Every finding on record at Life Care Center of Columbia

Based on policy review, review of the Centers for Disease Control and Prevention (CDC) Enhanced Barrier Precautions, medical record review, observation, and interview, the facility failed to ensure the prevention and spread of infection during medication administration for 3 of 7 (Resident #1, Resident #5, and Resident #51) sampled residents. The findings: 1.Review of the facility policy titled, Enhanced Barrier Precautions, dated 8/19/2025, revealed .The facility should use Enhanced Barrier Precautions (EBP).for residents with any of the following.wounds and /or indwelling medical devices.Indwelling medical device examples include.feeding tubes [a flexible feeding tube placed through the abdominal wall directly into the stomach to deliver nutrition, fluids, and medications when oral intake is unsafe].Examples of high-contact resident care activities requiring gown and glove use include.Device care or use.feeding tube. Review of the facility policy titled, Hand Hygiene, dated 10/28/2025, revealed .Associates perform hand hygiene (even if gloves are used) in the following situations.Before and after contact with the resident.After removing personal protective equipment [PPE] .gloves, gown. Review of the facility policy titled Cleaning and Disinfection of Non-Critical Patient Care Equipment, dated 7/15/2025, revealed .The following.non-critical reusable patient care equipment.is cleaned daily and before and after reuse with an .registered hospital disinfectant.examples of non-critical items include.blood pressure cuffs.pulse oximeters. Review of the facility's undated CDC Enhanced Barrier Precautions, signage revealed .Providers and staff must also.wear gloves and gown for the following high contact resident care activities.Device care or use.feeding tube. 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, and Dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was cognitively intact. Resident # 1 was assessed for the use of a feeding tube. Review of the Physicians Orders dated 4/7/2026, revealed .Enhanced Barrier Precautions Diagnosis .peg tube [Percutaneous Endoscopic Gastrostomy]. Review of the Physicians Orders dated 4/4/2026, revealed .Aspirin Tablet Chewable 81 mg[milligram] Give 81 mg via [by way of] PEG-Tube one time a day. Observation during medication administration in Resident #1's room on 5/12/2026 at 10:31 AM, revealed Licensed Practical Nurse (LPN) A gathered supplies and prepared Aspirin 81 mg for administration via PEG. LPN A crushed the medication, knocked on the door and entered the room. LPN A performed hand hygiene, donned gloves, checked residual, administered the medication and flushed the tube with 15cc of water, removed her gloves, performed hand hygiene, and exited the room. LPN A failed to wear a PPE gown when accessing Resident #1's peg tube. During an interview on 5/12/2026 at 10:45 am, LPN A was asked what enhanced barriers are used for. LPN A stated, Foley catheter or feeding tubes, stuff like that. LPN A was asked what Resident #1 was in EBP for. LPN A stated, A feeding tube. LPN A was asked what do you do differently for Resident #1's EBP. LPN A stated, Wash hands extra. LPN A was asked based on the EBP signage above Resident #1's bed, should she have worn a gown when administering medications per peg tube. LPN A stated, Yes absolutely. During an interview on 5/12/2026 at 2:59 PM, the Director of Nursing (DON) was asked if a gown and gloves should be worn during medication administration via peg tube. The DON stated, Yes. 3. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Diabetes, Anxiety, and Depression. Review of the Physicians Orders dated 2/3/2026, revealed .Insulin Aspart [used to decrease blood glucose] .Inject as per sliding scale.351-400= 13 units. Review of the quarterly MDS assessment dated [DATE], revealed Resident #5 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. Resident #5 received insulin 4 out of 7 days. Observation during mediation administration in Resident #5's room on 5/11/2025 at 11:35 AM, revealed Registered Nurse (RN) B gathered her supplies, cleaned the hub of the insulin pen and added a needle, performed hand hygiene, knocked on the door, entered the room, donned her gloves, and administered 13 units of Insulin Aspart into Resident #5's left thigh. RN B removed her gloves, disposed of the needle in sharps container and exited the room. RN B failed to perform hand hygiene after removing her gloves. During an interview on 5/11/2026 at 11:44 AM, RN B was asked if she should have performed hand hygiene after removing gloves. RN B stated, I should have and I did not. During an interview on 5/12/2026 at 2:59 PM, the DON was asked if she expected staff to wash their hands after removing gloves or between glove change. The DON stated, Yes. 4. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Diabetes, Hypertensive Heart, and Atrial Fibrillation. Review of the quarterly MDS assessment dated [DATE], revealed Resident #51 scored an 11 on the BIMS assessment, which indicated she was moderately cognitively impaired. Review of the Physicians Orders dated 4/19/2026, revealed .Metoprolol Tartrate Oral Tablet.Hold for SBP [Systolic Blood Pressure] less than 110 or HR [Heart Rate] less than 60.25 mg Give 3 tablets by mouth one time a day. Observation during medication administration in Resident #51's room on 5/12/2026 at 9:18 AM, revealed LPN C gathered supplies to administer medications, knocked on the door, entered the room, placed a blood pressure cuff on Resident # 51's arm and placed a pulse oximetry on her finger. The blood pressure reading was 155/78 and the heart rate was 78. LPN C placed both devices into a zippered bag, administered Metoprolol Tartrate, performed hand hygiene, exited the room, and placed the zippered bag back into the medication cart without cleaning the blood pressure cuff or pulse oximetry. During an interview on 5/12/2026 at 9:31 AM, LPN C was asked if she should have cleaned the blood pressure cuff and pulse oximetry before and after patient use. LPN C stated, Yes. I usually do but I didn't today. During an interview on 5/12/2026 at 2:59 PM, the DON was asked if she expected the staff to clean reusable equipment before and after resident use. The DON stated, Yes I do

Based on policy review, National Pressure Ulcer Advisory Panel (NPUAP) Position Statement review, medical record review, observation and interview, the facility failed to ensure that residents had a thorough assessment and documentation while receiving wound care treatments for 1 of 3 (Resident #42) sampled residents reviewed for pressure ulcers. The findings include: 1.Review of the facility policy titled, Skin Integrity and Pressure/Ulcer Injury Prevention, dated 6/11/2025, revealed .Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury. Complete wound assessment/documentation, and provide treatment and care of skin and wounds.a skin assessment/inspection should be performed weekly by a nurse. 2. Review of the undated article titled The Facts about Reverse Staging in 2000 The NPUAP Position Statement, revealed . Staging is an assessment system that classifies pressure ulcers based on anatomic depth of soft tissue damage .Pressure ulcers heal to progressively more shallow depth, they do not replace lost muscle, subcutaneous fat, or dermis [the deeper connective tissue layer of the skin that provides structural support, elasticity, and strength to the skin] .Instead, the ulcer is filled with granulation (scar) tissue .If a pressure ulcer re-opens in the same anatomical site [location on the body], the ulcer resumes the previous staging diagnosis (i.e once a Stage IV always a Stage IV) . 3. Review of the medical record review revealed Resident #42 was admitted to the facility on [DATE], with diagnoses of Psychosis, Schizophrenia, Dementia, Diabetes, and Morbid Obesity. Review of the quarterly Minimum Date Set (MDS) assessment dated [DATE], revealed Resident #42 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #42 had severe cognitive impairment. Resident #42 was assessed as being at risk for pressure ulcers. Review of a Progress Note dated 4/13/2026, revealed .area to the left knee reopened .MD (Medical Doctor) made aware. Previous tx [treatment] restarted. Review of the Physician's Order dated 4/13/2026, revealed .Cleanse left knee with normal saline, skin prep intact skin, apply [named brand] honey to wound bed, cover with foam dressing. Change 3 x [times] a wk [week] and as needed. Review of the Care Plan dated 5/4/2026, revealed .The resident has an open wound Left Anterior (inner) Knee. Review of the medical record revealed a chronic stage 4 pressure area to Resident #42's left anterior knee reopened on 4/13/2026. The first documentation of an assessment or measurements of the wound was dated 5/4/2026. Review of the facility's .Wound Observation Tool. dated 5/4/2026, revealed Resident #42's left anterior knee wound measurements were 1.0 x 1.0 x 0.3 cm [centimeters]. It was identified as a pressure injury, Stage 4, a past chronic wound. Review of the Progress Note dated 5/6/2026, revealed Resident has a chronic Stage 4 pressure injury (PI) to the anterior left knee, first noted in 2022 .The wound has a history of repeated resolution and reopening at the same site, suspected to be related to weakened tensile [can be stretched or elongated] strength, resident picking at the area, and body alignment. The PI was last documented as resolved in December 2025 .staging has since been confirmed .as a chronic Stage 4 pressure injury . During an interview on 5/12/2026 at 11:59 AM, Licensed Practical Nurse (LPN) F was asked can you provide any documentation describing the wound or wound measurements on 4/13/2026. LPN F confirmed the wound is a chronic area that is classified as a Stage 4 when it opens up. LPN F stated, No I cannot, LPN F was asked how often the wound should be documented and measured once it turned into a pressure ulcer. LPN F stated, It should be done weekly. LPN F was asked should there have been an initial assessment and measurements when the wound reopened. LPN F stated, Yes. Observation in the resident's room on 5/12/2026 at 2:28 PM, revealed Resident #42 sitting on the side of the bed with her left knee exposed. Licensed Practical Nurse (LPN) F was next to the resident, squatting and measuring the wound. Measurements were 0.8 x 0.6 x 0.1 cm. During an interview on 5/12/2026 at 2:55 PM, the Director of Nurses (DON) was asked if there was an assessment or measurement on the pressure ulcer to the left knee that opened on 4/13/2026. The DON stated, I do not see a measurement. The DON was asked would you expect to see documentation when it was found. The DON stated, Typically yes. The DON was asked how often wounds should be assessed and measured. The DON stated, Weekly. The DON was asked would you have expected missing documentation and measurements on this wound. The DON stated, No.

Based on policy review, medical record review, and interview, the facility failed to notify the physician timely for 1 of 2 (Resident #96) sampled residents reviewed for hospitalization s. The findings include: Review of the facility's policy titled, Changes in Resident's Condition of Status, dated 5/5/2020, revealed .To outline the actions required to address a change in resident's condition or status .This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status . Review of the medical record, revealed Resident #96 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed Resident #96 had severe cognitive impairment and required limited staff assistance for activities of daily living (ADLs). Review of the Progress Notes dated 10/24/2021, revealed Resident #96 had several episodes of vomiting throughout the night and the physician was not notified of the resident's vomiting, until approximately 7:17 AM the following morning, when an order was obtained to send her to the emergency room (ER). The resident was sent to theER on [DATE] at approximately 8:06 AM. During an interview on 12/8/2021 at 3:50 PM, Licensed Practical Nurse (LPN) #1 stated, .[Resident #96] started throwing up . LPN #1 confirmed that she did not notify the physician of the resident's vomiting (change in condition). During an interview on 12/8/2021 at 4:52 PM, the Director of Nursing (DON) confirmed the physician should have been notified when Resident #96 began vomiting.

Based on policy review, medical record review, and interview, the facility failed to have a current Physician's Order for [CONDITION(S)] and failed to provide adequate services for 1 of 2 sampled residents (Resident #146) reviewed for [CONDITION(S)]. The findings include: Review of the facility's policy titled, [CONDITION(S)], revised 11/12/2021, revealed .This facility assures that each resident receives care and services for the provision of hemodialysis .consistent with professional standards of practice including .Ongoing assessment of the resident's condition and monitoring for complications before and after [CONDITION(S)] treatments .Ongoing communication and collaboration with the [CONDITION(S)] facility regarding [CONDITION(S)] care and services .Initiate the Pre/Post [CONDITION(S)] Communication Form to be sent to the [CONDITION(S)] clinic with the resident .Post-[CONDITION(S)] .Obtain vital signs upon return from [CONDITION(S)] and complete the Pre/Post [CONDITION(S)] Communication Form . Review of the medical record, revealed Resident #146 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's Orders for November and December 2021, revealed there was no order for [CONDITION(S)], there was no order to assess the thrill and bruit upon return from [CONDITION(S)] until 12/7/2021, 9 days after admission, and there was no order for post [CONDITION(S)] vital signs and dry weights until 12/8/2021, 10 days after admission. Review of the Pre/Post [CONDITION(S)] Communication Form dated 11/29/2021, revealed Resident #146 was dialyzed and returned to the facility at 2:06 PM. Review of the medical record, revealed there were no Pre/Post [CONDITION(S)] Communication Form for 12/1/2021 and 12/3/2021. Review of the Pre/Post [CONDITION(S)] Communication Form dated 12/6/2021, revealed no pre/post [CONDITION(S)] vital signs, no pre/post [CONDITION(S)] signature of the facility staff who transferred the resident to [CONDITION(S)] and received him back into the facility, no post documentation that the thrill and bruit were assessed by facility staff, and no documentation by the [CONDITION(S)] facility. During an interview on 12/8/2021 at 10:52 AM, the Director of Nursing (DON) confirmed that staff should complete the Pre/Post [CONDITION(S)] Communication Form. During an interview on 12/8/2021 at 12:06 PM, Registered Nurse (RN) #1 confirmed that Resident #146's correct [CONDITION(S)] orders were not entered on admission. RN #1 stated, I normally review the charts .had not done that [Entered the orders] yet . During an interview on 12/8/2021 at 2:33 PM, the DON confirmed that [CONDITION(S)] orders should be obtained on admission to the facility. The DON confirmed that staff should assess the shunt site for thrill and bruit before and after [CONDITION(S)]. The DON confirmed the Pre/Post [CONDITION(S)] Communication Forms were not completed on 12/1/2021, 12/3/2021, and 12/6/2021.

Based on policy review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 23 (Certified Nursing Assistant (CNA) #1) staff members failed to perform hand hygiene and touched food with their bare hands and 1 of 2 (Dietary Aide #1) kitchen staff did not perform hand hygiene with glove use while preparing meal trays. The findings include: 1. The facility's undated Proper Use of Gloves to Handle Food policy documented, .Wash hands each time new gloves are used .Never touch ready-to-eat food with contaminated gloves .Each time you pick up food without a utensil, be sure that the glove on your hand has not been contaminated . 2. Observations in the Magnolia Hall on 4/23/19 beginning at 12:06 PM, revealed CNA #1 placed a meal tray on Resident #252's overbed table and pulled the cover from Resident #252's feet. CNA #1 did not perform hand hygiene. CNA #1 then set up the meal tray, removed the cornbread from a wax paper bag, and handled the cornbread with her bare hands. Observations in the Magnolia Hall on 4/23/19 beginning at 12:38 PM, revealed CNA #1 placed a meal tray on Resident #54's overbed table. CNA #1 then set up the meal tray, removed the cornbread from a wax paper bag, and handled the cornbread with her bare hands. Interview with the Assistant Director of Nursing (ADON) on 4/24/19 at 6:21 PM, in the hall outside the Private Dining Room, the ADON was asked if it staff should remove cornbread from a wax paper bag with their bare hands. The ADON stated, No, not with their hands, it's usually easy to get it out of the bag without touching it. Interview with the Certified Dietary Manager (CDM) on 4/24/19 at 7:13 PM, in the Private Dining Room, the CDM was asked if staff should touch a resident's food with their bare hands. The CDM stated, No, never touch ready to eat food with their bare hands. 3. Observations in the Main Dining Room on 4/23/19 beginning at 12:41 PM, during steam table set-up, revealed Dietary Aide #1 entered the Main Dining Room wearing gloves. Dietary Aide #1 placed pans of food that were covered with aluminum foil on the steam table. She then removed the aluminum foil from the pans, placed serving utensils on the steam table, and removed her gloves. Dietary Aide #1 entered the kitchen and placed the soiled gloves and the foil in the trash can. She then returned to the steam table and put on clean gloves without washing her hands. She began to serve the residents' plates. An empty plastic bowl fell into a pan of yams. Dietary Aide #1 removed the bowl from the yams, served pinto beans in the dirty bowl, and placed the bowl on a serving plate. Dietary Aide #1 continued to serve meal trays, touching utensils and handling cornbread with the soiled gloves. Interview with Dietary Aide #1 on 4/23/19 at 12:06 PM, in the Main Dining Room, Dietary Aide #1 was asked if it was appropriate to remove and don gloves without washing hands. Dietary Aide #1 stated, No, ma'am. Dietary Aide #1 was asked if it was appropriate to handle the cornbread muffins with soiled gloves. Dietary Aide #1 stated, No, ma'am. Interview with the Certified Dietary Manager (CDM) on 4/24/19 at 7:10 PM, in the Private Dining Room, the CDM was asked what she expected dietary staff to do between glove changes. The CDM stated, .wash their hands . The CDM was asked if it was appropriate for staff to serve corn muffins wearing soiled gloves. The CDM stated, .no .use tongs . The CDM was asked what staff should do if a bowl falls into a pan of food. The CDM stated, The bowl should be put to the side and not used .

Based on policy review, medical record review, and interview, the facility failed to follow physician's orders for intravenous (IV) care as ordered for 1 of 3 (Resident #251) sampled residents reviewed with IV orders. The findings include: The facility's Physician's Orders policy revised 1/2018 documented, A physician .must provide orders for the resident's immediate care . Medical record review revealed Resident #251 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Physician's Order dated 1/20/19 documented, .Change IV tubing every 24 hours . A Physician's Order dated 1/20/19 documented, .Change PICC (Percutaneous Indwelling Central Catheter) dressing .weekly on Tuesdays . Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 4/24/19 at 5:06 PM, in the DON Office, the DON was asked if the IV tubing and dressing should be changed as ordered. The DON stated, Yes .

Based on policy review, medical record review, and interview, the facility failed to implement written care plan interventions related to falls for 1 of 5 (Resident #57) sampled residents. The facility failed to implement Resident #57's fall interventions. The failure to implement and follow the care plan interventions resulted in actual Harm when Resident #57 fell and sustained a nasal fracture, head injury with a possible subdural hematoma (a collection of blood between the brain cover and the brain), a laceration to the forehead that required suture repair and skin tears to the right hand and the right cheek. The findings included: 1. Review of the facility's undated Fall Management policy documented, .to promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators .comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care .the comprehensive person-centered care plan, and the patient's choice .remains as free of accident hazards as is possible and each patient receives adequate supervision and assistance devices to prevent accidents .Avoidable Accident: means that an accident occurred because the facility failed to: 1. Identify environmental hazards and individual patient risk of an accident, including the need for supervision .2. Evaluate/analyze the hazards and risks .3. Implement interventions, including supervision, consistent with a patient's needs, goals, plan of care and current standards of practice in order to reduce the risk of an accident; and/or 4. Monitor the effectiveness of the interventions and modify the interventions as necessary . 2. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Fall Risk Evaluation forms revealed Resident #57 was a high risk for falls with a score on 3/8/18 of 26, 4/3/18 of 22, 4/8/18 of 24 and 4/17/18 of 24. High risk for falls was a score of 10 or higher. The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #57 had a Brief Interview of Mental Status (BIMS) score of 01 which indicated Resident #57 was severely cognitively impaired, required total staff assistance with transfers and extensive assistance with walking. Resident #57 had 1 fall with no injury and 2 falls with injury. Medical record review of the care plan dated 12/11/17 with revisions documented, .Problems .Potential for falls .4/3/18 Encourage resident to push chair up next to the table when sitting in dining room chairs .4/9/18 Remove resident from table after meals as allowed .4/17/18 Re-educate staff to escort pt. (patient) to recliner when sleepy . 3. Review of a facility Incident Follow-up & (and) Recommendation form dated 4/3/18 documented the following: a. 4:30 PM Summary .found resident laying on the floor on her right side in the dining room between the dining chair and the table . b. Recommendations .when resident sits in dining room chair scoot it up to the table due to falling asleep in chairs and refusing to go to bed and not staying in one position for much longer than 15-20 mins (minutes) at a time . c. Follow-Up: Staff intervention of pushing resident up close to the table has proven to be ineffective. Resident pushes self away & crosses legs .See new intervention 4/9/18 . 4. Review of a facility Incident Follow-up & (and) Recommendation form dated 4/9/18 documented the following: a. 8:35 AM Summary .Resident fell asleep @ (at) dining table after breakfast and fell onto floor on knees and staff gently lowered her on to ground . b. Recommendations .To remove resident from table after meals as allowed . c. Follow Up: On 4/17/18 staff failed to follow new intervention & subsequent fall happened see follow up for 4/17/18 . 5. Review of a facility Incident Follow-up & (and) Recommendation form dated 4/17/18 documented the following: a. 4:50 AM Pt (patient) found on floor, sitting on buttocks in front of dining table. Skin tears to top of R right) hand and (R) cheek, small laceration to forehead. Blood noted to L (left) side of head and skin tears & swollen nose . b. Recommendations .Re-educate staff to escort pt to recliner in dayroom rather than less stable chair when sleepy . Review of the hospital emergency room Report dated 4/17/18 documented, .Triage Note .PT fell IN DINING ROOM (At Nursing Home) AND HIT A CHAIR .SKIN TEARS NOTED TO RIGHT HAND. EMS (Emergency Medical Services) REPORTS HEAD WOUND AS A PUNCTURE TYPE WOUND . Skin: Laceration (2.8 cm (centimeters) laceration right forehead-gaping and actively bleeding. 2 cm superficial laceration right maxillary face) .Other bruising and soft tissue swelling nasal bridge .Number of Stitches 4 Discharge (back to nursing home) .Diagnosis 2.8 centimeter laceration repair right forehead; superficial laceration right maxillary face; nasal fracture; fall with head injury .possible left subacute subdural hematoma . The facility staff failed to follow Resident #57's care plan interventions and on 4/17/18 Resident #57 fell and sustained a nasal fracture, head injury with a possible subdural hematoma (a collection of blood between the brain cover and the brain), a laceration to the forehead that required suture repair and skin tears to the right hand and the right cheek. Interview with the Director of Nursing (DON) on 6/13/18 at 10:34 AM, in the DON office, the DON was asked about Resident #57's falls and interventions. The DON stated, .4/3/18 the intervention was push (Resident #57) up to the table and this was ineffective .4/9/18 it was ineffective to push her up to the table because she pushes herself back so the intervention was to remove her from the dining room to the recliner in the day room .4/17/18 staff were not informed of the change in interventions .we started a new intervention binder so the staff reads and knows . The DON was then asked how staff knew about interventions prior to the incident on 4/17/18. The DON stated, .verbally passed down . Interview with the Director of Nursing (DON) on 6/14/18 at 1:11 PM, in the DON's office, the DON was asked what fall interventions were in place for Resident #57. The DON stated, .on the 4/17/18 fall .the staff did not implement the interventions .didn't look at the new interventions for fall . The DON confirmed that staff should be aware and implement new interventions for falls. The facility staff failed to implement a new fall intervention for Resident #57. Resident #57 fell on [DATE] and sustained a nasal fracture, head injury with a possible subdural hematoma (a collection of blood between the brain cover and the brain), a laceration to the forehead that required suture repair and skin tears to the right hand and the right cheek.

Based on policy review, medical record review, observation, and interview, the facility failed to prevent accidents related to falls for 1 of 5 (Resident #57) sampled residents when new fall interventions were not implemented which resulted in actual harm to Resident #57 when Resident #57 fell and sustained a nasal fracture, head injury with a possible subdural hematoma (a collection of blood between the brain cover and the brain), a laceration to the forehead that required suture repair and skin tears to the right hand and the right cheek. The findings included: 1. Review of the facility's undated Fall Management policy documented, .to promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators .comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care .the comprehensive person-centered care plan, and the patient's choice .remains as free of accident hazards as is possible and each patient receives adequate supervision and assistance devices to prevent accidents .Avoidable Accident: means that an accident occurred because the facility failed to .Evaluate/analyze the hazards and risks .implement interventions, including supervision .Monitor the effectiveness of the interventions and modify the interventions as necessary . 2. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 01, which indicated Resident #57 had severe cognitive impairment, required total staff assistance with transfers, extensive assistance walking and had 1 fall with no injury and 2 falls with injury. The care plan dated 12/11/17 with revisions documented, .Problems .Potential for falls .4/3/18 Encourage resident to push chair up next to the table when sitting in dining room chairs .4/9/18 Remove resident from table after meals as allowed .4/17/18 Re-educate staff to escort pt. (patient) to recliner when sleepy . Review of the Fall Risk Evaluation forms (an assessment completed on admission and quarterly by nursing staff to assess the resident's potential to fall) revealed Resident #57 was a high risk for falls (more likely to fall) with a score on 3/8/18 of 26, 4/3/18 of 22, 4/8/18 of 24 and on 4/17/18 of 24. High risk for falls was a score of 10 or higher. 3. Review of a facility Incident Follow-up & (and) Recommendation form dated 4/3/18 documented the following: a. 4:30 PM Summary .found resident laying on the floor on her right side in the dining room between the dining chair and the table . b. Recommendations .when resident sits in dining room chair scoot it up to the table due to falling asleep in chairs and refusing to go to bed and not staying in one position for much longer than 15-20 mins (minutes) at a time . c. Follow-Up: Staff intervention of pushing resident up close to the table has proven to be ineffective. Resident pushes self away & crosses legs .See new intervention 4/9/18 . 4. Review of a facility Incident Follow-up & (and) Recommendation form dated 4/9/18 documented the following: a. 8:35 AM Summary .Resident fell asleep @ (at) dining table after breakfast and fell on to floor on knees and staff gently lowered her on to ground . b. Recommendations .To remove resident from table after meals as allowed . c. Follow Up: On 4/17/18 staff failed to follow new intervention & subsequent fall happened see follow up for 4/17/18 . 5. Review of a facility Incident Follow-up & (and) Recommendation form dated 4/17/18 documented the following: a. 4:50 AM Pt (patient) found on floor, sitting on buttocks in front of dining table. Skin tears to top of R (right) hand and (R) cheek, small laceration to forehead. Blood noted to L (left) side of head and skin tears & swollen nose . b. Recommendations .Re-educate staff to escort pt to recliner in dayroom rather than less stable chair when sleepy . Review of an emergency room Report dated 4/17/18 documented, .Triage Note .PT (patient) fell IN DINING ROOM AND HIT A CHAIR .SKIN TEARS NOTED TO RIGHT HAND. EMS (Emergency Medical Services) REPORTS HEAD WOUND AS A PUNCTURE TYPE WOUND .Skin: Laceration (2.8 cm (centimeters) laceration right forehead-gaping and actively bleeding. 2 cm superficial laceration right maxillary face) .Other bruising and soft tissue swelling nasal bridge .Number of Stitches 4 Discharge .Diagnosis 2.8 centimeter laceration repair right forehead; superficial laceration right maxillary face; nasal fracture; fall with head injury .possible left subacute subdural hematoma . Observations on 6/13/18 at 7:34 AM revealed Resident #57 sitting in the day room in a recliner with nonskid footwear noted. Resident #57's wc had anti-tippers in place. Observations on 6/14/18 at 7:47 AM revealed Resident #57 in the dining room, sitting in a wc at the dining table with her eyes closed. Facility staff was assisting the resident to a couch in the dayroom. Interview with Director of Nursing (DON) on 6/14/18 at 1:11 PM, in the DON's office, the DON was asked what interventions were in place for Resident #57. The DON stated, .on the 4/17/18 fall .the staff did not implement the interventions because they did not know what the new intervention was . The DON was asked if it was acceptable for staff members to not implement new interventions for falls. The DON stated, .of course not . Interview with the Executive Director (ED) on 6/14/18 at 2:41 PM, in the ED office, the ED was asked to provide some examples of what the facility had implemented to decrease the number of falls and how oversight is provided for the clinical operations. The ED stated, .the DON will investigate the falls immediately, we are going to beef that back up and make sure it is being done . The facility failed to implement effective fall interventions for Resident #57. On 4/17/18 Resident #57 fell , sustained a head injury which required laceration repair, and [MEDICAL CONDITION] nasal bone and septum which resulted in actual Harm.

Based on policy review, medical record review, observation and interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to have an effective, ongoing quality program that identified, developed, implemented and monitored appropriate plans of action for falls. The QAA committee's failure to ensure an effective fall prevention system (an effective process to reduce patient falls) resulted in actual Harm for Resident #57. The QAA failed to ensure new interventions were implemented which resulted in actual harm to Resident #57 when she fell and sustained a nasal fracture, head injury with a possible subdural hematoma (a collection of blood between the brain cover and the brain), a laceration to the forehead that required suture repair and skin tears to the right hand and the right cheek. The findings included: 1. The QAA Committee failed to ensure the facility's fall prevention program was effective and the fall management policy was implemented. The QAA committee failed to effectively track, trend and monitor the effectiveness of the fall prevention program. Refer to F656 and F689. The deficient practice of F656, F689 and F867 is a repeat deficient practice for failure to ensure the services were provided in accordance with each resident's written plan of care. The facility was cited F656, F689 and F867 on the recertification survey on 4/29/15 and on 5/24/17. 2. Interview with the DON on 6/13/18 at 2:00 PM, in the Conference Room, the DON was asked if it was appropriate for a Resident with a BIMS of 01 to be able to tell the staff what had caused the fall. The DON stated, .we had a meeting last night to go over falls and we determined that some of the interventions that had been put in place for the falls were not appropriate . Interview with Director of Nursing (DON) on 6/14/18 at 1:11 PM, in the DON's office, the DON was asked what fall interventions were in place for Resident #57. The DON stated, .on the 4/17/18 fall .the staff did not implement the interventions .the staff didn't look at the new interventions for fall . The DON confirmed that the staff should be aware of new interventions for falls. Interview with the Executive Director (ED) on 6/14/18 at 2:41 PM, in the ED office, the ED was asked to provide some examples of what the facility had implemented to decrease the number of falls. The ED stated, .We had PI (Performance Improvement) last night to help develop new interventions and things we could do to help decrease the number of falls .purchased some recliners .added a full time Activities Assistant . The ED was asked how oversight is provided for the clinical operations. The ED stated, .we are doing fall huddles team, the number of falls has trended down with the Activity person back there (on the memory care unit) and house wide the number of falls have gone down .the DON will investigate the falls immediately, we are going to beef that back up and make sure it is being done . The ED was asked if the Medical Director was involved in the QA process. The ED stated, .He goes over every report and he is involved in the monthly meeting. We go over each incident report with him and discuss in the monthly PI meeting due to the IJ (Immediate Jeopardy) and Harm before . The failure of the QAA to implement new fall interventions for a resident with severe cognitive abilities resulted in actual Harm to Resident #57 when she fell and sustained a nasal fracture, head injury with a possible subdural hematoma (a collection of blood between the brain cover and the brain), a laceration to the forehead that required suture repair and skin tears to the right hand and the right cheek.

Based on facility policy review, observation, interview, review of Water Temperature log forms, and review of an Intrafacility Request for Repairs or Alterations, the facility failed to ensure resident safety by maintaining the hot water temperatures in the resident care areas at or less than 115 degrees Fahrenheit (F), and the facility resident care staff and the Maintenance Director failed to report hot water temperatures above 115 degrees F to administration. The facility's system failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death) for 24 residents (#3, #25, #40, #52, #85, #87, #94, #95, #99, #104, #107, #110, #112, #114, #123, #128, #134, #147, #150, #186, #217, #218, #219, #220) of 40 residents reviewed of the 105 residents in the facility and 3 of 3 resident common shower rooms and hand sinks. The Administrator and Regional Vice President were notified of the Immediate Jeopardy on 5/24/17 at 4:40 PM in the Administrator's office. The facility's failure at F-224 is Substandard Quality of Care. The findings included: Review of facility policy, Water Temperature Inspection, last revised on 3/15/2004 revealed .Standard .To ensure the water supplied to the facility is the correct temperature to maintain correct infection control techniques .Faucet Temperatures .Satisfactory temperature range is 100 degrees F (Fahrenheit) - 120 degrees F .Any temperatures found not to be within range should be reported immediately to the maintenance department, charge nurse of the unit, department head, and the Safety officer . Observations from 5/22/17 beginning at 10:45 AM through 5/23/17 at 4:50 PM revealed 27 resident room hand sinks had water temperatures hot enough for the surveyor to remove their hand due to excessive heat. Interview with the Maintenance Director on 5/22/17 at 5:28 PM in the Private Dining Room revealed he and his assistant monitored water temperatures weekly in 15 rooms randomly. Further interview revealed they always included the kitchen, laundry and 3 resident shower rooms in the weekly monitoring. When asked the temperature range the maintenance department was trying to maintain in the resident care areas the Maintenance Director stated .want to maintain the resident care area temperatures between 110-120 degrees F including the resident shower rooms . When asked what was done if the temperature was over 120 degrees F the Maintenance Director revealed they would adjust the mixing valve. Observation on 5/22/17 beginning at 5:35 PM to 6:27 PM revealed the resident room hand sink temperatures and the resident common shower rooms and hand sink temperatures were obtained by the Maintenance Director using the facility thermometer with the following results in degrees F: room [ROOM NUMBER] was 125; Rooms 103, 105, 110, 129 were 126.1-126.3; Rooms 125, 128, 143 were 127-127.8; room [ROOM NUMBER] was 128.3; Rooms 201, 225 were 125.8; Rooms 212, 217, 229 were 126-126.8; Rooms 210, 224, 231 were 127.2-127.9; room [ROOM NUMBER] was 128.3; room [ROOM NUMBER] was 125.4; Rooms 313, 324 were 127-127.2; room [ROOM NUMBER] was 129; Shower in room [ROOM NUMBER] was 125.1; Resident common shower rooms: 100 hall was 125.4, 300 hall was 121.5; Hand sinks in common shower rooms: 100 hall and 200 hall were 127, 300 hall was 125.8. Interview with the Maintenance Director on 5/22/17 beginning at 5:35 PM at the sites the temperatures were obtained confirmed the facility failed to maintain the water temperatures in the resident room hand sinks and/or common showers and/or hand sink below 115 degrees F. Further interview revealed the Maintenance Director planned to adjust the mixing valve. Interview with the Administrator on 5/22/17 at 6:16 PM in her office when asked if any resident had received an injury from hot water revealed no incident had occurred in the past 4 years [MEDICAL CONDITION] showers or with resident hand sinks. Observation on 5/23/17 beginning at 10:12 AM to 11:02 AM revealed the resident room hand sink temperatures and the resident common shower room temperatures were obtained by the Maintenance Director using the facility thermometer with the following results in degrees F as: Rooms 110, 143 were 117.7-117.9; room [ROOM NUMBER] was 117.9; Rooms 201, 210, 212, 217, 218, 224, 225, 229 were 118-118.2; room [ROOM NUMBER] was 118; Shower in room [ROOM NUMBER] was 118; Hand sinks in common shower rooms: 100 hall and 200 hall were 117.7. Interview with the Maintenance Director on 5/23/17 beginning at 10:12 AM at the sites the temperatures were obtained confirmed the facility failed to maintain the water temperatures in the resident room hand sinks and/or common showers and/or hand sink below 115 degrees F. Further interview revealed the Maintenance Director planned to adjust the mixing valve. Review of the Water Temperature log form revealed .Ensure patient water temperatures are between 105 degrees and 115 degrees Fahrenheit .test temperature in shower area . Review of the facility Water Temperature log forms revealed the following temperatures in degrees F as listed below: Prior to 1/12/17 revealed no temperature above 115 degrees F. 1/12/17: room [ROOM NUMBER] was 116. 1/16/17-1/19/17: room [ROOM NUMBER] was 116, room [ROOM NUMBER] was 123, 100 hall shower was 122, 300 hall shower was 118. 1/31/17: room [ROOM NUMBER] was 120, room [ROOM NUMBER] was 124, room [ROOM NUMBER] was 121, 100 hall shower was 128. 2/7/17-2/8/17: room [ROOM NUMBER] was 116. 2/13/17: room [ROOM NUMBER] was 117, room [ROOM NUMBER] was 118, room [ROOM NUMBER] was 117, 100 hall shower was 116, 200 hall shower was 117. 2/22/17-2/23/17: room [ROOM NUMBER] was 116, room [ROOM NUMBER] was 119, room [ROOM NUMBER] was 121. 2/27/17-2/28/17: room [ROOM NUMBER] was 117, room [ROOM NUMBER] was 119, room [ROOM NUMBER] was 122, room [ROOM NUMBER] was 120, room [ROOM NUMBER] was 117, room [ROOM NUMBER] was 119, room [ROOM NUMBER] was 118, 100 and 200 hall showers were 118, 300 hall shower 120. 3/7/17-3/8/17: room [ROOM NUMBER] was 123, room [ROOM NUMBER] was 122, room [ROOM NUMBER] was 119, room [ROOM NUMBER] was 121, room [ROOM NUMBER] was 122, 300 hall shower was 123. 3/15/17: room [ROOM NUMBER] was 116, room [ROOM NUMBER] was 119, room [ROOM NUMBER] was 119, 314 was 118, 100 hall shower was 118, 300 hall shower was 120. 3/20/17-3/24/17: room [ROOM NUMBER] was 121, 200 hall shower was 122. 3/29/17-3/30/17: room [ROOM NUMBER] was 120, room [ROOM NUMBER] was 118, room [ROOM NUMBER] was 117, room [ROOM NUMBER] was 116, 100 hall shower was 118, 200 hall shower was 120. 4/3/17-4/4/117: room [ROOM NUMBER] was 120, room [ROOM NUMBER] was 118, room [ROOM NUMBER] was 126, room [ROOM NUMBER] was 128, 100 hall shower was 117, 300 hall shower was 119. 4/10/17-4/13/17: room [ROOM NUMBER] was 119, room [ROOM NUMBER] was 118, room [ROOM NUMBER] was 118, room [ROOM NUMBER] was 117, room [ROOM NUMBER] was 118, room [ROOM NUMBER] was 121, room [ROOM NUMBER] was 121, room [ROOM NUMBER] was 121, 200 hall shower 117 and 118, 300 hall shower was 122. 4/19/17-4/20/17: room [ROOM NUMBER] was 120, room [ROOM NUMBER] was 121, room [ROOM NUMBER] was 119, room [ROOM NUMBER] was 120, room [ROOM NUMBER] was 122, room [ROOM NUMBER] was 123, room [ROOM NUMBER] was 121, room [ROOM NUMBER] was 122, 300 hall shower was 122. 4/25/17: room [ROOM NUMBER] was 116, room [ROOM NUMBER] was 116, 300 hall shower was 116. 5/4/17: room [ROOM NUMBER] was 118.2, room [ROOM NUMBER] was 120.7, room [ROOM NUMBER] was 122.4, room [ROOM NUMBER] was 122.5, 100 hall shower was 118.2. 5/11/17-5/12/17: room [ROOM NUMBER] was 119, room [ROOM NUMBER] was 120, room [ROOM NUMBER] was 121, room [ROOM NUMBER] was 118, room [ROOM NUMBER] was 116, 100, 200 and 300 hall showers were 118. 5/18/17-5/19/17: room [ROOM NUMBER] was 126, room [ROOM NUMBER] was 125, room [ROOM NUMBER] was 125, room [ROOM NUMBER] was 118, room [ROOM NUMBER] was 126, room [ROOM NUMBER] was 125, 100 hall shower was 124, 200 hall shower was 116, 300 hall shower was 126. Interview with the Maintenance Director and the Maintenance Assistant on 5/23/17 at 5:53 PM in the ice cream parlor revealed a Maintenance Director from another sister facility came to train the facility maintenance staff on the water temperature criteria and to maintain the water temperature between 105-115 degrees F. Further interview revealed there had been issues with water temperatures in the past and they had exchanged the mixing valve .somewhere around 2/2017 . in an attempt to get better consistency with the temperatures. Further interview revealed there had been times, the most recent was last Friday (5/19/17), when staff had reported hot water and the mixing valve was adjusted by the maintenance staff. Review of the INTRAFACILITY REQUEST FOR REPAIRS OR ALTERATIONS dated 3/21/17 revealed in the boiler room .change mixing valve .was completed by the Maintenance Director on 3/21/17 . Interview with the Maintenance Director on 5/24/17 at 9:05 AM in the Private Dining Room revealed the facility kept mixing valves in-house and he changed the mixing valve on 3/21/17 after getting temperatures that were high and low all over the facility. Interview with the Maintenance Director on 5/24/17 at 10:00 AM in the Administrator's office, revealed he thought the appropriate hot temperature for resident care areas was 118 degrees F. Further interview revealed when asked what he did when the water temperature exceeded 118 degrees he stated he .fixed it by adjusting the mixing valve and keep monitoring the temperatures . When asked if he reported the high temperatures to anyone in the facility he stated .I did not report it. I thought I could fix it, take care of it. I didn't think it was a big issue. I did not report it to the Administrator or Director of Nursing . When asked if the excessive temperatures were addressed in Quality Assurance/Performance Improvement (QA/PI Meeting) he stated .No .because I thought I had fixed it . Interview with Certified Nurse Aide (CNA) #1 on 5/23/17 at 4:45 PM on the 300 hall stated she worked 6:00 AM to 2:00 PM and at times to 6:00 PM. Further interview revealed the CNA had noted the water was hot at times and did not report it. Continued interview with CNA #1 when asked why she did not report it, CNA #1 revealed she adjusted the temperature by adding more cold water. Interview with CNA #4 on 5/23/17 at 4:45 PM on the 200 hall stated she worked the 2:00 PM to 10:00 PM shift. Further interview revealed she had .noted the water being too hot for the past 8-9 months .Thought it was that hot to kill germs .had discussed it with other CNA numerous times but did not report the hot water .thought everyone knew it . Interview with CNA #6 on 5/23/17 at 5:45 PM on the 100 hall revealed she worked 2:00 PM to 10:00 PM. Further interview revealed the CNA had noted the water was hot in resident areas. Continued interview revealed .I thought it was just me . and did not report the hot water. Interview with CNAs #13 and #14 on 5/24/17 beginning at 11:20 AM at the 300 hall nursing station confirmed they were aware the water was hot in the resident care areas and did not report it. Continued interview when asked why they did not report the hot water revealed they added cold water until it was cooler. Interview with Licensed Practical Nurse (LPN) #1 on 5/24/17 at 11:30 AM at the 300 hall nursing station confirmed she was aware the water was hot in resident care areas and failed to report it. Continued interview revealed LPN #1 had ran cold water until the water was a comfortable temperature. Interview with LPN #5 on 5/24/17 at 11:41 AM on the 100 hall revealed she noticed the water .way too hot a few times . Further interview revealed the hot water issue occurred over a weekend, maintenance was not in the facility so the LPN did not report it. Interview with CNA #15 on 5/24/17 at 11:49 AM on the 100 hall stated she was aware the water was hot starting Saturday 5/20/17, .we all noticed it . Further interview revealed the CNA did not report it (hot water) and did not know who to report it to. Interview with the Maintenance Director on 5/24/17 at 3:37 PM in the ice cream parlor revealed the maintenance director for the sister facility trained him within 2 weeks of being hired in 12/2016. The Maintenance Director stated he was not aware of any corporate level staff coming in to the facility to review maintenance work or data. Further interview revealed the Administrator had in-serviced him on 5/22/17 on the water temperature range of 105-115 degrees F, to monitor water temperatures every 2 hours, and to report any issues to the Administrator or the Director of Nursing. Interview with the Administrator on 5/24/17 at 3:55 PM in the Administrator's office confirmed the Administrator was not aware the hot water temperatures were above 115 degrees F in resident care areas on all units prior to 5/22/17. Further interview revealed when asked why she thought the direct care staff and the maintenance staff failed to report hot water or water temperatures above 115 degees F, the Administrator stated I don't know. Interview with the Regional Vice President on 5/24/17 at 4:22 PM in the Administrator's office revealed the corporate office was not aware of excessive water temperatures prior to 5/22/17 when notified by the Administrator. Further interview revealed the random Regional Team Visit would include checking environmental issues and taking action by a Performance Improvement Plan with 30 day follow-up to ensure correction. Further interview revealed the Regional Team Visit was prior to January 2017 and did not identify the water temperature as an issue at that time. The Immediate Jeopardy was effective from 1/12/17 through 5/24/17 at 6:30 PM. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated through review of temperature log forms monitored every 2 hours from 5/23/17 through 5/24/17; direct care staff education of monitoring water temperatures, reporting inappropriate water temperature to the Administrator/Charge Nurse/Maintenance/Supervisor, if temperature was above 115 degrees F to shut it off at the source; direct care staff interview regarding education; maintenance staff interview to assess education; review skin audits to 100% of the residents to ensure integrity; independent resident education on not to use the shower until the water temperature was appropriate; plumber contacted to review mixing valve operation. The surveyors verified the allegation of compliance by: 1. Reviewed the every 2 hour temperature logs the facility initiated after becoming aware of the elevated water temperatures on 5/22/17 which included all resident rooms and the 3 common shower rooms. No temperatures were documented exceeding 115 degrees F from 5/23/17 through 5/24/17. Reviewed the facility plan to monitor water temperatures every 2 hours for 2 days ending on 5/25/17, then every 4 hours for 2 days ending on 5/27/17, then 2 times per shift for 2 days ending on 5/29/17, and then 1 time per shift ending on 5/31/17. 2. Reviewed the in-service training documentation dated 5/23/17 the facility completed after becoming aware of the elevated water temperatures on 5/22/17 for the Maintenance Director and maintenance staff regarding the appropriate water temperature range of 105-115 degrees F, the process of how to properly obtain water temperatures, to report to administration if temperatures exceed 115 degrees F, adjusting the mixing valve, and to shut off the water at the source. 3. Reviewed the in-service training records dated 5/23/17 the facility initiated after becoming aware of the elevated water temperatures on 5/22/17 for the licensed, and non-licensed direct care staff to validate the direct care staff were in-serviced on the appropriate resident care area water temperature range of 105-115 degrees F; direct care staff were to monitor temperatures; non-licensed staff was to report temperature above 115 degrees F to licensed staff, then the licensed staff were to report the excessive temperature to the administration and the maintenance staff, and if the temperature was above 115 degrees F licensed staff were to shut the water off at the source. Reviewed the facility plan to contact all employees directly as they came on duty or by telephone by end of day 5/24/17 to educate the staff on the above. 4. Interviewed the Maintenance Director and maintenance staff on 5/23/17 and 5/24/17 to determine the level of comprehension through the in-service training he received from administration on 5/23/17 regarding the appropriate water temperature range of 105-115 degrees F, the process of how to properly obtain water temperatures, to report to administration if temperatures exceed 115 degrees F, adjusting the mixing valve, and to shut off water at the source. 5. Interviewed on 5/24/17 the direct care staff on all 3 units on both shifts, including 6 Licensed Practical Nurses and 7 Certified Nurse Aides, and the Administrator to determine the level of comprehension through the in-service training regarding the changes in the temperature monitoring noted in number 3 above, the reporting of the temperature above 115 degrees F and to whom to report, and the action to take if temperatures were above 115 degrees F. 6. Reviewed the documentation of the residents skin audits the facility initiated and completed on 5/22/17 after becoming aware of the elevated water temperatures to ensure the residents skin was intact and not affected by elevated water temperatures. 7. Reviewed the 2 independent residents education documentation the facility had completed after becoming aware of the elevated water temperatures on 5/22/17 to not use the common showers until the temperatures were in-range. 8. Reviewed the plumber's documentation with recommendations the facility had obtained after becoming aware of the elevated water temperatures on 5/22/17. The plumber recommended the mixing valve adjustment; to return to the facility the morning of 5/23/17 to change the thermometer; and on 5/23/17 he obtained water temperatures in resident rooms and the common showers. Documentation review revealed the temperatures did not exceed 115 degrees F. Noncompliance continues at a scope and severity of F for monitoring the effectiveness of corrective actions and evaluation of monitoring by the QA/PI Committee. The facility is required to submit a plan of correction.

Based on facility policy review, observation, interview, review of the Water Temperature Log form, and Intrafacility Request for Repairs or Alterations form, the facility failed to maintain hot water temperatures in the resident care areas at or less than 115 degrees Fahrenheit (F), and the facility resident care staff and the Maintenance Director failed to report the excessively hot water to administration; the facility failed to provide supervision to prevent a fall resulting in a laceration requiring Dermabond application by the physician to the head (HARM) for 1 resident (#7) of 28 residents reviewed; and the facility failed to store chemicals in a safe manner in 1 resident room of 27 rooms observed in stage 1. The facility's system failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death) for 24 residents (#3, #25, #40, #52, #85, #87, #94, #95, #99, #104, #107, #110, #112, #114, #123, #128, #134, #147, #150, #186, #217, #218, #219, #220) of 40 residents reviewed of the 105 residents in the facility and 3 of 3 resident common shower rooms and hand sinks. The Administrator and Regional Vice President were notified of the Immediate Jeopardy on 5/24/17 at 4:40 PM in the Administrator's office. The facility's failure at F-323 is Substandard Quality of Care. The findings included: Review of facility policy, Water Temperature Inspection, last revised on 3/15/2004 revealed .Standard .To ensure the water supplied to the facility is the correct temperature to maintain correct infection control techniques .Faucet Temperatures .Satisfactory temperature range is 100 degrees F (Fahrenheit) - 120 degrees F .Any temperatures found not to be within range should be reported immediately to the maintenance department, charge nurse of the unit, department head, and the Safety officer . Observations from 5/22/17 beginning at 10:45 AM through 5/23/17 at 4:50 PM revealed 27 resident room hand sinks had water temperatures hot enough for the surveyor to remove their hand due to excessive heat. Interview with the Maintenance Director on 5/22/17 at 5:28 PM in the Private Dining Room revealed he and his assistant monitored water temperatures weekly in 15 rooms randomly. Further interview revealed they always included the kitchen, laundry and 3 resident shower rooms in the weekly monitoring. When asked the temperature range the maintenance department was trying to maintain in the resident care areas the Maintenance Director stated .want to maintain the resident care area temperatures between 110-120 degrees F including the resident shower rooms . When asked what was done if the temperature was over 120 degrees F the Maintenance Director revealed they would adjust the mixing valve. Observation on 5/22/17 beginning at 5:35 PM to 6:27 PM revealed the resident room hand sink temperatures and the resident common shower rooms and hand sink temperatures were obtained by the Maintenance Director using the facility thermometer with the following results in degrees F: Room 132 was 125; Rooms 103, 105, 110, 129 were 126.1-126.3; Rooms 125, 128, 143 were 127-127.8; Room 130 was 128.3; Rooms 201, 225 were 125.8; Rooms 212, 217, 229 were 126-126.8; Rooms 210, 224, 231 were 127.2-127.9; Room 218 was 128.3; Room 319 was 125.4; Rooms 313, 324 were 127-127.2; Room 323 was 129; Shower in room 210 was 125.1; Resident common shower room showers: 100 hall was 125.4, 300 hall was 121.5; Hand sinks in common shower rooms: 100 hall and 200 hall were 127, 300 hall was 125.8. Interview with the Maintenance Director on 5/22/17 beginning at 5:35 PM at the sites the temperatures were obtained confirmed the facility failed to maintain the water temperatures in the resident room hand sinks and/or common showers and/or hand sink below 115 degrees F. Further interview revealed the Maintenance Director planned to adjust the mixing valve. Interview with the Administrator on 5/22/17 at 6:16 PM in her office when asked if any resident had received an injury from hot water revealed no incident had occurred in the past 4 years involving burns in showers or with resident hand sinks. Observation on 5/23/17 beginning at 10:12 AM to 11:02 AM revealed the resident room hand sink temperatures and the resident common shower room temperatures were obtained by the Maintenance Director using the facility thermometer with the following results in degrees F: Rooms 110, 143 were 117.7-117.9; Room 231 was 117.9; Rooms 201, 210, 212, 217, 218, 224, 225, 229 were 118-118.2; Room 315 was 118; Shower in room 210 was 118; Hand sinks in common shower rooms: 100 hall and 200 hall were 117.7. Interview with the Maintenance Director on 5/23/17 beginning at 10:12 AM at the sites the temperatures were obtained confirmed the facility failed to maintain the water temperatures in the resident room hand sinks and/or common shower rooms and/or hand sink below 115 degrees F. Further interview revealed the Maintenance Director planned to adjust the mixing valve. Review of the Water Temperature Log revealed .Ensure patient water temperatures are between 105 degrees and 115 degrees Fahrenheit .test temperature in shower area . Review of the facility Water Temperature logs revealed the following temperatures in degrees F listed below: Prior to 1/12/17 revealed no temperature above 115 degrees F. 1/12/17: room 111 was 116. 1/16/17-1/19/17: room 213 was 116, room 128 was 123, 100 hall shower was 122, 300 hall shower was 118. 1/31/17: room 218 was 120, room 202 was 124, room 143 was 121, 100 hall shower was 128. 2/7/17-2/8/17: room 111 was 116. 2/13/17: room 144 was 117, room 324 was 118, room 326 was 117, 100 hall shower was 116, 200 hall shower was 117. 2/22/17-2/23/17: room 227 was 116, room 144 was 119, room 127 was 121. 2/27/17-2/28/17: room 144 was 117, room 112 was 119, room 201 was 122, room 213 was 120, room 319 was 117, room 311 was 119, room 315 was 118, 100 and 200 hall showers were 118, 300 hall shower 120. 3/7/17-3/8/17: room 103 was 123, room 111 was 122, room 242 was 119, room 316 was 121, room 313 was 122, 300 hall shower was 123. 3/15/17: room 103 was 116, room 324 was 119, room 315 was 119, 314 was 118, 100 hall shower was 118, 300 hall shower was 120. 3/20/17-3/24/17: room 215 was 121, 200 hall shower was 122. 3/29/17-3/30/17: room 143 was 120, room 322 was 118, room 312 was 117, room 313 was 116, 100 hall shower was 118, 200 hall shower was 120. 4/3/17-4/4/117: room 124 was 120, room 202 was 118, room 324 was 126, room 322 was 128, 100 hall shower was 117, 300 hall shower was 119. 4/10/17-4/13/17: room 215 was 119, room 229 was 118, room 227 was 118, room 242 was 117, room 143 was 118, room 111 was 121, room 322 was 121, room 318 was 121, 200 hall shower 117 and 118, 300 hall shower was 122. 4/19/17-4/20/17: room 112 was 120, room 102 was 121, room 201 was 119, room 214 was 120, room 201 was 122, room 231 was 123, room 324 was 121, room 317 was 122, 300 hall shower was 122. 4/25/17: room 111 was 116, room 324 was 116, 300 hall shower was 116. 5/4/17: room 111 was 118.2, room 240 was 120.7, room 318 was 122.4, room 315 was 122.5, 100 hall shower was 118.2. 5/11/17-5/12/17: room 213 was 119, room 202 was 120, room 231 was 121, room 324 was 118, room 311 was 116, 100, 200 and 300 hall showers were 118. 5/18/17-5/19/17: room 125 was 126, room 144 was 125, room 112 was 125, room 242 was 118, room 311 was 126, room 315 was 125, 100 hall shower was 124, 200 hall shower was 116, 300 hall shower was 126. Interview with the Maintenance Director and the Maintenance Assistant on 5/23/17 at 5:53 PM in the ice cream parlor revealed a Maintenance Director from another sister facility came to train the facility maintenance staff on the water temperature criteria and to maintain the water temperature between 105-115 degrees F. Further interview revealed there had been issues with water temperatures in the past and they had exchanged the mixing valve .somewhere around 2/2017 . in an attempt to get better consistency with the temperatures. Further interview revealed there had been times, the most recent was last Friday (5/19/17), when staff had reported hot water and the mixing valve was adjusted by the maintenance staff. Review of the INTRAFACILITY REQUEST FOR REPAIRS OR ALTERATIONS dated 3/21/17 revealed in the boiler room .change mixing valve .was completed by the Maintenance Director on 3/21/17 . Interview with the Maintenance Director on 5/24/17 at 9:05 AM in the Private Dining Room revealed the facility kept mixing valves in-house and he changed the mixing valve on 3/21/17 after getting temperatures that were high and low all over the facility. Interview with the Maintenance Director on 5/24/17 at 10:00 AM in the Administrator's office, revealed he thought the appropriate hot temperature for resident care areas was 118 degrees F. Further interview revealed when asked what he did when the water temperature exceeded 118 degrees he stated he .fixed it by adjusting the mixing valve and keep monitoring the temperatures . When asked if he reported the high temperatures to anyone in the facility he stated .I did not report it. I thought I could fix it, take care of it. I didn't think it was a big issue. I did not report it to the Administrator or Director of Nursing . When asked if the excessive temperatures were addressed in Quality Assurance/Performance Improvement he stated .No .because I thought I had fixed it . Interview with Certified Nurse Aide (CNA) #1 on 5/23/17 at 4:45 PM on the 300 hall stated she worked 6:00 AM to 2:00 PM and at times to 6:00 PM. Further interview revealed the CNA had noted the water was hot at times and did not report it. Continued interview with CNA #1 when asked why she did not report it, CNA #1 revealed she adjusted the temperature by adding more cold water. Interview with CNA #4 on 5/23/17 at 4:45 PM on the 200 hall stated she worked the 2:00 PM to 10:00 PM shift. Further interview revealed she had .noted the water being too hot for the past 8-9 months .Thought it was that hot to kill germs .had discussed it with other CNA numerous times but did not report the hot water .thought everyone knew it . Interview with CNA #6 on 5/23/17 at 5:45 PM on the 100 hall revealed she worked 2:00 PM to 10:00 PM. Further interview revealed the CNA had noted the water was hot in resident areas. Further interview revealed .I thought it was just me . and did not report the hot water. Interview with CNAs #13 and #14 on 5/24/17 beginning at 11:20 AM at the 300 hall nursing station confirmed they were aware the water was hot in the resident care areas and did not report it. Continued interview when asked why they did not report the hot water revealed they added cold water until it was cooler. Interview with Licensed Practical Nurse (LPN) #1 on 5/24/17 at 11:30 AM at the 300 hall nursing station confirmed she was aware the water was hot in resident care areas and failed to report it. Continued interview revealed LPN #1 had ran cold water until the water was a comfortable temperature. Interview with LPN #5 on 5/24/17 at 11:41 AM on the 100 hall revealed she noticed the water .way too hot a few times . Further interview revealed the hot water issue occurred over a weekend, maintenance was not in the facility so the LPN did not report it. Interview with CNA #15 on 5/24/17 at 11:49 AM on the 100 hall stated she was aware the water was hot starting Saturday 5/20/17, .we all noticed it . Further interview revealed the CNA did not report it (hot water) and did not know who to report it to. Interview with the Maintenance Director on 5/24/17 at 3:37 PM in the ice cream parlor revealed the maintenance director for the sister facility trained him within 2 weeks of being hired in 12/2016. The Maintenance Director stated he was not aware of any corporate level staff coming in to the facility to review maintenance work or data. Further interview revealed the Administrator had in-serviced him on 5/22/17 on the water temperature range of 105-115 degrees F, to monitor water temperatures every 2 hours, and to report any issues to the Administrator or the Director of Nursing. Interview with the Administrator on 5/24/17 at 3:55 PM in the Administrator's office confirmed the Administrator was not aware the hot water temperatures were above 115 degrees F in resident care areas on all units prior to 5/22/17. Further interview revealed when asked why she thought the direct care staff and the maintenance staff failed to report hot water or water temperatures above 115 degees F, the Administrator stated I don't know. Interview with the Regional Vice President on 5/24/17 at 4:22 PM in the Administrator's office revealed the corporate office was not aware of excessive water temperatures prior to 5/22/17 when notified by the Administrator. Further interview revealed the random Regional Team Visit would include checking environmental issues and taking action by a Performance Improvement Plan with 30 day follow-up to ensure correction. Further interview revealed the Regional Team Visit was prior to January 2017 and did not identify the water temperature as an issue at that time. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 of 15 indicating severe cognitive impairment. Resident #7 required extensive assistance of one person with transfer, locomotion on and off the unit, toileting and personal hygiene. Further review revealed the resident required extensive 2 person assistance for bed mobility. Further review revealed .Fall History on Admission .fall any time in last month prior to admission .Yes .resident have fracture related to fall in the 6 months prior to admission .Yes . Further review revealed .Has resident had any falls since admission .Yes .Number of Falls Since Admission .1 with injury . Medical record review of the Fall Risk Evaluation dated 2/11/17 and 2/12/17 revealed Resident #7 score was 22. Further review revealed .scores a 10 or higher is at risk . for falls. Medical record review of the Interim Care Plan dated 2/12/17 revealed Resident #7 was .At risk for physical injury from falls related to Fall Risk Score, Recent Fall(s), History of fall(s) with injury . Further review of the care plan revealed .Interventions .Assist x (times) 1 for transfers .Assist x 1 for ambulation .Assist x 1 for toileting .Call light within reach .make hourly rounds during HS (bedtime) .Wear non-skid socks esp (especially) @ (at) HS . Medical record review of a Nurse Progress note dated 2/12/17 revealed, .This nurse heard resident yelling for help and upon entering room found her lying in floor at foot of bed on left side with left arm behind her and head against closet .Knot noted to left side of head .Sent to ER (emergency room ) for eval (evaluation) and treat . Medical record review of an ER note dated 2/12/17 revealed Resident #7 was diagnosed with [REDACTED]. Review of the facility fall investigation documentation dated 2/12/17 revealed the .Rehab (rehabilitation) Services Post-Fall Screening Tool Interventions .low bed with fall mats, falling star program .education with pt (patient) on using call light or calling out for help-that's the purpose of staff .possibly put pt on toileting schedule . Medical record review of the Comprehensive Care Plan dated 2/13/17 revealed .Potential for falls Related to H/O (history of) falls, General weakness, Difficulty walking, Poor safety awareness, Unsteady gait, Dementia, osteoporosis . Further review revealed the .Interventions .Fall risk assessment .Provide/observe use of adaptive devices-wheelchair .Remind resident and reinforce safety awareness-Appropriate footwear .Assist of 1-2 person and a gait belt .Non-skid socks .low bed with mats .Falling star program . Further review revealed and intervention dated 2/21/17 for .Clip alarm to w/c x 14 days . Further review revealed the 2/21/17 intervention was discontinued on 3/6/17. Medical record review of the Comprehensive Care Plan dated 3/9/17 revealed the following approaches related to potential for falls .Family Request: Do not leave resident unattended while sitting up in w/c (wheelchair) in room. Encourage to sit in high All Staff traffic areas when up in w/c . Medical record review of a Nurse Progress note dated 4/16/17 revealed, .CNA (Certified Nurse Aide) #20 summoned this nurse into the day room where resident was lying on her left hip .CNA stated to this nurse that resident was in the dayroom .when resident was ambulating without assistance et (and) tripped over her wheelchair leg rests, falling onto her left hip .Redness noted to left hip et left knee .Resident stated that her left knee was tender upon touch . Review of the fall investigation dated 4/16/17 revealed the .Rehab Services Post-Fall Screening Tool Interventions .Suggest remove leg rest when not transporting pt; staff education on frequent checks on pt in dayroom to decrease risk for falls . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 of 15 indicating severe cognitive impairment. Resident #7 required extensive one person assistance with transfer, locomotion on unit, toileting and personal hygiene. Medical record review of a Nurse Progress note dated 5/15/17 revealed .At approximately 7:15 AM the CNA taking care of the resident summoned this nurse to the residents room, upon entry, resident was sitting on buttock beside commode with blood visibly noted on the floor et on head. When asked what happened, resident stated 'I don't know, maybe I just needed to get up' .CNA stated to this nurse that after she had assisted resident with toileting et getting her off the commode, another CNA had asked for assistance, she assisted resident into chair et went to assist the CNA. (Named Physician) was in the building at this time et was notified of residents fall. The (Physician) evaluated her head .N/O (New Order) Cleanse back of head with soap et water, Apply ice to reduce swelling et then apply dermabond (tissue adhesive that forms a strong bond across apposed wound edges allowing normal healing to occur) to 3cm (centimeter) laceration to back of head . Telephone interview with CNA #14 on 5/23/17 at 4:35 PM confirmed she was responsible for providing care for Resident #7 on 5/15/17 while the resident was in the bathroom. Continued interview revealed another aide came and asked for assistance with another resident. Further interview with CNA #14 confirmed she had left Resident #7 in the wheelchair alone in the bathroom while assisting the other aide. Further interview confirmed when CNA #14 returned to Resident #7's bathroom the resident was on the floor and there was blood on the floor. Interview with Licensed Practical Nurse (LPN) #9/Unit Manager on 5/24/17 at 3:45 PM in the Activities Department confirmed Resident #7 would have been sent out for treatment if the Physician had not been in the facility when Resident #7 fell on [DATE]. Continued interview with LPN #9 stated leaving the resident in the wheelchair alone in the restroom while going to assist another resident was safe, and would have a concern if the CNA had left the resident on the commode. Interview with the Director of Nursing (DON) on 5/24/17 at 4:49 PM in the Private Dining Room revealed .resident would have potential for falls even if not in a high traffic area . The DON would not confirm the facility failed to provide adequate supervision to prevent a fall resulting in a laceration requiring Dermabond and HARM to Resident #7. The facility failed to provide adequate supervision to prevent a fall resulting in a laceration to the back of the head requiring a Dermabond application and HARM to Resident #7. Review of facility policy, Hazardous Materials Storage Program, last revised 3/15/2004 revealed .To provide for safe storage of hazardous materials and protect the safety and health of all .residents . Further review revealed .Specific Requirements and Incompatibilities: All flammable and combustible materials .must be stored in .approved storage cabinets or inside storage areas . Observation on 5/22/17 at 2:04 PM and 5:51 PM, and on 5/23/17 at 8:01 AM revealed a 32 ounce spray bottle of Clorox Bleach Germicidal Cleaner stored on Resident #150's bed side table. Further observation revealed the bottle was approximately 1/3 full with a .Warning: Keep Out of Reach of Children . Interview with Resident #150 on 5/23/17 at 7:48 AM revealed the resident did not know where the bottle came from and it was not hers. Further interview revealed the bottle had been on the bedside table .for a few days . Interview with Licensed Practical Nurse #4 on 5/23/17 at 8:01 AM in Resident #150's room confirmed the bottle of cleaner .should not be there . Interview with the Environmental Director on 5/23/17 beginning at 8:28 AM in the Private Dining Room confirmed the Clorox Bleach Germicidal Cleaner was a product the facility housekeepers used and .should have been stored under lock and key . Further interview confirmed the facility failed to store the chemical per the facility policy. The Immediate Jeopardy was effective from 1/12/17 through 5/24/17 at 6:30 PM. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated through review of temperature logs monitored every 2 hours from 5/23/17 through 5/24/17; direct care staff education of monitoring water temperatures, reporting inappropriate water temperature to the Administrator/Charge Nurse/Maintenance/Supervisor, if temperature was above 115 degrees F to shut it off at the source; direct care staff interview regarding education; maintenance staff interview to assess education; review skin audits to 100% of the residents to ensure integrity; independent resident education on not to use the shower until the water temperature was appropriate; plumber contacted to review mixing valve operation. The surveyors verified the Allegation of Compliance by: 1. Reviewed the every 2 hour temperature logs the facility initiated after becoming aware of the elevated water temperatures on 5/22/17 which included all resident rooms and the 3 common shower rooms. No temperatures were documented exceeding 115 degrees F from 5/23/17 through 5/24/17. Reviewed the facility plan to monitor water temperatures every 2 hours for 2 days ending on 5/25/17, then every 4 hours for 2 days ending on 5/27/17, then 2 times per shift for 2 days ending on 5/29/17, and then 1 time per shift ending on 5/31/17. 2. Reviewed the in-service training documentation dated 5/23/17 the facility completed after becoming aware of the elevated water temperatures on 5/22/17 for the Maintenance Director and maintenance staff regarding the appropriate water temperature range of 105-115 degrees F, the process of how to properly obtain water temperatures, to report to administration if temperatures exceed 115 degrees F, adjusting the mixing valve, and to shut off the water at the source. 3. Reviewed the in-service training records dated 5/23/17 the facility initiated after becoming aware of the elevated water temperatures on 5/22/17 for the licensed, and non-licensed direct care staff to validate the direct care staff were in-serviced on the appropriate resident care area water temperature range of 105-115 degrees F; direct care staff were to monitor temperatures; non-licensed staff was to report temperature above 115 degrees F to licensed staff, then the licensed staff were to report the excessive temperature to the administration and the maintenance staff, and if the temperature was above 115 degrees F licensed staff were to shut the water off at the source. Reviewed the facility plan to contact all employees directly as they came on duty or by telephone by end of day 5/24/17 to educate the staff on the above. 4. Interviewed the Maintenance Director and maintenance staff on 5/23/17 and 5/24/17 to determine the level of comprehension through the in-service training he received from administration on 5/23/17 regarding the appropriate water temperature range of 105-115 degrees F, the process of how to properly obtain water temperatures, to report to administration if temperatures exceed 115 degrees F, adjusting the mixing valve, and to shut off water at the source. 5. Interviewed on 5/24/17 the direct care staff on all 3 units on both shifts, including 6 Licensed Practical Nurses and 7 Certified Nurse Aides, and the Administrator to determine the level of comprehension through the in-service training regarding the changes in the temperature monitoring noted in number 3 above, the reporting of the temperature above 115 degrees F and to whom to report, and the action to take if temperatures were above 115 degrees F. 6. Reviewed the documentation of the residents skin audits the facility initiated and completed on 5/22/17 after becoming aware of the elevated water temperatures to ensure the residents skin was intact and not affected by elevated water temperatures. 7. Reviewed the 2 independent residents education documentation the facility had completed after becoming aware of the elevated water temperatures on 5/22/17 to not use the common showers until the temperatures were in-range. 8. Reviewed the plumber's documentation with recommendations the facility had obtained after becoming aware of the elevated water temperatures on 5/22/17. The plumber recommended the mixing valve adjustment; to return to the facility the morning of 5/23/17 to change the thermometer; and on 5/23/17 he obtained water temperatures in resident rooms and the common showers. Documentation review revealed the temperatures did not exceed 115 degrees F. Noncompliance continues at a scope and severity of F for monitoring the effectiveness of corrective actions and evaluation of monitoring by the QA/PI Committee. The facility is required to submit a plan of correction. Refer to F-224 Substandard Quality of Care.

Based on facility policy review, observation, interview, review of Water Temperature log form, and review of Intrafacility Reguest for Repairs or Alterations form, the facility failed to maintain the hot water temperatures in the resident care areas at or less than 115 degrees Fahrenheit (F), and the facility resident care staff and the Maintenance Director failed to report the water was above 115 degrees F to administration. The facility's system failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death) for 24 residents (#3, #25, #40, #52, #85, #87, #94, #95, #99, #104, #107, #110, #112, #114, #123, #128, #134, #147, #150, #186, #217, #218, #219, #220) of 40 residents reviewed of the 105 residents in the facility and 3 of 3 resident common shower rooms and hand sinks. The Administrator and Regional Vice President were notified of the Immediate Jeopardy and Substandard Quality of Care on 5/24/17 at 4:40 PM in the Administrator's office. The findings included: Interview with the Administrator on 5/24/17 at 3:55 PM in the Administrator's office confirmed the Administrator was not aware the hot water temperatures were above 115 degrees F in resident care areas on all units prior to 5/22/17. When asked why she thought the direct care staff and the maintenance staff failed to report hot water or water temperatures above 115 degrees F, the Administrator stated I don't know. Further interview with the Administrator on 5/24/17 at 3:55 PM in the Administrator's office confirmed the facility failed to ensure the direct care staff and maintenance staff were educated to maintain water temperatures between 105-115 degrees F and failed to ensure the direct care staff and maintenance reported water temperatures above 115 degrees F to administration prior to 5/22/17. The Immediate Jeopardy was effective from 1/12/17 through 5/24/17 at 6:30 PM. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated through review of temperature logs monitored every 2 hours from 5/23/17 through 5/24/17; direct care staff education of monitoring water temperatures, reporting inappropriate water temperature to Administrator/Charge Nurse/Maintenance/Supervisor, if temperature was above 115 degrees F to shut it off at the source; direct care staff interview regarding education; maintenance staff interview to assess education; review skin audits to 100% of the residents to ensure integrity; independent resident education on not to use the shower until the water temperature was appropriate; plumber contacted to review mixing valve operation. The surveyors verified the allegation of compliance by: 1. Reviewed the every 2 hour temperature logs the facility initiated after becoming aware of the elevated water temperatures on 5/22/17 which included all resident rooms and the 3 common shower rooms. No temperatures were documented exceeding 115 degrees F from 5/23/17 through 5/24/17. Reviewed the facility plan to monitor water temperatures every 2 hours for 2 days ending on 5/25/17, then every 4 hours for 2 days ending on 5/27/17, then 2 times per shift for 2 days ending on 5/29/17, and then 1 time per shift ending on 5/31/17. 2. Reviewed the in-service training documentation dated 5/23/17 the facility completed after becoming aware of the elevated water temperatures on 5/22/17 for the Maintenance Director and maintenance staff regarding the appropriate water temperature range of 105-115 degrees F, the process of how to properly obtain water temperatures, to report to administration if temperatures exceed 115 degrees F, adjusting the mixing valve, and to shut off the water at the source. 3. Reviewed the in-service training records dated 5/23/17 the facility initiated after becoming aware of the elevated water temperatures on 5/22/17 for the licensed, and non-licensed direct care staff to validate the direct care staff were in-serviced on the appropriate resident care area water temperature range of 105-115 degrees F; direct care staff were to monitor temperatures; non-licensed staff was to report temperature above 115 degrees F to licensed staff, then the licensed staff were to report the excessive temperature to the administration and the maintenance staff, and if the temperature was above 115 degrees F licensed staff were to shut the water off at the source. Reviewed the facility plan to contact all employees directly as they came on duty or by telephone by end of day 5/24/17 to educate the staff on the above. 4. Interviewed the Maintenance Director and maintenance staff on 5/23/17 and 5/24/17 to determine the level of comprehension through the in-service training he received from administration on 5/23/17 regarding the appropriate water temperature range of 105-115 degrees F, the process of how to properly obtain water temperatures, to report to administration if temperatures exceed 115 degrees F, adjusting the mixing valve, and to shut off water at the source. 5. Interviewed on 5/24/17 the direct care staff on all 3 units on both shifts, including 6 Licensed Practical Nurses and 7 Certified Nurse Aides, and the Administrator to determine the level of comprehension through the in-service training regarding the changes in the temperature monitoring noted in number 3 above, the reporting of the temperature above 115 degrees F and to whom to report, and the action to take if temperatures were above 115 degrees F. 6. Reviewed the documentation of the residents skin audits the facility initiated and completed on 5/22/17 after becoming aware of the elevated water temperatures to ensure the residents skin was intact and not affected by elevated water temperatures. 7. Reviewed the 2 independent residents education documentation the facility had completed after becoming aware of the elevated water temperatures on 5/22/17 to not use the common showers until the temperatures were in-range. 8. Reviewed the plumber's documentation with recommendations the facility had obtained after becoming aware of the elevated water temperatures on 5/22/17. The plumber recommended the mixing valve adjustment; to return to the facility the morning of 5/23/17 to change the thermometer; and on 5/23/17 he obtained water temperatures in resident rooms and the common showers. Documentation review revealed the temperatures did not exceed 115 degrees F. Noncompliance continues at a scope and severity of F for monitoring the effectiveness of corrective actions and evaluation of monitoring by the QA/PI Committee. The facility is required to submit a plan of correction. Refer to F 224 Substandard Quality of Care. Refer to F 323 Substandard Quality of Care.

Based on facility policy review, observation, interview, review of Water Temperature logs, and review of Intrafacility Facility Reguest for Repairs or Alterations, the facility Quality Assurance/Performance Improvement (QA/PI) Committee failed to identify areas for improvement related to the hot water temperatures in the resident care areas were to be maintained at or less than 115 degrees Fahrenheit (F), the Maintenance staff was knowledgeable of the temperature range for resident care areas, and the facility resident care staff and the Maintenance Director failure to report the water was hot or above 115 degrees F to administration. The facility's system failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death) for 24 residents (#3, #25, #40, #52, #85, #87, #94, #95, #99, #104, #107, #110, #112, #114, #123, #128, #134, #147, #150, #186, #217, #218, #219, #220) of 40 residents reviewed of the 105 residents in the facility and 3 of 3 resident common shower rooms and hand sinks. The Administrator and Regional Vice President were notified of the Immediate Jeopardy and Substandard Quality of Care on 5/24/17 at 4:40 PM in the Administrator's office. The findings included: Interview with the Maintenance Director on 5/22/17 at 5:28 PM in the fine dining room revealed he and his assistant monitored water temperatures weekly in 15 rooms randomly. Further interview revealed they always included the kitchen, laundry and 3 resident shower rooms in the weekly monitoring. When asked the temperature range the maintenance department was trying to maintain in the resident care areas revealed they .want to maintain the resident care area temperatures between 110-120 degrees Fahrenheit (F) including the resident shower rooms . When asked what was done if the temperature was over 120 degrees F the Maintenance Director revealed they would adjust the mixing valve. Interview with the Maintenance Director, a QA/PI Committee member, on 5/24/17 at 10:00 AM in the Administrator's office, revealed he thought the appropriate temperature for resident areas was 118 degrees F. Further interview revealed when asked what he did when the water temperature exceeded 118 degrees he stated he .fixed it by adjusting the mixing valve and keep monitoring the temperatures . When asked if he reported the high temperatures to anyone in the facility he stated .I did not report it. I thought I could fix it, take care of it. I didn't think it was a big issue. I did not report it to the Administrator or Director of Nursing . When asked if the excessive temperatures were addressed in QA/PI he revealed .No .because I thought I had fixed it Interview with the Administrator on 5/24/17 at 3:55 PM in the Administrator's office confirmed the Administrator was not aware the hot water temperatures were above 115 degrees F in resident care areas on all units prior to 5/22/17. When asked why she thought the direct care staff and the maintenance staff failed to report hot water or water temperatures above 115 degrees F, the Administrator stated I don't know. The Immediate Jeopardy was effective from 1/12/17 through 5/24/17 at 6:30 PM. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated through review of temperature logs monitored every 2 hours from 5/23/17 through 5/24/17; direct care staff education of monitoring water temperatures, reporting inappropriate water temperature to Administrator/Charge Nurse/Maintenance/Supervisor, if temperature was above 115 degrees F to shut it off at the source; direct care staff interview regarding education; maintenance staff interview to assess education; review skin audits to 100% of the residents to ensure integrity; independent resident education on not to use the showers until the water temperature was appropriate; plumber contacted to review mixing valve operation. The surveyors verified the allegation of compliance by: 1. Reviewed the every 2 hour temperature logs the facility initiated after becoming aware of the elevated water temperatures on 5/22/17 which included all resident rooms and the 3 common shower rooms. No temperatures were documented exceeding 115 degrees F from 5/23/17 through 5/24/17. Reviewed the facility plan to monitor water temperatures every 2 hours for 2 days ending on 5/25/17, then every 4 hours for 2 days ending on 5/27/17, then 2 times per shift for 2 days ending on 5/29/17, and then 1 time per shift ending on 5/31/17. 2. Reviewed the in-service training documentation dated 5/23/17 the facility completed after becoming aware of the elevated water temperatures on 5/22/17 for the Maintenance Director and maintenance staff regarding the appropriate water temperature range of 105-115 degrees F, the process of how to properly obtain water temperatures, to report to administration if temperatures exceed 115 degrees F, adjusting the mixing valve, and to shut off the water at the source. 3. Reviewed the in-service training records dated 5/23/17 the facility initiated after becoming aware of the elevated water temperatures on 5/22/17 for the licensed, and non-licensed direct care staff to validate the direct care staff were in-serviced on the appropriate resident care area water temperature range of 105-115 degrees F; direct care staff were to monitor temperatures; non-licensed staff was to report temperature above 115 degrees F to licensed staff, then the licensed staff were to report the excessive temperature to the administration and the maintenance staff, and if the temperature was above 115 degrees F licensed staff were to shut the water off at the source. Reviewed the facility plan to contact all employees directly as they came on duty or by telephone by end of day 5/24/17 to educate the staff on the above. 4. Interviewed the Maintenance Director and maintenance staff on 5/23/17 and 5/24/17 to determine the level of comprehension through the in-service training he received from administration on 5/23/17 regarding the appropriate water temperature range of 105-115 degrees F, the process of how to properly obtain water temperatures, to report to administration if temperatures exceed 115 degrees F, adjusting the mixing valve, and to shut off water at the source. 5. Interviewed on 5/24/17 the direct care staff on all 3 units on both shifts, including 6 Licensed Practical Nurses and 7 Certified Nurse Aides, and the Administrator to determine the level of comprehension through the in-service training regarding the changes in the temperature monitoring noted in number 3 above, the reporting of the temperature above 115 degrees F and to whom to report, and the action to take if temperatures were above 115 degrees F. 6. Reviewed the documentation of the residents skin audits the facility initiated and completed on 5/22/17 after becoming aware of the elevated water temperatures to ensure the residents skin was intact and not affected by elevated water temperatures. 7. Reviewed the 2 independent residents education documentation the facility had completed after becoming aware of the elevated water temperatures on 5/22/17 to not use the common showers until the temperatures were in-range. 8. Reviewed the plumber's documentation with recommendations the facility had obtained after becoming aware of the elevated water temperatures on 5/22/17. The plumber recommended the mixing valve adjustment; to return to the facility the morning of 5/23/17 to change the thermometer; and on 5/23/17 he obtained water temperatures in resident rooms and the common showers. Documentation review revealed the temperatures did not exceed 115 degrees F. Noncompliance continues at a scope and severity of F for monitoring the effectiveness of corrective actions and evaluation of monitoring by the QA/PI Committee. The facility is required to submit a plan of correction. Refer to F 224 Substandard Quality of Care. Refer to F 323 Substandard Quality of Care. Refer to F 490.

Based on medical record review, review of fall investigation, and interview, the facility failed to follow care plan interventions related to fall prevention resulting in a laceration to the back of the head requiring a Dermabond application and HARM to 1 resident (#7) of 2 residents reviewed for falls. The findings included: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 of 15 indicating severe cognitive impairment. Resident #7 required extensive assistance of one person with transfer, locomotion on and off the unit, toileting and personal hygiene. Further review revealed the resident required extensive 2 person assistance for bed mobility. Further review revealed .Fall History on Admission .fall any time in last month prior to admission .Yes .resident have fracture related to fall in the 6 months prior to admission .Yes . Further review revealed .Has resident had any falls since admission .Yes .Number of Falls Since Admission .1 with injury . Medical record review of the Fall Risk Evaluation dated 2/11/17 and 2/12/17 revealed Resident #7 score was 22. Further review revealed .scores a 10 or higher is at risk . for falls. Medical record review of the Interim Care Plan dated 2/12/17 revealed Resident #7 was .At risk for physical injury from falls related to Fall Risk Score, Recent Fall(s), History of fall(s) with injury . Further review of the care plan revealed .Interventions .Assist x (times) 1 for transfers .Assist x 1 for ambulation .Assist x 1 for toileting .Call light within reach .make hourly rounds during HS (bedtime) .Wear non-skid socks esp (especially) @ (at) HS . Medical record review of a Nurse Progress note dated 2/12/17 revealed, .This nurse heard resident yelling for help and upon entering room found her lying in floor at foot of bed on left side with left arm behind her and head against closet .Knot noted to left side of head .Sent to ER (emergency room ) for eval (evaluation) and treat . Medical record review of an ER note dated 2/12/17 revealed Resident #7 was diagnosed with [REDACTED]. Review of the facility fall investigation documentation dated 2/12/17 revealed the .Rehab (rehabilitation) Services Post-Fall Screening Tool Interventions .low bed with fall mats, falling star program .education with pt (patient) on using call light or calling out for help-that's the purpose of staff .possibly put pt on toileting schedule . Medical record review of the Comprehensive Care Plan dated 2/13/17 revealed .Potential for falls Related to H/O (history of) falls, General weakness, Difficulty walking, Poor safety awareness, Unsteady gait, Dementia, [MEDICAL CONDITION] . Further review revealed the .Interventions .Fall risk assessment .Provide/observe use of adaptive devices-wheelchair .Remind resident and reinforce safety awareness-Appropriate footwear .Assist of 1-2 person and a gait belt .Non-skid socks .low bed with mats .Falling star program . Further review revealed and intervention dated 2/21/17 for .Clip alarm to w/c x 14 days . Further review revealed the 2/21/17 intervention was discontinued on 3/6/17. Medical record review of the Comprehensive Care Plan dated 3/9/17 revealed the following approaches added to the 2/13/17 Comprehensive Care Plan Interventions related to potential for falls .Family Request: Do not leave resident unattended while sitting up in w/c (wheelchair) in room .Encourage to sit in high traffic areas when up in w/c . Medical record review of a Nurse Progress note dated 4/16/17 revealed, .CNA (Certified Nurse Aide) #20 summoned this nurse into the day room where resident was lying on her left hip .CNA stated to this nurse that resident was in the dayroom .when resident was ambulating without assistance et (and) tripped over her wheelchair leg rests, falling onto her left hip .Redness noted to left hip et left knee .Resident stated that her left knee was tender upon touch . Review of the fall investigation dated 4/16/17 revealed the .Rehab Services Post-Fall Screening Tool Interventions .Suggest remove leg rest when not transporting pt; staff education on frequent checks on pt in dayroom to decrease risk for falls . Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 3 of 15 indicating severe cognitive impairment. Resident #7 required extensive one person assistance with transfer, locomotion on unit, toileting and personal hygiene. Medical record review of a Nurse Progress note dated 5/15/17 revealed .At approximately 7:15 AM the CNA taking care of the resident summoned this nurse to the residents room, upon entry, resident was sitting on buttock beside commode with blood visibly noted on the floor et on head. When asked what happened, resident stated 'I don't know, maybe I just needed to get up' .CNA stated to this nurse that after she had assisted resident with toileting et getting her off the commode, another CNA had asked for assistance, she assisted resident into chair et went to assist the CNA. (Named Physician) was in the building at this time et was notified of residents fall. The (Physician) evaluated her head .N/O (New Order) Cleanse back of head with soap et water, Apply ice to reduce swelling et then apply dermabond (tissue adhesive that forms a strong bond across apposed wound edges allowing normal healing to occur) to 3cm (centimeter) laceration to back of head . Telephone interview with CNA #14 on 5/23/17 at 4:35 PM confirmed she was responsible for providing care for Resident #7 on 5/15/17 while the resident was in the bathroom. Continued interview revealed another aide came and asked for assistance with another resident. Further interview with CNA #14 confirmed she had left Resident #7 in the wheelchair alone in the bathroom while assisting the other aide. Further interview confirmed when CNA #14 returned to Resident #7's bathroom the resident was on the floor and there was blood on the floor. Interview with Licensed Practical Nurse (LPN) #9/Unit Manager on 5/24/17 at 3:45 PM in the Activities Department confirmed Resident #7 would have been sent out for treatment if the Physician had not been in the facility when Resident #7 fell on [DATE]. Continued interview with LPN #9 stated leaving the resident in the wheelchair alone in the restroom while going to assist another resident was safe, and would have a concern if the CNA had left the resident on the commode. Interview with the Director of Nursing (DON) on 5/24/17 at 4:49 PM in the Private Dining Room revealed .resident would have potential for falls even if not in a high traffic area . The DON would not confirm the facility failed to provide adequate supervision to prevent a fall resulting in a laceration requiring Dermabond and HARM to Resident #7. The facility failed to follow the care plan to prevent a fall resulting in a laceration to the back of the head requiring a Dermabond application and HARM to Resident #7.

Based on observation and interview, the facility failed to date food and store food in a sanitary manner; failed to prevent the possible contamination of food for 1 of 4 tray line services observed; failed to prevent the possible contamination of clean dishes for 1 of 2 dish machine observations; failed to sanitize equipment appropriately during 1 of 2 observations; failed to maintain equipment in a sanitary manner during 1 of 4 observations, and failed to dispose of expired food timely for 1 of 3 nourishment rooms. The findings included: Observation and interview with the Certified Dietary Manager (CDM) on 5/22/17 at 9:04 AM in the dietary department walk-in refrigerator confirmed 3 of 6 red onions were moldy. Further observation and interview confirmed an undated bag of salad mix, an undated partially used roll of bologna and an undated container of bacon crumbles stored on the shelves of the walk-in refrigerator and ready to use. Observation and interview with the CDM on 5/22/17 at 11:37 AM, at the resident mid-day meal tray line service in the main dining room, confirmed the dietary staff member serving the food at the steam table used 1 pair of tongs to serve the corn bread, fried fish, country fried steak and french fries, thereby possibly contaminating the food. Observation on 5/22/17 at 11:54 AM in the dietary department dish room revealed a wall mounted fan with a layer of blackened debris on the blades and hanging debris on the front and back grates directed toward the clean side of the dish machine not in operation. Observation and interview with the CDM on 5/23/17 at 11:13 AM in the dietary department dish room confirmed the dish machine was in operation and the wall mounted fan with debris was also in operation. Further observation and interview confirmed the fan air was directed toward the clean dishes coming out of the dish machine, contaminating the clean dishes and the dishes in storage. Observation and interview with the CDM on 5/23/17 at 11:15 AM in the dietary department dish room revealed the 3 compartment sink was set-up and in use. Further observation revealed a stainless steel bowl submerged in the sink with sanitizer and 1 stainless steel bowl, 1 stock pot and a strainer air drying. Further observation revealed the CDM obtained the sanitizer level with no registered result after 3 repeated attempts using different test strips. Further interview with the CDM confirmed the facility failed to sanitize the equipment appropriately. Observation and interview with the CDM on 5/23/17 at 11:27 AM in the dietary department, confirmed the grill perimeter and left side wall had a heavy black accumulation of debris. Further observation revealed a plastic covered floor mixer. Interview with the CDM revealed the plastic covered equipment meant the equipment was clean and ready to use. Further observation and interview confirmed the floor mixer had dried white splattered debris on the safety guard and white powdery debris on the arms of the mixer. Interview with the CDM confirmed the facility failed to maintain the equipment in a sanitary manner. Observation and interview with the CDM on 5/23/17 at 11:46 AM in the 100 hall nourishment room revealed 5 cartons of milk with expiration dates of 5/12/17, 5/20/17, and 5/22/17. Interview with the CDM confirmed the facility failed to dispose expired foods timely.

Based on observation and interview, the facility failed to maintain the exterior dumpster and dumpster site in a manner to prevent possible harborage and feeding of pests. The findings included: Observation on 5/22/17 at 11:56 AM, with the Certified Dietary Manager present, at the facility exterior dumpster revealed a sheet hanging on the outside of the dumpster. Further observation revealed the sheet was wedged between the top and the base of the dumpster. Further observation revealed a 2 inch gap between the top and the base of the dumpster. Further observation revealed the area surrounding the dumpster had a fried chicken wing, fries, paper debris, gloves, styrofoam, 2 plastic bags with exposed debris, a milk carton, and a sandwich. Interview with the Certified Dietary Manger on 5/22/17 at 11:56 AM by the exterior dumpster confirmed the facility failed to store the garbage in a sanitary manner and failed to prevent the possibility of harborage and feeding of pests.

Based on observation and interview, the facility failed to serve hot food at or above 135 degrees Fahrenheit (F) for 1 of 4 resident tray line services observed. The findings included: Observation on 5/22/17 at 11:37 AM in the main dining room revealed the resident mid-day meal tray line service was in progress. Further observation revealed the Certified Dietary Manager obtained the temperature of french fries at 122 degrees F and the mashed potatoes at 132 degrees F and the food continued to be served after the temperature was obtained. Interview with the Certified Dietary Manager on 5/22/17 at 11:40 AM in the main dining room confirmed the facility failed to serve hot food at or above 135 degrees F and continued to serve the food.

Based on review of facility policy form, medical record review, observation, and interview, the facility failed to assess the need for a restraint, failed to provide a medical [DIAGNOSES REDACTED].#1) of 40 residents reviewed. The findings included: Review of facility policy, Physical Restraint Informed Consent form, revealed, .The use of restraints is prohibited for purposes of discipline or staff convenience and are used solely to treat a resident's medical symptoms. When alternatives to restraint are not effective, the interdisciplinary team evaluates the least restrictive restraint to promote safety and attain/maintain the highest practical physical, mental and psychosocial function of the resident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE]. Medical record review of an Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired and had behavioral symptoms not directed toward others. The resident required extensive assistance of one person for bed mobility, transfers, dressing, eating, toileting and personal hygiene. She required limited assistance of one person for walking in the corridor and was dependent for bathing. Continued review revealed the resident had no extremity impairment and used a wheelchair for mobility. Further review revealed the resident did not use physical restraints. Observation of Resident #1 on [DATE] at 10:55 AM in the day room of the Secured Unit revealed the resident was alert, seated in a wheelchair with a velcro seat belt across her lap and a chair alarm on the wheelchair. The resident was observed propelling self forward and backward and attempting to rise at times. Interview and observation revealed Certified Nurse Aide (CNA) #18 was asked if Resident #1 could release the seat belt on her own, and the CNA stated yes. The CNA asked the resident to release the seat belt, but the resident did not attempt to remove the seat belt even after several requests were made by the CNA. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 11:05 AM in the day room of the Secured Unit who had observed CNA #18's attempts stated, She does release it at times. Her daughter is insistent that the resident have it on at all times because of her high fall risk. Observation of the resident on [DATE] at 11:08 AM in the day room of the Secured Unit revealed LPN #1 asked Resident #1 if she knew where her seat belt was and the resident stated, No, not really. Observation of Resident #1 on [DATE] at 3:20 PM in the day room of the Secured Unit revealed the resident was seated in a wheelchair with a seat belt and chair alarm in place. Continued observation revealed LPN #1 and CNA #2 both asked the resident if she could release her seat belt. The resident stated, Yes but failed to do so. Continued observation revealed CNA #2 placed the resident's hands on the seat belt and asked her to remove it. The resident never moved her arms, or hands and did not look at the seat belt. Further observation revealed the resident could not release the seat belt when requested. Observation of Resident #1 on [DATE] at 7:50 AM in the dining area of the Secured Unit revealed the resident was awake, seated in the wheelchair with a velcro seat belt in place, and an alarm to the wheelchair. Observation and interview on [DATE] at 1:50 PM revealed Resident #1 was dozing in the wheelchair with the seat belt intact. Interview with LPN #1 when asked why the seat belt was fastened, if the resident was making no attempts to stand and was visualized by staff revealed It's supposed to be on her all of the time. Continued observation until 3:15 PM revealed no observations of staff checking the seat belt every 30 minutes, offering toileting, or ambulation. Medical record review of a physician's orders [REDACTED].Seat belt with alarm to W/C (wheelchair) (self release) check every 30 min. (minutes) Reposition & offer toileting/ambulation every 2 hours and as needed/requested . Medical record review of a Physical Restraint Informed Consent dated [DATE] revealed the type of restraining device was a self release seat belt. The frequency and duration was daily (family/POA (Power of Attorney)) refuse to D/C (discontinue). The medical reason for the restraining device was, Multiple falls requiring medical intervention. Continued review revealed the consent was signed by a family member. Further review revealed no POA was found on the resident's chart. Interview with the Director of Nursing (DON) and Corporate Nurse in the DON's office on [DATE] at 3:15 PM confirmed the only restraint policy the facility had was listed on the Physical Restraint Informed Consent form. Continued interview revealed an Initial and Quarterly Restraint Assessment form was to be utilized by the facility's Interdisciplinary Team (IDT) to assess the need for a specific restraint device, the medical condition that warranted the use of the device, and any restraint reduction interventions and attempts utilized. Continued interview confirmed the last fall the resident had occurred on [DATE]. Further interview confirmed the resident was severely cognitively impaired and incapable of releasing the seat belt restraint voluntarily. Interview with the DON on [DATE] at 4:05 PM in the Private Dining Room confirmed there was no initial or quarterly assessment forms or documentation regarding a medical condition warranting the need for a restraint, why the seat belt restraint was an appropriate choice of restraint, or any reduction attempts of the restraint for the resident. Continued interview confirmed the resident was ambulatory with assistance, the seat belt restraint had been in place for 1 year, and had not been reviewed by the IDT during that time. The DON confirmed the facility failed to prevent the use of a physical restraint for Resident #1.

Based on medical record review, observation, and interview, the facility failed to accurately assess the use of a restraint for 1 resident (#1) of 40 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE]. Medical record review of an Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired, and had behavioral symptoms not directed toward others. The resident required extensive assistance of one person for bed mobility, transfers, dressing, eating, toileting and personal hygiene. She required limited assistance of one person for walking in the corridor, and was dependent for bathing. Continued review revealed the resident had no extremity impairment and used a wheelchair for mobility. Further review revealed the resident did not use physical restraints. Observation of Resident #1 on [DATE] at 10:55 AM in the day room of the Secured Unit revealed the resident was alert, seated in a wheelchair with a velcro seat belt across her lap and a chair alarm on the wheelchair. The resident was observed propelling self forward and backward and attempting to rise at times. Interview and observation revealed Certified Nurse Aide (CNA) #18 was asked if Resident #1 could release the seat belt on her own, and the CNA stated yes. The CNA asked the resident to release the seat belt, but the resident did not attempt to remove the seat belt even after several requests were made by CNA #18. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 11:05 AM in the day room of the Secured Unit who had observed the CNA's attempts revealed She does release it at times. Her daughter is insistent that the resident have it on at all times because of her high fall risk. Observation of the resident on [DATE] at 11:08 AM revealed LPN #1 asked Resident #1 if she knew where her seat belt was and the resident stated, No, not really. Observation of Resident #1 on [DATE] at 3:20 PM in the day room of the Secured Unit revealed the resident was seated in a wheelchair with a seat belt and chair alarm in place. Continued observation revealed LPN #1 and CNA #2 both asked the resident if she could release her seat belt. The resident stated, Yes but failed to do so. Continued observation revealed CNA #2 placed the resident's hands on the seat belt and asked her to remove it. The resident never moved her arms, or hands and did not look at the seat belt. Further observation revealed the resident could not release the seat belt when requested. Interview with the MDS Coordinator on [DATE] at 11:30 AM in the MDS office confirmed the Annual MDS dated [DATE] assessed Resident #1 as being severely cognitively impaired, requiring extensive assistance with her Activities of Daily Living, and she did not use a restraint. Continued interview confirmed the MDS Coordinator did not observe, or assess the resident releasing the seat belt voluntarily. Further interview revealed the MDS Coordinator confirmed the facility failed to accurately assess Resident #1 for the use of a physical restraint.

Based on policy review, medical record review, observation and interview, the facility failed to provide dignity related to a drainage bag not being covered with a dignity bag for 1 of 3 (Resident #242) with a foley catheter reviewed of the 30 sampled residents in the stage 2 review. The findings included: 1. Review of the facility's Dignity policy revealed, .All residents are treated in a manner and in an environment that maintains and enhances each residents's dignity .Assisting residents' in daily care in a dignified manner .covering appliances attached to residents . 2. Medical record review for Resident #242 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. 3. Observations in Resident #242's room on 5/15/16 at 5:43 PM, revealed Resident #242 sitting in the wheelchair eating breakfast and the foley catheter bag was hanging on the side of wheelchair without a dignity bag. Observations in Resident #242's room on 5/16/16 at 7:44 AM, revealed Resident #242 lying in the bed with eyes closed. The foley catheter bag was hanging on side of the bed facing the door without a dignity bag. 4. Interview with the Director of Nursing (DON) on 5/17/16 at 10:15 AM, in the private dining room, the DON was asked if a resident was admitted with a foley catheter when should it placed in a dignity bag. The DON stated, .immediately upon admission .

Based on policy review, medical record review and interview, it was determined the facility failed to prevent and identify the development of pressure ulcers for 1 of 7 (Resident #3) sampled residents with pressure ulcers. The failure to identify and prevent skin breakdown prior to the development of a Stage 3 pressure ulcer and a Stage 4 pressure ulcer resulted in actual harm to Resident #3. The findings included: Review of the facility's "Evaluations, Screenings, and Assessments" policy documented, "...Policy...Skin should be checked daily..." Review of the facility's "Post-admission Weekly Skin Assessments" policy documented, "...The skin is observed for pressure damage caused by medical devices (e.g., (such as) catheters, oxygen tubing, cervical collars...etc. (et cetera))..." Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. (R) LEG TO MONITOR FOR S/S (signs and symptoms) OF SKIN BREAKDOWN EVERY SHIFT AND REPLACE... 1/24/11 pm (as needed) shift only checked... 1/25/11 pm shift only checked... 1/27/11 pm shift only checked... 1/28/11 pm shift only checked..." The facility did not always complete the skin assessment every shift in accordance with the physician's orders [REDACTED]. Review of Resident #3's nurses notes dated 1/31/11 at 3:40 PM documented, "...Cleanse stage III (R) lateral leg apply [MEDICATION NAME] skin prep periwound apply foam secure with Kerlix same tx (treatment) to stage IV (R) lat (lateral) side of knee..." During an interview in the Director of Nursing's (DON) office on 7/7/11 at 8:40 AM, the DON stated, "...I see no documentation of brace to right leg removed to monitor for skin breakdown on shifts 1/25 am, 1/27 am, 1/28 am... On the note 1/31/11 was the first documentation of a Stage 3 to the right lateral leg and a Stage 4 pressure sore to the right leg lateral side of the knee... that is where the brace was..." The failure to identify and prevent skin breakdown prior to the development of a Stage III pressure ulcer and a Stage IV pressure ulcer resulted in actual harm to Resident #3.