been trained. f. Signs were placed outside the facility at both front entrances which reflect the implementation of the facility's smoking policy. g. The facility's smoking policy was reviewed with the resident's family and/or responsible party who are in attendance at the facility's Family Meeting on 7/23/14. h. The facility will not allow residents to have O2 etanks in designated smoking areas. i. The facility will revise its smoking policy to mirror that of the oxygen policy which reflects smoking is not allowed within 10 feet while oxygen is in use. 4. The facility will monitor its performance to ensure that solutions are sustained by: a. The DON or designee will make random rounds 3 times per day to monitor and document on a QA (quality assurance) form that appropriate safety interventions are in place. Any areas of concerns will be addressed by further in-servicing and re-education of residents as needed while also trying to respect resident rights without compromising resident safety. b. The facility will continue QA monitoring daily for one month after compliance is achieved and quarter there after. 5. Corrective action will be complete by 7/23/14. The deficient practice remains at a level 2 more that minimal harm for all residents in the facility. Findings: A review of the clinical record revealed Resident #2 was admitted on [DATE] from a local hospital. Her [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/16/14 revealed the following: Resident #2 had a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact), required oxygen, and needed limited assistance for her activities of daily living. A review of the physician's orders [REDACTED]. A review of the facility's Smoking Policies and Regulations (revised 6/13) revealed the following in part: ..."The decision with regard to smoking is a personal matter and should be treated as such. However, the administration of this facility realizes that smoking is a source of possible fires and, therefore, has developed these policies and procedures to ensure the safety of the residents, employees and visitors. Residents are not permitted to smoke in their rooms. Cigarette lighters and matches are not permitted in a resident's room and will be kept at the nurses stations. The facility will provide matches and will light cigarettes upon request in designated areas set aside for smoking. These areas will be monitored by designated staff ... All smokers will have a "smoking Screening Form (AD-224) completed and appropriate interventions implemented and placed on the Care Plan. Residents who smoke will be identified and placed on a computer-generated log with interventions noted. The log will be kept at the nurse's station. Smokers will be screened on admission/readmission, annually and at significant change ..." A review of the facility's Oxygen Policy revealed the following in part: "... Oxygen Safety-1. Store tanks in a cool place away from a source of heat....4. Do not smoke or allow others to smoke within 10 feet while oxygen is in use..." An observation was made of Resident #2 on 07/22/14 at 11:52 a.m. sitting alone outside the right front entrance in her wheelchair smoking. An O2 tank was attached to the back of her wheelchair with oxygen flowing at 2LPM per nasal cannula (NC). No staff members were observed on this porch area with the resident. An observation was made of S5LPN on 07/22/14 at 12:00 p.m. assisting a male resident outside the right front entrance. She briefly spoke to Resident #2 and walked back inside the facility. Upon S5LPN's re-entry into the facility at 12:02 p.m., she confirmed Resident #2 was sitting outside in her wheelchair smoking with O2 in progress. She was asked what amount of oxygen Resident #2 was receiving and she stated 2 liters. S5LPN then stated she is supposed to be on 3 liters. S5LPN further stated, "She should not have any on right now while she is smoking." S5LPN walked out to the resident and turned off Resident #2's oxygen at 12:03 p.m. S5LPN confirmed that residents are not supposed to have oxygen on while smoking. A review of the Smoking Screening Form for Resident #2 revealed she was assessed to "safely smoke independently" on 2/20/14, 4/8/14, 4/27/14, 5/13/14, 5/27/14, and 6/23/14. A review of the Resident #2's care plan revealed the following: Problem: No onset date-Potential for injury related to smoking, history of wearing O2 while smoking. Goals: No reports of injury related to resident being a smoker in the next 90 days. Approaches: Observe for smoking in inappropriate areas; redirect resident as needed; complete smoker's high risk on admit and quarterly; encourage to wear smoker's apron as needed; educate resident on risk of wearing O2 while smoking; encourage resident to remove O2 while smoking. This care plan was noted on the morning of 7/22/14 in the clinical record. A review of the Skilled Nursing Facility (SNF) Documentation Record reviewed from April 2014-July 2014 revealed in part: 5/10/14-Observation and Assessment of the following conditions: Resident sitting outside on porch smoking. No distress noted. Respirations even and unlabored. No SOB or complaints voiced ...O2 at 3 LPM per NC in progress .... 5/12/14- Observation and Assessment of the following conditions: Resident awake and alert outside smoking, denies SOB ...Constantly requiring O2 at 3LPM for COPD ... A second observation was made of Resident #2 on 7/22/14 at 2:56 p.m. The resident was seated outside in her wheelchair at the right front entrance. She was observed smoking a cigarette with her oxygen in progress at 3 liter per minute via nasal cannula. There were 5 other residents on the porch area with Resident #2, with no staff present. An interview was conducted with S5LPN on 07/22/14 at 12:02 p.m. She was asked where residents were allowed to smoke. She stated the residents are supposed to smoke in the back, but the residents that reside in the front hall go out in the front to smoke. She explained that staff informs the residents to go in the back to smoke, but they continue to go to the front porch area. On 07/22/14 at 2:58 p.m. an observation was made, with S6LPN, of Resident #2 sitting outside in her wheelchair with 5 other residents. She explained the resident uses oxygen at 2 LPM per NC. She reported the resident always wore her oxygen and smoked. She stated, "We tell her about it all the time." She stated the resident will tell the staff, "I know how to smoke with it (oxygen) as long as there's no leak in the line." An interview was conducted with Resident #2 on 07/22/14 at 3:10 p.m. She was asked if she wears her oxygen while she is smoking outside. She stated, "Yes." She was asked if the staff told her not to wear the oxygen while smoking and she stated, "Yes, they tell me that." She stated she kept her cigarettes and lighter in her room and lit her own cigarettes. An interview was conducted with S9CNA on 7/23/14 at 10:10 a.m. She said she worked Monday thru Friday, 6 a.m. -2 p.m. She said she had worked for the facility for 1.5 years and routinely worked with Resident #2. She said Resident #2 could propel herself in her wheelchair, sometimes needing assistance with the door leading to the outside smoking area. She said the resident kept her cigarettes and lighters in her room. S9CNA was asked if she was aware of any smoking restrictions and/or precautions for Resident #2. She stated the resident was not supposed to use her oxygen when she smoked. S9CNA said the resident used an oxygen concentrator when she was in her room and had an oxygen tank on the back of the wheelchair. She was asked if she ever observed Resident #2 outside smoking with her oxygen on or in progress. S9CNA said she saw the resident outside smoking all of the time with her nasal cannula in place, but she was not sure if the oxygen was actually on. She was asked when she observed the resident outside smoking with the NC in her nose, did she ever check to see if the oxygen was on or off. She said she did not. She was asked if a staff member was supposed to be present with the residents when they smoked; she responded she did not know. An interview was conducted with S5LPN on 7/23/14 at 10:47 a.m. She said she routinely worked with Resident #2, Monday thru Friday, 6 a.m. - 2 p.m. She said the resident kept her cigarettes and lighter in her room. She said the resident knew she was not supposed to smoke with her oxygen in progress and that this issue had been care planned. She said it was a "daily occurrence to see the resident outside smoking with the oxygen on." She said the resident may or may not have a nasal cannula in her nose. She said if the resident did not have the nasal cannula in place, the cannula would be in the resident's chair with the oxygen blowing as she smoked. She said she had counseled the resident on several occasions related to her smoking with the oxygen in place. She said she had even informed the resident her smoking privileges could be taken away if she continued smoking with the oxygen in place. An interview was conducted with S3DON on 7/23/14 at 11:03 a.m. He was asked if the residents were informed they should not be smoking with O2 in place. He stated that upon admit each resident was given a pamphlet which contained information regarding smoking. He reviewed the pamphlet (page 20) of the Nursing Home Care in Louisiana (Form HSS-99, Rev. 10/10). He read from the pamphlet: Residents shall have the right to use tobacco at their own expense under the facility's safety rules and applicable state and federal laws and rules unless the use of tobacco is medically contraindicated as documented in the medical record by the attending physician. S3DON provided a signed copy of the forms signed by Resident #2 on the admission acknowledgements and authorizations and the smoking policies and regulations. He stated Resident #2 kept her cigarettes and lighter in her room. He said Resident #2 was non-compliant and smoked with oxygen in progress. He said the care plan had been updated for the resident's non-compliance and the resident had been educated and re-educated on this matter. S3DON stated there was a verbal rule for the resident to leave the oxygen tank inside the building when going out to smoke. He was asked what was done if the resident was non-complaint with this verbal rule. S3DON stated the staff would go out and turn off the oxygen. He verified there was a concern for the safety of Resident #2 and other residents in the facility when oxygen tanks were in an area where residents were smoking. He stated, "It was an unsafe practice for (Resident #2) and other residents in the facility for her (Resident #2) to smoke with oxygen in use." An interview was conducted with S2PADM on 7/23/14 at 12:35 p.m. He stated he had spoken with Resident #2 about smoking with O2 tank and/or oxygen in progress. He said the resident had been told that her oxygen tank should be removed from her wheelchair prior to her going outside to smoke and if no staff was available to remove the tank, the resident should be turning the oxygen off before smoking. He stated that obviously this system is not working and another smoking assessment should be completed for this resident. S2PADM verified Resident #2's SNF documentation notes revealed entries on 5/10/14 and 5/12/14 of the resident sitting outside in the smoking area with oxygen in progress. He reviewed the facility's "Smoking Policy and Regulations" and confirmed the facility was not following the policy in that the resident was allowed to keep a lighter in her room and the residents were not smoking in the designated areas. He stated that O 2 tanks should not be in the smoking area even if the oxygen is not flowing (turned off). He said if staff observed Resident #2 outside smoking with an oxygen tank, the staff member should have turned the oxygen off and brought the tank in the building. He said the resident should now be deemed an unsafe smoker. An interview was conducted with S1Administrator on 7/23/14 at 12:53 p.m. He stated had been the administrator of the facility for the past 3 weeks. He verified the facility was not following its own policy in that Resident #2 was in possession of an ignition device. He also confirmed that residents were being allowed to smoke in a non-designated area. He stated Resident #2 was non-compliant with her care plan in regards to smoking with O2 in progress. He stated the resident had been made aware of the dangers of smoking with oxygen in progress. He stated the CNAs and staff should be making rounds and checking to see if the oxygen was turned off and should remove the cylinder from the wheelchair. He verified Resident #2 smoking in the presence of free-flowing oxygen was placing her in danger as well as other residents. An interview was conducted with S7LPN on 7/23/14 at 3:05 p.m. She stated her department updated the care plans for the residents. She stated Resident #2's care plan was updated on 7/22/14 after she and S8RN observed the resident in the early afternoon outside in the front smoking area with her oxygen on via her NC and an oxygen tank noted to the back of her wheelchair. She stated the resident had been sitting there for a while and they felt she was getting ready to smoke. They both stated the resident was not smoking a cigarette at this time. An observation was made of Resident #2 on 7/23/14 at 3:15 p.m. The resident was observed lying across her bed with O2 in progress via concentrator. One box of cigarettes was noted in a pouch on the wheelchair and a second box had cigarette butts. There was an unopened package of 7 cigarette lighters noted on her bed. The oxygen cylinder on the back of the resident's wheelchair displayed an oxygen tank safety sign (a yellow diamond shaped sign with oxygen written in the middle and a flammable sign to the top). A telephone interview was conducted with the facility's physician for Resident #2 on 7/24/14 at 11:19 a.m. He was asked if he was aware of Resident #2 smoking with oxygen in use. He stated the resident was counseled daily and was non-compliant.

Based on observations, interviews and record review, the facility failed to be administered in a manner that ensured the highest practicable physical well-being was maintained for 1 (#2) of 3 (#2, #6, #7) resident identified as smokers who utilized oxygen. The administration failed to ensure: 1. Resident #2, who had been identified by the facility as a non-compliant smoker, did not smoke while actively utilizing oxygen and she did not bring a combustible (oxygen) into an area where it may come into contact with flammable materials. 2. The facility's Smoking Policy and Procedure was consistently implemented to prevent actual/potential accident hazards for each resident identified and care planned by the facility as having a history of smoking with oxygen. 3. Cigarette lighters and matches were not permitted in a resident's room and would be kept at the nurse's station. 4. All designated areas for smoking were monitored to ensure that residents who were actively utilizing oxygen were prevented from bringing a combustible substance (oxygen) into areas with flammable materials. 5. Oxygen tanks were stored in a cool place away from a source of heat. 6. Smokers were not allowed within 10 feet of the oxygen source while in use. The Immediate Jeopardy situation began on 5/12/14 when facility documentation revealed Resident #2 was observed by staff "outside smoking, constantly requiring O2 at 3 liters per minute (LPM) for her [DIAGNOSES REDACTED]." S1Administrator was notified of the Immediate Jeopardy situation on 7/23/14 at 4:12 p.m. The Immediate Jeopardy ended on 7/23/14 at 6:40 p.m. when the facility's Administrator provided a plan of removal. The Plan of Removal was listed as: 1. Upon notification that Resident #2 was witnessed as smoking with her PRN (as needed) O2 in use, the following was implemented: a. The facility's Smoking Assessment for Resident #2 was updated to reflect that she is not safe to have an O2 etank and lighters in her possession. b. The O2 etank for Resident #2 was removed from her wheelchair to prevent her from smoking outdoors with oxygen in use. The SSD (social service director) and NFA (nursing facility administrator) reviewed the facility's policy with targeted Resident #2 relating to designated smoking areas and lighters being kept at the nursing station. c. The plan of care for Resident #2 has been reviewed and updated to reflect current interventions and staff in-serviced on the use of oxygen and safety hazards associated with oxygen usage. 2. Those residents who have the potential to be affected by the deficient practice will be identified as any resident within the facility's population or visitor. 3. Measures put into place to ensure the deficient practice will not reoccur are: a. The DON (director of nurses) and the NFA have immediately implemented the facility's policy for designated smoking areas and lighters kept at the nursing station. Designated smoking areas are: Patio at station two and (other than during meal time) the patio outside the restorative dining room. b. The DON immediately in-serviced all staff currently working in the facility at this time on the above plan. c. The facility's smoking policy was discussed with each resident in the facility's population that currently smokes. d. Residents who had been previously assessed as smokers have had their Smoking Assessment and Plan of Care updated to reflect the facility's smoking policy. e. Other staff will be in-serviced each shift until after all staff have been trained. f. Signs were placed outside the facility at both front entrances which reflect the implementation of the facility's smoking policy. g. The facility's smoking policy was reviewed with the resident's family and/or responsible party who are in attendance at the facility's Family Meeting on 7/23/14. h. The facility will not allow residents to have O2 etanks in designated smoking areas. i. The facility will revise its smoking policy to mirror that of the oxygen policy which reflects smoking is not allowed within 10 feet while oxygen is in use. 4. The facility will monitor its performance to ensure that solutions are sustained by: a. The DON or designee will make random rounds 3 times per day to monitor and document on a QA (quality assurance) form that appropriate safety interventions are in place. Any areas of concerns will be addressed by further in-servicing and re-education of residents as needed while also trying to respect resident rights without compromising resident safety. b. The facility will continue QA monitoring daily for one month after compliance is achieved and quarter thereafter. 5. Corrective action will be complete by 7/23/14. The deficient practice remains at a level 2 more that minimal harm for all residents in the facility. Findings: A review of the clinical record revealed Resident #2 was admitted on [DATE] from a local hospital. Her [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/16/14 revealed the following: Resident #2 had a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact), required oxygen, and needed limited assistance for her activities of daily living. A review of the physician's orders [REDACTED]. A review of the facility's Smoking Policies and Regulations (revised 6/13) revealed the following in part: ..."The decision with regard to smoking is a personal matter and should be treated as such. However, the administration of this facility realizes that smoking is a source of possible fires and, therefore, has developed these policies and procedures to ensure the safety of the residents, employees and visitors. Residents are not permitted to smoke in their rooms. Cigarette lighters and matches are not permitted in a resident's room and will be kept at the nurses stations. The facility will provide matches and will light cigarettes upon request in designated areas set aside for smoking. These areas will be monitored by designated staff... All smokers will have a "smoking Screening Form (AD-224) completed and appropriate interventions implemented and placed on the Care Plan. Residents who smoke will be identified and placed on a computer-generated log with interventions noted. The log will be kept at the nurse's station. Smokers will be screened on admission/readmission, annually and at significant change..." A review of the facility's Oxygen Policy revealed the following in part: "... Oxygen Safety-1. Store tanks in a cool place away from a source of heat....4. Do not smoke or allow others to smoke within 10 feet while oxygen is in use ..." An observation was made of Resident #2 on 07/22/14 at 11:52 a.m. sitting alone outside the right front entrance in her wheelchair smoking. An O2 tank was attached to the back of her wheelchair with oxygen flowing at 2LPM per nasal cannula (NC). No staff members were observed on this porch area with the resident. An observation was made of S5LPN on 07/22/14 at 12:00 p.m. assisting a male resident outside the right front entrance. She briefly spoke to Resident #2 and walked back inside the facility. Upon S5LPN's re-entry into the facility at 12:02 p.m., she confirmed Resident #2 was sitting outside in her wheelchair smoking with O2 in progress. She was asked what amount of oxygen Resident #2 was receiving and she stated 2 liters. S5LPN then stated she is supposed to be on 3 liters. S5LPN further stated, "She should not have any on right now while she is smoking." S5LPN walked out to the resident and turned off Resident #2's oxygen at 12:03 p.m. S5LPN confirmed that residents are not supposed to have oxygen on while smoking. A review of the Smoking Screening Form for Resident #2 revealed she was assessed to "safely smoke independently" on 2/20/14, 4/8/14, 4/27/14, 5/13/14, 5/27/14, and 6/23/14. A review of the Resident #2's care plan revealed the following: Problem: No onset date-Potential for injury related to smoking, history of wearing O2 while smoking. Goals: No reports of injury related to resident being a smoker in the next 90 days. Approaches: Observe for smoking in inappropriate areas; redirect resident as needed; complete smoker's high risk on admit and quarterly; encourage to wear smoker's apron as needed; educate resident on risk of wearing O2 while smoking; encourage resident to remove O2 while smoking. This care plan was noted on the morning of 7/22/14 in the clinical record. A review of the Skilled Nursing Facility (SNF) Documentation Record reviewed from April 2014-July 2014 revealed in part: 5/10/14-Observation and Assessment of the following conditions: Resident sitting outside on porch smoking. No distress noted. Respirations even and unlabored. No SOB or complaints voiced ...O2 at 3 LPM per NC in progress.... 5/12/14- Observation and Assessment of the following conditions: Resident awake and alert outside smoking, denies SOB ...Constantly requiring O2 at 3LPM for [MEDICAL CONDITION] A second observation was made of Resident #2 on 7/22/14 at 2:56 p.m. The resident was seated outside in her wheelchair at the right front entrance. She was observed smoking a cigarette with her oxygen in progress at 3 liter per minute via nasal cannula. There were 5 other residents on the porch area with Resident #2, with no staff present. An interview was conducted with S5LPN on 07/22/14 at 12:02 p.m. She was asked where residents were allowed to smoke. She stated the residents are supposed to smoke in the back, but the residents that reside in the front hall go out in the front to smoke. She explained that staff informs the residents to go in the back to smoke, but they continue to go to the front porch area. On 07/22/14 at 2:58 p.m. an observation was made, with S6LPN, of Resident #2 sitting outside in her wheelchair with 5 other residents. She explained the resident uses oxygen at 2 LPM per NC. She reported the resident always wore her oxygen and smoked. She stated, "We tell her about it all the time." She stated the resident will tell the staff, "I know how to smoke with it (oxygen) as long as there's no leak in the line." An interview was conducted with Resident #2 on 07/22/14 at 3:10 p.m. She was asked if she wears her oxygen while she is smoking outside. She stated, "Yes." She was asked if the staff told her not to wear the oxygen while smoking and she stated, "Yes, they tell me that." She stated she kept her cigarettes and lighter in her room and lit her own cigarettes. An interview was conducted with S9CNA on 7/23/14 at 10:10 a.m. She said she worked Monday thru Friday, 6 a.m. -2 p.m. She said she had worked for the facility for 1.5 years and routinely worked with Resident #2. She said Resident #2 could propel herself in her wheelchair, sometimes needing assistance with the door leading to the outside smoking area. She said the resident kept her cigarettes and lighters in her room. S9CNA was asked if she was aware of any smoking restrictions and/or precautions for Resident #2. She stated the resident was not supposed to use her oxygen when she smoked. S9CNA said the resident used an oxygen concentrator when she was in her room and had an oxygen tank on the back of the wheelchair. She was asked if she ever observed Resident #2 outside smoking with her oxygen on or in progress. S9CNA said she saw the resident outside smoking all of the time with her nasal cannula in place, but she was not sure if the oxygen was actually on. She was asked when she observed the resident outside smoking with the NC in her nose, did she ever check to see if the oxygen was on or off. She said she did not. She was asked if a staff member was supposed to be present with the residents when they smoked; she responded she did not know. An interview was conducted with S5LPN on 7/23/14 at 10:47 a.m. She said she routinely worked with Resident #2, Monday thru Friday, 6 a.m. - 2 p.m. She said the resident kept her cigarettes and lighter in her room. She said the resident knew she was not supposed to smoke with her oxygen in progress and that this issue had been care planned. She said it was a "daily occurrence to see the resident outside smoking with the oxygen on." She said the resident may or may not have a nasal cannula in her nose. She said if the resident did not have the nasal cannula in place, the cannula would be in the resident's chair with the oxygen blowing as she smoked. She said she had counseled the resident on several occasions related to her smoking with the oxygen in place. She said she had even informed the resident her smoking privileges could be taken away if she continued smoking with the oxygen in place. An interview was conducted with S3DON on 7/23/14 at 11:03 a.m. He was asked if the residents were informed they should not be smoking with O2 in place. He stated that upon admit each resident was given a pamphlet which contained information regarding smoking. He reviewed the pamphlet (page 20) of the Nursing Home Care in Louisiana (Form HSS-99, Rev. 10/10). He read from the pamphlet: Residents shall have the right to use tobacco at their own expense under the facility's safety rules and applicable state and federal laws and rules unless the use of tobacco is medically contraindicated as documented in the medical record by the attending physician. S3DON provided a signed copy of the forms signed by Resident #2 on the admission acknowledgements and authorizations and the smoking policies and regulations. He stated Resident #2 kept her cigarettes and lighter in her room. He said Resident #2 was non-compliant and smoked with oxygen in progress. He said the care plan had been updated for the resident's non-compliance and the resident had been educated and re-educated on this matter. S3DON stated there was a verbal rule for the resident to leave the oxygen tank inside the building when going out to smoke. He was asked what was done if the resident was non-complaint with this verbal rule. S3DON stated the staff would go out and turn off the oxygen. He verified there was a concern for the safety of Resident #2 and other residents in the facility when oxygen tanks were in an area where residents were smoking. He stated, "It was an unsafe practice for (Resident #2) and other residents in the facility for her (Resident #2) to smoke with oxygen in use." An interview was conducted with S2PADM on 7/23/14 at 12:35 p.m. He stated he had spoken with Resident #2 about smoking with O2 tank and/or oxygen in progress. He said the resident had been told that her oxygen tank should be removed from her wheelchair prior to her going outside to smoke and if no staff was available to remove the tank, the resident should be turning the oxygen off before smoking. He stated that obviously this system is not working and another smoking assessment should be completed for this resident. S2PADM verified Resident #2's SNF documentation notes revealed entries on 5/10/14 and 5/12/14 of the resident sitting outside in the smoking area with oxygen in progress. He reviewed the facility's "Smoking Policy and Regulations" and confirmed the facility was not following the policy in that the resident was allowed to keep a lighter in her room and the residents were not smoking in the designated areas. He stated that O 2 tanks should not be in the smoking area even if the oxygen is not flowing (turned off). He said if staff observed Resident #2 outside smoking with an oxygen tank, the staff member should have turned the oxygen off and brought the tank in the building. He said the resident should now be deemed an unsafe smoker. An interview was conducted with S1Administrator on 7/23/14 at 12:53 p.m. He stated had been the administrator of the facility for the past 3 weeks. He verified the facility was not following its own policy in that Resident #2 was in possession of an ignition device. He also confirmed that residents were being allowed to smoke in a non-designated area. He stated Resident #2 was non-compliant with her care plan in regards to smoking with O2 in progress. He stated the resident had been made aware of the dangers of smoking with oxygen in progress. He stated the CNAs and staff should be making rounds and checking to see if the oxygen was turned off and should remove the cylinder from the wheelchair. He verified Resident #2 smoking in the presence of free-flowing oxygen was placing her in danger as well as other residents. An interview was conducted with S7LPN on 7/23/14 at 3:05 p.m. She stated her department updated the care plans for the residents. She stated Resident #2's care plan was updated on 7/22/14 after she and S8RN observed the resident in the early afternoon outside in the front smoking area with her oxygen on via her NC and an oxygen tank noted to the back of her wheelchair. She stated the resident had been sitting there for a while and they felt she was getting ready to smoke. They both stated the resident was not smoking a cigarette at this time. An observation was made of Resident #2 on 7/23/14 at 3:15 p.m. The resident was observed lying across her bed with O2 in progress via concentrator. One box of cigarettes was noted in a pouch on the wheelchair and a second box had cigarette butts. There was an unopened package of 7 cigarette lighters noted on her bed. The oxygen cylinder on the back of the resident's wheelchair displayed an oxygen tank safety sign (a yellow diamond shaped sign with oxygen written in the middle and a flammable sign to the top). A telephone interview was conducted with the facility's physician for Resident #2 on 7/24/14 at 11:19 a.m. He was asked if he was aware of Resident #2 smoking with oxygen in use. He stated the resident was counseled daily and was non-compliant.

Based on observations, record reviews, and interviews, the facility failed to ensure that residents remained free of accident hazards for 2 of 2 residents that wandered outside of the facility (#5, #122) out of a sample of 10 residents the facility determined to be wanderers. The facility failed to: 1. care plan who exactly was to check the functioning of the wanderguard system; 2. ensure someone checked every shift, as care planned, to ensure the doors alarmed and locked when a resident wearing a wanderguard bracelet (secure bracelet/secure care bracelet) approached the door; 3. increase supervision of residents that eloped from the facility (#5, #122); 4. evaluate residents for wandering/elopement risks upon admission (#5); 5. implement changes to a resident's plan of care to address elopement after a resident eloped from the facility (#5, #122); 6. place another secure bracelet on resident #122 after the resident removed her secure bracelet. 7. ensure the staff member responsible for checking the proper function of the doors knew how the wanderguard system worked and when the doors should lock; 8. check a resident's secure bracelet for functioning on an ongoing basis (#122). The Main Lobby door and the Station 1 door were equipped with a wanderguard locking system which locked the doors when a resident wearing a secure bracelet approached the doors. During an interview with the maintenance supervisor he said that the Main Lobby door was set to open regardless if a secure bracelet (wanderguard bracelet) was within distance of the door. He further stated that he had been employed at the facility for over a year and since he had been at the facility, the doors had always been set to function in this manner. On 4/14/11 at 3:30 p.m. both doors controlled by the wanderguard/secure system failed to lock when a wanderguard bracelet was in close proximity to the doors. Resident #122 eloped from the facility and fell while outside on 3/14/11. The resident was placed in Immediate Jeopardy on 3/14/11 after the elopement when the facility failed to increase supervision, update the plan of care with interventions to prevent future elopements, and ensure the wanderguard door system was in proper working condition. Resident #5 eloped from the facility on 3/15/11. The resident was placed in Immediate Jeopardy on 3/15/11 after the elopement when the facility failed to assess the resident as being a high risk for elopement and failed to implement measures to prevent future elopements. The DON was not aware of the incident that occurred on 3/15/11 involving resident #5 being found in the parking lot. She stated that she initiated all interventions for incidents and due to not being aware of the incident (no incident report written), there had been no interventions implemented for this incident. On 4/15/11 the facility presented a plan of removal to supervise residents at risk for wandering. The Immediate Jeopardy was removed for Resident #122 and Resident #5 on 4/15/11 at 1:00 p.m. when the facility implemented the a plan of removal. The deficient practice continues at scope and severity level II potential for more than minimal harm for residents determine to be wanderers currently residing in the facility and for all new admissions that are at risk for wandering or elopement. Findings: General observations were made of the facility throughout the survey week of 4/11/11 - 4/15/11. The facility had two large parking lots that was noted across a two lane street. The facility was next door to a dialysis center and was within close proximity to a hospital. The streets around the facility were observed to be in frequent use. Resident #122 Resident #122 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Elopement Risk Screening dated 12/31/10 revealed the resident was determined to be an elopement risk. Review of the Departmental Notes revealed the following: 2/1/11 at 11:09 a.m. the resident was up at the nurses' station with her purse on her shoulder stating that she wanted to call her daughter to come and pick her up to take her to the bus station... 2/9/11 at 12:03 p.m. the resident packed her belongings and asked to speak with her daughter so she can go back to ____ (her hometown). 3/6/11 at 11:48 a.m. the resident was anxious, crying, upset because her daughter put her in facility. Insist on calling a cab to bring her home. Packed clothes and belongings in bags in her bedroom...Will continue to monitor for elopement. Secure care bracelet in place. Review of the Care Plan revealed the following: Problem (onset date 1/25/11): Potential for injury related to wandering. Goal: Will remain free from injury due to wandering. Approaches: * Wanderguard at all times to notify staff of resident's attempts to leave facility. Check placement and function. * Redirect resident as needed. Review of the Incident Report dated 3/14/11 revealed: Resident #122 stated that she was trying to go sit outside to wait on a taxi when she lost her balance and fell . Small abrasion noted to the bridge of her nose and over her right eye. Another portion of the Report included the 24 Hour Follow-up: "resident sustained [REDACTED]." Review of the Elopement Risk Screening dated 3/29/11 and 4/4/11 revealed the resident was determined to be an elopement risk. An interview was held with S7LPN(Licensed Practical Nurse)-MDS(Minimum Data Set) Nurse, on 4/14/11 at 10:30 a.m. She stated the DON (Director of Nursing) handles all the fall investigations and updates the Care Plan with the appropriate interventions. Upon further review of the resident's computer clinical record, the LPN stated the resident's original order date for the wander guard bracelet was for 1/2/11. An interview was held with S3LPN on 4/14/11 at 2:30 p.m. She recalled the incident that included resident #122 on 3/14/11. She verified she was the nurse on duty on the date/time of the incident. She stated the resident had gotten out of the front door of the facility and fell . She stated that she could not be certain how the resident made it out of the front door or of who had found the resident. She stated she was sure the resident's secure bracelet was on her wrist the day of the incident. She said "I want to say something wasn't working properly with the front door, but I can't be sure." She verified that the MAR (Medication Administration Record) included, "Secure Care Bracelet on at all times to alert staff of resident attempts to leave facility. Check proper functioning every shift." This had a start date of 1/2/11. She verified her initials for 3/14/11 at 6:00 a.m. She stated that she had never checked any of the bracelets for function, only to see if they were actually on the residents. She said that to her knowledge that the maintenance supervisor checked the functioning of all the secure bracelets. She recalled resident #122's bracelet being on her wrist originally, but that she kept "fooling with it". She said on the day of the incident 3/14/11, she placed a secure bracelet on the resident's right ankle. An observation was made of the resident with S3LPN on 4/14/11 at 3:00 p.m. The resident was awake and lying in bed on her right side. Upon assessing the resident, there was no secure bracelet found on the resident's right ankle or any other extremity. The resident was questioned, and she stated that she had "cut it off". She was unable to state how, when, or where she removed the secure bracelet. The LPN searched the resident's bedside table, dresser drawers, and closet, but did not find the secure bracelet. There was a plastic bag full of clothing sitting on the floor next to the resident's bed. S3LPN acknowledged the bag as having the resident's clothing within it and stated the resident frequently packed her clothes to go home. During this time an interview was held with the S3LPN and she stated that she had seen the bracelet on the resident's right ankle this morning. An interview was held with S4LPN on 4/14/11 at 3:15 p.m. She stated that she worked the 2p-10p shift. She stated that she initialed the MARs once on her shift to verify that the resident had a secure bracelet intact. She stated that she had never checked the functioning of the bracelet. An interview was held with S2DON on 4/14/11 at 3:20 p.m. S3LPN had informed the DON of the resident not having a secure bracelet intact and stating that she had removed it. On 4/14/11 at 3:30 p.m. observations were made of the doors of the facility with S5Maintenance Supervisor. There were two doors that were controlled by the wanderguard/secure system. Both doors were located at the front of the building. Each door had a walkway that declined to a drive thru area used for vehicle passing. All remaining doors were locked and required the use of a code to enter or exit the facility. The Station 1 door was checked first with S5Maintenance Supervisor. As the secure bracelet approached the door, the key pad next to the door was observed to have flashing lights. With the secure bracelet directly in front of the door, the door was opened by the surveyor. There was no alarm that sounded and the door never locked. S5Maintenance Supervisor stated the door was not working appropriately and "someone must have changed the settings". He stated the door was supposed to alarm when a secure bracelet was within a few feet of the door and the door was supposed to lock when the secure bracelet was next to the door. Next, the Main Lobby door (located at the front entrance of the building next to administrative offices) was checked using the same secure bracelet. As the Maintenance Supervisor approached the Main Lobby door, an alarm sounded. However, the door was opened by the surveyor. S5Maintenance Supervisor stated that this door was set to react this way to a secure bracelet, meaning that the alarm was to sound, but the door was not supposed to lock. He said the Main Lobby door was the most used door of the facility and that was why the door was set to open regardless if a secure bracelet was within distance. He further stated that he had been employed at the facility for over a year and since he had been at the facility, the doors had always been set to function that way. He further stated that he made weekly inspections of the secure bracelets and doors, but had not done the inspection for this week. He denied any previous problems with the functioning of the two doors controlled by the wanderguard/secure system. Another interview was held with the S2DON on 4/14/11 at 3:50 p.m. She reviewed resident #122's clinical record and verified the resident had been determined an elopement risk on 12/31/10. She stated that she was not aware of the resident's elopement risk when she made the intervention for the secure bracelet application after the incident on 3/14/10. She verified the MAR indicated to check for proper functioning, but further stated the nurses were to check the resident for placement of the bracelet each shift, that the bracelet functioning was done by the maintenance supervisor. An interview was held with the S1Administrator on 4/14/11. She stated that when a resident with a secure bracelet comes to either door (Station 1 or the Main Lobby), the system was supposed to alarm and the doors were supposed to lock. She obtained a secure bracelet and walked to the Main Lobby door. The alarm sounded but she was able to push the door open. She stated the system should lock the doors. She obtained a key from the administrative office, placed the key in the side of the key pad, and turned it. S2DON was now present. She gave the DON the secure bracelet and the DON approached the main door. At this time the door locked and alarm sounded. The Administrator stated this was the correct function of the doors to a secure bracelet. Review of the Weekly Inspection Checklist revealed the doors for Station 1 and the Main Lobby had been checked by S5Maintenance Supervisor, on 3/8/11 3/16/11, 3/34/11, 4/4/10 and was documented as being "ok". Further review of the checklist revealed the resident's secure bracelet had not been tested for functioning by S5 since her admission on 12/29/10. An observation was made on 4/15/11 at 10:25 a.m. of S5Maintenance Supervisor, working on the key pad/control panel for the wander system at the Station 1 door. On 4/15/11 at 10:45 a.m. an observation was made of resident #122 while in the beauty shop getting hair done. The resident was not wearing a secure bracelet. The resident was alert to name only. Another observation was made of the resident on 4/15/11 at 12:30 p.m. The resident was in her wheelchair sitting in front of Unit 2 Nurses Station. She was oriented to person only. She stated that she would like to catch a plane but a bus would be cheaper to get back home. She stated her daughter was trying to take her house and she was taking her to court. She further stated that she was going to call the police "this time" because she (her daughter) had done this to her before. There was no secure bracelet intact to the resident or her w/c. An interview was held with S3LPN on 4/15/11 at 12:40 p.m. She verified the resident was not wearing a secure bracelet. Resident #5 Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set) dated 3/3/11 revealed a documented score of "99" for Section C0500. Summary Score (Cognitive Patterns) that indicated the resident was unable to complete the interview. Further review of the Cognitive Patterns section of the MDS revealed the resident was unable to complete the interview, had a short and long term problem and had moderately impaired cognitive skills for daily decision making. The resident was also coded as having disorganized thinking. Review of the Departmental Notes dated 3/15/11 and timed for 7:41 p.m. revealed the "resident was found by CNA (Certified Nursing Assistant) in parking lot , resident stated she was going to her car to go home..." Review of the initial Elopement Risk Screening dated 3/17/11 revealed the resident was determined to be an elopement risk. She was cognitively impaired with poor decision-making skills, ambulated independently with or without the use of an assistive device, and had a history of [REDACTED]. Review of the Care Plan revealed no documentation to indicate the resident was an elopement risk. An interview was held with S6LPN-MDS Nurse on 4/14/11 at 5:45 p.m. She verified the Care Plan did not reflect that the resident was a high risk for elopement. An interview was held with S2DON in the presence of S1Administrator on 4/14/11 at 6:15 p.m. She stated that she was not aware of the incident that occurred on 3/15/11 involving the resident being found in the parking lot. She stated that she initiated all interventions for incidents and due to not being aware of the incident (no incident report written), there had been no interventions implemented for this incident.

Based on observations, record reviews, and interviews the facility failed to be administered in a manner that used resources effectively and efficiently for 2 of 2 residents that wandered outside of the facility (#5, #122) out of a sample of 10 residents the facility determined to be wanderers. Administration failed to: 1. Train staff to as to who was to check the wanderguard system each shift to ensure the two doors with the wanderguard system were in working order (#5, #122); 2. Provide training to personnel regarding the proper function of the secure bracelets/wanderguard system (#5, #122); 3. ensure the maintenance man, who checked and set the wanderguard system for functioning, knew the proper way the system was to work (#5, #122); 4. implement clinical supervision to ensure the two doors with the wanderguard system locked when residents with wanderguard bracelets approached the doors (#5, #122); 5. failed to train staff to complete an incident report and to notify the DON of incidents of elopement when they occurred so that the DON could initiate interventions. The DON was responsible for initiating interventions after an elopement incident (#5). The Main Lobby door and the Station 1 door were equipped with a wanderguard locking system which locked the doors when a resident wearing a secure bracelet approached the doors. During an interview with the maintenance supervisor he said that the Main Lobby door was set to open regardless if a secure bracelet (wanderguard bracelet) was within distance of the door. He further stated that he had been employed at the facility for over a year and since he had been at the facility, the doors had always been set to function in this manner. On 4/14/11 at 3:30 p.m. both doors controlled by the wanderguard/secure system failed to lock when a wanderguard bracelet was in close proximity to the doors. Resident #122 eloped from the facility and fell while outside on 3/14/11. The resident was placed in Immediate Jeopardy on 3/14/11 after the elopement when the facility failed to increase supervision, update the plan of care with interventions to prevent future elopements, and ensure the wanderguard door system was in proper working condition. Resident #5 eloped from the facility on 3/15/11. The DON was not aware of the incident that occurred on 3/15/11 involving resident #5 being found in the parking lot. She stated that she initiated all interventions for incidents and due to not being aware of the incident (no incident report written), there had been no interventions implemented for this incident. The resident was placed in Immediate Jeopardy on 3/15/11 after the elopement when the facility failed to assess the resident as being a high risk for elopement and failed to implement measures to prevent future elopements. On 4/15/11 the facility presented a plan of removal to supervise residents at risk for wandering. The Immediate Jeopardy was removed for Resident #122 and Resident #5 on 4/15/11 at 1:00 p.m. when the facility implemented the a plan of removal. The deficient practice continues at scope and severity level II potential for more than minimal harm for residents determine to be wanderers currently residing in the facility and for all new admissions that are at risk for wandering or elopement. Findings: General observations were made of the facility throughout the survey week of 4/11/11 - 4/15/11. The facility had two large parking lots that was noted across a two lane street. The facility was next door to a [MEDICAL TREATMENT] center and was within close proximity to a hospital. The streets around the facility were observed to be in frequent use. Resident #122 Resident #122 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Elopement Risk Screening dated 12/31/10 revealed the resident was determined to be an elopement risk. Review of the Departmental Notes revealed the following: 2/1/11 at 11:09 a.m. the resident was up at the nurses' station with her purse on her shoulder stating that she wanted to call her daughter to come and pick her up to take her to the bus station... 2/9/11 at 12:03 p.m. the resident packed her belongings and asked to speak with her daughter so she can go back to ____ (her hometown). 3/6/11 at 11:48 a.m. the resident was anxious, crying, upset because her daughter put her in facility. Insist on calling a cab to bring her home. Packed clothes and belongings in bags in her bedroom...Will continue to monitor for elopement. Secure care bracelet in place. Review of the Incident Report dated 3/14/11 revealed: Resident #122 stated that she was trying to go sit outside to wait on a taxi when she lost her balance and fell . Small abrasion noted to the bridge of her nose and over her right eye. (Another portion of the Report included the 24 Hour Follow-up: "resident sustained [REDACTED].") Review of the Elopement Risk Screening dated 3/29/11 and 4/4/11 revealed the resident was determined to be an elopement risk. An interview was held with S3LPN on 4/14/11 at 2:30 p.m. She recalled the incident that involved resident #122 on 3/14/11. She verified she was the nurse on duty on the date/time of the incident. She stated the resident had gotten out of the front door of the facility and fell . She stated that she could not be certain how the resident made it out of the front door. She said "I want to say something wasn't working properly with the front door, but I can't be sure." She verified that the MAR (Medication Administration Record) included, "Secure Care Bracelet on at all times to alert staff of resident attempts to leave facility. Check proper functioning every shift." This had a start date of 1/2/11. She verified her initials on 3/14/11 at 6:00 a.m. She stated that she had never checked any of the bracelets for function, only to see if they were actually on the residents. She said that to her knowledge that the maintenance supervisor checked the functioning of all the secure bracelets. She recalled resident #122's bracelet being on her wrist originally, but that she kept "fooling with it". She said on the day of the incident 3/14/11, she placed a secure bracelet on the resident's right ankle. An observation was made of the resident with S3LPN on 4/14/11 at 3:00 p.m. The resident was awake and lying in bed on her right side. Upon assessing the resident, there was no secure bracelet found on the resident's right ankle or any other extremity. The resident was questioned, and she stated that she had "cut it off". She was unable to state how, when, or where she removed the secure bracelet. The LPN searched the resident's bedside table, dresser drawers, and closet, but did not find the secure bracelet. There was a plastic bag full of clothing sitting on the floor next to the resident's bed. S3LPN acknowledged the bag as having the resident's clothing within it and stated the resident frequently packed her clothes to go home. During this time an interview was held with the S3LPN and she stated that she had seen the bracelet on the resident's right ankle this morning. An interview was held with S4LPN on 4/14/11 at 3:15 p.m. She stated that she worked the 2p-10p shift. She stated that she initialed the MARs once on her shift to verify that the resident had a secure bracelet intact. She stated that she had never checked the functioning of the bracelet. She further stated that the resident was seen just last night walking up and down the halls without her wheelchair. An interview was held with S2DON on 4/14/11 at 3:20 p.m. S3LPN had informed the DON of the resident not having a secure bracelet intact and stating that she had removed it. On 4/14/11 at 3:30 p.m. observations were made of the doors of the facility with S5Maintenance Supervisor. There were two doors that were controlled by the wanderguard/secure system. Both doors were located at the front of the building. Each door had a walkway that declined to a drive thru area used for vehicle passing. All remaining doors were locked and required the use of a code to enter or exit the facility. The Station 1 door was checked first with S5Maintenance Supervisor. As the secure bracelet approached the door, the key pad next to the door was observed to have flashing lights. With the secure bracelet directly in front of the door, the door was opened by the surveyor. There was no alarm that sounded and the door did not lock. S5Maintenance Supervisor stated the door was not working appropriately and "someone must have changed the settings". He stated the door was supposed to alarm when a secure bracelet was within a few feet of the door and the door was supposed to lock when the secure bracelet was next to the door. Next, the Main Lobby door (located at the front entrance of the building next to administrative offices) was checked using the same secure bracelet. As the Maintenance Supervisor approached the Main Lobby door, an alarm sounded. However, the door was opened by the surveyor. S5Maintenance Supervisor stated that this door was set to react this way to a secure bracelet, meaning that the alarm was to sound, but the door was not supposed to lock. He said the Main Lobby door was the most used door of the facility and that was why the door was set to open regardless if a secure bracelet was within distance. He further stated that he had been employed at the facility for over a year and since he had been at the facility, the doors had always been set to function that way. He further stated that he made weekly inspections of the secure bracelets and doors, but had not done the inspection for this week. He denied any previous problems with the functioning of the two doors controlled by the wanderguard/secure system. Another interview was held with the S2DON on 4/14/11 at 3:50 p.m. She reviewed resident #122's clinical record and verified the resident had been determined an elopement risk on 12/31/10. She stated that she was not aware of the resident's elopement risk when she made the intervention for the secure bracelet application after the incident on 3/14/10. She verified the MAR indicated [REDACTED]. An interview was held with the S1Administrator on 4/14/11. She stated that when a resident with a secure bracelet comes to either door (Station 1 or the Main Lobby), the system was supposed to alarm and the doors were supposed to lock. She obtained a secure bracelet and walked to the Main Lobby door. The alarm sounded but she was able to push the door open. She stated the system should lock the doors. She obtained a key from the administrative office, placed the key in the side of the key pad, and turned it. S2DON was now present. She gave the DON the secure bracelet and the DON approached the main door. At this time the door locked and alarm sounded. The Administrator stated this was the correct function of the doors to a secure bracelet. Review of the Weekly Inspection Checklist revealed the doors for Station 1 and the Main Lobby had been checked by S5Maintenance Supervisor, on 3/8/11 3/16/11, 3/34/11, 4/4/10 and was documented as being "ok". Further review of the checklist revealed the resident's secure bracelet had not been tested for functioning by S5 since her admission on 12/29/10. An observation was made on 4/15/11 at 10:25 a.m. of S5Maintenance Supervisor, working on the key pad/control panel for the wander system at the Station 1 door. On 4/15/11 at 10:45 a.m. an observation was made of resident #122 while in the beauty shop getting hair done. The resident was not wearing a secure bracelet. The resident was alert to name only. Another observation was made of the resident on 4/15/11 at 12:30 p.m. The resident was in her wheelchair sitting in front of Unit 2 Nurses Station. She was oriented to person only. She stated that she would like to catch a plane but a bus would be cheaper to get back home. She stated her daughter was trying to take her house and she was taking her to court. She further stated that she was going to call the police "this time" because she (her daughter) had done this to her before. There was no secure bracelet intact to the resident or her wheelchair. An interview was held with S3LPN on 4/15/11 at 12:40 p.m. She verified the resident was not wearing a secure bracelet. Resident #5 Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set) dated 3/3/11 revealed a documented score of "99" for Section C0500. Summary Score (Cognitive Patterns) that indicated the resident was unable to complete the interview. Further review of the Cognitive Patterns section of the MDS revealed the resident was unable to complete the interview, had a short and long term problem and had moderately impaired cognitive skills for daily decision making. The resident was also coded as having disorganized thinking. Review of the Departmental Notes dated 3/15/11 and timed for 7:41 p.m. revealed the "resident was found by CNA (Certified Nursing Assistant) in parking lot, resident stated she was going to her car to go home..." Review of the initial Elopement Risk Screening dated 3/17/11 revealed the resident was coded to be an elopement risk. She was cognitively impaired with poor decision-making skills, ambulated independently with or without the use of an assistive device, and had a history of [REDACTED]. Review of the Care Plan revealed no documentation to indicate the resident was an elopement risk. An interview was held with S6LPN-MDS Nurse on 4/14/11 at 5:45 p.m. She verified the Care Plan did not reflect that the resident was a high risk for elopement. An interview was held with S2DON in the presence of S1Administrator on 4/14/11 at 6:15 p.m. She stated that she was not aware of the incident that occurred on 3/15/11 involving the resident being found in the parking lot. She stated that she initiates all interventions for incidents and due to not being aware there had been no interventions for this incident. Resident #127 In further review, resident #127 was also ordered to have a secure care bracelet in place. Upon review of the Nurses Notes, documentation dated 1/27/11 at 4:15 a.m. included that the resident was not in her bed and the staff began to search for the resident. During the search, it was found that "the front door alarm was not on". The resident was later found in another bed within the facility. In conclusion, the Administration failed to intervene after residents were eloping from the facility.

Based on record review and interviews the facility failed to: 1.) Provide weekly skin assessments to detect development of pressure ulcers by not performing skin assessments from 12/30/2010 through 1/15/2011, 1/16/2011 through 1/31/11, and from 2/1/2011 through 2/11/11 for resident #1 which resulted in the development of a stage 4 sacral pressure ulcer which required hospitalization with extensive surgical debridement down to the bone of the sacral wound for resident #1. 2). Care plan appropriate intervention for the prevention and treatment or progress toward healing for 7 days for pressure ulcers noted on both heels and sacrum of resident #1 3). Turn resident #5 as specified in care plan for prevention and treatment of [REDACTED]. 4). Float resident #3's heel off of the bed resulting in a stage 6 pressure ulcer of the left lateral heel. The facility failed to assess the resident's skin ongoing to prevent the development of pressure ulcers for 4 of 5 sampled resident reviewed for pressure sores. The total census being 78 as documented on the facility's Resident Census and Condition of Residents. This resulted in actual harm when the facility did not ensure continual monitoring of residents skin, assessing for skin breakdowns, resident not receiving appropriate interventions for the prevention and treatment or progress toward healing for 7 days. The development of the Stage IV sacrum pressure ulcer caused Resident #1 to have a surgical procedure and a long extended hospital stay. Findings: Resident#1 Resident #1 was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]., Difficulty in Walking, Muscle Weakness - General, Lack of Coordination, Depress [MEDICAL CONDITION] - Unspecified, Hypertension Nos, Diabetes Mellitus II without Comp., [MEDICAL CONDITION] Reflux. According to the MDS (Minimum Data Set) dated 01/18/11, the following information was revealed...: Section M: Skin Conditions M0100. Determination of Pressure Ulcer Risk C. Clinical assessment (checked) M0150. Risk of Pressure Ulcers Is this resident at risk of developing pressure ulcers? 1 - Yes M0210. Unhealed Pressure Ulcer(s) Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? 0 - No According to Resident #1's care plan, the following was revealed...: Problem Onset: Skin Breakdown. *L heel Stage 2 onset 2/11/11 *R heel Stage onset 2/11/11 *Sacrum Unstageable - onset 2/11/11. The facility's Wound/Skin Management Documentation Record revealed the following information..: STAGE 1 = Stage 1 - non-blanchable redness 2 = Stage 2 - partial thickness loss of dermis 3 = Stage 3 - full thickness tissue loss 4 = Stage 4 - exposed bone, tendon or muscle 5 = unstageable - non-movable dressing 6 = unstageable - slough and/or eschar 7 = unstageable - deep tissue injury 8 = surgical wound 9 = other _____________ The Physician order [REDACTED]. 02/11/11 Paint left heel and right heel fluid-filled blister with [MEDICATION NAME]. Wrap with kling daily until healed. Left Heel: 2/11/11 Stage 2 4 x 4 x 16 2/15/11 Stage 2 5 x 5 x 25 2/21/11 Stage 2 4.6 x 5.0 x 23 2/26/11 Stage 2 4.0 x 5 x 20 3/3/11 Healed Right Heel: 2/11/11 Stage 2 4 x 6 x 24 2/15/11 Stage 2 5 x 6 x 30 2/21/11 Stage 2 5 x 6 x 30 2/26/11 Stage 2 4.8 x 6 x 28.8 3/3/11 Hospital The facility's Physician order [REDACTED]. 02/11/11 clean coccyx unstageable wound with normal saline, pat dry, apply barrier cream TID 02/21/11 clean coccyx unstageable wound with normal saline, pat dry, apply thin layer of santyl ointment, cover with [MEDICATION NAME] dressing. Change Q3 days and PRN Sacral: 2/11/11 Stage 6 3 x 5 x 15 2/15/11 Stage 6 3 x 3 x 9 2/21/11 Stage 6 3 x 5.5 x 16.5 2/26/11 Stage 6 3.5 x 5.5 x 19 3/3/11 In Hospital An interview was held with S3RN/Treatment Nurse on 03/21/11 at 10:00 a.m. She stated that when she first assessed and identified Resident #1's sacral area on 02/11/11 the wound was unstageable. She also said prior to this assessment, Resident #1 did not have a sacral wound. The facility's Initial and Quarterly Nursing Data on admitted [DATE] at 5:30 p.m. documented the following...: The manikin picture diagram noted bruising to the right upper shoulder from previous fall, bruising above the right patellar from previous fall, and a peri rash to the inner thigh. Skin Audit: Date: 12/29/10 / 12/30/10 0900 Comments: *Skin Intact! Skin Audit: Date: 1/15/11 Time: 7 p.m. Comments: Skin Intact Skin Audit: Date: 1/31/11 Time: 6:30 pm The manikin picture diagrams noted dry flaky skin to right/left bilateral feet and red area to sacrum. Skin Audit: Date: 2/1/11 Time: 0830 Comments: 1. B/L feet dry & falky, heels boggy, no breakdown noted. A& ointment daily. The facility's Photographic Wound Documentation dated 02/11/11 revealed the following...: Taken By: S3Treatment Nurse Date: 2/11/11 admitted to hospital Location (Anatomical Site): R (right) heel blister Wound Type (check below): Pressure Ulcer: Stage 2 Size (cm) (LxW): 4 x 4 Depth (cm): Tunneling (cm): 0 Undermining (cm): 0 Date first observed: 2/11/11 Granulation %: 100 Exudate: Odor: None Type: None Amt: None Wound Bed: Normal for skin Surrounding Skin Color: Normal for Skin Wound Edges/Surrounding Tissue: Normal for skin Date: 2/11/11 Location (Anatomical Site): R (right) heel blister Wound Type (check below): Pressure Ulcer: Stage 2 Size (cm) (LxW): 4 x 6 Depth (cm): intact Tunneling (cm): 0 Undermining (cm): 0 Date first observed: 2/11/11 Granulation %: 100 Exudate: Odor: None Type: None Amt: None Wound Bed: Normal for skin Surrounding Skin Color: Normal for skin Wound Edges/Surrounding Tissue: Normal for skin Date: 2/11/11 admitted to Hospital Location (Anatomical Site): Coccyx Wound Type (check below): Unstageable Size: (cm) (LxW): 3 x 5 Depth (cm): 0.1 Tunneling (cm): 0 Undermining (cm): 0 Date first observed: 2/11/11 Granulation %: 0 Exudate: Odor: None Type: None Amt: None Wound Bed: Slough Black/brown (eschar) Surrounding Skin Color: Pink Wound Edges/Surrounding Tissue: Normal to skin On 03/23/11 at 10:31 a.m., an interview was held with S2RN/DON, S1Administrator, S3RNTreatment Nurse, S4ADON, S5RNMedicare Case Manager, S6LPN Medicare Case Manager, S7LPN Case Manager and S8RN Case Manager. During the interview, S3RN Treatment Nurse stated that R1 was admitted to the facility on [DATE]. She also said that she had reddened areas to the left and right heel that eventually developed into Stage 2 pressure ulcers. She said that Resident #1 also developed an unstageable sacral wound. S2RN DON said that they utilized the physician's standing order for the treatment of [REDACTED].#1's sacral wound had worsened though the wound treatment had changed, she was sent to a local hospital. Resident #1 was admitted to a local medical center on 3/2/11 with [DIAGNOSES REDACTED]. Consults/Additional Medication: Consult Wound RN for decubitis care. Consult doctor regarding sacral decubitus ulcer. Recommend consult surgeon for sacral decubitus. According to the Medical Surgical Patient Care Flowsheet dated 3/1/11, Resident #1 was received from emergency via stretcher. Patient confused and IV infusing via right forearm without difficulty. Stage IV decubitis noted, photos taken. Right heel decubitis noted with black eschar; photos taken. The TENET Operative Report documented the following...: Date of Procedure: 03/04/11 Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Procedure Performed: Sharp, excisional debridement of necrotic and sacral decubitus including skin, subcutaneous tissue, muscle, and bone. PROCEDURE IN DETAIL: After appropriate consent was obtained, consent forms signed, and questions answered, the patient was taken to the Operating Room where general endotracheal anesthesia was induced without difficulty. She was placed in the right lateral decubitus position, exposing the sacral decubitus. There was necrotic area which was excised with a scalpel. The necrotic area extended deep to the sacrum. It also extended laterally beyond the borders of the skin necrosis. A sharp excisional debridement was then performed. All necrotic tissue was removed and this included the skin, subcutaneous tissues, muscle, and down to bone. A piece of the bone at the sacrum was biopsied and sent for culture. Tissue culture was also sent as were swab cultures done at the time of surgery. All necrotic debris was removed and this left a huge defect overlying the sacrum and down to the sacrum itself. Once necrotic tissue was removed, adequate hemostasis was achieved with electrocautery. The wound was then packed with Idoform-soaked gauze. Dressings were applied. The patient was awakened, extubated, and transferred to the Recovery Room in stable condition. She tolerated the procedure without complication. The hospital's Progress Record Operative Note dated 3/4/11 stated the following...: Procedure: Sharp excisional debridement of necrotic sacral decubitus including bone. Finding: Full thickness necrosis to midline including bone. Tissue Removed: Yes Complications: No Blood Loss: 50cc The hospital's Wound, Ostomy and Continence Nurse Initial Evaluation dated 3/2/11 at 11:00 a.m. states the following...: Wound #1: Wound Location: Sacral Wound Type: Decubitis - Unstageable Drainage Type Amount: Serous, periwound [DIAGNOSES REDACTED] Cleaning Agent: Wound cleaner Primary Dressing: Gauze 4 x 4 Secondary Dressing: Further orders from surgeon Wound #2: Wound Location: Left Heel Wound Type: Decubitis Drainage Type Amount: 0 Cleaning Agent: Wound cleaner Primary Dressing(s): Non adherent gauze Secondary Dressing: Heel boot Wound #3: Wound Location: Right Heel Wound Type: Decubitis Drainage Type Amount: 0 Cleaning Agent: Wound cleaner Primary Dressing(s): Non adherent gauze Secondary Dressing: Heel boot WOC Nurse Comments and Recommendations: Surgeon The hospital's clinical laboratory report documented the following...: Date: 03/01/11 WBC 13.6 H Normal Range: (14.8 -10.8) RBC 4.11 L Normal Range: (4.20 - 5.40) MCHC 32.8 L Normal Range: (33.0 - 37.0) RDW 14.7 H Normal Range: (11.5 - 14.5) % LYMP 7.3 L Normal Range: (20.5 - 51.1) [DIAGNOSES REDACTED]S 86.5 H Normal Range: (42.2 - 75.2) Date: 03/02/11 WBC 15.8 H Normal Range: (14.8 -10.8) RBC 3.74 L Normal Range: (4.20 - 5.40) HGB 11.4 L Normal Range: (12.0 - 16.0) HCT 35.1 l Normal Range: (37.0 - 47.0) MCHC 32.5 L Normal Range: (33.0 - 37.0) RDW 14.9 H Normal Range: (11.5 - 14.5) % LYMP 4.5L Normal Range: (20.5 - 51.1) [DIAGNOSES REDACTED]S 0.7Lf Normal Range: (42.2 - 75.2) Date: 03/03/11 WBC 13.2 H Normal Range: (14.8 -10.8) RBC 3.28 L Normal Range: (4.20 - 5.40) HGB 10.2 L Normal Range: (12.0 - 16.0) HCT 30.6 L Normal Range: (37.0 - 47.0) RDW 14.9 H Normal Range: (11.5 - 14.5) % LYMP 5.5 L Normal Range: (20.5 - 51.1) [DIAGNOSES REDACTED]S 90.5 H Normal Range: (42.2 - 75.2) TOTAL PROTEIN 5.8 L Normal Range: (6.0 - 8.0) [MEDICATION NAME] 2.7 L Normal Range (3.5 - 5.0) A/G RATIO .9 L Normal Range (1.1 - 2.0) SGOT (AST) 47 H Normal Range (10 - 30) SGPT 72 H Normal Range (10-36) Date: 03/04/11 WBC 11.7 H Normal Range: (14.8 -10.8) RBC 3.03 L Normal Range: (4.20 - 5.40) HGB 9.3 L Normal Range: (12.0 - 16.0) HCT 27.9 L Normal Range: (37.0 - 47.0) RDW 14.5 Normal Range: (11.5 - 14.5) PLATELET 134 L Normal Range: (150 - 400) % LYMP 5.1 L Normal Range: (20.5 - 51.1) [DIAGNOSES REDACTED]S 91.8 HF Normal Range (42.2 - 75.2) Date: 03/06/11 WBC 10.3 Normal Range: (14.8 -10.8) RBC 2.67 L Normal Range: (4.20 - 5.40) HGB 8.2 L Normal Range: (12.0 - 16.0) HCT 24.8 L Normal Range: (37.0 - 47.0) RDW 14.9 Normal Range: (11.5 - 14.5) PLATELET 141 L (Normal Range: (150 - 400) % LYMP 6.3 L Normal Range: (20.5 - 51.1) [DIAGNOSES REDACTED]S 89.9 H Normal Range (42.2 - 75.2) Date: 03/07/11 WBC 9.5 Normal Range: (14.8 -10.8) RBC 2.66 L Normal Range: (4.20 - 5.40) HGB 8.3 L Normal Range: (12.0 - 16.0) HCT 24.6 L Normal Range: (37.0 - 47.0) MCH 31.1 H Normal Range: (27.0 - 31.0) RDW 14.6 H Normal Range: (11.5 - 14.5) PLATELET 149 L (Normal Range: (150 - 400) % LYMP 8.2 L Normal Range: (20.5 - 51.1) [DIAGNOSES REDACTED]S 86.8 H Normal Range (42.2 - 75.2) Date: 03/08/11 WBC 9.8 Normal Range: (14.8 -10.8) RBC 2.56 L Normal Range: (4.20 - 5.40) HGB 7.9 L Normal Range: (12.0 - 16.0) RDW 14.9 H Normal Range: (11.5 - 14.5) % LYMP 7.9 L Normal Range: (20.5 - 51.1) % [DIAGNOSES REDACTED]S 87.6 H Normal Range: (42.2 - 75.2) Date: 03/09/11 WBC 10.5 Normal Range:(14.8 - 10.8) RBC 3.45 L Normal Range: (4.20 - 5.40) HGB 10.7 L Normal Range: (12.0 - 16.0) RDW 15.0 H Normal Range: (11.5 - 14.5) % LYMP 8.4 L Normal Range: (20.5 - 51.1) % [DIAGNOSES REDACTED]S 85.5 H Normal Range: (42.2 - 75.2) Date: 03/10/11 WBC 12.4 H Normal Range: (14.8 - 10.8) RBC 3.50 L Normal Range: (4.20 - 5.40) HGB 10.8 L Normal Range (12.0 - 16.0) RDW 15.3 H Normal Range: (11.5 - 14.5) %LYMP 9.1 L Normal Range: (20.5 - 51.1) % [DIAGNOSES REDACTED]S 84.8 H Normal Range: (42.2 - 75.2) Date 03/11/11 WBC 31.0 H Normal Range: (14.8 - 10.8) RBC 3.26 L Normal Range: (4.20 - 5.40) HGB 9.9 L Normal Range: (12.0 - 16.0) RDW 15.2 H Normal Range: (11.5 - 14.5) % LYMP 10.9 L Normal Range: (20.5 - 51.1) % [DIAGNOSES REDACTED]S 81.9 H Normal Range: (42.2 - 75.2) The initial nursing assessment for the Long Term Ambulatory Center (LTAC) hospital revealed the following...: TYPE: Pressure Sore LOCATION: Sacral COLOR: Red/green ODOR: 0 DRAINAGE: S/S DESCRIPTION OF DRESSING & SURROUNDING TISSUE: Wet to Dry Stage IV softball sized; coccyx exposed. Photos taken. TYPE: Left Heel Pressure Sore LOCATION: Left Heel COLOR: Black ODOR: 0 DRAINAGE: 0 DESCRIPTION OF DRESSING & SURROUNDING TISSUE: Drainage; paint with [MEDICATION NAME]; black eschar; gauze and kerlix TYPE: Right Heel Pressure Sore LOCATION: Right Heel COLOR: Black ODOR: 0 DRAINAGE: 0 DESCRIPTION OF DRESSING & SURROUNDING TISSUE: No drainage; paint with [MEDICATION NAME]; black eschar; gauze and kerlix applied An interview was held with Resident #1's physician at the local hospital and LTAC on 03/22/11 at 12:50 p.m. She said that when she had received the resident at the hospital she was not in good condition. She also said that she had poor communication, poor eating, was severely mal-nourished and dehydrated. The physician stated that Resident #1 was in bad shape and the sacral wound was definitely infected and smelly. On 03/22/11 at 12:37 p.m. an interview was held with the LTAC Administrator at which time she stated that Resident #1 was being fed all meals. She also said she is more alert and talkative. Her husband visited her on yesterday and she was very responsive. The LTAC Braden Scale Score was 10 indicating the resident was high risk for getting pressure ulcers. The LTAC Admit/Weekly Photographic Wound Documentation Sheet revealed the following..: Date: 03/14/11 Location of wound/incision: Sacrum Length x Width x Depth: 12.5 x 11.0 x 4.0 Drainage: Yes Odor: Yes Wound Bed Color: Red Tunneling or Undermining: 3 cm @ 2:00 [MEDICATION NAME]: 1.6 Wound Care: Wound Vac / Mist Therapy Date: 03/21/11 Location of wound/incision: Sacrum Length x Width x Depth: 11.0 x 12.1 x 3.9 Drainage: Yes Amount of Color Drainage: Moderate Wound Bed Color: Red Pain: Yes Undermining: 6:00 - 4:00 7:00 @ 6.7 Wound Care: Wound Vac / Mist Therapy Resident #2 Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Coli Infection and a history of Pressure Ulcers. The Initial Wound Assessment Nursing Data Sheet performed by S3RN/Treatment Nurse revealed the following...: 06/28/10: Healed pressure wounds to the buttocks. Bilateral heels boggy and red. A and D ointment applied. *Turn schedule, Heel Protectors and Float Heels. Resident #2's Care plan revealed the following...: Problem Onset: Skin breakdown, Left buttock; Stage II, Onset 02/04/11. Approaches: * Body audits daily per CNA, Weekly per nurse. * Reposition Q (every) 2 hours while in bed and Q1 hour while in wheel chair. The facility's Wound/Skin Management Documentation Record revealed the following...: Stage 1= Stage 1 - non-blanchable redness. 2= Stage 2 - partial thickness loss of dermis. 3= Stage 3 - full thickness tissue loss 4= Stage 4 - exposed bone, tendon or muscle. Site: Left buttock Pressure Ulcer/ Stage II: Onset Date: 02/04/11. Present on admit/re-admit: No. Measurements: 2.2 x 1.6 x 1.0 cm, no odor or drainage. According to the nurses notes dated 03/05/11 ..., CNA reports 2 small areas of breakdown, both Stage II on Resident #2's buttocks. Both approximately 1.0 x 1.0 cm in size, one located just below the sacral area in the vertical fold of the right buttock, the second one located on the left lower horizontal fold of the buttock. An interview was held with S3RN/Treatment Nurse on 03/21/11 at 11:00 a.m. She confirmed that Resident #2 had acquired the above mentioned pressure ulcers in the facility. An interview was held with Resident #2 on 03/21/11 at 11:15 a.m. She said that she would get up and get in her wheel chair about 6:00 a.m. and stayed in her chair as much as she wanted. She also said that she was not on a schedule for repositioning while in her chair nor turning when in bed. An interview was held with S9LPN(Licensed Practical Nurse)/Floor Nurse on 03/22/11 at 11:05 a.m. She said that Resident #3 was put in her wheel chair everyday and stays up until lunch. She said that the protocol states the she was to go back to bed after each meal. During an observation on 03/22/11 at 10:45 a.m. of Resident #2's wound treatment by S3RN/Treatment nurse, the surveyor discovered two skin breakdowns; one in the left fold of buttocks and one in the right fold of the buttock. Prior to the wound treatment, the resident had a soiled diaper and was cleaned by S11CNA. S11CNA did not mention any change in the resident's skin condition. S3RN/Treatment Nurse performed wound care and also did not notice the skin break downs. An interview was held with S3RN/Treatment Nurse on 03/22/11 at 10:55 a.m. She said that she did not see the new skin break downs and must have missed them. She preceded to measure the new breakdowns and stated they were both new stage II pressure sores. She also said the the right buttock measured at .6 x .7cm and the left buttock measured at .7 x .7cm. Resident #3 Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Initial Wound Assessment Nursing Data Sheet performed by S3RN/Treatment Nurse revealed the following...: 08/12/10: Dry skin to abdomen, Tattoos to left and right upper arms, upper dentures, bruise to right inner arm, scab to right knee, Dried abrasion to top of right foot measured at 1.5 x 0.6 x 0.1, 2nd toe of right foot measured at 0.4 x 0.5 intact, left small toe measured at 1.1 x 1.0 intact, 3rd toe on left foot measured at 0.4 x 0.4 intact, scab to left and right elbow. 1. Monitor healed old pressure areas x 7 days. 2. Apply A and D ointment to bilateral feet daily. Resident #3's Care Plan revealed the following...: Problem Onset: Skin breakdown, Left Lateral heel Unstageable; Onset: 03/03/11. Approaches: Reposition Q2 hours while in bed and Q1hour while in wheel chair. *Heel Protectors and Float heels at all times while in bed. On 03/21/11 at 1:55 p.m., Resident #3 was observed lying on his back facing the ceiling and heels were not floating. The turning schedule stated resident #3 should have been facing the door between 1:00 p.m. and 3:00 p.m. Resident #3 was observed still on the 11:00 a.m. and 1:00 p.m. turning/reposition according to the turning schedule diagram. An interview was held with S2RN/DON on 03/22/11. She said that the CNAs were inserviced yesterday (03/21/11) on the importance of turning and repositioning the residents according to the schedule. She also said that all residents were not turned and repositioned according to the schedules. The facility's Wound/Skin Management Documentation Record revealed the following...: Stage: 1= Stage 1 - non-blanchable redness. 2= Stage 2 - partial thickness loss of dermis. 3= Stage 3 - full thickness tissue loss 4= Stage 4 - exposed bone, tendon or muscle. 5= Stage 5 - Unstageable- non-removable dressing. 6= Stage 6 - Unstageable- slough and or eschar. 02/27/11 at 4:00 p.m. the Charge Nurse nurses' notes stated...; assisting CNA with changing/dressing resident to get ready for dinner, noted unstageable decubitus approximately 1.0 x 1.0 in measurement, intact, brownish in color to the Left Lateral heel. On 03/04/11; the wound documentation sheet stated the wound was a Stage 6 with measurements at 1.5 x 1.5 x 2.3. Site: Left lateral heel; Pressure ulcer. Onset: 03/03/11. Present on admit/re-admit: No. During an interview with S3RN/Treatment Nurse on 03/21/11 at 11:28 a.m., she confirmed that Resident #3 had the above mentioned wounds and they was acquired in the facility. Resident #5 Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Care Plan revealed the following...: Problem Onset: Skin breakdown; Sacrum Stage II; Onset: 03/02/11. Left lateral ankle; Stage II; Onset: 03/02/11. Left Gluteal fold; Stage II; Onset: 03/13/11. Approaches: Reposition Q2 hours while in bed and Q1 hour while in wheel chair. An observation was made of Resident #5 on 03/21/11 at 1:53 p.m.. Resident #5 was lying in bed facing the window. The turning schedule stated she should have been facing the door. Resident #5 was still on the 11:00 a.m.. to 1:00 p.m. turning and repositioning schedule. The facility's Initial Wound Assessment Nursing Data Sheet revealed the following...: 03/02/11: - performed by the staff LPN floor nurse and signed by S2RN/DON. 1.) Stage II across the sacrum measured at 12.0 cm x 5.5. 2.) Stage II- left lateral heel measured at 3.5 cm x 3.5 cm x <0.1 cm. 3.) Bilateral lower extremities (BLE) right and left flakiness; A and D ointment to BLE. On 03/04/11, S3RN/Treatment Nurse measured the resident #5's sacrum wound at 1.5 x 10.0 x 15.0. The left lateral heel was measured at 0.5 x 0.3 x 0.15 cm. The facility's Wound/Skin Management Documentation Record revealed the following...: Stage: 1= Stage 1 - non-blanchable redness. 2= Stage 2 - partial thickness loss of dermis. 3= Stage 3 - full thickness tissue loss 4= Stage 4 - exposed bone, tendon or muscle. 5= Stage 5 - Unstageable- non-removable dressing. 6= Stage 6 - Unstageable- slough and or eschar. Site: Left Gluteal fold; Stage II. Onset: 03/13/11. Present on admit/re-admit (area left blank). During an interview with S3RN/Treatment Nurse on 03/21/11 at 11:50 a.m., she said that Resident #5 was admitted with two of the three pressure ulcers and acquired the left gluteal fold pressure ulcer in the facility. An interview was held with S3RN/Treatment Nurse on 03/23/11 at 2:00 p.m. She said that she has been a RN for little over a year; first as a floor nurse. She also said that when the Treatment Nurse position became available she accepted the position. S3RN/ Treatment Nurse said that she had received wound treatment training from the prior Treatment Nurse. She also said that the former Treatment Nurse still works at the facility as a LPN floor nurse. She said she did not receive any outside training and the facility was not using any Wound Care resources at this time. Review of S3RN/Treatment Nurse facility's training/ inservices revealed the following...: Skin Care-- 02/25/10. Turning, rashes, heel protectors, skin tears, peri-care and tissue tolerance-- 02/25/10. Infection Control-- 02/25/10, 04/29/10, 10/22/10. Blood borne Pathogen standard-- 04/29/10. Universal Precautions-- 04/29/10..