Every finding on record at Lake Village Rehabilitation and Care Center

Number of residents sampled: Number of residents cited: Based on record review, observations, interviews and facility policy review, it was determined that the facility failed to ensure that the resident environment remained free of avoidable accidents and hazards for one (Resident #11) of two residents reviewed. The findings include: Review of an admission Record, indicated the facility admitted Resident #11 on 01/31/2023 with diagnosis that included heart disease, osteoarthritis [break down of cartilage in the joints of bones causes pain, stiffness and reduced mobility], anxiety, muscle weakness, difficulty walking, unsteady on feet, abnormalities of gait and mobility, lack of coordination, reduced mobility, schizophrenia [brain disorder that affects how a person think, feels and acts], dementia [memory loss, poor reasoning and personality changes], auditory hallucinations [hearing sounds or voices that are not real], post-traumatic stress disorder (PTSD) and fracture of the femur. Review of a signification change MDS with an ARD of 07/02/2025, revealed Resident #11 had a BIMS score of 13 which indicated the resident was cognitively intact. The MDS also indicated Resident #11, during that time, displayed no physical or verbal behavior symptoms, utilized a walker, had no impairment to arms or legs, and all mobility functions were independent. The MDS did indicate PTSD disorder and a major injury. Review of a Care Plan initiated on 03/01/2023, revealed the resident liked to be left alone while in room and Resident #11 would place objects in front of the door while sleeping for security. Resident #11 had ADL changes due to a total left hip replacement, revised on 06/18/2025. Resident #11 was Care Planned for an actual fall with major injury to left hip on 06/08/2025. Resident #11 had behavior problems related to diagnosis such as PTSD, anxiety and hallucinations. Care Plan interventions included explaining procedures prior to starting and approaching the resident in a soft and calm manner. Review of Hospital Records dated 06/08/2025 at 9:20 PM, indicated Resident #11's disposition as Femoral neck fracture. The Computed Tomography (CT) scan report indicated the impression as a comminuted displaced and angulated fracture of the neck of the left femur [a fracture in which the bone breaks into three or more pieces, tilts at an angle and moves from its normal anatomical alignment]. During an interview on 03/04/2026 at 3:40 PM, with Registered Nurse (RN) #10, the RN indicated that she was not familiar with the residents on the 400 Hall, that the hall was not where RN #10 normally worked and she was unaware of Resident #11's diagnosis of PTSD. RN #10 indicated for guidance on how to care for a resident, you would review the Care Plan. RN #10 indicated she entered Resident #11's room on 06/08/2025 to administer medication and Resident #11 jumped up, slammed the cup from RN #10's hand. RN #10 reported Resident #11 grabbed a cane or stick and ran after RN #10. RN #10 indicated running from the room and grabbing a laundry cart and placing the cart in between RN #10 and Resident #11. RN #10 stated Resident #11 grabbed the laundry cart, lost their balance, and fell into the door frame then onto the floor. RN #10 denied receiving any training in the facility on how to handle the situation. RN #10 admitted placing the laundry cart between Resident #11 and RN #10 for both the resident and nurses' safety. During an interview on 03/05/2026 at 8:11 PM, LPN #1 indicated that she did not see the incident regarding Resident #11 on 06/08/2025 but heard CNA #11 state, Oh my God, did you see that? She just pushed him. LPN #7 indicated she looked down the hall from the 100 Hall toward the 400 hall and saw RN #10 standing in the hall and saw the laundry cart. LPN #7 did not see Resident #11. LPN #7 stated all in-services, such as abuse, how to care for a resident with dementia and behaviors, were recently completed February of 2026 During an interview on 03/06/2026 at 7:52 AM, CNA#11 indicated on 06/08/2025 she walked towards the 400 Hall that Resident #11 and RN #10 were on. CNA #11 reported both Resident #11 and RN #10 had their hands on the laundry cart. CNA#11 stated Resident #11 pushed the cart and RN #10 pushed the cart back on Resident #11 and Resident #11 fell back on the floor. CNA# 11 indicated being trained on how to respond in these situations. CNA #11 stated, I would try to get away or back away if possible. During an interview on 03/06/2026 at 8:11 AM, CNA #8 reported she had Resident #11 as a patient the night of the incident on 06/08/2025. CNA #8 denied that Resident #11 displayed any behaviors that night on 06/08/2025. CNA #8 reported walking onto the hall. CNA #8 saw Resident #11 and RN #10 pushing the laundry cart back and forth. CNA #8 reported she saw the laundry cart being pushed back in the direction of the resident, towards Resident #11's door. CNA #8 reported Resident #11 stated RN #10 pushed Resident #11. During a previous interview on 03/05/2026 at 7:58 PM, CNA #8 stated an abuse, dementia, and neglect in-service was completed in February of 2026. During an interview on 03/06/2026 at 8:41 AM, CNA #12 stated she observed the incident on 06/08/2025 between RN #10 and Resident #11. CNA #12 reported she was seated in a chair on the 400-hall talking to a different resident and observed RN #10 coming out of Resident #11's room fast and reported Resident #11 was also coming out of the room after RN #10 fast. CNA #12 reported that RN #10 grabbed the laundry cart and pulled it between RN #10 and Resident #11. CNA #12 reported she got up to check on Resident #11 because, when RN #10 pushed the laundry cart back towards Resident #11 it was a hard shove and Resident #11 ended up on the floor. During an interview on 03/06/2026 at 10:45 AM, the Administrator indicated all in-services were completed by the Administrator, the Director of Nursing (DON) or the Assistant Director of Nursing (ADON). The Administrator indicated in-services were completed annually, routinely and as needed. The Administrator indicated RN #10 was terminated after the incident involving Resident #11. The Administrator stated training was received and interventions were taught to staff concerning behaviors, dementia, and abuse on 06/08/2025. Review of a Resident #11 Reportable document indicated an in-service was completed on 06/08/2025 conducted by the administrator and the ADON regarding Trauma-Informed care/Managing difficult Behaviors and abuse. This in-service defined neglect as The failure of facility, employees or service providers to provide goods/services to a resident necessary to avoid physical harm, pain mental anguish and emotional stress. A power point slide in the in-service on Nursing Home resident Abuse Neglect and Theft indicated you are to back off, get your supervisor, ask to be reassigned, or ask for quiet time if a resident has pushed your last button. The facility re-educated all staff on following the incident on 06/08/2025, on Trauma-Informed care/Managing difficult Behaviors and abuse. Per an in-service initiated on 06/08/2025, all staff behaviors, dementia, and abuse. In addition, RN#10 was terminated after the incident involving Resident #11. These actions were performed before the survey team entered the facility, verified by document review and staff interview resulting in this finding being cited at past non-compliance.

Number of residents sampled: Number of residents cited: Based on observation, record review, interview and facility guidance review, the facility failed to ensure the medication error rate was less than five percent during the medication administration observation of two (Residents #51 and #58) of four residents who received medications from two Licensed Practical Nurses (LPNs). This surveyor observed 25 opportunities for medication administration and two of the 25 medications were not administered in accordance with the physician's orders, resulting in a medication error rate of eight percent. The findings include: Review of a Medication Administration guidance, not dated, from an in-service given on 02/17/2026, conducted by the Director of Nursing (DON) revealed, included in the six rights of medication was the right dosage and to check the label three times, comparing the label with the order and if the medication was a tablet or caplet, to pour the correct number in the cap and then into the medication cup. Resident #51: On 03/05/2026 at 8:33 AM, after preparing medications for Resident #51, this surveyor observed LPN #1 put on gloves. LPN #1 counted the pills in the cup and stated she had 10 and a half pills in her cup. At 8:36 AM the nurse administered the medications to the resident with a cup of water. Review of a Physician Order for Resident # 51 revealed a 20 milligram (mg) diuretic medication with instructions to give three tablets by mouth twice a day with a start date of 02/11/2026. The medication card LPN #1 removed the diuretic pills from during the 8:33 AM medication pass indicated to give four 20 mg tablets in the day and three 20 mg tablets in the evening, and she removed the last four 20mg pills from the card during the observed medication pass. Review of an electronic Medication Administration Record (eMAR) for Resident #51 revealed to give three tablets of the 20 mg diuretic medication two times a day. The eMAR revealed that the diuretic medication was last administered on 03/05/2026 at 8:00 AM and LPN #1's last name was in the box with a check mark. The eMAR also revealed LPN #1 administered the 8:00 AM diuretic medication to Resident #51 on 03/01/2026 and 03/04/2026. On 03/05/2026 at 8:18 PM, LPN #7 was at the medication cart, this surveyor asked her to remove Resident #51's diuretic medication card for the morning dose. She stated those would be in the morning section of the medication cart and she removed all the medication cards from the cart and retrieved the diuretic card. The diuretic medication card indicated the tablet was an 80 mg tablet with instructions to give one tablet by mouth two times a day. The card was filled on 02/01/2026. She placed the cards back in the medication cart in the designated area for the morning medication pass. Durning an interview on 03/06/2026 at 9:49 PM, LPN #6 stated she passed the morning medications on the hall Resident #51 resided. She was asked to retrieve the resident's diuretic medication card, and she stated she had removed the last three pills on the medication card and placed the card in the shred box. This surveyor asked LPN #6 to retrieve the medication card from the shred bin for surveyor's review. LPN #6 retrieved a diuretic card for the resident which revealed the tablet was 20 mg with instructions to give four tablets in the day and three tablets in the evening. LPN #6 stated the diuretic medication card retrieved from the shred bin was not the card she removed the diuretic medication from. LPN #6 stated prior to administering medications, the medication card should be compared to the MAR, vital signs should be checked if needed and resident's pain level should be checked if they need pain medication. She stated if she gave the wrong dose of medication to a resident, she checked the resident's vital signs, notified her superior, whom she did not specify, reported the error to the doctor, completed an incident report and charted the error. She stated nurses received a three-day training on medication administration when hired, with another nurse or the Assistant Director of Nursing (ADON). She stated if a resident received the wrong medication, their blood pressure may be different, and depending on the amount of medication given, the resident could experience cramps or spasms. She stated the process for receiving medications from the pharmacy was to check the medication papers from the pharmacy with the medication and if the nurses see something wrong, call the pharmacy to let them know. She stated nurses would send the medication back with the pharmacy representative if that person was still in the building. If the pharmacy rep had left the building, the nurse would hold the medication by putting the medication (med) in the med room or locked the medication in the medication cart and send the medication back on the next pharmacy delivery. During a telephone interview on 03/06/2026 at 11:00 AM, LPN #1 acknowledged that she gave four 20mg diuretic pills to Resident #51 during the med pass on 03/05/2026. When asked for her process in administering meds safely, she stated prior to giving medications to a resident, she looked at the MAR as she was getting the meds out of the med cart. She stated she looked at the name to ensure she had the right patient and the right dose. She stated she would call the nurse practitioner if she gave the wrong dose of medication to a resident. She stated she would check the resident also. She stated she did not recall what the eMAR showed for Resident #51's diuretic medication. She stated she was pretty sure the label on the bubble pack indicated to give four pills in the day and three pills in the evening. She stated for as long as she could recall, she had been giving Resident #51 four diuretic pills in the morning when she worked, and she had been employed at the facility almost 3 months and usually passed medications on the hall Resident #51 resided. During a telephone interview on 03/07/2026 at 2:49 PM, the Pharmacist from a medication provider for the facility verified their pharmacy filled a prescription for Resident #51 on 02/02/2026 for a diuretic medication with 210 pills and sent those pills to the facility. He stated two cards were sent with one card having four pills in each bubble and the other card having three pills in each bubble. He stated the instructions on the card indicated four tablets by mouth every day and three tablets at bedtime. He also verified the pharmacy filled a prescription for a diuretic medication on 03/03/2026 of 180 pills with two cards, each card having three pills in each bubble to total 90 pills per card and the medication was sent to the facility. Resident #58: During a medication observation and concurrent interview on 03/05/2026 at 8:05 PM, LPN #2 stated Resident #58 was ordered to receive an anticoagulant, the medication was not available but had been ordered. She stated she reordered the medication last night, 03/04/2026, after she administered the last pill. Resident #58 did not receive the scheduled dose during the observation. Review of a Physician's Order for Resident #58 revealed a diagnosis of cerebral atherosclerosis (hardening or narrowing of arteries in the brain), and the resident was to receive an antiplatelet medication with a start date and time of 12/20/2025 at 8:00 PM. Review of a March 2026 eMAR revealed Resident #58 was to receive an anticoagulant medication at bedtime related to cerebral atherosclerosis. The eMAR indicated the time for administration as 8:00 PM and on 03/05/2026 the number five was in the box with LPN #2's initials in the box. The chart code revealed the number five indicated hold/see progress notes. The March 2026 eMAR did not have any documentation under progress notes as to why the medication was not given. During an interview on 03/06/2026 at 12:28 PM, the ADON stated if a nurse gave the wrong dose of medication to a resident, the nurse should notify the nurse practitioner or the doctor. She stated if the provider had any recommendations or orders, the nurse would follow those orders. She stated the nurse should also check on the resident in case they had adverse reactions from the medication. The ADON stated the nurses received education/training quarterly and the facility also did skills check off for nurses. She stated LPN #1 would have done medication administration training on hire and she was asked to provide this information for review. She also stated the nurses were responsible for reordering prescribed medications and the nurses were also to follow up with the pharmacy to ensure the medication had been received once ordered. She stated if the nurses had issues receiving the medication, they would come to her. She stated any omitted doses of medication should be reported to the medical provider. She stated the turnaround time for the pharmacy to deliver medication after it was ordered was 24 hours. As of 03/06/2026 at 5:05 PM, the facility had not provided any skills check off for medication administration for LPN #1 to the survey team.

Based on record review, interviews and facility policy review, it was determined that the facility failed to have the medical care of each resident supervised by a Physician for three (Resident #3, Resident #6, Resident #20) of three residents reviewed for unnecessary medications and antibiotic stewardship. The findings include:Review of the facility's undated policy titled Antibiotic Stewardship indicated the medical director provides oversight to team functions and responsible for program outcomes, provides clinical guidance and enforcement, and provides monitoring of patients receiving selected microbials. The policy also indicated the Antibiotic Stewardship Team, core members, included at a minimum, an infection preventionist, physician and a pharmacist, along with any administrative, developmental and IT support. Review of a facility policy titled, Consultant Pharmacist Services Provider Requirements dated 01/01/2015, indicated A written or electronic response of report of findings and recommendations resulting from the activities as described is given to the attending physician, the director of nursing, medical director and other as appropriate at least monthly, The facility has a process to ensure that the findings are acted upon.Resident #3 Review of an admission Record indicated the facility admitted Resident #3 on 04/11/2025 with diagnoses that included chronic kidney disease, respiratory failure, pressure ulcer of sacral region and urinary tract infections. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/02/2026, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. Review of a Care Plan, initiated on 11/14/2025, revealed Resident #3 had an open wound. Care Plan interventions included Enhanced Barrier Precautions (EBP). Review of a Pharmacy Medication Regimen Reviews (MMR) for Antibiotic Stewardship with antibiotic recommendations from the pharmacist for Resident #3 completed on 05/17/2025, 07/20/2025, 07/24/2025, 08/16/2025, and 10/04/2025 were signed by ADON/LPN #1 in place of the Physician's signature. Review of Progress Notes for Resident #3 indicated no verbal orders documented on 05/17/2025, 07/20/2025, 07/24/2025, 08/16/2025, and 10/04/2025. Resident #6Review of an admission Record indicated the facility admitted Resident #6 on 12/07/2021 with diagnoses that included type two diabetes, enlarged heart, bronchitis, infection of the skin and subcutaneous tissue, cough, retention of urine, and bacterial bone infection.Review of a quarterly MDS, with an ARD of 11/26/2025, revealed Resident #6 had a BIMS score of 15, which indicated the resident was cognitively intact and was independent for daily decision making. The MDS also indicated Resident #6 was dependent on self-care and mobility with substantial to maximum assistance. Lastly, the MDS indicated Resident #6 had a diagnosis of kidney disease and received hemodialysis. Review of a Care Plan, initiated on 01/17/2025, revealed Resident #6 would pick at scabs and skin until open areas developed. Care Plan interventions included administering medications as prescribed by the Physician. Review of a Pharmacy Medication Regimen Reviews (MMR) for Antibiotic Stewardship with antibiotic recommendations from the pharmacist for Resident #6 completed on 11/02/2025, 12/25/2025, 01/09/2025, 01/24/2025, 01/24/2025 and 02/21/2026 were signed by ADON/LPN #1 in place of the Physician's signature. A different antibiotic was listed on each of the 01/24/2025 MRR's. Review of Progress Notes for Resident #6 indicated no verbal orders documented on 11/02/2025, 12/25/2025, 01/09/2025, 01/24/2025, 01/24/2025, and 02/21/2026. Resident #20Review of an admission Record indicated the facility admitted Resident #20 on 08/18/2023 with diagnoses that included lung disease, type two diabetes, and a stroke. Review of a quarterly MDS, with an ARD of 11/30/2025, revealed Resident #20 had a BIMS score of 13, which indicated the resident was cognitively intact and independent for daily decision making. The MDS also indicated Resident #20 was completely dependent on staff for self-care and mobility and Resident #20 had an active diagnosis of asthma/chronic lung disease. Review of a Care Plan, initiated on 08/18/2023, revealed Resident #20 had diabetes, chronic lung disease, and bladder incontinence. Care Plan interventions included if an infection was present to consult with the Physician regarding any changes in medication, administer medication as prescribed, and observe for any signs or symptoms related to a bladder infection. Review of a Pharmacy Medication Regimen Reviews (MMR) for Antibiotic Stewardship with antibiotic recommendations from the Pharmacist completed on 04/27/2025, 09/14/2025 and 09/14/2025 were signed by ADON/LPN #1 in place of the Physician's signature. A different antibiotic was listed on each of the 09/14/2025 MRR's. Review of Progress Notes for Resident #20 indicated no verbal orders documented on 04/27/2025, 09/14/2025 and 09/14/2025. During an interview on 03/04/2026 at 4:30 PM, the Director of Nursing (DON) stated the Assistant Director of Nursing (ADON) who was a Licensed Practical Nurse (LPN) oversees the MRR reviews monthly. The DON indicated no MRR forms were signed by the DON. The MRR forms nurses' signature would be the ADON. The DON stated a nurse should never sign in a Physician's place unless there was a verbal order to do so. The DON indicated if a nurse does sign for a Physician there should be documentation of the reason, such as a verbal order. The DON indicated the signatures on the MRR should be the pharmacist, the physician and then the nurse.During an interview on 03/05/2026 at 2:54 PM, the ADON, who was an LPN, indicated the Pharmacist came monthly and reviewed different medications. The ADON indicated once the review was complete it would trigger the Physician to sign when there were new orders or suggestions made. The ADON stated the signatures on the MRR were the Pharmacist, the Physician, and the nurse. The ADON indicated a nurse's signature would be acceptable if no new orders were made and there were just recommendations for the residents to change medication. The ADON stated the difference in the MMRs that were signed by the nurse in the Physician's place verses the MRRs that were signed by the Physician was that the physician was present those days and was assisted in logging into the computer to sign the MRRs. The ADON stated the medical director was unable to access the electronic system without the ADON's assistance. The ADON stated a phone call was made to the Physician and antibiotic stewardship orders were completed over the phone. The ADON stated a call was made and the ADON then recorded what was said and signed in the Physician's place. The ADON indicated an Advance Practical Registered Nurse (APRN) was present in the facility Monday through Friday and previously was in the facility three days weekly. During an interview on 03/05/2026 at 3:55 PM, Pharmacist #13 indicated a MRR was completed monthly and a Gradual Dose Reduction (GDR) was completed quarterly, every six months and annually. Pharmacist #13 stated, recommendations are made and the Physician must agree to them or document a reason why they disagree. Pharmacist #13 stated with a GDR, the Physician should sign for any changes to stop medication or alter the orders. The Pharmacist indicated three signatures were needed on the MRR/GDR form: the Pharmacist, the Physician and the nurse. During an interview on 03/05/2026 at 4:21 PM, the APRN indicated the role of the APRN regarding the MRR and GDR forms was to review recommendations and make changes accordingly for the residents' medications. The APRN stated reviews were done monthly and as needed. The APRN stated she checked the recommendations and the residents' medication and documented if the risks outweighed the benefits. The APRN stated there was really no reason for a nurse to sign in a Physician's place unless the nurse was given a verbal order. If the MRR/GDR was signed for a Physician by a nurse there should be documentation where the discussion took place. During an interview on 03/06/2026 at 10:5 AM, the Administrator indicated that a nurse should not sign in a Physician's place without a verbal order. The Administrator stated if a verbal order was received then the nurse would sign the physicians' name, the nurse's name with verbal order written behind it and a note should be documented if that were the case. The Administrator stated if it was just a recommendation to change the medication and not an order then the nurse can sign the MRR/GDR. During an interview on 03/06/2026 at 12:40 PM, the APRN stated that all orders were entered into the electronic system and not written. The APRN stated if there was a verbal order given the electronic system alerted them to sign the orders. The APRN stated if a recommendation was made by a Pharmacist the APRN/Physician should review and sign it. During an interview on 03/06/2026 at 1:38 PM, the ADON stated if a written order was received it was scanned into the electronic system and entered into the electronic system under orders. This process would populate Progress Notes automatically. When a verbal order was received it was entered the same way into orders and it triggered an automatic note in the electronic system. The ADON stated the Physician would get an alert when new orders were entered and recommendations were sent to the physicians as well. The ADON denied any other places where an MRR/GDR were accessed or signed other than through the electronic system.

Number of residents sampled: Number of residents cited: Based on observation, record review, interview and facility policy review the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented during tracheostomy (trach) care for one (Resident #1) of one resident reviewed for tracheostomy care. The findings include: On 03/06/2026 at 9:22 AM, this surveyor observed Registered Nurse (RN) # 3 provide trach care to Resident #1. RN #3 did not put on a gown before or during the trach care. Review of March 2026 Physician's Orders (PO) for Resident #1, revealed an order for EBP related to trach and gastrostomy tube with a revision date of 02/08/2026. The PO also revealed an order with a start date of 06/05/2025 to change the inner cannula every day. Review of a quarterly Minimum Data Set, with an Assessment Reference Date of 02/04/2026 for Resident #1 revealed a Staff Assessment for Mental Status score of 3, which indicated Resident #1 had severe cognitive impairment, never or rarely made decisions, and received tracheostomy care. Review of a Care Plan, with a revision date of 02/20/2026, revealed Resident #1 required EBP related to Percutaneous Endoscopic Gastrostomy (PEG) tube feedings and tracheostomy with an intervention to wear disposable gloves and gowns when providing high contact care. During an interview on 03/06/2026 at 9:40 AM, RN #3 stated Resident #1 was on regular standard precautions and not EBP. This surveyor and RN #3 stepped out of the resident's room, and she stated she was familiar with EBP, and she was not wearing a gown. When asked if a gown should have been worn for trach care RN #3 looked up at the EBP signage posted on the outside of Resident #1's door and stated, Yes ma'am. During an interview on 03/06/2026 at 12:10 PM, the Assistant Director of Nursing (ADON) stated Resident #1 was on EBP and the nurse should wear a disposable gown and gloves to perform trach care. She stated she had done EBP in-services with the staff but was not positive of the date of the last in-service. She was asked to provide a policy for EBP and any in-services on EBP to staff. Review of an in-service dated 07/02/2025 with a topic of EBP, conducted by a different Director of Nursing (DON), indicated providers must wear gloves and a gown for the following high-contact care activities: tracheostomy care was listed. RN #3's name did not appear on the in-service sign-in sheet. The DON was unavailable for interview. Review of facility policy titled Enhanced Barrier Precautions policy, with no revision date, indicated enhanced barrier precautions involved the use of gown and gloves during high-contact resident care activities for residents known to be colonized with a MDRO (Multi-drug-resistant organism) as well as those at increased risk of MDRO acquisitions (i.e. (for example) residents with wounds or indwelling medical devices. The policy indicated an order for enhanced barrier precautions will be obtained for residents with certain conditions which included a tracheostomy tube.

Based on observation, record review and interview, the facility failed to ensure foods in the pantry were dated to maintain freshness and prevent potential cross contamination. This failed practice had the potential to affect 52 residents who received meals from the kitchen according to the list provided by the Director of Nursing (DON) dated 09/03/2024 (Total Census 55). The findings are: 1. On 09/05/2024 at 9:06 AM, a shelf above the food processer next to the stove had bottles of spices. A container of onion powder with a build-up dried matter on the open, and a container of salt with the lid open were found on the shelf. The Dietary Manager (DM) was asked how spices are supposed to be stored. The DM indicated that the lids are supposed to be closed. 2. On 09/05/2024 at 9:14 AM, the following observations were made in the dry storage panty: a. One 20 liter clear dry storage container with a blue lid with a label indicating corn meal was observed to the left upon entry into the pantry. No date indicating when it was placed in the container, or a date of when it should be used by, was on the container. The DM was asked how much corn meal was left in the container and indicated about 15 quarts were left. b. One 1 gallon jug that had no markings on it or date of when opened. The DM indicated it was white vinegar, and indicated about 2 ounces were left in the jug. 3. On 09/05/2024 at 9:21 AM, the following observation was made in the walk-in cooler: a. One 48-ounce glass jar of grape jelly had been opened, with no open date. The DM was asked how much grape jelly was in the jar. The DM indicated about 3 ounces were left in the jar. 4. A Document titled Food and Nutrition Services was provided by the Director of Nursing (DON) on 09/03/2024 at 1:20 PM. The document did not address putting a date of when a food item it opened or proper closer of food items.

Based on observation, interview, record review, and policy review, the facility failed to ensure the medication error rate was less than five percent (%). 31 opportunities of medication administration were observed and 2 of the 31 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 6.45%. The findings are: On 09/05/2024 at 8:26 AM, Registered Nurse (RN) #3 was observed retrieving Resident #53's medication from the medication cart for the 8:00 AM medication pass. She retrieved a box of Famotidine tablets, 10 milligrams (mg) strength, removed two tablets from the box and placed them in a pill cup. Once she gathered the medication, she administered the medication to Resident #53. Resident #53's Order Summary dated 09/05/2024 was reviewed and indicated an order for Famotidine 20 mg tablets and give two by mouth one time a day for 40 mg daily. On 09/05/2024 at 4:24 PM, (RN) #3 was interviewed and asked to look at the box of Famotidine she used to administer medication from to Resident #53. She was asked what the strength of the medication was displayed on the box, and she stated, 10 mg. She was asked to look at Resident #53's medication orders in the electronic health record (EHR) and state what the strength of the medication on the order was and she stated, 20 mg. RN #3 confirmed the dose on the order was 40 mg, but she administered 20 mg to the resident. On 09/06/2024 at 8:29 AM, Licensed Practical Nurse (LPN) #4 was observed retrieving Resident #28's medication from the medication cart for the 8:00 AM med pass. She removed a bottle of Fluticasone 50 micrograms (mcg) nasal spray and placed the bottle on top of the med cart. Once she removed all the meds for Resident #28 from the medication cart, she took the meds to the resident's room and placed them on the bedside table. With gloved hands, she administered two sprays of Fluticasone nasal spray in each of the resident's nostrils. Resident #28's Order Summary dated 09/03/2024 was reviewed and indicated an order for Fluticasone Nasal Suspension, one spray in each nostril every morning and a bedtime. On 09/06/2024 at 9:21 AM, LPN #4 was interviewed, and she confirmed she administered two sprays of Fluticasone in each of Resident #28's nostrils during the 8 AM med pass. She was asked to look at Resident #28's medication orders in the EHR and state what the instructions for the Fluticasone nasal spray were. She confirmed the order was for one spray in each nostril. She was asked what should be done before administering meds to the resident and she stated, Double check the order and read it. LPN #4 stated the reason for double checking the order was to make sure the right dose was being given to the resident. On 09/06/2024 at 9:51 AM, a Specific Medication Administration Procedures policy, revised January 2018 and provided by the Assistant Director of Nursing on 09/06/2024, was reviewed and indicated before removing the medication package/container from the cart/drawer, the medication administration record (MAR) orders were to be checked. The policy indicated before removing the medication from the container, the label should be checked against the MAR.

Based on interview, record review, and policy review, the facility failed to convey a resident's personal funds to the individual or representative administering the individual's estate within 30 days for 1 (Resident #164) of 3 sampled residents for whom the facility-maintained trust accounts per a list provided by the Business Office Manager (BOM) on [DATE] at 3:00 PM. The findings are: l. Review of the Mortician's Receipt-Record of Death indicated that Resident #164 passed away on [DATE]. 2. A document titled Lake Village Rehabilitation and Care Center Trust-Current Account Balance As of [DATE] documented that a trust account for Resident #164 contained a closing balance of $145.21. 3. On [DATE] at 3:00 PM the Surveyor asked the Business Office Manager (BOM) how long the facility has to return the resident money from trust accounts when a resident passes away or discharges. The BOM indicated one month. 4. On [DATE] at 10:15AM, the Surveyor asked the BOM to identify the date Resident #164 had expired. The BOM verified that Resident #164 passed away on [DATE]. 5. The BOM was asked if they had a policy regarding resident trust accounts. The BOM indicated the facility follows DHS guidelines. 6. A document titled Management of Resident and Elder Trust Accounts was provided by the BOM on [DATE] at 11:15 AM. The document did not address the return of resident funds upon resident discharge or death.

Based on observation, interview and record review, the facility failed to ensure a resident was able to self-hydrate by consistently keeping fluids in reach for 1 (Resident #28) of 1 sampled resident reviewed for accommodation of needs. The findings are: Resident #48 had diagnoses of arthritis in multiple joints (poly osteoarthritis) and the loss of cushioning between the disc in the back (intervertebral disc degeneration) indicated on an Order Summary dated 09/06/2024. A quarterly Minimum Data Set with an Assessment Reference Date of 07/15/2024 was reviewed and indicated Resident #48 had a Brief Interview for Mental Status score of 11, which indicated moderate cognitive impairment and required setup and/or clean up assistance with eating, as the resident had the ability to bring food and/or liquids to the mouth once the meal was placed before the resident. A Care Plan dated 08/19/2024 was reviewed and indicated Resident #48 was at risk for falls and had poly osteoarthritis. Interventions included keeping the resident's personal items within reach and encouraging adequate nutrition and hydration. On 09/03/2024 at 10:53 AM, Resident #48 was observed lying in bed on the resident's back with the head of bed (hob) slightly elevated. The resident was reaching both hands towards a water pitcher on the bedside (bs) table to the left of the resident. Resident #48 was asked if the resident was attempting to drink some water and the resident did confirm that was the intent. There was no cup on the bs table and no straw in the cup. On 09/04/2024 at 8:34 AM, Resident #48 was observed lying in bed on the resident's back and the bs table was positioned in front of the nightstand to the left of the resident's bed and out of the resident's reach. There was a water pitcher and a foam cup on the bs table. On 09/04/2024 at 2:02 PM, Resident #48 was observed lying in bed on the resident's back with the hob up and a wedge cushion to the resident's right side. A water pitcher, with a straw inside, was on the bs table which was positioned to the left of the bed and out of the resident's reach. On 09/05/2024 at 3:30 PM, Resident #48 was observed lying in bed with eyes closed. A water pitcher was on the nightstand to the left of the resident's bed and out of reach. On 09/06/2024 at 12:11 PM, Resident #48 was lying in bed with eyes closed. A water pitcher was on the nightstand to the left of the resident's bed and out of reach. On 09/06/2024 at 12:25 PM, Certified Nursing Assistant (CNA) #5 was interviewed and she was asked if Resident #48 could get a drink of water and she stated the resident could if the water was placed in front of the resident. She stated the resident required a cup and was unable to pick up the water pitcher because the resident would waste the water. CNA #5 was asked where the resident's water pitcher was at that time and she stated, Right there, as she pointed to the nightstand and confirmed it was out of the resident's reach. She stated the resident would try to reach up to get it and get some water and waste it. She confirmed there was no cup in the room for the resident to use and confirmed the CNAs were responsible for placing the cup in the room for the resident's use. CNA #5 confirmed that when the cup was in the room, the CNAs would pour the water in the cup for the resident. On 09/06/2024 at 2:55 PM, the Director of Nursing provided a document which was reviewed and indicated the facility did not have a policy regarding the accommodation of a resident's need for items to be within reach.

Based on record review and interview, the facility failed to revise the care plan of 1 (Resident #52) sampled resident after the quarterly assessment was completed. The findings include: Review of the quarterly Minimum Data Set (MDS) with the Assessment Reference Date of 7/07/2024 revealed Resident #52 score 5 on a Brief Interview for Mental Status, indicating severely impaired cognition. Resident #52 had a diagnosis of Schizophrenia and depression. Resident #52 was taking an antipsychotic and antidepressant. A Care Plan (revision date 05/21/2024) revealed Resident #52 used an antidepressant medication, but did not reference the use of an antipsychotic medication. A review of the Physician Order portion of Resident #53's electronic health record revealed an order for an antipsychotic intended to treat Schizophrenia, with a start date of 6/27/2024. On 9/06/2024 at 11:33 AM, the Director of Nursing confirmed the care plan did not address Resident #52 taking an antipsychotic medication. On 9/06/2024 at 11:33 AM, the Director of Nursing provided documentation that the facility did not have a resident care plan policy.

Based on observations, interviews, and record reviews the facility failed to ensure that 1 (Resident #35) of 2 sampled resident with an indwelling urinary catheter received proper catheter care. The findings include: According to the admission Minimum Data Set (MDS) with the Assessment Reference Date of 8/04/2024, Resident #35 had a Brief Interview for Mental Status score of 03, indicating severe cognitive impairment, and that Resident #35 had an indwelling catheter. A Care Plan (revision date 8/06/2024) revealed Resident #35 had a urinary catheter related to urinary retention, overactive bladder, and benign prostatic hyperplasia (BPH). On 09/03/24 at 02:00 PM, the Surveyor observed Resident #35 sitting in a wheelchair with catheter collection bag hooked to the back of wheelchair. The collection bag was not positioned below the level of the resident ' s bladder to facilitate the flow of urine. On 09/04/24 at 08:44 AM, the Surveyor observed Resident #35 sitting in a wheelchair in the common area. The Surveyor noted that catheter tubing was wrapped around the resident's right ankle with the tubing touching the floor. On 09/04/24 at 11:00 AM, the Surveyor observed Resident #35 sitting in a wheelchair with catheter tubing draped over the wheelchair lock. The Surveyor noted the tubing was almost full of urine due to the kinking of the tubing. On 09/04/24 at 11:53 AM, the Surveyor observed Resident #35 sitting in a wheelchair with catheter tubing draped over the wheelchair lock. The Surveyor noted the tubing was almost full of urine due to the kinking of the tubing. On 09/06/24 at 10:50 AM, the Assistant Director of Nursing stated that the facility did not have a policy on catheter care the facility follows the Lippincott Manual of Nursing.

Based on observation, interview, record review, the facility failed to ensure a glucometer was cleansed after being used to check a fingerstick blood sugar for 1 (Resident #2) of 1 sampled resident who was reviewed for glucometer checks. On 09/05/2024 at 4:36 PM, Licensed Practical Nurse (LPN #2) was observed gathering a glucometer machine and other items. She sanitized her hands, put on a clean pair of gloves, took the items to Resident #2's room and placed them on the bedside table. She informed the resident she was about to check the resident's blood sugar. She cleansed the ring finger of the resident's left hand, performed other steps and collected a blood sample from Resident #2's finger using the test strip in the glucometer machine. After the results were displayed on the glucometer machine, LPN #2 discarded the used items, placed hand sanitizer in her hands, rubbed her hands together and picked up the glucometer machine. She rubbed her hands over the front and back of the glucometer machine for less than five seconds and placed the glucometer machine in the top right drawer in the medication cart. On 09/05/2024 at 4:43 PM, LPN #2 was interviewed and asked what she did with the glucometer machine. She opened the medication cart, and the glucometer machine was observed in a basket in the top drawer. She was asked did she cleanse the machine and she stated, What I do is use [brand-name] sanitizer, and I rub my hands. Then I rub it on the glucometer [machine], and I put it back in the drawer. LPN #2 was asked if this was how she was instructed to cleanse the glucometer machine and she confirmed it was not. She stated no one [at the facility] instructed her on how the glucometer machine should be cleansed. On 09/05/2024, the Director of Nursing provided the manufacture's guidelines for the glucometer machine. The guidelines were reviewed, and a section titled Cleaning and Disinfecting Procedures for the Meter indicated in the disinfection instructions on page 43, the meter was to be disinfected between patient uses by wiping it with a [brand-name] towelette or EPA-registered disinfecting wipe in between tests. Page 44 of the guidelines indicated in step five if the [brand-name] towelette was used, it should remain wet for two minutes. For other wipes, the surface of the meter was to remain wet for the contact time listed on the other wipe's instructions.

Based on observation, interview, and record review, the facility failed to remove dented cans from food circulation; label and date leftover food items in the refrigerator; and date opened spice containers to ensure food is used or discarded prior to the use by date. The failed practices had the ability to affect 42 residents (Resident Census: 44), who received meals from the kitchen. The findings are: 1. On 10/02/23 at 10:47 AM, the following spices were on a shelf in the kitchen and did not have an opened date: i) Whole Celery Seed ii) Ground Allspice iii) Mediterranean Style Ground Oregano iv) Ground Cinnamon v) Salt vi) Rubbed Sage vii) Celery Salt viii) Ground [NAME] Pepper ix) Ground Ginger x) Dill Weed a. The Surveyor asked Dietary Employee (DE) #2 if there was an opened date on the spices. DE #2 said, I cannot find a date written on these. b. On 10/02/23 at 10:50 AM, the Surveyor asked DE #2 if a 'use by date' was on the unlabeled spices. DE #2 stated No, I usually date the bottle and keep mine for a year. 2. On 10/02/23 at 11:00 AM, observed in the cooler square containers covered with plastic wrap without a date or label on them. a. On 10/02/23 at 11:00 AM, the Surveyor asked DE #2 what was in the square containers covered with plastic wrap. DE #2 said, It's something pureed. One looks like meat. DE #1 stated the containers contained mashed potatoes, green beans, meat, ground chicken, boiled eggs, and pureed meat from today. DE #1 stated that the unlabeled food was from yesterday and today. The Surveyor asked DE #1 if the containers should have a date and label on them. DE #1 stated, Yes, it supposed to be dated. 3. On 10/02/23 at 11:10 AM, observed a metal rack with a #15 can of mandarin oranges with a dent on the bottom, and three cans of cream of mushroom soup with small dents on the top. b. On 10/02/23 at 11:20 AM, the Surveyor asked DE #1 what do you do when you receive a dented can. DE #1 said, Sometimes we use dented cans if we need them. Sometimes it may be bruised when you open them. 4. A facility policy titled, Food and Nutrition Services, provided by the Director of Nursing (DON) on 10/05/23 at 2:00 PM stated: Purpose: To prevent contamination of food products and therefore prevent foodborne illness.I. Director of Food Service Responsibilities .A. Provide safe food services for patients and employees .F. Provide for the proper receipt and storage of all food supplies.V. Food Storage A. Upon arrival, all food will be inspected for damage . VI. Proper Food Handling .B. Foods coming from broken packages or swollen cans or food with an abnormal appearance or odor will not be served .K. Leftovers must be dated, labeled, covered, cooled and stored (within 1/2 hour) in a refrigerator, not at room temperature .

Based on observation, interview, and record review, the facility failed to ensure the Comprehensive Care Plan addressed the use of an anticoagulant for 1 (Resident #45) of 1 sampled resident. The findings are: Resident #45: 1. A Physicians Order dated 09/15/23 noted Resident #45 was to receive Apixaban 5 milligrams two times a day for an anticoagulant. 2. The Care Plan, last reviewed on 9/25/23, did not address anticoagulant use and/or precautions. 3. On 10/04/23 at 3:20 PM, LPN #1 confirmed she did not find anticoagulants on Resident #45's Care Plan.

Based on observation, record review, and interview, the facility failed to ensure oral care was performed to keep the lips moist and free of dry skin to promote good oral hygiene for 1 (Resident #1) of 2 (Resident #1 and #3) sampled residents who were dependent for oral care. The findings are: 1. Resident #1 had diagnoses of Spastic Quadriplegic Cerebral Palsy, Profound Intellectual Disabilities, and Lack of Coordination. The Medicare-5 Day/Discharge Return Anticipated (modification) Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/23 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and was totally dependent of one person for personal hygiene and received 51% or more of her calories through a feeding tube. a. The Plan of Care with a revision date of 12/06/22 documented, .Problem .has an ADL [activities of daily living] self-care performance deficit related to spastic quadriplegic cerebral palsy, profound intellectual disabilities, muscle wasting and atrophy, stiffness to right and left knee, ankle, hip, and foot, and lack of coordination . Goal . will be clean and well groomed daily . Approaches/Task . Personal Hygiene/oral care: .is totally dependent on staff for personal hygiene and oral care . Oral/Dental Care . Provide mouth care/oral care as per ADL personal hygiene . b. On 02/21/23 at 3:37 PM, Resident #1 was lying in her bed on her back with her eyes opened. The skin on her lips was dry and she had a white build up at the corners of her mouth. c. On 02/21/23 at 3:44 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1, who was at the residents' bedside, What do the residents' lips look like to you? She stated, They look dry. The Surveyor asked, How should the resident's lips look? She stated, Lubricated. The Surveyor asked, How often is she provided with oral care? She stated, I really don't know. I work PRN [as needed] and usually on 100 [Hall]. d. On 02/21/23 at 3:50 PM, the Surveyor asked Registered Nurse (RN) #1, who was at the residents' bedside, What do the residents' lips look like to you? She stated, They could use a little moisture. The Surveyor asked, How should the residents' lips look? She stated, Moist. The Surveyor asked, How often is she provided with oral care? She stated, I'm not sure, but she was showered yesterday. e. On 02/23/23 at 9:46 AM, the Surveyor asked the Director of Nursing (DON), How often is the resident provided with oral care? She stated, Daily and any time they have to suction her. They should do it after that. f. The facility In-Service titled, Resident Mouth & Nail Care - When & Why, dated 02/23/23, and provided by Licensed Practical Nurse (LPN) #1 on 02/23/23 at 2:08 PM documented, .Why is mouth care important? Mouth care is important because it prevents infections, plaque, bleeding gums, mouth sores, and cavities . When should I give mouth care? Mouth care should be given in the morning, after each meal, and before bed each night. The person may need more frequent or hourly mouth care if his mouth is in poor condition . What items will I need to perform mouth care? . Water-based lip balm or moisturizer . How do I brush the person's teeth? . Dry around his mouth. Apply water-based lip balm or moisturizer to his lips to avoid cracking and dryness .

Based on observation, record review, and interview, the facility failed to ensure palmer guards were applied to prevent further decline in Range of Motion (ROM) and a wedge to bilateral hips was in place while in bed to promote a more neutral position for 1 (Resident #1) of 2 (Residents #1 and #2) sampled residents who had Physician Orders for splints and 1 (Resident #1) of 1 sampled resident who required the use of wedges for positioning. The findings are: 1. Resident #1 had diagnoses of Spastic Quadriplegic Cerebral Palsy, Profound Intellectual Disabilities, and Lack of Coordination. The Medicare-5 Day/Discharge Return Anticipated (modification) Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/23 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and was totally dependent on two plus persons for bed mobility, transfer, dressing, toilet use and bathing and had functional limitation in range of motion to both upper and lower extremities on both sides. a. The Plan of Care with a revision date of 12/06/22 documented, .is at risk for Impaired Skin Integrity related to nail fungus, spastic quadriplegic cerebral palsy, profound intellectual disabilities, muscle wasting and atrophy, stiffness to right and left knee, ankle, hip, and foot, and lack of coordination . [Resident #1] is to have palmar guards to bilateral hands placed daily . [Resident #1] is to have wedge cushions to support bilateral hips while in bed . b. The February 2023 Physician's Order documented, .OT [Occupational Therapy] Clarification: OT to treat 5x [times] a week x 1 week to educated staff on demonstration/performance of correct PROM [Passive Range of Motion]/positioning/donning & [and] doffing of palmer guards to maintain joint and skin integrity while ADLs [activities of daily living] and bed positioning are performed in a pain free effort . Start Date 01/27/2023 . OT Clarification: OT to treat 5 x week x 1 week to educate/train staff to demonstrate/perform correct PROM/positioning/donning and doffing of palmer guards to maintain joint mobility and skin integrity while ADLs and bed positioning are performed in a pain free effort for patient . Start Date 02/02/2023 . c. The Physical Therapy Treatment Encounter Note(s) provided by the Administrator on 02/24/23 at 9:57 AM documented, .Date of Service 2/2/2023 . Skilled intervention focused on bed mobility training to increase functional skills. Proper positioning with use of positioning wedges at hips to position hips in proper alignment positioning . Skilled Instruction . Patient and Caregiver Training: Proper positioning . Date of Service 2/3/2023 . Skilled intervention focused on bed mobility training to increase functional skills. Proper positioning with use of positioning wedges at hips to position hips in proper alignment positioning . Skilled Instruction . Patient and Caregiver Training: Proper positioning . Date of Service 2/6/2023 . Skilled interventions focused on bed mobility training to increase functional skills. Proper positioning while in bed with head elevated and use of positioning wedging and pillows with positioning B hips to bring to proper alignment positioning and pillows with BLE to keep pressure sores from forming and off heels . Skilled Instruction . Patient and Caregiver Training: Education and training with CNA staff on multiple shifts for proper positioning and ROM . Date of Service 2/7/2023 . Skilled interventions focused on bed mobility training to increase functional skills. Proper positioning while in bed with head elevated and use of positioning wedging and pillows with positioning B hips to bring to proper alignment positioning and pillows with BLE to keep pressure sores from forming and off heels . Skilled Instruction . Patient and Caregiver Training: Education and training with staff with proper positioning and ROM . Date of Service 2/8/2023 . Skilled interventions focused on bed mobility training to increase functional skills. Proper positioning while in bed with head elevated and use of positioning wedging and pillows with positioning B hips to bring to proper alignment positioning and pillows with BLE to keep pressure sores from forming and off heels . Skilled Instruction . Patient and Caregiver Training: Education and training with CNA staff on multiple shifts for proper positioning and ROM . d. On 02/21/23 at 3:37 PM, Resident #1 was lying in her bed on her back with her blanket pulled up above her waist. The residents' hands were contracted with no devices present. e. On 02/21/23 at 3:44 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1, who was at the residents' bedside, Should the resident have a device in her hands? She stated, Most definitely yes, and the therapy lady told us two weeks ago. [CNA #1 pulled back the residents' blanket.] She is also supposed to have a pillow under each of her legs [No pillow was under the residents' legs]. f. On 02/21/23 at 3:50 PM the Surveyor asked Registered Nurse (RN) #1, who was at the residents' bedside, Should the resident have a device in her hands? She stated, Normally she wears bracing, therapy does it and we will start braces Thursday. The Surveyor asked RN #1 to pull back the blankets on the bed and asked, Should the resident have pillows under her legs? She stated, Under her feet. I don't know about her legs [No pillows were under the residents' feet]. The Surveyor asked, Can you tell me why she should have pillows under her feet? She stated, I'm not sure if it's for positioning or to prevent pressure. g. On 02/23/23 at 9:46 AM the Surveyor asked the Director of Nursing (DON), Should the resident have a device in her hands? She stated, She does for so long, it's not continuous. The Surveyor asked, Should the resident have wedges under her hips while she is in bed? She stated, Yes, she should.

Based on observation, record review, and interview, the facility failed to ensure Physician's Orders for an in and out catheterizations were followed for 1 (Resident #2) of 1 sampled resident who had Physician's Orders for an in and out catheterization. The findings are: 1. Resident #2 was admitted to the facility on [DATE] with a diagnosis of Retention of Urine. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 01/02/2023 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. The Plan of Care with a revision date of 06/23/22 documented, .has an ADL [activities of daily living] self-care performance deficit . [Resident #2] requires extensive assistance of (#1 staff) with toileting . b. The Urogynecology Clinic order dated 02/03/23 documented, .Self-cath 2-3 times daily w [with]/14 french catheters . c. The February 2023 Physician's Orders documented, In & Out catheter after voiding two times a day for urinary retention for 3 Days Administration Nurses to complete . Start Date 02/06/2023 . In and out catheterization of bladder for residual urine BID [two times daily] x [times] 4 days. Send results with patient to follow up appointment 2/13/2023. two times a day every 4 day (s) for documentation of effectiveness of current therapy until 02/09/2023 23:59 [11:59 PM] Start Date 02/09/2023 . d. The Verbal Physician's Order dated 02/09/23 documented, .In and out catheterization of bladder for residual urine BID x 4 days. Send results with patient to follow up appointment 2/13/2023 . e. The February 2023 Medication Administration Record documented, .In & Out catheter after voiding two times a day for urinary retention for 3 Days Administration Nurses to complete. Start Date 02/06/2023 . 02/06/2023 0800 [8:00 AM] op [output] 250 . 02/06/2023 1700 op X . 02/07/2023 0800 op 25 . 02/07/2023 1700 [5:00 PM] op 210 . 02/08/2023 0800 op 200 . 02/08/2023 1700 op 150 . In and out catheterization of bladder for residual urine BID x 4 days. Send results with patient to follow up appointment 2/13/2023. Two times a day every 4 day(s) for documentation of effectiveness of current therapy until 02/09/2023 23:59 Start Date 02/09/2023 . 02/09/2023 (no output was documented). f. The Nursing Progress Notes documented catheterizations on: 02/06/2023 at 18:34 [6:34 PM] . refused .; 02/07/2023 at 09:21 [9:21 AM] . 25 cc [cubic centimeters] .; 02/07/2023 at 18:36 . 210 ml [milliliters] .; 02/09/2023 at 13:33 [1:33 PM] . 150 cc .; 02/09/2023 at 13:22 [1:22 PM] . 250 ml .; 02/10/2023 at 20:45 [8:45 PM] . 125 ml . g. On 02/23/23 at 9:46 AM, the Surveyor asked the Director of Nursing (DON), Do staff follow Physician Orders written by outside Specialist? She stated, Yes, we have to follow up with it and verify it is something we can do. We call the Nurse Practitioner and the Medical Doctor to make sure and we speak with the specialty clinic. The Surveyor asked, Should the orders from [Hospital] Urogynecology Clinic have been followed for the resident with in and out catheterizations two to three times a day from the order date of 02/03/23 through 02/13/23 when she had her follow-up appointment? She stated, Yes, the order was entered incorrectly. The resident had left the faciity on [DATE] for a family funeral and was gone for the weekend, so we started on that Monday 02/06/23.

Based on observation and interview, the facility failed to ensure food items stored in the freezer or dry storage areas were sealed or covered, failed to ensure Dietary Staff washed their hands and changed gloves between dirty and clean tasks and before handling clean equipment or food items; failed to ensure expired food items were promptly removed / discarded on or before the expiration or use by dates; floors in the dish washer and kitchen, walls, door frames and baseboards were free of debris, and ceiling vents were maintained in clean, intact condition and proper working order to provide a sanitary area for food preparation and prevent potential food borne illness for residents who received meals from 1 of 1 kitchen and hot foods were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service and cold food was maintained at or below 41 degrees Fahrenheit. The failed practices had the potential to affect 47 residents who received meals from the kitchen (total census: 52), as documented on a list provided by Dietary Employee and the findings are: 1. On [DATE] at 3:00 PM, the following observations were made going into the walk-in refrigerator, freezer and around the dry storage area were. a. The base board leading to the walk-in refrigerator was loose from the wall. b. An opened box of beef steak was stored on a shelf in the freezer. The box was not covered or sealed. c. An opened box of Sysco Classic Iodized Salt was stored on a shelf above the food preparation counter. The box was not covered. 2. On [DATE] at 3:07 PM, the following observations made in the kitchen were: a. The air vent above steam table had greasy looking dirt and lint particles stuck to the ceiling. At 4:45 PM, Dietary Employee #2 was to describe the appearance of the greasy lint on the ceiling tiles above the steam table. She stated, The lint was brown and loose. b. There was a black encrusted ceiling vent with brown, dusty lint hanging from the vent slats above the bread rack and the door leading to the toilet. c. The wall frame by the food preparation counter next to the oven was missing exposing the concrete. The area that was missing was covered with black residue. d. The wall above and below the food preparation counter were discolored with black stains. 3. On [DATE] at 3:16 PM, the following observations were made going to the dish washing room were: a. On the entering door to the dish washing machine, the door frames had rust stains on them. The left side door frame was rotten, and remaining frames consisted of rotted wood. b. The floor behind the dish washing machine had accumulation of caked on black greasy residue, dirt, and debris, especially in the corners. The door frames leading to the dish washing room had rust on them. The left side wood was rotted out. 4. On [DATE] at 3:20 PM, An opened box of cornstarch was stored on a shelf in the kitchen. The box was not covered or sealed. 5. On [DATE] at 3:21 PM, one half gallon of chocolate milk in the refrigerator had an expiration date of [DATE]. 6. On [DATE] at 4:18 PM, Dietary Employee #1 removed mittens from her hands and placed them on the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to serve to the residents who required pureed diets. At 4:19 PM, she used a #8 scoop to place 15 servings of Philly steak into a blender to be ground. She poured the pureed ground meat in a pan and placed in the oven 7. On [DATE] at 4:20 PM, Dietary Employee #1 turned on sink faucet and rinsed a spatula. She then turned off the faucet. Without washing her hands, she picked up a clean blade and attached it to the base of the blender. As she was ready to put food item into the blender, she immediately was stopped and was asked, what should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. She took the blender and blade and rewashed them. 8. On [DATE] at 4:27 PM, Employee #1 used a rag to wipe off spilled food particles from the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. She immediately was asked What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. I will rewash them. 9. On [DATE] at 4:51 PM, the temperatures of the food items when tested and read on the on the cold side of the steam table for cold food items and on the steam table for hot food items by Employee #1 were: Regular broccoli salad on a pan of ice: 96 degrees Fahrenheit. Employee #1 stated, I just made it at 3:00 PM and put it in the refrigerator. The Pureed broccoli was 130 degrees Fahrenheit. 10. The facility's policy on hand washing under personal hygiene documented, Wash hands after handling dirty dishes.

Based on interview and record review, the facility failed ensure an advance directive was available in the medical record for 2 (Resident #43 and #1) of 15 (Res #1, #2, #9, #10, #14, #15, #17, #20, #21, #30, #31, #33, #43, #48, and #251) sampled residents whose records were reviewed for an advance directive. The findings are: 1. Res #43 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 6/1/22 documented the resident scored 04 (00-07 indicates severely impaired) on the Brief Interview for Mental Status, required limited one-persons physical assist with bed mobility, and extensive one-person physical assistance with transfers. a. On 7/06/22 at 8:48 AM, there was no advance directive in the medical records. b. On 7/06/22 at 10:25 AM, the Social Services Director was asked, Does [Resident #43] have an advance directive? She stated, I don't think he has one. c. On 7/07/22 at 8:58 AM the Social Service Director was asked, Did you locate the advance directive for [Resident #43]? She stated, No, I talked to his sister, and she said she would come by here to complete one. 2. Res #1 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 3/30/22 documented the resident scored 08 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status, required extensive two plus persons physical assist with bed mobility, and total two plus persons physical assistance with transfers. a. On 7/06/22 at 9:51 AM, there was no advance directive in the clinical record. b. On 7/06/22 at 10:34 AM the Social Services Director was asked, Does [Resident #1] have an advance directive? She stated, No she does not have one she just has a POA [power of attorney]. c. On 7/07/22 at 9:02 AM, the Social Service Director was asked, Did you locate the advance directive for [Resident #1]? She stated, No, I called her family about getting one for her. 3. On 7/07/22 at 11:21 AM, the Administrator was asked, When should an advance directive be formulated? She stated, Upon admission.

Based on observation, record review, and interview, the facility failed to ensure residents' fingernails were trimmed and cleaned to promote good personal hygiene and grooming for 2 (Residents #3 and #5) of 2 sampled residents who were dependent for nail care. The facility also failed to ensure facial hair was removed to promote good grooming for 1 (Resident #5) of 1 sampled resident who required assistance with shaving. The findings are: 1. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/22 documented the resident scored 4 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS) and required extensive assistance of one person with personal hygiene. a. A Comprehensive Care Plan revised on 12/14/2021 documented, [Resident #3] has an ADL [activity of daily living] self-care performance deficit r/t [related to] balance deficit and cognition . will be clean and well-groomed daily . requires extensive assistance by 1 person with personal hygiene . b. On 02/02/22 at 1:14 PM, Resident #3 was sitting in a wheelchair in his room, watching TV. The resident's fingernails were approximately 1/4-inch beyond the tips of his fingers with a dried brown substance underneath the nails. The resident was asked, Do you prefer your fingernails to be trimmed? He stated, Yes, they need to be trimmed. c. On 02/07/22 at 12:44 PM, Certified Nursing Assistant (CNA) #1 was at the bedside, assisting the resident with lunch. She was asked, Who is responsible for resident nail care? She stated, The CNAs clip nails on bath days and when needed, unless they are Diabetic, then the treatment nurse will cut them. d. On 02/07/22 at 2:24 PM, CNA #2 was asked, Who is responsible for resident nail care and shaving? She stated, The CNAs perform nail care and shaving on bath days and when needed, only if the resident is not Diabetic. If the resident is Diabetic, then we let the treatment nurse know. We can file them down, but we can't cut them if they are Diabetic. She was asked, Who is responsible for making sure that nail care is being performed? She stated, The Charge Nurse. 2. Resident #5 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 11/14/21 documented the resident scored 09 (08-12 indicates moderately impaired) on the BIMS and required extensive assistance of one person with personal hygiene. a. A Comprehensive Care Plan revised on 11/22/2021 documented, [Resident #5] has an ADL self-care performance deficit . will be clean and well-groomed daily . requires extensive assistance by 1 person with personal hygiene . b. On 2/2/22 at 10:48 AM, Resident #5 was sitting in a wheelchair in his room. The resident's fingernails on both hands were approximately ¼ inch beyond the tips of his fingers with a dried brown substance underneath the nails. He had facial hair that was approximately ¼ inch long. When asked about shaving, he stated, I asked them to shave me, but nobody has come to do it.

Based on observation and interview the facility failed to ensure food items stored in the dry goods area were properly sealed and dated to prevent the potential for contamination. This failed practice had the potential to affect 46 residents according to the Resident Census and Conditions of Residents form provided by the Administrator on 04/21/21 at 9:17 a.m. The findings are: 1. On 04/19/21 at 10:10 a.m., a Ziploc bag containing oatmeal was on a shelf in the dry goods storage area of the kitchen. The bag was unsealed and not dated. The Dietary Manager (DM) was asked, Should the bag be sealed? The DM stated, Yes, it should be. It should have a date on it too. The DM was asked, What can happen if the bag isn't sealed? The DM stated, Bugs can get in. 2. On 04/22/21 at 9:25 a.m., Dietary Aid #1 (DA #1) was asked, How should food items that have been opened be stored? DA #1 stated, They should be put in a plastic bag and sealed with the date it was opened on the bag. DA #1 was asked, What can happen if the bag isn't sealed? DA #1 stated, Bugs or anything can get in it. On 04/22/21 at 9:30 am., Dietary Aid #2 (DA #2) was asked, How should food items that have been opened be stored? DA #2 stated, In a freezer bag with the date on the bag and you should always make sure that the bag is sealed. DA #2 was asked, What can happen if the bag isn't sealed? DA #2 stated, It can get stale or bugs can get inside.

Complaints # (AR 315) and # (AR 317) were substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure residents were provided with adequate supervision to prevent accidents / injuries to the extent possible, as evidenced by: failure to ensure interventions were promptly developed and implemented after a fall to prevent a subsequent fall with injury requiring hospitalization and failure to ensure fall prevention interventions were promptly developed and implemented upon the resident's return from the hospital, to minimize the potential for further falls / injuries for 1 (Resident #2) of 3 (Residents #1, 2 and 6) case mix residents who had falls in (MONTH) and (MONTH) (YEAR); failure to ensure the post-fall hospital discharge orders for placement of a sling and follow-up with an orthopedic surgeon were implemented to prevent further re-injury or exacerbation of a fracture that resulted from a fall for 1 (Resident #2) of 1 case mix resident who was transferred to the hospital as a result of a fall-related injury; and, failure to ensure planned fall-prevention interventions (fall mat and bed in lowest position) were consistently implemented to decrease the potential for fall-related injury for 1 (Resident #1) of 3 (Residents #1, 2 and 6) case mix residents who had falls in the past 2 months (November and (MONTH) (YEAR)). These failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #2, who fell , sustained a fracture and subsequently returned to the facility with no interventions developed and implemented to prevent further falls / injuries, and had the potential to cause more than minimal harm to 11 residents who had a fall in the past 2 months (November and (MONTH) (YEAR)), as documented on a list provided by the Director of Nursing (DON) on [DATE] at 9:36 a.m. The Administrator and DON were notified of the immediate jeopardy situation on [DATE] at 4:45 p.m. The findings are: 1. Resident #2 was originally admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. a. The Admission Evaluation dated [DATE] documented the resident was admitted from a hospital; entered the facility via wheelchair; had no pain or history of chronic pain and was not on a pain management regimen; had impaired cognitive function but had good safety awareness and was able to make decisions appropriately; was totally dependent on 1 person for bed mobility and toileting; required limited assistance and cueing / prompting / supervision during transfers; was incontinent of bowel and bladder; had a history of [REDACTED]. The Care Plan - Fall Risk portion of the evaluation form documented, The resident is at risk for falls . Approach: .Encourage resident to use call light or ask for assistance as needed . Keep personal items within reach . Observe resident for appropriate footwear . Pharmacy Consultant / Physician to review medication regimen to identify medications which may contribute to risk for falls . PT (physical therapy) evaluate and treat as ordered or PRN (as needed) . b. The Care Plan dated as initiated [DATE] documented, Problem . care performance deficit r/t (related to) weakness . Approaches / Tasks . (Resident) requires extensive assist (assistance) by 2 staff with repositioning and turning in bed . (Resident) requires extensive assist by 2 staff with toileting . (Resident) required extensive assist by 2 staff with transfers . (Resident) requires extensive assist by 1 staff for locomotion using wheelchair . Problem (Resident #2) is at risk for falls r/t poor safety awareness, weakness, limited mobility . Approaches / Tasks . Educate (resident)/family/caregivers about safety reminders . Encourage (resident) to participate in activities that promote exercise . Encourage (resident) to use call light . Keep personal items within reach . Observe (resident) for appropriate footwear . Pharmacy consultant / Physician to review medication regimen to identify medications which may contribute to risk for falls . Pt (physical therapy) evaluate and treat as ordered or PRN . c. An Incident note dated [DATE] at 00:25 (12:25 a.m.) documented, .Incident Location Resident Room . Incident Description Nursing Description: 00:25. Called to resident room per 300 hall nurse to check on resident. Resident found on floor at the FOB (foot of bed) with his head underneath the FOB . when asked what happen (sic) resident stated, 'I don't know where I am'. Roommate stated, 'He was trying to go to the bathroom'. Resident complained of pain to left shoulder et (and) left elbow. Small hematoma noted to back of his head, skin intact . Immediate Action Taken Description: Resident was assisted back to bed per CNA (Certified Nursing Assistant) . skin audit done abrasion et bruise area found to left shoulder. Abrasion 1.5 cm (centimeters) x (by) 3 cm, scanty (sic) amount of blood noted. Bruise 0.5 x 2 cm, skin intact . 911 et ER (emergency room ) called, report given on resident status . Resident taken to hospital? No . There was no documentation to indicate any fall prevention interventions were implemented and added to the plan of care after this fall. d. A Fall Risk assessment dated [DATE] at 01:25 (1:25 a.m.), after the above fall, documented the resident's fall risk score was 12, with a score of 12 or greater indicating a high risk for falls. c. An Incident note dated [DATE] at 16:30 (4:30 p.m.) documented, .Incident Location Resident Room . Incident Description staff requesting assistance at this time. Resident is noted lying in supine position in the floor with feet directed towards door entry. Head is resting beside recliner. Resident's roommate reports that resident fell after getting self up from bed without assistance .roommate verbalizes resident falling sideways and landing on left arm and then rolling over onto back. Roommate informs resident did not hit head due to arm being extended above head when made contact with floor. Resident is unable to give details. Resident is alert and confused. Resident stated, 'I was going to go pee' . Immediate Action Taken Description: assessment for injuries and neuro (neurological) check provided . Predisposing Environmental Factors None . Predisposing Physiological Factors Confused Drowsy Impaired Memory . Predisposing Situation Factors admitted within last 72h (hours) . There was no documentation to indicate any fall prevention interventions were implemented after this fall. A Late Entry Progress Note / Incident Note dated [DATE] at 20:15 (8:15 p.m.) regarding the above fall documented the same description as above and, .Resident has socks on at this time . Resident yells out in pain with movement of left arm . Calls for ambulance transport to (hospital) ER . 1720 (5:20 p.m.) EMT (Emergency Medical Technician) exits with resident for transport to (hospital) ER . Complaints of severe pain to left arm / shoulder . 2200 (10:00 p.m.) calls and speaks to ER nurse for status, nurse verbalizes will keep resident for observation due to possible fracture . d. A hospital Radiology Report dated [DATE] at 6:25 p.m. documented, .Examination: Shoulder LT (left) 2 Views . Date of Exam: [DATE] . Impression: 1. Comminuted mildly displaced fracture involving surgical neck of the left humerus with the glenohumeral articulation remaining intact . A handwritten note on the right side of the report documented, faxed to (Orthopedic Surgeon) ,[DATE]/ (2018) . e. The hospital Discharge Instructions dated as printed on [DATE] at 2:36 p.m. documented, .Discharge Diagnosis: [REDACTED].): Nursing home to make an appointment with ortho (Orthopedic) doctor . Treatment Instructions: Nursing home to make appointment with ortho doctor regarding humerus fracture. Ensure pt (patient) wears sling. New prescription for [MEDICATION NAME] . f. A Late Entry Nursing Note dated [DATE] at 16:30 (4:30 p.m.) documented, (Resident) returned to facility on [DATE] 5:00 p.m. (Resident) transported to facility via ambulance entering via wheelchair accompanied by EMS (Emergency Medical Services) personnel . New Orders: The resident has new orders. Refer to Physician orders. Additional comments: bruising, purple discoloration to bilateral arms. Dressings to right forearm from previous fall intact. This note did not reference that the resident had a fracture to the left humerus and there was no documentation to indicate a sling or splint was in place to the left upper extremity upon re-entry. There was also no documentation to indicate any additional interventions were developed and implemented upon readmission to prevent further falls or fall-related injuries. g. Progress Notes / Nursing Notes dated [DATE] through [DATE] contained no documentation to indicate a sling was ever in use after the resident's return from the hospital, and there was no documentation to indicate the resident received a consultation with an orthopedic surgeon as per the hospital discharge orders. h. There was no documentation in the clinical record to indicate any further fall prevention interventions were implemented until [DATE]. Care Plan revisions dated [DATE] documented, .Fall mat to floor at left side of bed, right side of bed against wall Date Initiated: [DATE] . Problem: (Resident #2) has had an actual fall with serious injury Date Initiated: [DATE] . Approaches/Tasks: . Check range of motion Date Initiated: [DATE] . For no apparent acute injury, determine and address causative factors of the fall Date Initiated: [DATE] . There was no documentation on the Care Plan to indicate the resident was supposed to wear a sling to the fractured left arm, nor any reference to a plan for an orthopedic surgery consult. i. An Admission / Re-Entry Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 5 (,[DATE] indicates severely impaired) on the Brief Interview for Mental Status (BIMS); required extensive assistance of 2 plus persons with bed mobility, transfers, and toilet use; not steady, only able to stabilize with staff assistance when moving from a seated to standing position, moving on and off the toilet, and surface-to-surface transfers; had functional limitation in range of motion to the upper extremity on one side; used a wheelchair for mobility; was always incontinent of bowel and bladder; had a fall in the last month prior to admission or re-entry; had a fall in the last 2 to 6 months prior to admission or re-entry; had a fracture related to a fall in the 6 months prior to admission or re-entry; had no falls since admission / re-entry; had skin tears; received an antidepressant and an opioid medication on 7 of the past 7 days; received zero minutes of physical therapy or restorative nursing services in the last 7 days; and had no restraints or alarms in use. j. As of [DATE] at 3:50 p.m., the (MONTH) and (MONTH) (YEAR) Transportation Log book had no documentation to indicate the resident was scheduled or transported to an orthopedic surgeon, as per the hospital discharge orders. k. On [DATE] at 3:52 p.m., the Director of Nursing (DON) was asked, I have looked through the appointments for (MONTH) and (MONTH) and I did not see an appointment for (Resident #2) with an Ortho doctor. Do you see an appointment for (Resident #2) with an Ortho doctor related to his fracture? After reviewing the log for (MONTH) and (MONTH) (YEAR), the DON stated, I don't see one, but I think he did have one. At 4:02 p.m., the DON was asked, Did (Resident #2) have an appointment with an Ortho Doctor related to his fracture? The DON stated, His son wanted to get that set up, but he ended up going to the hospital. She was asked, regarding the hospital discharge instruction to wear a sling to the left arm, Did (Resident #2) wear a sling while here? She stated, I'll have to check, but I believe I saw him with a brace or something on. l. On [DATE] at 10:25 a.m., the DON was asked, Were any interventions put in place for (Resident #2)? The DON stated, I'll have to get back with you. I'll have to ask (MDS Coordinator) about this. She normally goes through and puts interventions in. The nurses are supposed to put interventions in place after a resident falls, and she (MDS Coordinator) looks at the report after the nurse has completed it. The DON was asked where those interventions would be documented, since there was no documentation of interventions on the initial incident notes, nor in the Nursing Notes until [DATE], a period of 10 days after the resident returned from the hospital. She stated, I'll have to ask her. At 12:50 p.m., the DON was again asked whether any fall prevention interventions were implemented for Resident #2 and stated, The nurse didn't put any (interventions) in place. She was asked, What did (MDS Coordinator) say regarding the interventions? She stated, When we got back from the holiday, she looked at it, and that's when she put the fall mat in place. She was asked, Did (Resident #2) have an appointment with an Ortho doctor regarding his fracture? She stated, I'll have to check. m. On [DATE] at 8:50 a.m., the Assistant Director of Nursing (ADON) provided a Referral Authorization Form dated [DATE] at 12:11 p.m. from the Orthopedic Surgeon office, which documented the names of 2 Orthopedic Surgeons and, .We will not be able to schedule an appointment without all information requested . The form had spaces designated for documentation of the resident's insurance information, chief complaint, et cetera, and the word x-rays was circled at the bottom of the form. The ADON stated, They are going to send me a copy of his appointment, because he did have an appointment on (MONTH) 5th, but he was a no show, because he didn't come back until the 5th. (Orthopedic Surgeon's) office said they will fax over his appointment for that day to us. No additional documentation was provided by the facility regarding the missed orthopedic surgeon appointment as of the survey exit on [DATE]. Nursing Notes dated [DATE] and [DATE] documented the resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. There was no documentation in the Nursing Notes of any reference to a splint or sling being applied to the left upper extremity at any time between [DATE] and [DATE] when the resident expired in the facility. 2. Resident #1 had [DIAGNOSES REDACTED]. A Significant Change MDS with an ARD of [DATE] documented the resident scored 7 (,[DATE] indicates severely impaired) on the brief interview for mental status, required extensive assistance of one person for bed mobility, transfer and toilet use, was not steady and only able to stabilize with staff assistance when moving from seated to standing position, moving on and off the toilet and surface-to-surface transfers, had functional limitation in range of motion to the lower extremity on one side, used a wheelchair for mobility, was occasionally incontinent of bladder and frequently incontinent of bowel, had a fall in the last month prior to admission or re-entry and in the last 2 to 6 months prior to admission or re-entry, had a fracture related to a fall in the 6 months prior to admission or re-entry, and had 2 falls with no injury since admission or prior assessment. a. The Care Plan dated as initiated [DATE] documented, Problem: . (Resident #1) has had an actual fall with no injury r/t weakness and decline secondary to dx of [MEDICAL CONDITIONS] and neoplasm of unspecified bronchi. Fall, no injury, [DATE], intervention, staff in serviced r/t rounding, fall mat at bedside. Fall, [DATE], right hip fx (fracture), sent to ER. Fall, [DATE], no injury, room rearranged. Fall, [DATE], no injury, one on one care . Approaches/Tasks: . Fall mat to left side of bed Date Initiated: [DATE] . Right side of bed against wall, fall mat to floor at left side of bed. Date Initiated: [DATE] . Problem: (Resident #1) has a right [MEDICAL CONDITION] r/t Fall . Approaches/Tasks: Follow MD (Medical Doctor) orders for weight bearing status . b. Incident Notes documented the resident experienced falls as follows: .Date [DATE] 02:16 (2:16 a.m.) .Incident Location Resident Room . Incident Description Nursing Description: 23:10 (11:10 p.m.) This nurse heard a voice calling for help . Resident was found per nurse in sitting position on floor at the foot of her bed near bed side commode chair . Immediate Action Taken Description: Resident was checked for skin tears, abrasion, redness none found assisted back to bed [MEDICATION NAME] et [MEDICATION NAME] was given per request . .Date [DATE] 07:18 (7:18 a.m.) . Incident Location Resident Room . Incident Description Called to resident at 5:31 a.m. during med pass per 300 hall nurse, resident observed on floor lying on right side near the wall et bedside commode .Large size hematoma on right side of her forehead 7.2 cm (centimeters) x (by) 6.6 cm with superficial skin tear noted with scanty (sic) amount of blood noted, 1.5 cm x .1 cm on hematoma. Raised area to back of head Skin intact . Immediate Action Taken Description: Resident assisted back to bed, skin checked for skin tears . 911 called for ambulance service . .Date [DATE] (at) 21:16 (9:16 p.m.) . Incident Description Nursing Description: called to 100 hall by CNA (Certified Nursing Assistant) and Nurse, noticed resident lying on the floor on her right side, severe confusion noted . Immediate Action Taken Description: checked resident for apparent injuries, and removed resident form floor via mechanical lift, and placed resident back into bed, called MD (Medical Doctor) to report findings . Injuries Observed at Time of Incident Injury Type No Injuries observed . .Date [DATE] 11:45 (a.m.) .Incident Description Nursing Description: .Upon entering elders room elder was lying on the fall mat on her left side stating 'I need the tube'. Elder assisted back to bed and assessed for injuries, no injuries noted .Immediate Action Taken Description: Elder placed on one on (one) monitoring .Injuries Observed at Time of Incident Injury Type No Injuries observed . c. On [DATE] at 2:50 p.m., the resident was awake and resting quietly in bed on her left side. Side rails (SR) were in use on both sides of the head portion of the bed, and a bedside commode was sitting on the left side of the bed. There was no fall mat on the floor and her bed was not in lowest position. The right side of the bed was pushed against the wall. The bed frame was positioned approximately a foot and a half above the floor. The residents' son was sitting in a chair near the window, across the room. d. On [DATE] at 9:10 a.m., the resident was in bed. There was no fall mat on the floor to the left of the resident's bed, and the bed was not in the lowest position. The right side of the bed was pushed against the wall and the bed frame was positioned approximately a foot and a half above the floor. Resident #1's son was sitting in a chair across the room adjacent to the foot of the bed watching television. The surveyor informed Resident's #1 son the surveyor was looking to see if a fall mat was on the floor. The resident' son pointed to a grey mat across the room, that was folded and leaning on the wall beside a chest of drawers. He stated, You mean that? The surveyor stated, Yes. e. On [DATE] at 9:13 a.m., the DON was asked to accompany the surveyor to the resident's room. The DON was asked to look at the resident's floor on the left side of her bed and was asked, Do you know if there is something missing? She stated, Yes, I know. There was no fall mat in place on the floor on the left side of the resident's bed, and the bed frame remained positioned approximately a foot and a half above the floor. The DON was asked to determine if the bed could be lowered any further. The DON used the bed controls and lowered the bed approximately a foot and a half to reach its lowest position. f. On [DATE] at 3:27 p.m., the DON was asked, Who is responsible for making sure the interventions, such as fall mat to left side of resident's bed, are in place? She stated, The nurses on the hall. When there has been a fall, their nurse does an incident and accident report and their nurse is to put an intervention in place. The DON was asked, Why should staff follow the interventions that have been put in place for a resident who had a fall with a major injury? The DON stated, To keep them from falling again. Basically, as a prevention. 3. The immediate jeopardy was removed, and the scope and severity reduced to G on [DATE] at 10:00 a.m., when the facility implemented the following plan of removal: 1.) All falls will have an immediate acute intervention put in place by nursing supervisor at time of fall. 2.) In-services- begin immediately and no one can return to work until they are in-serviced. 3.) On [DATE] all nursing staff will be inserviced on the fall policy and procedure which will include interventions, notifications, resident assessment, and post - fall investigation. 4.) On [DATE] all falls will be reviewed by the clinical management team and administrator to ensure appropriate interventions, care plan updated, and referrals to appropriate providers including therapy have been completed. 5.) All accidents from the 24 hour report will be reviewed in the morning meeting to ensure all healthcare disciplines have reviewed updated and made recommendations agreed upon by the team. 6.) Additionally, facility risk meeting will occur every Friday with management team for additional oversight of programs implemented and their effectiveness. 7.) On [DATE] audits of all meeting will occur every Friday with management team for additional oversight of programs implemented and their effectiveness. 7.) On [DATE] audits of all current I&A's (Incidents and Accidents) were reviewed by the Administrator, DON. and MDS to ensure interventions and follow-up has been implemented. 8.) All nurses will be inserviced on reviewing discharge instructions when a resident is admitted or readmitted to the facility.

Complaint # (AR 777) was substantiated all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure a newly identified pressure ulcer to the coccyx was promptly assessed, documented, reported to the physician, and treated to promote healing and minimize the potential for deterioration or infection to the extent possible and failed to ensure after the wound rapidly deteriorated and was diagnosed as a Kennedy Terminal Ulcer, that it was documented and care planned as such and staff involved in the residents care were aware of the wound status and care required for 1 (Resident #1) of 1 case mix resident who had a pressure ulcer. This failed practice resulted in a pattern of actual harm for Resident #1 who was identified as having new skin breakdown which was not thoroughly assessed, documented and reported to the physician for 2 days after discovery, and had the potential to cause more than minimal harm for 33 residents who were at risk for developing a pressure ulcer, according to a list provided by the Director of Nursing (DON) on 7/30/18. The findings are: 1. Resident #1 had a [DIAGNOSES REDACTED]. a. A Care Plan dated as initiated on 7/3/18 documented, (Resident #1) will have intact skin, free of redness, blisters or discoloration .Observe/report prn (as needed) any changes in skin status. b. A Progress Note dated 7/3/18 documented, MD (Medical Doctor) and NP (Nurse Practitioner) rounded today with no new orders . c. A Braden Scale form dated 7/9/18 documented the resident's pressure ulcer risk score was 10, which indicated a high risk for pressure ulcer development. d. A Progress Note dated 7/10/18 at 11:33 a.m. and signed by the Wound Care Nurse (LPN #3) documented, Reported to me per (Licensed Practical Nurse (LPN) #4) performed treatments today that resident wound is now the size of a quarter . There was no previous documentation as to when this wound was initially identified, assessed or treated. There were no physician orders for treatment of [REDACTED]. e. A Progress Note dated 7/11/18 at 11:15 a.m. and signed by LPN #3 documented, Reported to me per nurse on floor performing treatments on 7/9/2018 that resident had an open area on buttocks that was the size of a nickel . Hospice nurse notified on 7/9/2018. Advised to place collagen to open area. Upon changing dressing this a.m. (morning), wound is noted to have a much larger open. f. A Weekly Wound Note dated 7/12/18 documented, Wound to coccyx 14.5 cm (centimeter) x (by) 20.5 cm x 2.5 cm with slough . g. The (MONTH) (YEAR) Treatment Administration Record (TAR) documented, .start date 7/7/18 denuded skin to buttock every day shift cleanse denuded skin to buttocks with dermal wound cleanser, pat dry, apply barrier cream . d/c: (discontinue) 7/11/18 . h. A physician order dated 7/11/2018 at (1:30) p.m. documented, .cleanse wound to coccyx with wound cleanser pat dry apply calcium alginate to wound bed and apply [MEDICATION NAME] . The (MONTH) (YEAR) TAR documented, Start date 7/12/18: cleanse wound to coccyx with wound cleanser pat dry, apply calcium alginate to wound bed and apply [MEDICATION NAME] gel to surrounding areas and cover with [MEDICATION NAME] dressing qd (every day) and prn (as needed) if soiled . d/c 7/13/18. The open wound to the coccyx was discovered on 7/9/18, but there was no documentation a treatment order was obtained for that wound until 7/11/18 and no documentation on the TAR the ordered treatment was initiated until 7/12/18. i. A Progress Note dated 7/16/18 at 1:03 p.m. documented, NP (Nurse Practitioner) rounded this shift with no new orders . j. An Interdisciplinary Care Plan Meeting note dated 7/16/18 documented, .skin status / wound/treatments: Kennedy ulcer to coccyx? / rapidly progressing pressure ulcer to coccyx . This document was in the resident admission packet in the admission office and there was no documentation in the clinical record indicating the ulcer had been diagnosed as, or was suspected of being, a Kennedy Terminal Ulcer. The Care Plan was not updated to reflect that the wound was, or was potentially, a Kennedy Terminal Ulcer. k. On 8/1/18 at 9:40 a.m., Licensed Practical Nurse (LPN #3) provided a treatment to the resident's coccyx wound. There was a foul odor emanating from the wound, and the wound measured 23 1/2 cm long by 27 cm wide, unable to determine depth, wound has multiple openings with 45% eschar, 30% slough, 25% granulation, with exposure of muscle, adipose tissue and bone. There was undermining at the 10 o'clock and 4 o'clock positions of the wound and there was slough and eschar in the wound bed. l. On 8/1/18 at 10:10 p.m., the Director of Nursing (DON) was asked to explain the sequence of events related to when the pressure ulcer to the coccyx was initially identified and by whom. She stated, The unstageable on her coccyx was identified on 7/9/18; we don't have documentation of it until 7/11/18. The physician and hospice were notified on 7/11/18. We received new orders for wound treatment on 7/11/18. We failed to notify the family of the new pressure ulcer, but we did notify hospice. The Nurse Consultant stated, We have QA'd this. The DON was asked if and when the resident's physician had observed and evaluated the resident's wound and stated this information should be in the progress notes. The DON also stated, (LPN #3), the Treatment Nurse failed to notify the family, but received new orders in and didn't put the new orders on the TAR. I'm not sure why she didn't talk with the family or put the new orders in. The DON was asked if the resident's hospice records and physician notes should be readily available. She stated, Yes. The resident's hospice records were reviewed and documented the onset date of the pressure ulcer to the coccyx as 7/11/18. At 11:15 a.m. the Nurse Consultant stated, I'm going to call Hospice and see if they have any records over there waiting to send. The Nurse Consultant later returned and stated, There in an emergency over there and will get back with me later. No further records from hospice were provided prior to the survey exit. The Quality Improvement Plan referenced in the above interview was provided by the DON on 8/2/18. The plan was dated 7/12/18 and documented, .1. Wounds not identified in a timely manner. 2. Orders not received upon identification. 3. Documentation errors. 4. Insufficient documentation . The Quality Improvement Plan listed the following task: In-service Tx (treatment) nurse and staff . Tx nurse given educational material . follow-up with supervisor q (every) week . 100 % body audit . wound care certification course when available . m. On 8/1/18 at 10:21 a.m., the surveyor took a photograph of the resident's coccyx wound. n. On 8/1/18 at 12:25 p.m., LPN #3 (Treatment Nurse) was asked to explain the onset and progression of the wound on the resident's coccyx. She stated, The Nurse that was doing treatments that day (7/9/18), (LPN #4), discovered the area on her coccyx. She came to me in the office and said there was an open area. I called hospice nurse and she told me to place collagen on the open area. I then turned to (LPN #4) and verbalized the order to her. (LPN #4) came back to work on Tuesday (7/10/18). She reported to me on Tuesday 7/10/18 the open area was the size of a quarter. I called the Hospice nurse myself. There were no new orders. On Wednesday, 7/11/18 was the first time I visualized the open area on her coccyx. I called hospice again and they said they would be at the facility in the afternoon. She was asked for the documentation of the newly identified wound on 7/9/18. She stated, (LPN #4) didn't document it. I documented it on 7/11/18. (LPN #4) didn't carry out the physician's orders. We didn't notice they hadn't been written until 7/11/18. She (resident) had denuded skin on her bottom that we were treating with barrier cream. I'm not sure if she treated the new open area, because it's not documented. She was asked if the physician should be notified of newly identified skin breakdown and stated, Yes. She was asked, Should staff identify, document, and treat newly identified skin issues? She stated, Yes. o. On 8/1/18 at 2:30 p.m., LPN #4 was asked to explain the onset and progression of the wound on the resident's coccyx. She stated, No, I didn't notify the doctor; I told the treatment nurse, (LPN #3). She came and looked at the wound on Monday (7/9/18) . She was asked if she documented a description of the wound on 7/9/18. She stated, No, I told (LPN #3). p. On 8/2/18 at 7:38 a.m., Certified Nurse Assistant (CNA) #3, a Hospice aide, was asked to explain the condition of the resident skin prior to the pressure ulcer on her coccyx. She stated, .At first there were no skin issues. I can remember coming to work on a Tuesday and there was a dressing on her butt and she had a foul odor. I went to (LPN #3) and she was aware that it occurred over the weekend and she had put a dressing over it. She was asked if she reported this to hospice. She stated, No, I reported it to (LPN #3). q. On 8/2/18 at 12:30 p.m., the DON was asked how they were monitoring pressure ulcers per their Quality Improvement plan. She stated, Using the QA wound observation monitoring. The DON provided the observation monitoring form. The form did Documented, Date monitored, monitored by, how often to be monitored: 2xwkly (weekly) x 4 wks, reason for monitoring: ensure wounds are appropriately assessed, Physician notified and treatment in place. The Monitoring form did not have documentation of any wound measurements or descriptions to identify the healing process nor any assessments of nurses who provided wound care to determine if wound care was completed correctly and did not identify which residents were being monitored for pressure ulcers. The DON stated, We monitored whoever had a pressure ulcer. r. On 8/3/18 at 10:09 a.m., LPN #3 was asked at what point the resident's physician observed the resident's coccyx wound and stated, I think on 7/16/18, because she had a change in her condition. She was asked where the physician's visit was documented and stated, I don't know. s. On 8/3/18 at 10:22 a.m., Physician #1 was interviewed via telephone. He was asked when he was first notified of the pressure ulcer. He stated, I can't recall (Resident #1) or when I was first contacted of the pressure ulcer . The surveyor provided details about the resident's wound, then the physician stated, .Oh, it rings a bell now. I have an APN (Advance Practice Nurse), and she rounds for me. We discussed it and felt her life wasn't going to be that long and to provide comfort care. It would put her through much pain if she went to wound clinic. I discussed it with my APN, and we diagnosed it as a Kennedy Ulcer. He was asked if there was documentation to support that the wound was a Kennedy ulcer and stated, I don't know if the APN documented it. t. On 8/3/18 at 11:00 a.m., the facility was asked for the resident admission packet. The DON provided a history and physical dated 7/3/18, a grievance form dated 7/16/18, and the Care Plan meeting dated 7/16/18, which were not available in the clinical record. u. On 8/3/18 at 11:10 a.m., the APN was asked when she first observed the resident's coccyx wound and whether she documented a Progress Note at that time. She stated, The first time I saw the wound was on 7/16/18, and I just faxed the progress notes today. Felt it was a Kennedy Ulcer due to the shape and progression of the ulcer. She was asked, Did you notify the facility of the findings? She stated, Yes, in a care plan meeting.

Complaint # (AR 957) was substantiated, all or in part, with these findings. Based on observation, record review, and interview, the facility failed to ensure a newly discovered wound was correctly identified as a pressure ulcer to facilitate the ability to determine and initiate an appropriate treatment; failed to ensure the pressure ulcer was thoroughly assessed, measured and staged upon discovery and the condition of the wound was consistently monitored after discovery to ensure deterioration of the wound was promptly identified and addressed; failed to ensure the physician was immediately consulted for appropriate treatment orders to promote healing and prevent further deterioration of the pressure ulcer; failed to ensure the need for a larger wheelchair and pressure relief device in the wheelchair seat was promptly identified and addressed to enable adequate repositioning and prevent friction/shearing forces when repositioning was attempted; and failed to ensure repositioning was provided at least every 2 hours to relieve pressure and prevent further exacerbation of the pressure ulcer for 1 (Resident #1) of 4 (Residents #1, #2, #3, and #4) case mix residents who were at risk for pressure ulcers. The failed practices resulted in a pattern of actual harm to Resident #1, who had a Stage 2 pressure ulcer to the posterior, left, upper thigh that was initially misidentified as a skin tear, covered with a dressing and not rechecked for a period of 7 days, resulting in deterioration of the wound to an unstageable pressure ulcer covered with slough and eschar and requiring repeated debridement procedures. The failed practices had the potential to cause more than minimal harm for 39 residents who were at risk for pressure ulcers, as documented on a list provided by the Director of Nursing on 2/8/18. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 12/7/17 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status, was totally dependent on two-plus persons for bed mobility, transfers, and toilet use, had functional limitation in range of motion of both lower extremities, was always incontinent of bladder and of bowel, pressure reducing device for chair and bed, had no pressure ulcers, and was at risk for developing pressure ulcers. a. A facility Incident and Accident form for an Injury of Unknown Origin dated 12/18/2017 at 10:59 a.m. documented, .Called to resident room by Treatment Nurse, which states CNA (Certified Nursing Assistant) noticed a skin tear to resident's back upper left leg. Cause has been determined to be the mechanical lift used to get patient to and from bed and w/c (wheelchair). Dressing applied to area at this time. RN (Registered Nurse) notified. Called and informed sister. Resident reports she was unaware of skin tear to back of leg . b. A Body Audit form dated 12/19/17 at 7:04 a.m. documented, .3 cm (centimeter) raw area to the back of left thigh . coccyx redness noted . There was no documentation of any further monitoring or assessment of the skin breakdown to the left, upper, posterior thigh wound until 12/26/17. c. A Nurses Note dated 12/19/17 at 9:59 a.m. documented, .Skin tear to upper left rear leg dry and dressed at this time . There was no documentation the dressing was removed to allow visualization of the wound at this time, or at any time between 12/19/17 and 12/26/17. There was no documentation of physician orders [REDACTED]. d. A Nurses Note dated 12/26/17 at 2:42 p.m. documented, .Notified RP (Responsible Party) of area to upper left posterior thigh. RP verbalizes awareness of the initial complaint of skin issue at previous time. Informed RP of change noted to wound . There was no documentation indicating what changes were noted to the wound. There was no assessment of a wound documented on this date. The physician was notified and an order obtained dated 12/26/18 which documented, .Cleanse area to back of left upper leg with wound cleanser, pat dry, apply Calcium Alginate and cover with bordered gauze QD (every day) and PRN (as needed) until healed .every day shift .Monitor dressing to back of left upper leg every shift and change dressing if necessary . e. A Body Audit form dated 12/27/17 at 3:00 p.m. documented, .3 cm x (by) 3 cm open area noted to the back of the left thigh . f. A weekly skin audit dated 12/27/17 at 3:03 p.m. documented, .Left thigh rear, unstageable due to slough / eschar, 3 cm (centimeters) (by) 3 cm, serosanguinous exudate, resident has pain . Clean wound with wound cleaner, pat dry. Apply Santyl ointment and cover with comfort foam border gauze daily and PRN (as needed), pressure reducing devices . This audit incorrectly documented the onset date for this pressure ulcer as 12/26/17. g. A Hospital Progress Note dated 12/28/17 documented, .The Nurse reports the patient has a wound to her left posterior thigh which was first noticed several days ago and has progressively worsened. The staff reports the lesion is round with 90% yellow slough . The hospital document, page 5 of 5, documented, .Send patient for further evaluation and tx (treatment) of wound at wound clinic . h. A Prescriber Telephone Order sheet dated 12/28/17 at 12:51 p.m. documented, .Cleanse area to back of left upper leg with wound cleanser, pat dry. Apply calcium alginate and cover with bordered gauze QD (every day) and PRN (as needed) until healed . The order was changed at 12:52 p.m. to, . Santyl Ointment 250 unit/GM (units per gram) [MEDICATION NAME] apply to per additional directions topically every day shift for wound care . apply to posterior upper left thigh . i. A Wound Clinic Wound assessment dated [DATE] documented, .Posterior Left Upper Thigh . Pre-procedure (debridement) . length 2.2 cm by width 2.0 cm by depth 1.5 cm . Total surface 4.4 cm . Post-procedure (debridement) .length 2.4 cm by width 2.1 cm by depth 1.6 cm . Total surface 5.04 cm . tunneling at 11:00 . distance 1.6 area larger . 70% slough . wound pain level 5 . j. The Plan of Care dated as reviewed on 1/10/18 documented, .Staff will provide services according to care plan in an effort to enhance optimum well-being . Anticipate and meet needs . Inspect skin weekly and PRN (as needed) .Potential for pressure ulcer development related to immobility and incontinence .educate (Resident) on the importance of changing positions for prevention of pressure ulcers .encourage small frequent position changes . The Care Plan did not address the existing unstageable pressure ulcer to the left, posterior, upper thigh. k. A Wound Clinic Wound assessment dated [DATE] documented, .Posterior Left Upper Thigh . Pre-procedure (debridement) . length 2.1 cm by width 2.4 cm by depth 1.2 cm . Total surface 5.04 cm . Post-procedure (debridement) . length 2.1 cm by width 2.6 cm by depth 1.3 cm . Total surface 5.46 cm . 50% slough . wound pain level . 5 . l. A Wound Clinic Wound assessment dated [DATE] documented, .Posterior Left Upper Thigh . Pre-procedure . length 3.1 cm by width 2.2 cm by depth 0.8 cm . Total surface 6.82 cm . Post-procedure . length 3.1 cm by width 2.2 cm by depth 1.1 cm . Total surface 6.82 cm . 100% slough . (0) pain . next appointment 2/20/18 . m. On 2/7/18 at 10:00 a.m. and from 11:30 a.m. continuously until 3:00 p.m., the resident was sitting in her wheelchair in the same position. The resident's body was tightly fitted in the wheelchair, allowing no room for her weight to be shifted or for her buttocks to be repositioned on the seat. During the 3.5-hour period from 11:30 a.m. to 3:00 p.m., no staff attempted to reposition the resident, offer toileting or check the resident for incontinence. At 11:30 a.m., Resident #1 was asked to explain how the pressure sore developed on the back of her upper left thigh / lower buttock area. She stated, That area had been tender for several days, but when they put me on the lift that day, it actually hurt worse. The CNA went and got a nurse, and they said it happened on the lift, and (that was) not so. The nurse put something on it and a bandage. She was asked, Did they change the dressing? She stated, No. It stayed there until one day they put me on the lift and it hurt bad. That day I went to the hospital. Resident #1 also stated, I sit in my chair (wheelchair) most of the day. She was asked if she could reposition herself in the wheelchair or bed. She stated, There's not much room in this wheelchair to move. She was asked if she ever asked staff to reposition her in the wheelchair. She stated, I didn't know I could ask them. The resident tried to reposition herself in the wheelchair but didn't have room to do so; she pressed her feet to the floor to attempt to reposition her buttocks or shift her weight, but her buttocks remained in the same position on the seat. She was asked when the pressure relief cushion was placed in her wheelchair seat and stated, Since I came from the hospital. The resident refers to the Wound Clinic as the hospital, and the pressure relief cushion was placed in her wheelchair seat when she went to the Wound Clinic on 1/9/18. The resident was asked if the surveyor could observe her wound care and she stated, I really don't see the need. I can tell you my needs. n. On 2/7/18 at 3:30 p.m., Licensed Practical Nurse (LPN) #1 (the facility's Treatment Nurse) was asked to explain how she initially identified the wound to the resident's left, posterior, upper thigh as a skin tear. She stated, Since it was a 3-centimeter, red, thin, raw area, I assumed it looked like it was where the edge of the lift pad was. I called the family and doctor and reported it. I put some antibiotic ointment on it and told the next shift nurse to keep an eye on it. She was asked who prescribed the antibiotic ointment and stated, It's a standing order for skin tears. I know I'm going to have to take the blame for this, because we identified the skin tear wrong. I went home. I assume the dressing stayed on and they forgot about it. o. On 2/8/18 at 3:06 p.m., the Director of Nursing (DON) was asked, when did staff receive training in caring for a pressure ulcer, and training in re-positioning residents while in a wheelchair. She stated, It's been awhile. I will have to look for the training. p. On 2/8/18 at 5:10 p.m., the Assistant Director of Nursing (ADON) provided a Wound Care Training document dated 5/27/16 from the facility's wound care supplier. There was no documentation regarding who attended the training. The Training document was titled, Pressure Ulcer Staging and Recommended Products. When asked for documentation that staff were trained on repositioning residents in wheelchairs, the ADON stated, We don't have training on repositioning residents that are in a wheelchair. q. On 2/9/18 at 11:59 p.m., LPN #2 was asked when she first became aware of the pressure ulcer on the resident's left upper thigh. She stated, On 12/26/17. She told me it hurt, and I removed the dressing. It was filled with slough. No one had ever mentioned to me that she had a pressure ulcer. She was asked, Had you been monitoring a skin tear before you found the pressure ulcer on 12/26/17? She stated, No, ma'am. r. On 2/9/18 from 12:39 p.m. to 1:10 p.m., Certified Nursing Assistants #1, #2, and #3 were interviewed. The CNAs were asked how the resident was toileted and repositioned. They all replied they provided incontinent care every two hours and as needed. CNA #1 stated, It's hard to move her body. We try to get her to help us, and it's a tight fit in that wheelchair. CNA #1 stated, I remember a dressing on her, and I thought it was being changed. CNA #2 stated, The resident (previously) had a wheelchair that laid back. It had more repositioning room. We reposition her in the bed, and in the wheelchair; we pull her up. There's no room in the wheelchair to move her up and down. CNA #3 stated, I take her to her room, put the gait belt around her, and pull her up in the wheelchair, or pull her side to side. It's more like a scooting or sliding of her body. She was asked if the resident's buttocks were lifted off of the seat when repositioning was attempted. She stated, If we do that, we might as well put her on the (mechanical) lift. The survey team asked CNA #3 to demonstrate how they repositioned the resident in the wheelchair. With a surveyor sitting in the wheelchair, the CNA demonstrated the repositioning technique. The technique demonstrated that the repositioning involved scooting the surveyor's buttocks on the seat, causing friction to the buttocks and posterior thighs. The surveyor was not lifted off of the seat. CNA #3 was asked who trained her on how to reposition a resident in a wheelchair. She stated, I had four days of gait belt and mechanical lift training, and I did a check-off.

Complaint # (AR 957) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure licensed nurses and Certified Nursing Assistants (CNAs) demonstrated competency in the care of an obese, wheelchair-bound resident who developed a pressure ulcer, as evidenced by failure to ensure a newly discovered wound was correctly identified as a pressure ulcer to facilitate the ability to determine and initiate an appropriate treatment; failure to ensure the pressure ulcer was thoroughly assessed, measured and staged upon discovery and the condition of the wound was consistently monitored after discovery to ensure deterioration of the wound was promptly identified and addressed; failure to ensure the physician was immediately consulted for appropriate treatment orders to promote healing and prevent further deterioration of the pressure ulcer; failure to ensure the need for a larger wheelchair and pressure relief device in the wheelchair seat was promptly identified and addressed to enable adequate repositioning and prevent friction/shearing forces when repositioning was attempted; and failure to ensure repositioning was provided at least every 2 hours to relieve pressure and prevent further exacerbation of the pressure ulcer for 1 (Resident #1) of 4 (Residents #1, #2, #3, and #4) case mix residents who were at risk for pressure ulcers. The failed practices resulted in a pattern of actual harm to Resident #1, who had a Stage 2 pressure ulcer to the posterior, left, upper thigh that was initially misidentified as a skin tear, covered with a dressing and not rechecked for a period of 7 days, resulting in deterioration of the wound to an unstageable pressure ulcer covered with slough and eschar and requiring repeated debridement procedures. The failed practices had the potential to cause more than minimal harm for 39 residents who were at risk for pressure ulcers, as documented on a list provided by the Director of Nursing on 2/8/18. The findings are: 1. The facility's Licensed Practical Nurse (LPN) / Charge Nurse Job Description, provided by the Administrator on 2/8/18, documented, .The primary purpose of your job position is to supervise the day-to-day nursing activities of the facility during your tour of duty. Such supervision must be in accordance with current Federal, State and local standards, guidelines and regulations that govern our facility, and as may be required by the Director of Nursing services, to assure that the highest degree of quality care is maintained at all times . Report problem areas to the DON (Director of Nursing) or Assistant (Assistant Director of Nursing) .Review the resident's chart for specific treatments, medication orders, diets, etc, (et cetera) as necessary . Review care plans daily to ensure that appropriate care is being rendered . 2. The facility's Certified Nursing Assistant Job Description, provided by the Administrator on 2/8/18, documented, .The primary purpose of your job position is to provide your assigned residents with routine daily nursing care in accordance with our established nursing care procedures, and as may be directed by your supervisor . Meet with your staff shift nursing personnel on regular scheduled basis, to assist in identifying and correcting problem areas, and/or the improvement of services . Assist with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, wheelchairs, lift, etc . Experience . None. On the job training . 3. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 12/7/17 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status, was totally dependent on two-plus persons for bed mobility, transfers, and toilet use, had functional limitation in range of motion of both lower extremities, was always incontinent of bladder and of bowel, pressure reducing device for chair and bed, had no pressure ulcers, and was at risk for developing pressure ulcers. a. A facility Incident and Accident form for an Injury of Unknown Origin dated 12/18/2017 at 10:59 a.m. documented, .Called to resident room by Treatment Nurse, which states CNA (Certified Nursing Assistant) noticed a skin tear to resident's back upper left leg. Cause has been determined to be the mechanical lift used to get patient to and from bed and w/c (wheelchair). Dressing applied to area at this time. RN (Registered Nurse) notified. Called and informed sister. Resident reports she was unaware of skin tear to back of leg . b. A Body Audit form dated 12/19/17 at 7:04 a.m. documented, .3 cm (centimeter) raw area to the back of left thigh . coccyx redness noted . There was no documentation of any further monitoring or assessment of the skin breakdown to the left, upper, posterior thigh wound until 12/26/17. c. A Nurses Note dated 12/19/17 at 9:59 a.m. documented, .Skin tear to upper left rear leg dry and dressed at this time . There was no documentation the dressing was removed to allow visualization of the wound at this time, or at any time between 12/19/17 and 12/26/17. There was no documentation of physician orders [REDACTED]. d. A Nurses Note dated 12/26/17 at 2:42 p.m. documented, .Notified RP (Responsible Party) of area to upper left posterior thigh. RP verbalizes awareness of the initial complaint of skin issue at previous time. Informed RP of change noted to wound . There was no documentation indicating what changes were noted to the wound. There was no assessment of a wound documented on this date. The physician was notified and an order obtained dated 12/26/18 which documented, .Cleanse area to back of left upper leg with wound cleanser, pat dry, apply Calcium Alginate and cover with bordered gauze QD (every day) and PRN (as needed) until healed .every day shift .Monitor dressing to back of left upper leg every shift and change dressing if necessary . e. A Body Audit form dated 12/27/17 at 3:00 p.m. documented, .3 cm x (by) 3 cm open area noted to the back of the left thigh . f. A weekly skin audit dated 12/27/17 at 3:03 p.m. documented, .Left thigh rear, unstageable due to slough / eschar, 3 cm (centimeters) (by) 3 cm, serosanguinous exudate, resident has pain . Clean wound with wound cleaner, pat dry. Apply Santyl ointment and cover with comfort foam border gauze daily and PRN (as needed), pressure reducing devices . This audit incorrectly documented the onset date for this pressure ulcer as 12/26/17. g. A Hospital Progress Note dated 12/28/17 documented, .The Nurse reports the patient has a wound to her left posterior thigh which was first noticed several days ago and has progressively worsened. The staff reports the lesion is round with 90% yellow slough . The hospital document, page 5 of 5, documented, .Send patient for further evaluation and tx (treatment) of wound at wound clinic . h. A Prescriber Telephone Order sheet dated 12/28/17 at 12:51 p.m. documented, .Cleanse area to back of left upper leg with wound cleanser, pat dry. Apply calcium alginate and cover with bordered gauze QD (every day) and PRN (as needed) until healed . The order was changed at 12:52 p.m. to, . Santyl Ointment 250 unit/GM (units per gram) [MEDICATION NAME] apply to per additional directions topically every day shift for wound care . apply to posterior upper left thigh . i. A Wound Clinic Wound assessment dated [DATE] documented, .Posterior Left Upper Thigh . Pre-procedure (debridement) . length 2.2 cm by width 2.0 cm by depth 1.5 cm . Total surface 4.4 cm . Post-procedure (debridement) .length 2.4 cm by width 2.1 cm by depth 1.6 cm . Total surface 5.04 cm . tunneling at 11:00 . distance 1.6 area larger . 70% slough . wound pain level 5 . j. The Plan of Care dated as reviewed on 1/10/18 documented, .Staff will provide services according to care plan in an effort to enhance optimum well-being . Anticipate and meet needs . Inspect skin weekly and PRN (as needed) . Potential for pressure ulcer development related to immobility and incontinence .educate (Resident) on the importance of changing positions for prevention of pressure ulcers .encourage small frequent position changes . The Care Plan did not address the existing unstageable pressure ulcer to the left, posterior, upper thigh. k. A Wound Clinic Wound assessment dated [DATE] documented, .Posterior Left Upper Thigh . Pre-procedure (debridement) . length 2.1 cm by width 2.4 cm by depth 1.2 cm . Total surface 5.04 cm . Post-procedure (debridement) . length 2.1 cm by width 2.6 cm by depth 1.3 cm . Total surface 5.46 cm . 50% slough . wound pain level . 5 . l. A Wound Clinic Wound assessment dated [DATE] documented, .Posterior Left Upper Thigh . Pre-procedure . length 3.1 cm by width 2.2 cm by depth 0.8 cm . Total surface 6.82 cm . Post-procedure . length 3.1 cm by width 2.2 cm by depth 1.1 cm . Total surface 6.82 cm . 100% slough . (0) pain . next appointment 2/20/18 . m. On 2/7/18 at 10:00 a.m. and from 11:30 a.m. continuously until 3:00 p.m., the resident was sitting in her wheelchair in the same position. The resident's body was tightly fitted in the wheelchair, allowing no room for her weight to be shifted or for her buttocks to be repositioned on the seat. During the 3.5-hour period from 11:30 a.m. to 3:00 p.m., no staff attempted to reposition the resident, offer toileting or check the resident for incontinence. At 11:30 a.m., Resident #1 was asked to explain how the pressure sore developed on the back of her upper left thigh / lower buttock area. She stated, That area had been tender for several days, but when they put me on the lift that day, it actually hurt worse. The CNA went and got a nurse, and they said it happened on the lift, and (that was) not so. The nurse put something on it and a bandage. She was asked, Did they change the dressing? She stated, No. It stayed there until one day they put me on the lift and it hurt bad. That day I went to the hospital. Resident #1 also stated, I sit in my chair (wheelchair) most of the day. She was asked if she could reposition herself in the wheelchair or bed. She stated, There's not much room in this wheelchair to move. She was asked if she ever asked staff to reposition her in the wheelchair. She stated, I didn't know I could ask them. The resident tried to reposition herself in the wheelchair but didn't have room to do so; she pressed her feet to the floor to attempt to reposition her buttocks or shift her weight, but her buttocks remained in the same position on the seat. She was asked when the pressure relief cushion was placed in her wheelchair seat and stated, Since I came from the hospital. The resident refers to the Wound Clinic as the hospital, and the pressure relief cushion was placed in her wheelchair seat when she went to the Wound Clinic on 1/9/18. The resident was asked if the surveyor could observe her wound care and she stated, I really don't see the need. I can tell you my needs. n. On 2/7/18 at 3:30 p.m., Licensed Practical Nurse (LPN) #1 (the facility's Treatment Nurse) was asked to explain how she initially identified the wound to the resident's left, posterior, upper thigh as a skin tear. She stated, Since it was a 3-centimeter, red, thin, raw area, I assumed it looked like it was where the edge of the lift pad was. I called the family and doctor and reported it. I put some antibiotic ointment on it and told the next shift nurse to keep an eye on it. She was asked who prescribed the antibiotic ointment and stated, It's a standing order for skin tears. I know I'm going to have to take the blame for this, because we identified the skin tear wrong. I went home. I assume the dressing stayed on and they forgot about it. o. On 2/8/18 at 3:06 p.m., the Director of Nursing (DON) was asked, when did staff receive training in caring for a pressure ulcer, and training in re-positioning residents while in a wheelchair. She stated, It's been awhile. I will have to look for the training. p. On 2/8/18 at 5:10 p.m., the Assistant Director of Nursing (ADON) provided a Wound Care Training document dated 5/27/16 from the facility's wound care supplier. There was no documentation regarding who attended the training. The Training document was titled, Pressure Ulcer Staging and Recommended Products. When asked for documentation that staff were trained on repositioning residents in wheelchairs, the ADON stated, We don't have training on repositioning residents that are in a wheelchair. q. On 2/9/18 at 11:59 p.m., LPN #2 was asked when she first became aware of the pressure ulcer on the resident's left upper thigh. She stated, On 12/26/17. She told me it hurt, and I removed the dressing. It was filled with slough. No one had ever mentioned to me that she had a pressure ulcer. She was asked, Had you been monitoring a skin tear before you found the pressure ulcer on 12/26/17? She stated, No, ma'am. r. On 2/9/18 from 12:39 p.m. to 1:10 p.m., Certified Nursing Assistants #1, #2, and #3 were interviewed. The CNAs were asked how the resident was toileted and repositioned. They all replied they provided incontinent care every two hours and as needed. CNA #1 stated, It's hard to move her body. We try to get her to help us, and it's a tight fit in that wheelchair. CNA #1 stated, I remember a dressing on her, and I thought it was being changed. CNA #2 stated, The resident (previously) had a wheelchair that laid back. It had more repositioning room. We reposition her in the bed, and in the wheelchair; we pull her up. There's no room in the wheelchair to move her up and down. CNA #3 stated, I take her to her room, put the gait belt around her, and pull her up in the wheelchair, or pull her side to side. It's more like a scooting or sliding of her body. She was asked if the resident's buttocks were lifted off of the seat when repositioning was attempted. She stated, If we do that, we might as well put her on the (mechanical) lift. The survey team asked CNA #3 to demonstrate how they repositioned the resident in the wheelchair. With a surveyor sitting in the wheelchair, the CNA demonstrated the repositioning technique. The technique demonstrated that the repositioning involved scooting the surveyor's buttocks on the seat, causing friction to the buttocks and posterior thighs. The surveyor was not lifted off of the seat. CNA #3 was asked who trained her on how to reposition a resident in a wheelchair. She stated, I had four days of gait belt and mechanical lift training, and I did a check-off.

Complaint # (AR000# ) was substantiated (all or in part) in these findings: Based on record review and interview, the facility failed to ensure adequate supervision was provided for Resident #1 to prevent elopement. The facility failed to ensure the development and implementation of a policy and procedure to detail steps staff were to take if a resident was missing. The facility failed to ensure staff performed checks to ensure the wanderguard alarm system was fully operational to prevent elopement; failed to ensure an elopement was promptly and thoroughly investigated to assist in determining corrective action; and failed to ensure a planned intervention for 1:1 monitoring was promptly and consistently implemented to prevent further elopement and decrease the potential for accident or injury for 1 (Resident #1) of 3 (Residents #1, #4 and #5) case mix residents with documented exit seeking behaviors. These failed practices resulted in Immediate Jeopardy, which likely caused or could have caused serious harm, injury or death to Resident #1, who exited the facility and was found 0.3 miles from the facility and had the potential to affect 5 residents who had exit seeking behaviors, as documented on a list provided by the Administrator on 9/14/14 at 4:30 p.m. The Administrator was informed of the Immediate Jeopardy on 9/15/14 at 11:50 a.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of 7/15/14 documented the resident scored 2 0-7 (indicates severe cognitive impairment) on the Brief Interview for Mental Status, had behavioral symptoms not directed toward others 4 to 6 days out of 7, had no wandering presence exhibited, required supervision with oversight for transfers, walking, locomotion on and off the unit, had no balance problems and had no impairment in range of motion. a. The resident's Elopement Risk Assessments dated 8/29/12, 11/21/12, 2/15/13, 5/10/13, 7/30/13, 10/23/13, 1/23/14, 4/21/14 and 7/17/14 documented, "...exit seeking." The assessment dated [DATE] documented, "...Wears Wanderguard." b. The Social Note dated 7/15/14 documented, "...(Resident #1) ambulates independently... Her movements are strong and quick. She is active in facility everyday... is an elopement risk and has a wanderguard bracelet..." c. The SBAR (Situation, Background, Assessment and Recommendation) Communication Form and Progress Note form dated 9/6/14 at 4:00 p.m. and provided by the Administrator on 9/14/14 at 5:20 p.m. documented, "(9/5/14) Resident was sitting in dining room about 5:30 p.(m.), was given medication and a few minutes later, she was noted not being in the dining area. Staff was feeding other residents and someone stated that the resident was gone. Staff members looked around inside and outside looking for resident. I did not (hear) the door alarm going off (during) that time. No more than about 15 to 20 min (minutes), a staff member found the resident down the street and returned her to the facility without harm. Family member notified and daughter stated she knows that her mother is a 'flight risk' and thanks for calling." The note documented both the resident's family and the physician were notified on 9/6/14 at 4:00 p.m. The form was signed by Licensed Practical Nurse (LPN) #2. The Event Report dated 9/5/14 documented, "...Date of Occurrence 9/5/14... Witness to Actual Event? No... Physician Notified? Yes... Date: 9/6/14... Family Notified? Yes... Date: 9/6/14 Time: 4:00 (p.m.)... Describe what occurred: Resident was sitting in dining room about 5:30 p.(m.), was given medication and a few minutes later, she was noted not being in the dining area, staff was feeding other residents and someone stated that the resident was gone, staff members looked around inside and outside looking for resident, I did not (hear) the door alarm going off (during) that time. no more than about 15 to 20 min, a staff member found the resident down the street and returned her to the facility, without harm, family members notified, and daughter stated she knows that her mother is a 'flight risk' and thanks for calling... Signature of Person Completing Form (LPN #2)... Date 9/5/14..." 1) The OLTC Witness Statement Form signed by LPN #2 on 9/6/14 documented, "Date: 9/6/14... Time: (blank) p.m. ...(9/5/14) Resident was sitting in dining room about 5:30 p(.m.), was given medication at that time, then a few minutes later, she was noted not being in the dining area, staff was feeding other residents and someone stated that the resident was gone, staff members looked around inside and outside looking for the resident, I did not (hear) the door alarm going off (during) that time, no more than about 15 to 20 min, a staff member found the resident down the street, walking on sidewalk, and returned her to the facility without harm." On 9/15/14 at 10:35 a.m., LPN #2 (Charge Nurse for Resident #1 on 9/5/14) stated, "Around 5:30 p.m. (on 9/5/14) I was administering meds (medications) and (Resident #1) was sitting in the dining room and I gave her meds. A few minutes later, no more than 10 minutes, (LPN #1) asked if anyone had seen (Resident #1). Everybody started looking for her. ... Staff looked inside and outside for her. (Resident #1) walks slow and with a shuffle gait. The next thing I knew I was going out the front door to look for her and (CNA #3) who was off duty had her in her SUV (sport utility vehicle). I held the door open and (CNA #3) brought her through the front door and the alarm went off. I did not assess her. She could not have walked there (Local Service Station on Highway 65) in that period of time. I did not hear the alarm going off anywhere when she must have left ... A CNA assisted her to the dining room." 2) The OLTC Witness Statement Form signed by CNA #6 on 9/6/14 documented, "Date: 9/6/14... Time: ev(en)ing... (9/5/14) (Resident #1) was in dining room earlier. I sent down the hall serving trays and was asked by a nurse have seen (Resident #1). (No). Later found out she had left and was brought back by a CNA that works morning." 3) The OLTC Witness Statement Form signed by CNA #2 on 9/8/14 documented, "Date - 9/8/14... Time - 4:30 ... (9/5/14) We miss (Resident #1) at meal time started looking then a few min(ute) (CNA #3) brought her in. Found her walking on Highway." On 9/14/14 at 4:45 p.m., CNA #2 stated, "I was (Resident #1)'s CNA on 9/5/14 on 100-Hall. (Resident #1) was not sitting in her place in the dining room at supper. (LPN #1) and I started looking for her. (CNA #3) brought (Resident #1) back in the building. She said she had made it to (Local Service Station) on Highway 65 about 3 blocks away. (CNA #3) was off duty. She brought her back in her car." On 9/14/14 at 5:10 p.m., surveyors drove from the facility on (facility's street) for 0.1 mile, turned right on Highway 65, crossed 1 side street and continued to (Local Service Station) an additional 0.2 mile. The total mileage from the front of the building to the local service station where the resident was found on 9/5/14 was 0.3 miles. 4) The OLTC Witness Statement Form signed by CNA #1 on 9/8/14 documented, "Date - 9/8/14... On 9-5-14 (Resident #1) (was) in (dining) room at 5:30 p.m. at (6:15 p.m.) the(y) (say) (Resident #1) was gone and some lady brought her back." On 9/15/14 at 1:35 p.m., CNA #1 who worked 3:00 p.m. to 11:00 p.m. on 9/5/14 stated, "We, the CNAs, one from each hall, put the residents in the dining room and (Resident #1) was seated in the dining room at 5:00 p.m. We came back in about 5:25 p.m. and she was not in the dining room. (LPN #1) asked me where she was. I didn't know. We all started looking for her inside and outside. We looked for about 30 minutes then a lady brought her back. About 5:00 p.m., we took her to smoke and back to her seat around 5:10 p.m. We heard the alarm around 5:30 p.m. to 5:45 p.m. I think it was the front. Somebody turned it off cause we were serving. It was about 6:00 p.m. when (LPN #1) asked where (Resident #1) was. (Resident #1) had her tray the last time I saw her ..." 5) The OLTC Witness Statement Form signed by CNA #4 on 9/8/14 documented, "Date - 9/5/14... Time - 5:45 p.m. ...We were in the dining room passing dinner trays when I came to (Resident #1)'s tray and she was not at her table. I asked (several) times where is she. Everyone (replied) I don't know. That's when I asked the LPN (LPN #1) did she see (Resident #1). She stated no but I will check the halls. By that time a CNA from morning shift call and said she was bringing (Resident #1 back. We did not hear a alarm go off at all." On 9/15/14 at 3:11 p.m., CNA #4 stated, "I was working 3:00 p.m. till 11:00 p.m. on 9/5/14. It was suppertime. I brought (Resident #1) to her table. When her tray came, she wasn't at the table. (LPN #1) went to look for her. There was no alarm. No one paged a code silver. A CNA from the day shift, (CNA #3) called the building and said she was on the way back to the building from (Local Service Station). (LPN #1) and another nurse and me met her at the door. The door did not alarm. 6) The OLTC Witness Statement Form signed by CNA #5 on 9/8/14 documented, "Date - 9-8-14... Time (blank)... On 9-5-14 (Resident #1) was in the dining room at 5:30 p.m. when her tray came up she was nowhere to be found. Then (CNA #3) brought her back." 7) The OLTC (Office of Long Term Care) Witness Statement Form signed by CNA #3 on 9/9/14 documented, "Date - 9/5/14... Time -5:30 - 6:00 p.m. ...On Friday (9/6/14) afternoon around 5:30 - 6 pm I noticed (Resident #1) walking on side walk down by (local gas station) and pick(ed) her up and brought her back to nursing home." On 9/15/14 at 9:45 a.m., CNA #3 stated, "On Friday, 9/5/14, I was headed north on Highway 65 when I noticed (Resident #1) walking. She was at (Local Service Station) when I went to her. I asked her where she was going and she shook her head side to side. I helped her into the vehicle and brought her back. It was between 5:30 p.m. and 6:00 p.m. When I got back to the nursing home, I parked under the breezeway. When I got her out an LPN held the door open. The alarm sounded ..." 8) The OLTC Witness Statement Form signed by LPN #1 on 9/10/14 documented, "Date - 9/6/14... time 5:40 p.m. ...(9/5/14) Elder was sitting in dining room for supper. When tray was ready elder was no longer (at) her table. I walked down 100 Hall (and) 300 Hall looking for her. When I started down 400 Hall (CNA #3) brought elder inside the facility. Stating 'I found her walking outside'." On 9/15/14 at 10:00 a.m., LPN #1 stated, "I was working 7:00 a.m. till 7:00 p.m. on 9/5/14. Around suppertime, about 5:30 p.m., CNA #4 asked if I had seen (Resident #1). I said I would go find her. I went looking for her. I checked all rooms and bathrooms on 100 and 300 halls. When I headed down 400 hall, I heard someone say 'Here she is.' ...No alarm had gone off anywhere. I heard no alarm when she came back in but I was at the fire doors on 400 hall. She tries to go out with the smokers. She will go to the front door and try to get out." 9) An undated and untimed OLTC Witness Statement form signed by CNA #7 documented, "...(Resident #1) was in dining room earlier. I went down the hall serving feeding did not (hear) the alarm go off." 10) On 9/16/14 at 10:00 a.m., the Director of Nursing (DON) stated, "On 9/5/14 (LPN #1) called me about 6:15 (p.m.) and told me that (Resident #1) had got out of the door." The Director of Nursing stated, "I did not come to the building." d. An undated and unsigned typed note was provided to the surveyor on 9/16/14 at 9:47 a.m. by the Administrator and documented, "On Saturday, September 6, 2014 while at the facility it was reported that resident (Resident #1) had gotten out of the facility on Friday September 5 (2014) and was picked up and brought back to the facility by an off-duty employee. Findings of Investigation: (LPN #2) reported that about 5:30 p.m., (Resident #1) was sitting in the dining room when she administered her medication. A few minutes later she was noted to not be in the dining room and staff began looking for her inside and outside of the facility. She did not hear a door alarm sounding at any point. A few minutes later she reported that an off duty employee returned her to the facility reporting that she found her walking down the street on the sidewalk. (Certified Nursing Assistant (CNA) #4) reported that she was in the dining room and went to pass (Resident #1)'s tray and she was not at her table and she began asking staff if they knew where she was and they began looking for her when an off-duty CNA called and said she had picked her up and was bringing her back to the facility. All other on-duty staff members were questioned with the same report that she had been in the dining room and then couldn't be found in the facility. All staff members reported that at no time did they hear the front door alarm sounding nor did any of them have to go to the door to reset it. Upon return to the facility the alarm did sound when she came back into the door. It is undetermined as to which door she exited or if a visitor assisted her out the door. Maintenance was contacted and all exit doors were checked as well as her wander guard bracelet and all were determined to be in working order. Notes were placed on the exit doors to alert visitors to check with staff before assisting a resident out the door." e. The Nurse's Notes dated 9/6/14 and timed 7:00 a.m. to 7:00 p.m. documented, "Remains on 1:1 observation d/t (due to) elopement. (No) attempts of elopement noted. Wanderguard in place (and) functioning properly. Closely observed for behaviors or (changes)." The entry was signed by LPN #3. On 9/16/14 at 9:45 a.m., LPN #3 stated specific to her 9/6/14 Nurse's Note, "I was told on 9/6/14 in the afternoon by the Administrator that (Resident #1) needed to be on 1:1 observations. I did not assign anyone. I started my observations in the afternoon of 9/6/14. I did not observe her ongoing minute to minute. I did not assign anyone else to monitor." f. On 9/15/14 at 2:00 p.m., the Maintenance Director stated, "After 9/5/14, I was texted by the Administrator to go and check the door for efficiency. I checked the doors on 9/6/14 around 9:30 p.m. to 10:30 p.m. When I checked the front door, I found it would close but take about 15 seconds. Now it will close in 5 seconds. On 9/5/14, the wind was strong and I had adjusted the tension on the door (before the resident's elopement)." g. The Nurse's Notes dated 9/7/14 and timed 7:00 a.m. to 7:00 p.m. documented, "1:1 observations continues (without) any attempted elopement. Wanderguard in place (and) functioning properly." The entry was signed by LPN #3. On 9/16/14 at 9:54 a.m., LPN #3 stated specific to her 9/7/14 Nurse's Note, "I did not assign anyone to monitor (Resident #1) 1:1. I kept an eye on her anytime I was around. To my knowledge she was not on 1:1 with any assigned person." h. The resident's Risk of Elopement / Wandering Review dated 9/5/14 and dated as signed by LPN #4 on 9/8/14 documented, "...Does the resident have a history of: elopement while at home Y (yes)... Leaving facility without needed supervision N (no)... Leaving facility without informing staff N (no)... Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door... Y (yes)... Summary of Review... Resident is at risk for elopement / wandering, as evidenced by (blank)... Appropriate interventions have been... reviewed... Family / Responsible Party / Resident notified per facility policy... Additional comments: Wanderguard in place and working properly." i. The Resident Plan of Care updated 9/8/14 documented, "Problem Date: 04/21/2014... (Resident #1) exhibits exit-seeking behavior. She tries to get outside and walks away from others... Monitor resident for tailgating when visitors are in the building. Use verbal and if necessary physical cues for redirection to persuade exit-seeking behaviors. Use diversional activities when exit-seeking behavior is occurring (i.e.: offer food, activities, one-on-one company). Reassess elopement risk at least quarterly. Provide direct staff supervision for her when attending an out-of-facility activity. Use audible monitoring system to alert staff of exit seeking behaviors. Check for proper functioning of the audible alarm system every shift and PRN (as needed). " An undated handwritten entry documented, "Wanderguard." j. The resident's September 2014 physician's orders [REDACTED]. Discontinue all current Wanderguard orders. 2. Wanderguard to alert staff of attempts of elopement. Check placement (and) function QS (every shift)." k. On 9/14/14 at 4:17 p.m., LPN #5 stated, "If a resident has a Wanderguard, the band is checked on the 7 a-7 p (7:00 a.m. to 7:00 p.m.) and 7 p -7 a (7:00 p.m. to 7:00 a.m.) shifts by a machine which signals if it is operational. We use the same machine to check the doors. I have not used the machine until this week. Before that, I would check to see if the Wanderguard bracelet was on the resident. I did not check the doors. I take it on hearsay that a resident left the building." LPN #5 checked Resident #1's Wanderguard bracelet and it worked. LPN #5 stated, "I am the only one on my shift that checks the doors." LPN #5 checked the following doors, with the following response, utilizing the 707 tester: 200 hall door - no response from tester Back door - quick response from tester Front door - no response from tester Back Hall door near dining room - quick response from tester Exit door to Laundry - no response from tester 100 hall door - no response from tester 1) On 9/14/14 at 5:17 p.m., the Administrator checked the doors with the 707 tester. All doors had a quick response with the 707 tester, with the exception of the 100 Hall door and the Back Hall Dining room door which did not have a Wanderguard. 2) On 9/14/14 at 5:55 p.m., the Administrator stated, "Prior to 9/11/14 there was a sheet for nurses to check the doors on the night shift. I found the tester in the 400 hall med (medication) cart on 9/8/14 or 9/10/14. On the 10th of September (2014) I asked the nurses if the 707 tester was used. They said they did not. On 9/9/14 I came early and asked (LPN #5) about the tester and she did not know about it. I told her it was in the 400 hall cart and that I would show (LPN #3) how to use it and she could show her. Then I fixed a sheet for each door and they started the checks on 9/11/14. The front door and the exit by laundry, you have to place the tester about 12-inches off the floor. This ensures that all ankle bracelets will activate. I did not know which nurses know how to use the tester." 3) On 9/14/14 at 6:30 p.m., the surveyors, the Administrator, Registered Nurse (RN) #1 and Resident #1 went to the front door. Resident #1 had a Wanderguard bracelet on her left arm. The door locked and would not allow exit. l. On 9/16/14 at 10:30 a.m., the Administrator stated, "There was no elopement policy in effect on 9/5/14. The Policy Suspected Elopement Procedures was written by myself on 9/8/14. The entire staff was not in-serviced prior to 9/14/14 (survey start date). The policy was written on 9/8/14. The policy does not have a date on it." 1) On 9/16/14 at 11:21 a.m., the DON stated, "The code for elopement was Code Green from my point of hire (1 and 1/2 years ago) through about 4 months ago; the Maintenance Director in-serviced about the change in code. If elopement occurred, we were to get on the intercom and call Code Yellow with the resident's name. Then, all staff goes to the nursing station for assignment. The nurse would give assignments. The Director of Nursing was to be notified if not here. The family and physician were to be notified. After the resident is found assess the resident, assess how they got out of the building, check doors and resident alarms and document in the Nurse's Notes and do an I and A (Incident and Accident Report). The Administrator asked if there was an Elopement policy. I told her No because there was no policy in our book. Before the surveyors arrived everyone had not been in-serviced on the new policy." 2) On 9/16/14 at 11:15 a.m., RN #1 (Assistant Director of Nursing) stated, "I have worked her for 1 year. On 9/5/14, and before then, the code (for elopement) was Code Green then the resident's name. Then the building is searched. Someone searches outside. If the resident is not found and if we are not here, the Administrator and Director of Nursing is notified. If the resident is found, take the vital signs and do an assessment. The family should have been called. I was told in orientation the code is Code Green and go to the nursing station and get assignments." 3) On 9/15/14 at 10:00 a.m., LPN #1 stated, " ...No code was paged when (Resident #1) was missing. No alarm had gone off anywhere. I heard no alarm when she came back in but I was at the fire doors on 400 hall. She tries to go out with the smokers. She will go to the front door and try to get out. I have not had an in-service on elopement since the event. This a.m., the Administrator showed me the 707 tester and how to use it." On 9/16/14 at 11:00 a.m., LPN #1 stated, "On 9/5/14 I did know there was something in place as far as policy regarding elopement. The code has always been Code Green. I don't remember what it said about searching. We were supposed to call the department heads and Administrator. We were supposed to notify the family and the doctor." 4) On 9/16/14 at 11:10 a.m., LPN #4 stated, "The elopement policy before 9/5/14 was to search the building, inform the Director of Nursing and then send someone outside to look for the resident. We, once the resident was found, were to assess the resident for any injuries, notify the Director of Nursing that they were found, complete the incident report and notify family and physician. The code for elopement was Code Green." 5) On 9/15/14 at 10:35 a.m., LPN #2 (Charge Nurse for Resident #1 on 9/5/14) stated, "No one made assignments of where to search. The doors were not checked. A CNA assisted her to the dining room. She was not placed on 1:1 monitoring. I did not notify the family or the doctor on 9/5/14, nor the law. I notified the family and physician, but not the law on 9/6/14 around 4:00 p.m. (LPN #1) called the Director of Nursing on 9/5/14. The Administrator was not notified. There has been no in-service on elopement since and no counseling." 6) CNA #2 stated, "I was (Resident #1)'s CNA on 9/5/14 on 100-Hall .... I have not been in-serviced and no counseling. I filled out a report, this was not the day it happened. They just said to write it down. There is no difference since that happened. (CNA #1) was working with me that day. No RN (Registered Nurse) was on duty." 7) On 9/15/14 at 1:35 p.m., CNA #1 who worked 3:00 p.m. to 11:00 p.m. on 9/5/14 stated, " ...There hasn't been any in-services since 9/5/14." 8) On 9/15/14 at 3:11 p.m., CNA #4 stated, "I was working 3:00 p.m. till 11:00 p.m. on 9/5/14 ... The door did not alarm. No one worked 1:1 with her." 9) On 9/15/14 at 9:45 a.m., CNA #3 stated, "On Friday, 9/5/14, I was headed north on Highway 65 when I noticed (Resident #1) walking... I helped her into the vehicle and brought her back... We have not had an in-service since this happened." 2. The Immediate Jeopardy was removed on 9/15/14 at 3:45 p.m. and reduced to a scope / severity of "E" after the facility began implementation of the following Plan of Removal: a. All scheduled staff inserviced beginning 5:00 p.m. on 9/14/14 by ADON (Assistant Director of Nursing) and will be conducted at the beginning of each shift ongoing to include new hires and staff returning from leave. Training will take place before staff work on floor. Training will be done by DON (Director of Nursing) / designee and inservice sign-in sheets used. Training will include directives for staff to respond to any and all alarms in the facility. b. All staff inservices beginning at 11:00 a.m. on 9/15/14 by Administrator and will be conducted at the beginning of each shift ongoing to include new hires and staff returning from leave. Training will take place before staff work on floor. Training will be done by DON / designee and inservice sign-in sheets used. Training will cover the Suspected Elopement Procedures including the following: Calling code alert (Silver Alert) when unable to locate a resident; Staff assignments to carry out search procedures; Notifications to Administrator, DON, family and physician; Documentation of events with timeline; Assessment and documentation upon return; and Actions to notify law enforcement if resident not immediately found. All employees will receive a copy of the suspected elopement procedure by DON / designee and will be provided to all new hires. c. All staff inserviced beginning 9:00 a.m. on 9/15/14 by Social Director and will be ongoing to include new hires and staff returning from leave. Training will take place before staff work on the floor. Training will be done by DON / designee and inservice sheets used. Training will include that identification symbols that will be placed on the door name plates to indicate 'at risk' residents. d. All licensed nursing staff inserviced beginning at 7:00 p.m. on 9/14/14 by Administrator and will be conducted at the beginning of each shift ongoing to include new hires and staff returning from leave. Training will take place before licensed staff work on floor. Training will be done by DON / designee and inservice sign-in sheets used. Training will include proper use of the 707 tester, testing the wanderguard bracelets and documenting on the MAR (Medication Administration Record) every shift and testing the 3 wanderguard exit doors daily and documenting in the Wanderguard testing log daily. Also to monitor and replace any bracelet transmitter if not working properly and to assign monitoring and notify maintenance if any doors fails testing. e. Maintenance Director inserviced on 9/15/14 at 1:00 p.m. by the Administrator to include testing the wanderguard doors weekly with the wanderguard tester and/or a bracelet document that the door locked, alarm sounded and the activation time. Also instructed that if a door is found to not be working properly to assign monitoring, notify the technician immediately for repairs and if not able to repair immediately doors must be monitored ongoing until repaired. f. This failed practice had the potential to affect 14 at risk residents identified. During the investigation the facility has reviewed the facility elopement procedures and an action plan with monitoring actions will be submitted to the QA (Quality Assurance) Committee on 9/15/14. The facility RVP (Regional Vice President) / designee will monitor the above action items during weekly visits until resolved."

Complaint # was substantiated (all or in part) in these findings: Based on record review and interview, the facility Administration and Nursing Administration failed to ensure the development and implementation of a policy and procedure to detail steps staff were to take if a resident was missing; failed to ensure staff performed checks to ensure the wanderguard alarm system was fully operational to prevent elopement; failed to ensure an elopement was promptly and thoroughly investigated to assist in determining corrective action; and failed to ensure a planned intervention for 1:1 monitoring was promptly and consistently implemented to prevent further elopement and decrease the potential for accident or injury for 1 (Resident #1) of 3 (Residents #1, #4 and #5) case mix residents with documented exit seeking behaviors. These failed practices resulted in Immediate Jeopardy, which likely caused or could have caused serious harm, injury or death to Resident #1, who exited the facility and was found 0.3 miles from the facility and had the potential to affect 5 residents who had exit seeking behaviors, as documented on a list provided by the Administrator on 9/14/14 at 4:30 p.m. The Administrator was informed of the Immediate Jeopardy on 9/15/14 at 11:50 a.m. The findings are: 1. The Administrator's Job Description received from the Administrator on 9/16/14 at 8:55 a.m. documented, "The primary purpose of your job position is to direct the day to day functions of the facility in accordance with Federal, State and local standards, guidelines and regulations that govern the Long-Term Care Facility to assure that the highest degree of quality care can be provided to our residents at all times. The Director of Nursing Services' Job Description received from the Administrator on 9/16/14 at 8:55 a.m. documented, "The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Services Department in accordance with current Federal, State and local standards, guidelines and regulations that govern our facility and as may be directed by the Administrator and Medical Director to ensure that the highest degree of quality care is maintained at all times. 2. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of 7/15/14 documented the resident scored 2 0-7 (indicates severe cognitive impairment) on the Brief Interview for Mental Status, had behavioral symptoms not directed toward others 4 to 6 days out of 7, had no wandering presence exhibited, required supervision with oversight for transfers, walking, locomotion on and off the unit, had no balance problems and had no impairment in range of motion. a. The resident's Elopement Risk Assessments dated 8/29/12, 11/21/12, 2/15/13, 5/10/13, 7/30/13, 10/23/13, 1/23/14, 4/21/14 and 7/17/14 documented, "...exit seeking." The assessment dated [DATE] documented, "...Wears Wanderguard." b. The Social Note dated 7/15/14 documented, "...(Resident #1) ambulates independently... Her movements are strong and quick. She is active in facility everyday... is an elopement risk and has a wanderguard bracelet..." c. The SBAR (Situation, Background, Assessment and Recommendation) Communication Form and Progress Note form dated 9/6/14 at 4:00 p.m. and provided by the Administrator on 9/14/14 at 5:20 p.m. documented, "(9/5/14) Resident was sitting in dining room about 5:30 p.(m.), was given medication and a few minutes later, she was noted not being in the dining area. Staff was feeding other residents and someone stated that the resident was gone. Staff members looked around inside and outside looking for resident. I did not (hear) the door alarm going off (during) that time. No more than about 15 to 20 min (minutes), a staff member found the resident down the street and returned her to the facility without harm. Family member notified and daughter stated she knows that her mother is a 'flight risk' and thanks for calling." The note documented both the resident's family and the physician were notified on 9/6/14 at 4:00 p.m. The form was signed by Licensed Practical Nurse (LPN) #2. The Event Report dated 9/5/14 documented, "...Date of Occurrence 9/5/14... Witness to Actual Event? No... Physician Notified? Yes... Date: 9/6/14... Family Notified? Yes... Date: 9/6/14 Time: 4:00 (p.m.)... Describe what occurred: Resident was sitting in dining room about 5:30 p.(m.), was given medication and a few minutes later, she was noted not being in the dining area, staff was feeding other residents and someone stated that the resident was gone, staff members looked around inside and outside looking for resident, I did not (hear) the door alarm going off (during) that time. no more than about 15 to 20 min, a staff member found the resident down the street and returned her to the facility, without harm, family members notified, and daughter stated she knows that her mother is a 'flight risk' and thanks for calling... Signature of Person Completing Form (LPN #2)... Date 9/5/14..." 1) The OLTC Witness Statement Form signed by LPN #2 on 9/6/14 documented, "Date: 9/6/14... Time: (blank) p.m. ...(9/5/14) Resident was sitting in dining room about 5:30 p(.m.), was given medication at that time, then a few minutes later, she was noted not being in the dining area, staff was feeding other residents and someone stated that the resident was gone, staff members looked around inside and outside looking for the resident, I did not (hear) the door alarm going off (during) that time, no more than about 15 to 20 min, a staff member found the resident down the street, walking on sidewalk, and returned her to the facility without harm." On 9/15/14 at 10:35 a.m., LPN #2 (Charge Nurse for Resident #1 on 9/5/14) stated, "Around 5:30 p.m. (on 9/5/14) I was administering meds (medications) and (Resident #1) was sitting in the dining room and I gave her meds. A few minutes later, no more than 10 minutes, (LPN #1) asked if anyone had seen (Resident #1). Everybody started looking for her. ... Staff looked inside and outside for her. (Resident #1) walks slow and with a shuffle gait. The next thing I knew I was going out the front door to look for her and (CNA #3) who was off duty had her in her SUV (sport utility vehicle). I held the door open and (CNA #3) brought her through the front door and the alarm went off. I did not assess her. She could not have walked there (Local Service Station on Highway 65) in that period of time. I did not hear the alarm going off anywhere when she must have left ... A CNA assisted her to the dining room." 2) The OLTC Witness Statement Form signed by CNA #6 on 9/6/14 documented, "Date: 9/6/14... Time: ev(en)ing... (9/5/14) (Resident #1) was in dining room earlier. I sent down the hall serving trays and was asked by a nurse have seen (Resident #1). (No). Later found out she had left and was brought back by a CNA that works morning." 3) The OLTC Witness Statement Form signed by CNA #2 on 9/8/14 documented, "Date - 9/8/14... Time - 4:30 ... (9/5/14) We miss (Resident #1) at meal time started looking then a few min(ute) (CNA #3) brought her in. Found her walking on Highway." On 9/14/14 at 4:45 p.m., CNA #2 stated, "I was (Resident #1)'s CNA on 9/5/14 on 100-Hall. (Resident #1) was not sitting in her place in the dining room at supper. (LPN #1) and I started looking for her. (CNA #3) brought (Resident #1) back in the building. She said she had made it to (Local Service Station) on Highway 65 about 3 blocks away. (CNA #3) was off duty. She brought her back in her car." On 9/14/14 at 5:10 p.m., surveyors drove from the facility on (facility's street) for 0.1 mile, turned right on Highway 65, crossed 1 side street and continued to (Local Service Station) an additional 0.2 mile. The total mileage from the front of the building to the local service station where the resident was found on 9/5/14 was 0.3 miles. 4) The OLTC Witness Statement Form signed by CNA #1 on 9/8/14 documented, "Date - 9/8/14... On 9-5-14 (Resident #1) (was) in (dining) room at 5:30 p.m. at (6:15 p.m.) the(y) (say) (Resident #1) was gone and some lady brought her back." On 9/15/14 at 1:35 p.m., CNA #1 who worked 3:00 p.m. to 11:00 p.m. on 9/5/14 stated, "We, the CNAs, one from each hall, put the residents in the dining room and (Resident #1) was seated in the dining room at 5:00 p.m. We came back in about 5:25 p.m. and she was not in the dining room. (LPN #1) asked me where she was. I didn't know. We all started looking for her inside and outside. We looked for about 30 minutes then a lady brought her back. About 5:00 p.m., we took her to smoke and back to her seat around 5:10 p.m. We heard the alarm around 5:30 p.m. to 5:45 p.m. I think it was the front. Somebody turned it off cause we were serving. It was about 6:00 p.m. when (LPN #1) asked where (Resident #1) was. (Resident #1) had her tray the last time I saw her ..." 5) The OLTC Witness Statement Form signed by CNA #4 on 9/8/14 documented, "Date - 9/5/14... Time - 5:45 p.m. ...We were in the dining room passing dinner trays when I came to (Resident #1)'s tray and she was not at her table. I asked (several) times where is she. Everyone (replied) I don't know. That's when I asked the LPN (LPN #1) did she see (Resident #1). She stated no but I will check the halls. By that time a CNA from morning shift call and said she was bringing (Resident #1 back. We did not hear a alarm go off at all." On 9/15/14 at 3:11 p.m., CNA #4 stated, "I was working 3:00 p.m. till 11:00 p.m. on 9/5/14. It was suppertime. I brought (Resident #1) to her table. When her tray came, she wasn't at the table. (LPN #1) went to look for her. There was no alarm. No one paged a code silver. A CNA from the day shift, (CNA #3) called the building and said she was on the way back to the building from (Local Service Station). (LPN #1) and another nurse and me met her at the door. The door did not alarm. 6) The OLTC Witness Statement Form signed by CNA #5 on 9/8/14 documented, "Date - 9-8-14... Time (blank)... On 9-5-14 (Resident #1) was in the dining room at 5:30 p.m. when her tray came up she was nowhere to be found. Then (CNA #3) brought her back." 7) The OLTC (Office of Long Term Care) Witness Statement Form signed by CNA #3 on 9/9/14 documented, "Date - 9/5/14... Time -5:30 - 6:00 p.m. ...On Friday (9/6/14) afternoon around 5:30 - 6 pm I noticed (Resident #1) walking on side walk down by (local gas station) and pick(ed) her up and brought her back to nursing home." On 9/15/14 at 9:45 a.m., CNA #3 stated, "On Friday, 9/5/14, I was headed north on Highway 65 when I noticed (Resident #1) walking. She was at (Local Service Station) when I went to her. I asked her where she was going and she shook her head side to side. I helped her into the vehicle and brought her back. It was between 5:30 p.m. and 6:00 p.m. When I got back to the nursing home, I parked under the breezeway. When I got her out an LPN held the door open. The alarm sounded ..." 8) The OLTC Witness Statement Form signed by LPN #1 on 9/10/14 documented, "Date - 9/6/14... time 5:40 p.m. ...(9/5/14) Elder was sitting in dining room for supper. When tray was ready elder was no longer (at) her table. I walked down 100 Hall (and) 300 Hall looking for her. When I started down 400 Hall (CNA #3) brought elder inside the facility. Stating 'I found her walking outside'." On 9/15/14 at 10:00 a.m., LPN #1 stated, "I was working 7:00 a.m. till 7:00 p.m. on 9/5/14. Around suppertime, about 5:30 p.m., CNA #4 asked if I had seen (Resident #1). I said I would go find her. I went looking for her. I checked all rooms and bathrooms on 100 and 300 halls. When I headed down 400 hall, I heard someone say 'Here she is.' ...No alarm had gone off anywhere. I heard no alarm when she came back in but I was at the fire doors on 400 hall. She tries to go out with the smokers. She will go to the front door and try to get out." 9) An undated and untimed OLTC Witness Statement form signed by CNA #7 documented, "...(Resident #1) was in dining room earlier. I went down the hall serving feeding did not (hear) the alarm go off." 10) On 9/16/14 at 10:00 a.m., the Director of Nursing (DON) stated, "On 9/5/14 (LPN #1) called me about 6:15 (p.m.) and told me that (Resident #1) had got out of the door." The Director of Nursing stated, "I did not come to the building." d. An undated and unsigned typed note was provided to the surveyor on 9/16/14 at 9:47 a.m. by the Administrator and documented, "On Saturday, September 6, 2014 while at the facility it was reported that resident (Resident #1) had gotten out of the facility on Friday September 5 (2014) and was picked up and brought back to the facility by an off-duty employee. Findings of Investigation: (LPN #2) reported that about 5:30 p.m., (Resident #1) was sitting in the dining room when she administered her medication. A few minutes later she was noted to not be in the dining room and staff began looking for her inside and outside of the facility. She did not hear a door alarm sounding at any point. A few minutes later she reported that an off duty employee returned her to the facility reporting that she found her walking down the street on the sidewalk. (Certified Nursing Assistant (CNA) #4) reported that she was in the dining room and went to pass (Resident #1)'s tray and she was not at her table and she began asking staff if they knew where she was and they began looking for her when an off-duty CNA called and said she had picked her up and was bringing her back to the facility. All other on-duty staff members were questioned with the same report that she had been in the dining room and then couldn't be found in the facility. All staff members reported that at no time did they hear the front door alarm sounding nor did any of them have to go to the door to reset it. Upon return to the facility the alarm did sound when she came back into the door. It is undetermined as to which door she exited or if a visitor assisted her out the door. Maintenance was contacted and all exit doors were checked as well as her wander guard bracelet and all were determined to be in working order. Notes were placed on the exit doors to alert visitors to check with staff before assisting a resident out the door." e. The Nurse's Notes dated 9/6/14 and timed 7:00 a.m. to 7:00 p.m. documented, "Remains on 1:1 observation d/t (due to) elopement. (No) attempts of elopement noted. Wanderguard in place (and) functioning properly. Closely observed for behaviors or (changes)." The entry was signed by LPN #3. On 9/16/14 at 9:45 a.m., LPN #3 stated specific to her 9/6/14 Nurse's Note, "I was told on 9/6/14 in the afternoon by the Administrator that (Resident #1) needed to be on 1:1 observations. I did not assign anyone. I started my observations in the afternoon of 9/6/14. I did not observe her ongoing minute to minute. I did not assign anyone else to monitor." f. On 9/15/14 at 2:00 p.m., the Maintenance Director stated, "After 9/5/14, I was texted by the Administrator to go and check the door for efficiency. I checked the doors on 9/6/14 around 9:30 p.m. to 10:30 p.m. When I checked the front door, I found it would close but take about 15 seconds. Now it will close in 5 seconds. On 9/5/14, the wind was strong and I had adjusted the tension on the door (before the resident's elopement)." g. The Nurse's Notes dated 9/7/14 and timed 7:00 a.m. to 7:00 p.m. documented, "1:1 observations continues (without) any attempted elopement. Wanderguard in place (and) functioning properly." The entry was signed by LPN #3. On 9/16/14 at 9:54 a.m., LPN #3 stated specific to her 9/7/14 Nurse's Note, "I did not assign anyone to monitor (Resident #1) 1:1. I kept an eye on her anytime I was around. To my knowledge she was not on 1:1 with any assigned person." h. The resident's Risk of Elopement / Wandering Review dated 9/5/14 and dated as signed by LPN #4 on 9/8/14 documented, "...Does the resident have a history of: elopement while at home Y (yes)... Leaving facility without needed supervision N (no)... Leaving facility without informing staff N (no)... Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door... Y (yes)... Summary of Review... Resident is at risk for elopement / wandering, as evidenced by (blank)... Appropriate interventions have been... reviewed... Family / Responsible Party / Resident notified per facility policy... Additional comments: Wanderguard in place and working properly." i. The Resident Plan of Care updated 9/8/14 documented, "Problem Date: 04/21/2014... (Resident #1) exhibits exit-seeking behavior. She tries to get outside and walks away from others... Monitor resident for tailgating when visitors are in the building. Use verbal and if necessary physical cues for redirection to persuade exit-seeking behaviors. Use diversional activities when exit-seeking behavior is occurring (i.e.: offer food, activities, one-on-one company). Reassess elopement risk at least quarterly. Provide direct staff supervision for her when attending an out-of-facility activity. Use audible monitoring system to alert staff of exit seeking behaviors. Check for proper functioning of the audible alarm system every shift and PRN (as needed). " An undated handwritten entry documented, "Wanderguard." j. The resident's September 2014 physician's orders [REDACTED]. Discontinue all current Wanderguard orders. 2. Wanderguard to alert staff of attempts of elopement. Check placement (and) function QS (every shift)." k. On 9/14/14 at 4:17 p.m., LPN #5 stated, "If a resident has a Wanderguard, the band is checked on the 7 a-7 p (7:00 a.m. to 7:00 p.m.) and 7 p -7 a (7:00 p.m. to 7:00 a.m.) shifts by a machine which signals if it is operational. We use the same machine to check the doors. I have not used the machine until this week. Before that, I would check to see if the Wanderguard bracelet was on the resident. I did not check the doors. I take it on hearsay that a resident left the building." LPN #5 checked Resident #1's Wanderguard bracelet and it worked. LPN #5 stated, "I am the only one on my shift that checks the doors." LPN #5 checked the following doors, with the following response, utilizing the 707 tester: 200 hall door - no response from tester Back door - quick response from tester Front door - no response from tester Back Hall door near dining room - quick response from tester Exit door to Laundry - no response from tester 100 hall door - no response from tester 1) On 9/14/14 at 5:17 p.m., the Administrator checked the doors with the 707 tester. All doors had a quick response with the 707 tester, with the exception of the 100 Hall door and the Back Hall Dining room door which did not have a Wanderguard. 2) On 9/14/14 at 5:55 p.m., the Administrator stated, "Prior to 9/11/14 there was a sheet for nurses to check the doors on the night shift. I found the tester in the 400 hall med (medication) cart on 9/8/14 or 9/10/14. On the 10th of September (2014) I asked the nurses if the 707 tester was used. They said they did not. On 9/9/14 I came early and asked (LPN #5) about the tester and she did not know about it. I told her it was in the 400 hall cart and that I would show (LPN #3) how to use it and she could show her. Then I fixed a sheet for each door and they started the checks on 9/11/14. The front door and the exit by laundry, you have to place the tester about 12-inches off the floor. This ensures that all ankle bracelets will activate. I did not know which nurses know how to use the tester." 3) On 9/14/14 at 6:30 p.m., the surveyors, the Administrator, Registered Nurse (RN) #1 and Resident #1 went to the front door. Resident #1 had a Wanderguard bracelet on her left arm. The door locked and would not allow exit. l. On 9/16/14 at 10:30 a.m., the Administrator stated, "There was no elopement policy in effect on 9/5/14. The Policy Suspected Elopement Procedures was written by myself on 9/8/14. The entire staff was not in-serviced prior to 9/14/14 (survey start date). The policy was written on 9/8/14. The policy does not have a date on it." 1) On 9/16/14 at 11:21 a.m., the DON stated, "The code for elopement was Code Green from my point of hire (1 and 1/2 years ago) through about 4 months ago; the Maintenance Director in-serviced about the change in code. If elopement occurred, we were to get on the intercom and call Code Yellow with the resident's name. Then, all staff goes to the nursing station for assignment. The nurse would give assignments. The Director of Nursing was to be notified if not here. The family and physician were to be notified. After the resident is found assess the resident, assess how they got out of the building, check doors and resident alarms and document in the Nurse's Notes and do an I and A (Incident and Accident Report). The Administrator asked if there was an Elopement policy. I told her No because there was no policy in our book. Before the surveyors arrived everyone had not been in-serviced on the new policy." 2) On 9/16/14 at 11:15 a.m., RN #1 (Assistant Director of Nursing) stated, "I have worked her for 1 year. On 9/5/14, and before then, the code (for elopement) was Code Green then the resident's name. Then the building is searched. Someone searches outside. If the resident is not found and if we are not here, the Administrator and Director of Nursing is notified. If the resident is found, take the vital signs and do an assessment. The family should have been called. I was told in orientation the code is Code Green and go to the nursing station and get assignments." 3) On 9/15/14 at 10:00 a.m., LPN #1 stated, " ...No code was paged when (Resident #1) was missing. No alarm had gone off anywhere. I heard no alarm when she came back in but I was at the fire doors on 400 hall. She tries to go out with the smokers. She will go to the front door and try to get out. I have not had an in-service on elopement since the event. This a.m., the Administrator showed me the 707 tester and how to use it." On 9/16/14 at 11:00 a.m., LPN #1 stated, "On 9/5/14 I did know there was something in place as far as policy regarding elopement. The code has always been Code Green. I don't remember what it said about searching. We were supposed to call the department heads and Administrator. We were supposed to notify the family and the doctor." 4) On 9/16/14 at 11:10 a.m., LPN #4 stated, "The elopement policy before 9/5/14 was to search the building, inform the Director of Nursing and then send someone outside to look for the resident. We, once the resident was found, were to assess the resident for any injuries, notify the Director of Nursing that they were found, complete the incident report and notify family and physician. The code for elopement was Code Green." 5) On 9/15/14 at 10:35 a.m., LPN #2 (Charge Nurse for Resident #1 on 9/5/14) stated, "No one made assignments of where to search. The doors were not checked. A CNA assisted her to the dining room. She was not placed on 1:1 monitoring. I did not notify the family or the doctor on 9/5/14, nor the law. I notified the family and physician, but not the law on 9/6/14 around 4:00 p.m. (LPN #1) called the Director of Nursing on 9/5/14. The Administrator was not notified. There has been no in-service on elopement since and no counseling." 6) CNA #2 stated, "I was (Resident #1)'s CNA on 9/5/14 on 100-Hall .... I have not been in-serviced and no counseling. I filled out a report, this was not the day it happened. They just said to write it down. There is no difference since that happened. (CNA #1) was working with me that day. No RN (Registered Nurse) was on duty." 7) On 9/15/14 at 1:35 p.m., CNA #1 who worked 3:00 p.m. to 11:00 p.m. on 9/5/14 stated, " ...There hasn't been any in-services since 9/5/14." 8) On 9/15/14 at 3:11 p.m., CNA #4 stated, "I was working 3:00 p.m. till 11:00 p.m. on 9/5/14 ... The door did not alarm. No one worked 1:1 with her." 9) On 9/15/14 at 9:45 a.m., CNA #3 stated, "On Friday, 9/5/14, I was headed north on Highway 65 when I noticed (Resident #1) walking... I helped her into the vehicle and brought her back... We have not had an in-service since this happened." 3. The Immediate Jeopardy was removed on 9/15/14 at 3:45 p.m. and reduced to a scope / severity of "E" after the facility began implementation of the following Plan of Removal: a. All scheduled staff inserviced beginning 5:00 p.m. on 9/14/14 by ADON (Assistant Director of Nursing) and will be conducted at the beginning of each shift ongoing to include new hires and staff returning from leave. Training will take place before staff work on floor. Training will be done by DON (Director of Nursing) / designee and inservice sign-in sheets used. Training will include directives for staff to respond to any and all alarms in the facility. b. All staff inservices beginning at 11:00 a.m. on 9/15/14 by Administrator and will be conducted at the beginning of each shift ongoing to include new hires and staff returning from leave. Training will take place before staff work on floor. Training will be done by DON / designee and inservice sign-in sheets used. Training will cover the Suspected Elopement Procedures including the following: Calling code alert (Silver Alert) when unable to locate a resident; Staff assignments to carry out search procedures; Notifications to Administrator, DON, family and physician; Documentation of events with timeline; Assessment and documentation upon return; and Actions to notify law enforcement if resident not immediately found. All employees will receive a copy of the suspected elopement procedure by DON / designee and will be provided to all new hires. c. All staff inserviced beginning 9:00 a.m. on 9/15/14 by Social Director and will be ongoing to include new hires and staff returning from leave. Training will take place before staff work on the floor. Training will be done by DON / designee and inservice sheets used. Training will include that identification symbols that will be placed on the door name plates to indicate 'at risk' residents. d. All licensed nursing staff inserviced beginning at 7:00 p.m. on 9/14/14 by Administrator and will be conducted at the beginning of each shift ongoing to include new hires and staff returning from leave. Training will take place before licensed staff work on floor. Training will be done by DON / designee and inservice sign-in sheets used. Training will include proper use of the 707 tester, testing the wanderguard bracelets and documenting on the MAR (Medication Administration Record) every shift and testing the 3 wanderguard exit doors daily and documenting in the Wanderguard testing log daily. Also to monitor and replace any bracelet transmitter if not working properly and to assign monitoring and notify maintenance if any doors fails testing. e. Maintenance Director inserviced on 9/15/14 at 1:00 p.m. by the Administrator to include testing the wanderguard doors weekly with the wanderguard tester and/or a bracelet document that the door locked, alarm sounded and the activation time. Also instructed that if a door is found to not be working properly to assign monitoring, notify the technician immediately for repairs and if not able to repair immediately doors must be monitored ongoing until repaired. f. This failed practice had the potential to affect 14 at risk residents identified. During the investigation the facility has reviewed the facility elopement procedures and an action plan with monitoring actions will be submitted to the QA (Quality Assurance) Committee on 9/15/14. The facility RVP (Regional Vice President) / designee will monitor the above action items during weekly visits until resolved."

Based on observation, record review and interview, the facility failed to ensure a pressure relieving device (PRD) was in place in a wheelchair seat and heels were off-loaded to reduce the risk of pressure ulcer development for 1 (Resident #4) of 4 case mix residents (Residents #2, #3, #10 and #12) who were at risk for pressure sores or had pressure sores. The facility also failed to ensure the physician was consulted regarding deterioration and lack of improvement of a pressure sore to enable the physician to evaluate whether a change in treatment was warranted for 1 (Resident #2) of 3 (Residents #2, 10 and 12) who had pressure ulcers. The facility failed to ensure physician orders [REDACTED].#2) of 3 (Residents #2, 10 and 12) who had pressure ulcers. The failed practice resulted in a pattern of actual harm for Resident #2 when the facility failed to notify the physician after lack of improvement of a pressure sore and further deterioration of the wound with the current treatment and had the potential to affect 6 residents who had pressure sores. The failed practice also had the potential to cause more than minimal harm for 12 residents who were at risk for pressure sores, and 38 residents who required PRD's in their wheelchairs, according to lists provided by the Director of Nursing and Administrator on 2/1/13. The findings are: 1. The facility's Policy and Procedure for Pressure Ulcers received from Director of Nursing on 2/14/13 documented: "Care and Prevention of Pressure Ulcer and Skin Conditions: ...The Interdisciplinary team will review interventions and modify as necessary in care planning. Skin conditions will be reviewed and re-evaluated as needed to assess for appropriate treatment is in place. MD (Medical Doctor) and resident/elder and designated contact person will be informed as necessary. .. 9. Notify physician, designated contact person, and dietary of any new wound ... Treatment: treatment of [REDACTED]. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers ..." 2. Resident #2 had [DIAGNOSES REDACTED]. The Modified Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 1/23/13 documented the resident scored 2 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS); was totally dependent for all Activities of Daily Living (ADLs) except required extensive assist for eating; was incontinent of bowel and bladder; was at risk for developing Pressure Ulcer; had one Stage 3 Pressure Ulcer, documented at admit/reentry, with granulation tissue-pink or red tissue with shiny, moist, granular appearance, and worsened since prior assessment; and required a pressure reducing device for the chair and the bed. b. The Plan of Care dated 8/7/12 documented, Risk for Pressure ULC (Ulcer) (Resident #2) is at risk for developing a pressure ulcer related to: Immobility, incontinence...Report changes in skin status to physician... Assist her PRN to reposition/shift weight to relieve pressure...10/10/12 Ulcer to coccyx area. May use Cal-Alginate to coccyx (with) border dsg (dressing). Provide (with) Rest-Q mattress. Give Vitamin C 500 mg (milligrams) 1 PO (by mouth) QD (every day). Zinc Sulfate 220 mg 1 PO QD for wound healing ..." As of 1/30/13, the care plan documented, "11/2/12 cont (continue) POC (plan of care) ...1/24/13 cont POC." c. The Weekly Pressure Ulcer Record dated 10/10/12 and signed by Treatment Nurse #1 documented: "Stage 2, Size in CM (centimeter) (Length x width): 1 x 0.4, Depth (cm): 0.1, Exudate Type/Amount: Sm (small), ... Odor: N/A (not applicable), Wound Bed: Red, Surrounding Skin Color: Normal, Surrounding Tissue/Wound Edges: Flat, Response to Treatment/Comments: New wound on coccyx, no bleeding, no odor, wound bed is red. Will treat with Calcium Alginate QD cover with border gauze...Turned Q 2 hours ..." d. A Nutritional Progress Notes dated 10/19/12 documented: "(Resident) is treated for [REDACTED]. Wt. (weight) 10/12 - 196.8# (pounds), (decreased) 2.2# in 1 mo. (month), up11.2# in 6 months. Order dated 10/16/12 to (increase) [MEDICATION NAME] to BID (twice daily) X 3 days. Diet: LCS, (low concentrated sweets) Reg (regular), 1 can Glucerna TID (three times a day) (with) meals. Receives Senior Care Tabs. Will adj (adjust) Pro (protein) needs to 74 g (grams). The Glucerna 1.5 provides 19.6 g per 8 oz (ounce) can. No changes are recommended." This entry was documented by the Registered Dietician. There were no other entries by the Registered Dietician in the resident's record. e. The Weekly Pressure Ulcer Record dated 10/24/12 and signed by Treatment Nurse #1 documented documented: "Stage (blank), Size in CM (Length x width): 0.7 x 0.2, Depth (cm): 0.1, Exudate Type/Amount: N/A, Odor: N/A, Wound Bed: Red, Surrounding Skin Color: Normal, Surrounding Tissue/Wound Edges: Flat, Response to Treatment/Comments: ...Cont (continue) to turn from L (left) to R (right). Wound is doing well. No S/S (signs and symptoms) of infection noted ..." f. The Weekly Pressure Ulcer Record dated 11/22/12 and signed by Treatment Nurse #2 documented: "Stage 2, Size in CM (Length x width): 1.5 x 0.8, Depth (cm): 0.2, Exudate Type/Amount: Sm, clear, ... Odor: NA, Wound Bed: Red, Surrounding Skin Color: Normal, Surrounding Tissue/Wound Edges: Flat, Response to Treatment/Comments: ... Wound to coccyx cleaned daily (with) W/C (and) Cal - Alginate (and) border gauze applied. ... Turned Q 2 hours. ..." This entry was signed by Treatment Nurse #2. There was no documentation that the physician was notified of the increase in size of the pressure ulcer. g. The Wound Assessment Form (Complicating Clinical Factors) dated 12/6/12 and signed by Treatment Nurse #1 documented, "... Stage III, L (Length):1.3 cm, W (Width): 0.6 cm, D (Depth): 0.2 cm. ... Cont Tx (treatment): QD, turn Q 2 (hours)..." The Weekly Pressure Ulcer Record dated 12/7/12 and signed by Treatment Nurse #2 documented: "Stage 2, Size in CM (Length x width): 1.5 x 0.8, Depth (cm): 0.2, Exudate Type/Amount: Sm, clear ... Odor: NA, Wound Bed: Red, Surrounding Skin Color: Normal, Surrounding Tissue/Wound Edges: Flat, Response to Treatment/Comments: Wound cleaned daily (with) W/C. Covered (with) Cal - Alginate (and) covered (with) border gauze. (No) S/S of infection noted...Turned Q 2 hours ..." h. The Weekly Pressure Ulcer Record dated 12/27/12 documented: "Stage 2, Size in CM (Length x width): 2.5 x 0.2, Depth (cm): 0.3, Exudate Type/Amount: Sm, clear, ... Odor: NA, Wound Bed: Red, Surrounding Skin Color: Normal, Surrounding Tissue/Wound Edges: Flat, Response to Treatment/Comments: Continue to dress wound to coccyx Cal - Alg (Alginate) daily, clean (with) W/C (wound cleanser), Apply border gauze. ...Turned Q 2 hours. ..." This entry was signed by Treatment Nurse #2. There was no documentation that the physician was notified of the increase/change in the size of the pressure ulcer. i. A Hospital Medication Reconciliation Report dated 1/5/13 documented the resident was admitted on [DATE] with an admission [DIAGNOSES REDACTED]. Neither form addressed pressure sores. The Resident Admission/Re-Admission Assessment documented the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There were no measurements or description. j. The Weekly Pressure Ulcer Record dated 1/5/13 and signed by Treatment Nurse #2 documented: "Stage 2, Size in CM (Length x width): 1.5 x 0.2, Depth (cm): 0.3, Exudate Type/Amount: Sm, clear, ... Odor: NA, Wound Bed: Red, Surrounding Skin Color: Normal, Surrounding Tissue/Wound Edges: Flat, Response to Treatment/Comments: Area between buttocks small. (No) odors, cleaned daily (with) W/C, covered (with) Cal Alginate... Border gauze applied... Turned Q 2 hours ..." The Wound Assessment Form (Complicating Clinical Factors) dated 1/5/13 and signed by Treatment Nurse #2 documented: "...Stage III, L: 2.5 W: 0.3 cm, D: 0.3 ... Cont Tx daily. Turn Q 2 hrs... Clean (with) W/C, apply Cal Alginate daily. ..." There was no documentation that the physician was notified of the increase/change in the size of the pressure ulcer. k. The Wound Assessment Form (Complicating Clinical Factors) dated 1/19/13 and signed by Treatment Nurse #2 documented: "... L: 2.5 W: 0.3 cm, D: 0.3 ... Continue Tx daily. Turn Q 2 hrs ... Clean (with) W/C daily, apply Cal Alginate (and) cover (with) border gauze ... Chronicity: Stage II ..." The Wound Assessment Form (Complicating Clinical Factors) dated 1/27/13 and signed by Treatment Nurse #1 documented, "... L: 3.5 W: 2 cm, D: 0.2 ... Stage III ... Change Q day (and) prn ..." There was no documentation that the physician was notified of the increase/change in the size of the pressure ulcer. l. On 1/29/13 at 9:07 a.m., the treatment nurse was observed performing the treatment. She cleansed the wound with wound cleaner and covered with Calcium Alginate and border gauze. The pressure sore to the coccyx measured 2.5 cm in length by 1.5 cm in width and 0.3 cm in depth. As of 1/31/13, there was no documentation in the physician orders [REDACTED]. The October, November, December 2012 and January 2013 TAR's documented the Cal-Alginate treatments were provided daily except while the resident was hospitalized throughout this 3.5 month period. m. On 1/31/13 at 2:05 p.m., the Director of Nursing (DON) was asked when the physician should be consulted about a pressure ulcer. She stated, "When you find it ... when they worsen." The DON was asked when the physician should be notified of no improvement of the pressure ulcer. She stated, "A couple of weeks." n. The February 2013 Physicians Orders sheet documented a Physicians order dated 11/4/11 documented, " [MEDICATION NAME] 2 scoops Mix in H2O (water) juice or food BID (twice a day) ..." A Laboratory report dated 2/4/13 documented: "... Protein, Total: 5.3, L (low), ... Normals: 5.7-8.2 ... [MEDICATION NAME], Serum: 2.4, L, Normals: 3.2-4.8. ..." 1) As of 2/13/13 at 11:10 a.m., the November and December 2012, January and February 2013 Medication Administration Records (MARs) were reviewed and did not document that [MEDICATION NAME] was ever given to the resident. 2) On 2/13/13 at 4:50 p.m., the DON was asked about the order for [MEDICATION NAME] in November 2012. The DON stated, "It did not print out on the MAR indicated [REDACTED]' instead of as a medication or treatment." She also stated that she could not prove it had been given. She stated that she had put it on the February 2013 MAR indicated [REDACTED] 3) On 2/14/13 at 9:45 a.m., the DON was asked if she had found any more recommendations for the resident by the RD. She stated, "Nothing other than what is in the record." o. The Wound Assessment Form (Complicating Clinical Factors) dated 2/3/13 and signed by Treatment Nurse #2 documented: "... L: (blank) W: (blank), D: (blank) ... Change dsg daily (and) prn. Clean (with) w/c, cover (with) border gauze... Resident c/o (complains of) severe pain when placed on either side due to [MEDICAL CONDITION] (and) [MEDICAL CONDITION]." A telephone order dated 2/4/13 documented: "Clean wound with wound cleanser pat dry. Apply Collagen dressing and cover with bordered gauze QD to wound on coccyx." p. On 2/13/13 at 10:30 a.m., Treatment Nurse/LPN #1 was asked if the Doctor was notified when the pressure ulcer increased in size on 11/22/12. The LPN stated, I don't think so, I think (Resident #2) had just returned from the hospital when it was bigger." The LPN reviewed the resident's chart and then stated, "No she didn't go to the hospital at that time." The LPN was asked if the doctor was notified when the wound had not improved, and had increased in size on 12/27/12. The LPN stated, "No, I didn't call, I felt like even though it wasn't getting smaller, the characteristics were better. The wound bed was healthy, red and no slough. The drainage was just a small amount, which is what you want." The LPN was asked about the discrepancies of the measurements on the different forms when the resident returned from the hospital on [DATE]. The LPN could not explain the discrepancies and stated, "(Treatment Nurse/LPN #2) usually works on the resident's hall, but I look at the wounds every week. When the resident returned from the hospital, the wound was deeper. The contour of the edge of the wound was changed." The LPN was asked if the Doctor was notified then. The LPN stated that she told him when he visited that it was ok, cause I felt it was still doing ok. Not infected, no increased drainage, just a change in wound edge and depth. Still a Stage 2." The LPN agreed that there was no documentation by the other Treatment Nurse that the doctor was notified when the wound increased in size. Treatment/LPN #1 also stated that the resident will not stay on her sides, only on her back and that the resident complains when on sides due to Arthritis and [MEDICAL CONDITION]. The LPN stated, "On 2/4/13 I called the doctor and got a new order for wound care, Collagen and border dressing, due to the wound worsening to a Stage 3. Not a Stage 3 until 2/4/13." The LPN was asked what should have been done when the wound had become larger before 2/4/13. The LPN stated, "We probably should have called the doctor, but like I said, it wasn't looking worse when I looked at it. On 2/4/13 I changed the treatment after I saw the wound." The LPN continued, "We also implemented a safety net, when a resident comes back from the hospital, we have a new form to assess wound, ... with description of wound and will fax to (Physician #1). Also having weekly meetings with the other treatment nurse." On 2/13/13 at 2:05 p.m., Treatment Nurse/LPN #2 was interviewed by telephone. The LPN was asked if she had notified the doctor when the measurements of the pressure ulcer had increased in size. She stated, "I did not." The LPN was asked why the doctor was not notified. She stated, "We did not see any signs and symptoms of infection. A small amount of drainage, no odor, nothing out of the ordinary. (Resident #2) will not stay on her sides. I've been a nurse for [AGE] years, I would have called if necessary." The LPN was asked what would normally be done if a wound is not improving. The LPN stated, "If not improving, we are to consult with the doctor or to bring it to our supervisor." The LPN was asked, "Do you think you should have called when the measurements increased?" The LPN stated, "Yes, we should have." q. On 2/13/13 at 10:50 a.m., the resident's clinical record was reviewed. 1) The Doctor's Progress Notes from October, 2012 to current (2/13/13) were reviewed. The notes dated, 10/18/12, 11/8/12, 12/21/12, and 2/7/13 did not contain any documentation related to a pressure sore. 2) The Nurses Notes from 10/7/12 until current (2/13/13) were reviewed and there was no documentation of notification to the physician of the condition of the pressure ulcer found. There was documentation that the resident was being turned and repositioned every 2 hours, but nothing to indicate the resident was non-compliant with this. The documentation of the pressure ulcer in the nurses notes was documentation that the treatment was "continued by the Treatment Nurse" on the following dates: 11/19/12, 11/23/12, 1/5/13, 1/7/13, and 2/10/13. 3) The Care Plan was reviewed and did not document non-compliance of the resident with turning and repositioning. r. On 2/13/13 at 12:05 p.m., Treatment Nurse/Licensed Practical Nurse (LPN) #1 prepared supplies to do wound care. Certified Nurse Assistant (CNA) #1 came into the room to assist. The resident was turned onto his left side. There was no dressing on the wound area. The CNA stated that it came off in the shower. There was a wound on the coccyx area that the LPN measured at 3.5 cm x 1.6 cm x 0.3 cm and said was a Stage 3. There were 2 other wounds lower on each cheek of the buttocks. The right buttock wound the LPN measured at 1.5 x 3 cm x 0 cm, the left measurements were 2.5 x 1.5 x 0 cm. All wounds had a red moist wound bed. The surrounding skin of each wound was without signs or symptoms of infection. No drainage was observed and there was no odor. The LPN stated that she had found the 2 new areas on Monday (2/11/13) when changing the dressing. The LPN stated, "It happened when they removed the dressing over the weekend, when they pulled the border dressing off. It's from the tape." The LPN completed the wound care using the Collagen on all of the areas. The resident was positioned on her left side and asked to stay on her left side if possible. The resident stated, "I will try." On 2/13/13 at 12:35 p.m., Treatment Nurse/LPN #1 was asked if the physician was notified of the 2 new areas on the resident's buttocks. The LPN stated, "I faxed him, but I was going to call him today, cause he didn't call me back. The LPN was asked how she knew what treatment to use. The LPN stated, "I just used the same as I was using on the Pressure Ulcer. I know I should have called him, but we had the Valentine Fashion Show with the residents yesterday (2/12/13) and it slipped my mind." The LPN also stated that she had not documented this yet. The LPN was asked for a copy of the fax and any documentation done today. The LPN also stated that the weekend nurse had not reported the two new areas that she was aware of. 1) A copy of the fax dated 1/11/13 (actual date 2/11/13) was received from Treatment Nurse #1 on 2/13/13 at 1:00 p.m. and documented, "... (Physician #1) (Resident #2) has two new wounds from tape, one on L (left) buttock about 2.5 X 1.5 X 0, one on the right buttock 1.3 X 3 X 0. They are clean, red, no s/s of infection. Need order." The fax was signed by Treatment Nurse #1. 2) A Nurses Note dated 1/13/13 (2/11/13 actual date of events) was provided by the Treatment Nurse #1 on 2/13/13 at 1:00 p.m. that documented: "Elder has two new wounds, one on L buttock, size 2.5 x 1.5 x0. Wound bed is red, clean, no S/S of infection. R (right) buttock is 1.5 x3 x 0, Clean, red wound bed. Will Tx with Collagen QD until new order, or order change from (Physician #1)... Refaxed to (Physician #1) the report from Monday." s. On 2/13/13 at 1:35 p.m., the Director of Nursing (DON) was asked to review the documentation (notes dated 11/22/12 and 12/27/12) that showed an increase in the size of the pressure ulcer and then asked what should have been done. The DON stated, "I would have called and gotten something different because evidently it quit responding to the treatment. I'm from the old school where you changed the treatments every 2 weeks." The DON was asked if she was aware of the 2 new areas on the resident. The DON stated, "Yes, (Treatment Nurse #1) told me Monday. LPN #1 was the one who changed the dressing over the weekend. She just works every now and then." The DON stated that she had not spoken to this nurse as of yet, but planned to. The DON was asked if she was aware (Treatment Nurse #1) had faxed the doctor about the 2 new wounds, but although no order had been received, was treating the wounds with Collagen. The DON stated, "I'm sure she did not get a response from him, he had to have emergency surgery, won't be back until the 25th. I guess the other doctors did not pick it up." The DON was informed that the Treatment Nurse had refaxed it today. The DON stated, "I have told them not to rely on the fax. She should have called back. I will try to call his assistant today." The DON also agreed that Resident #2 was not compliant with turning and repositioning. The DON was informed that this non-compliance was not documented in the chart or on the care plan. A telephone order dated 1/13/13 (2/13/13 actual date) and provided by the DON on 2/13/13 at 3:45 p.m. documented, "Change order from Collagen to: Calcium Alginate, cover with 4 X 4s and foam dressing. Secure with paper tape. Do not tape over previous tape areas." The DON stated that Physician #1 had not had emergency surgery, she had talked with physician to get this order, he was having surgery in the a.m. The DON also stated that the (Physician's) Assistant did not receive the fax on 2/11/13. 3. Resident #4 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an Assessment Reference Date of 12/11/12 documented the resident was severely impaired in cognitive skills for daily decision making per a staff assessment for mental status, required extensive assistance of 1 person for bed mobility and transfers, was incontinent of bowel and bladder and was at risk for the development of pressure ulcers. a. The Plan of Care dated 12/12/12 documented, "The resident is at risk for developing a pressure sore related to: immobility and incontinence. Approaches: Assist PRN (as needed) to reposition/shift weight to relieve pressure. Provide pressure relieving or reduction device. Pressure reduction mattress/chair cushion ..." b. On 1/28/13 at 11:41 a.m., the resident was sitting in a wheelchair in the dining room. There was no pressure relieving device (PRD) in the wheelchair. At 2:45 p.m. and 5:40 p.m., the resident was in bed with his heels resting directly on the bed, not off loaded. c. On 1/29/13 at 8:40 a.m., the resident was in bed lying in a supine position with his heels resting directly on the mattress, not offloaded. At 9:50 a.m., CNA #6 and #7 got the resident up out of bed for a shower. After the resident was dressed, he was placed in a wheelchair with no PRD in the seat. d. The facility's Care and Prevention of Pressure Ulcer and Skin Conditions Policy, provided by the Administrator on 2/1/13 documented, "Prevention of skin conditions: Use pressure-reducing devices to relieve pressure. Off-load heels with pillows/devices."