Every finding on record at Lutheran Hillside Village

Based on interview, observation and record review, the facility failed to provide appropriate nursing interventions related to life-sustaining treatment during a choking episode, failed to provide supervision during meals and failed to follow a physician's diet order; and failed to obtain a Negotiated Risk Assessment for one of three (R1) residents reviewed with swallowing difficulty and on special/modified diets who required supervision during meals. This failure resulted in R1 choking on a tater tot and ultimately expired. This past non-compliance, which involved R1, occurred from 4/15/26 to 5/12/26.Findings include:The Emergency Response policy revised 10/23/24 documents the goal of staff training is to enable employees to provide basic life support and/or first aid interventions. In case of life-threatening injuries or situations, the goal is patient stabilization until emergency responders arrive. Basic first aid intervention includes choking and breathing emergencies.Licensed Practical Nurse (LPN) role description dated 12/24 documents nurses to practice nursing care within the scope of licensure and in accordance with the state Nurse Practice Act and facility's policies and procedures. Utilizes the electronic medical record to capture full clinical documentation in accordance with policy and procedure. Observe residents' status to assure quality of care, coordinates with other resident services to assure continuity of care and document in the medical record detailed, timely and accurate reports. Overseas and directs the certified staff and others as assigned to ensure standards of care and services are provided. Works collaboratively with the interdisciplinary team in defining individualized plans of care for each resident. Maintains working knowledge and understanding of the observation/assessment and documentation process for the level of licensure in which they work. LPN's must be Cardiopulmonary Resuscitation (CPR) certified.The 2025 American Heart Association Adult Basic Life Support (BLS) Procedure Part 7: Adult Basic Life Support documents for adults with severe Foreign Body Airway Obstruction (FBAO), repeated cycles of 5 back blows (slaps) followed by 5 abdominal thrusts should be performed until the object is expelled or the person becomes unresponsive. Rescuers should activate the emergency response system for adults with severe FBAO. If adults with severe FBAO become unresponsive, rescuers should start CPR, beginning with chest compressions and activate the emergency response system if not already done. Remove any visible foreign body when opening the airway to provide breaths. Blind finger sweeps should not be performed for adults with FBAO. Observational data suggest that when a foreign body is not visible, the risk associated with performing a blind sweep and worsening an airway obstruction outweighs any potential benefit.The Staff Education Sign-In Sheets Choking Emergency Policy (Emergency Response policy dated 10/23/24)-Staff Education All staff are reminded that choking is a medical emergency requiring an immediate response. Our policy is to call 911 without delay for any individual who is actively choking, regardless of their code status (including DNR) or hospice enrollment. While some residents may have comfort-focused goals of care, choking represents an acute and potentially reversible airway obstruction. Emergency services are necessary to provide advanced airway management that cannot be delivered within the facility. Key Points: Call 911 immediately at the first sign of choking. Initiate appropriate first aid (e.g. abdominal thrust) per training while awaiting EMS. Do not delay calling 911 to verify code status or hospice directives. Continue to prioritize resident comfort and dignity throughout the event. Staff Educations Sign-In Sheet Diet Order Compliance and Supervision- Staff Education All staff are reminded that resident diet orders must be followed at all times, without exception. Diets are prescribed to ensure resident safety and to reduce the risk of complications such as choking, aspiration or other medical concerns. Even if a resident requests food or drink that is not consistent with their ordered diet, staff are not permitted to override or modify diet orders. Residents do have the right to refuse or not comply with therapeutic or mechanically altered diets. However, this must be formally addressed through the care planning process. The risks and potential consequences must be clearly discussed with the residents and/or Power of Attorney (POA), and the decision must be documented and reflected in the care plan with appropriate orders in place. Any resident on a modified diet must eat and drink in the main dining room or be within staff sight with close supervision at all times during meals and consumption of fluids. This ensures timely intervention if difficulty swallowing or choking occurs. The only exception to a resident's ordered diet is if the resident has a signed Negotiated Risk Agreement Form and it has been reviewed, approved and documented in the resident's medical record and entered into the dietary management system. No deviations from diet orders may occur without completion of this process. Residents must have a signed Negotiated Risk Agreement Form in place in order to: request food or drink items that do not comply with their ordered diet and request to have thickened liquids available in their own room at all times without direct supervision. Any approved altered resident preferences must also be clearly documented on the meal ticket to ensure dietary staff are aware and able to safely and accurately prepare the resident's meals.R1 was admitted on [DATE] with diagnoses of Parkinson's Disease, Dementia, Spondylosis, Heart Failure, Dysphagia and Cerebral Infarction.R1's current Care Plan documents R1 is at risk for alteration in respiratory status due to potential for aspiration. R1 receives a regular diet with moderate honey thickened liquids. No bread products. R1 has elected Hospice benefits and has a Physician's Order for Life Sustaining Treatment (POLST) which documents Do Not Resuscitate.R1's Practitioner Order for Life-Sustaining Treatment (POLST) Form dated 4/22/25 documents R1 requests no cardiopulmonary resuscitation (CPR) and to provide comfort measures only such as oxygen, suctioning and manual treatment of airway obstruction.A Physician's Note dated 4/6/26 documents the visit resulted post multiple recent choking incidents in which the last occurrence required the Heimlich maneuver and emergency responders responded to the call. Due to advanced dysphagia, (R1) was previously on pureed diet with honey thickened liquids. Since, transitioning to hospice (3/25/26.) he has started eating a general diet.R1's Physician's Order dated 4/6/26 ordered an IDDSI Level 5 diet (International Dysphagia Diet Standardization Initiative/minced and moist, is a diet for individuals with reduced chewing ability, featuring small, soft, moist food pieces that require minimal chewing and are safe to swallow).R1's record did not include a signed Negotiated Risk Agreement or other documentation in the medical record or dietary management system.R1's Progress Note dated 4/15/26 (documented by V2/Director of Nursing currently retired) documents R1's meal was delivered to his room by V5 although V5 (Certified Nurse Aide) left the room to deliver another resident their meal tray. R1 ate a tater tot without supervision. At 4:45 PM, R1 activated his call light and self-propelled himself to the doorway of his room. V3 (Licensed Practical Nurse) responded and noted R1 to be in distress, retrieved a tater tot from his mouth and then R1 started to slide down in his chair. R3 instructed staff to assist with transferring R1 back to bed first and then to call 911 (emergency response services). V5 (Certified Nurse Aide) left the room to retrieve the crash cart while V3 and V6 (Certified Nurse Aid) transferred R1 back to bed. Following the transfer, R1 was noted to quit breathing and went pulseless. Due to R1's POLST (Do Not Resuscitate order) no resuscitation was attempted and R1 was pronounced dead at 5:00 PM, 15 minutes after choking event started.On 6/16/26 at 11:53 AM, V3 (Licensed Practical Nurse) stated at dinner time R1 was at his doorway in his wheelchair. R1's call light was on and appeared to be choking. V3 stated she conducted the Heimlich maneuver, and the tater tot came out. R1 was slumped over and limp in his chair. I thought he was going to fall on the floor. I didn't want him to get hurt. (V5 and V6/Certified Nurse Aides) transferred (R1) back to bed but he was already gone. V3 stated she left the room to get another nurse (V4/Licensed Practical Nurse), and he had passed away before she returned. V3 stated 911 was not called because R1 passed away before she could make the call and because R1 was on Hospice, had a Do Not Resuscitate orders and wanted to honor his wishes.On 6/16/26 at 12:02 PM, V5 (Certified Nurse Aide) stated on 4/15/26, R1 was supposed to be on a soft-bite diet but the nurse told him R1 signed a waiver to eat whatever he wanted to eat. V5 delivered R1's meal which consisted of a cheeseburger and tater tots and left the room to deliver another resident's meal tray. Upon returning to R1's room, R1 was visibly choking. V5 went to get the emergency cart with suction and V6 (Certified Nurse Aide) stated she would call 911. Upon returning with the emergency cart, V3 stated 911 was not called because R1 was on hospice and was a DNR. V5 stated (V3) did a finger sweep. She got something out, but I feel (R1) should have been able to breathe or cough if it was fully removed. He made no sound and was blocked (airway). V3 left R1's room to get another nurse without the Heimlich maneuver or suctioning being conducted and R1 expired. V5 stated a week and a half ago R1 had a choking event and 911 was called.On 6/17/26 at 10:13 AM, V6 (Certified Nurse Aide) stated upon arrival, R1 was coughing and was about to come off his chair, so V3 (Licensed Practical Nurse) and V6 sat R1 up in his chair. V3 instructed V6 to go get a mechanical lift. V6 brought the mechanical lift to the room although had to send V5 (Certified Nurse Aide) to go get a sling to lift R1. Once R1 was transferred to the bed, V3 conducted a blind finger sweep, and no Heimlich maneuver was attempted. V3 stated R1 was on Hospice and was a Do Not Resuscitate and instructed V6 not to call 911. V3 left the room to go get another nurse. V6 stated R1 was alive and was making a gagging sound and noises until he expired prior to V3's return. V6 stated Typically, we call 911. That's what we were taught to do. (V2/Director of Nursing/currently retired) said 911 should be called when a resident is choking even if they are a DNR (Do Not Resuscitate) and are on Hospice.On 6/16/26 at 3:18 PM, V7 (Hospice Nurse) stated V3 (Licensed Practical Nurse) notified her that R1 had passed away from choking on a tater tot and she had performed a blind finger sweep to get the tater tot out but couldn't get all of it. V7 was unable to recall if V3 stated the Heimlich maneuver had been attempted.The Coroner's Death Certificate documents on 4/15/26 at 5:00 PM, R1 expired due to a choking episode said suffered health decline due to choking on a tater tot.On 6/17/26 at 1:00 PM, V1 (Administrator) agreed blind finger sweeps are not recommended for residents with Foreign Body Airway Obstruction and should not have been performed on R1; the Heimlich maneuver including back blows and abdominal thrust should have been conducted on R1 immediately and it was unable to be determined if the Heimlich maneuver was performed due to conflicting statements; 911 is to be called for every resident that has a choking event including residents on hospice care and have a Do Not Resuscitate order and 911 was not called and should have been for R1; Residents with modified diets must eat/drink in the main dining room or be with staff and have close supervision during meals and R1 was on a modified diet, then left alone in his room with a general diet meal tray; R1 was served a general diet which was not the diet ordered by the physician; and R1 did not have a signed Negotiated Risk Agreement.Prior to 6/16/26, the facility had taken the following actions to correct the non-compliance:1. Between 4/16/26 and 5/8/26, all clinical staff including nurses and certified nurse aides and dietary staff were educated on the Choking Emergency Policy and Diet Orders Compliance and Supervision.2. On 4/22/26, V3 received a written warning for unsatisfactory performance, conduct, attitude and non-compliance. V3 received education on the Choking Emergency policy and the Dining Supervision Requirements policy. Required to repeat the Cardiopulmonary Resuscitation certification class scheduled for 5/12/26. Expectations were defined for future performance and future disciplinary actions if protocols were not adhered to.3. On 5/12/26, V3 received the American Red Cross Training Service's Certificate of Completion and successfully completed the requirements for Basic Life Support.4. On 4/17/26, V1 requested access to the Dining RD (Registered Dietician) (Diet ordering software) access for V1, V8 (Director of Nursing) and V10 (Assisting Director of Nursing) which allows them to audit real-time and add diet orders. Access provided on 4/22/26.5. On 4/22/26, an email to V2 (Director of Nursing currently retired) which documents report sheets with resident's diet information, negotiated Risk Assessment signed and identified the residents that must be in the dining room or 1:1 when dining in room had been updated (last updated 6/15/26). Instructions to observe residents and staff at mealtimes to ensure residents that are required to eat in the dining room are in the dining room and those dining in their room have a staff member with them while eating. If food is brought in from family, V1 is to be informed, and a Negotiated Risk Assessment is completed. On 6/17/26, V1 stated daily observations were conducted by V2 or delegated to a supervisor if V2 was unable to conduct observations. V1 and V2 discussed findings of observations at the end of each day although they did not document the findings daily.

Based on interview, observation and record review, the facility failed to de-escalate a resident prior to transfer, investigate incident to identify the root cause and implement interventions to potentially prevent further events for 2 of 3 residents (R1, R3) reviewed for falls in a sample of 4.Findings include:The Event Reporting policy dated 7/29/21 documents an adverse event is defined as an unexpected occurrence which was not expected within normal course of care of disease process and condition of the resident. An adverse event may or may not result in injury and may or may not have resulted from a medical or healthcare error. A witness statement form is used only for witnesses who observed the adverse event. The Administrator, Director of Nursing, Risk Designee and their delegates should conduct investigations. Reporting of abuse/neglect of reasonably suspected resident abuse and/or neglect will be reported to the state agency. 1. R1 was admitted on [DATE] with diagnoses of Hemiplegia following a Cerebral Infarct, Dementia, Severe with Agitation and Mood Disturbance, Major Depressive Disorder severe with Psychiatric Disorder, Insomnia, and Sensorineural Hearing Loss. R1 was discharged home on 6/2/25. The May 2025 Medication Administration Report documented the following medications were ordered and administered as ordered each day from 5/1/25 through 5/31/25: Melatonin (sleep aid) 5 mg one time daily at night, Quetiapine (antipsychotic) 75 mg one time daily at night, Sertraline (treats depression and anxiety) 75 mg one time daily, Eliquis (blood thinner) 5 mg twice daily, Prevagen ( supports brain health and improves memory loss) one tablet daily and Memantine (treats moderate to severe dementia) 5 mg daily. R1's Care Plan documents R1 was on anticoagulants and was at risk for bleeding, had verbal/physical rejection of cares due to behavioral symptoms directed toward staff, experienced delusions and paranoia particularly in the evening, became fixated on certain staff members and made false accusations, was at risk for falls and was at risk for developing impaired skin integrity. The Care Plan's interventions included to implement safety/fall precautions, use extra caution with manually transferring, administer medication as ordered, redirect with conversation or talk about family, children are very involved in care, offer to call son to speak with R1 to help with de-escalation when R1 expresses signs of heightened expressions, report falls to physician and responsible party and use lifting device or draw sheet to reduce friction. R1's Progress Notes dated 5/10/25 at 12:30 AM documented R1 slid out of bed and was on the floor at 9:43 PM on 05/09/25. R1 was combative, physically and verbally abusive. R1 sustained 3 skin tears, no skin loss: - large skin tear on Left Forearm; 6 cm L (length) x 10 cm (centimeter) W (width) x 0.1cm D (depth) - small skin tear on Left Forearm; 2 cm L x 2cm W x 0.1 cm D - small skin tear on posterior arm; 2 cm L x 2cm W x 0.1 cm D Skin tears were treated per facility protocol (cleansed, triple antibiotic ointment, steri-strips and foam border dressing). The Physician on call, V2 (Director of Nursing) and V5 (R1's Family Member/POA) notified. Neurological checks could not be completed due to resident refusal. The investigation report provided by V2 (Director of Nursing) titled Falls documented R1 fell on 5/9/25, sustained skin tears, care plan was updated and family was notified. The report did not include interviews of witnesses, cause of the skin tears or that any further investigation was conducted. On 10/14/15 at 3:46 PM, V4 (Certified Nurse Aide) stated V7 (Registered Nurse) asked V4 to come into R1's room and help because she had fallen and was on the floor. R1 did not want staff to touch her. R1 was laying on her elbow. V4 and V9 (Certified Nurse Aide) put a gait belt on R1 but she was combative. R1 said I don't want to see you. Get out of here. R1 was cussing at staff and yelling racial slurs. During the transfer, R1 started flailing her arms again and we noticed her arm was bleeding when she raised it. V4 stated he was unsure if R1 was initially laying on her arm and staff didn't see R1's blood and/or skin tears or if it happened during the transfer. On 10/15/25 at 2:11 PM, V9 (Certified Nurse Aide) stated she was at the foot end and V4 at the head end of R1. R1 combative and called V9 names. Upon lifting R1 into bed, R1 already had blood spots. V9 stated I think (V4) may have grabbed (R1) hard because (R1) was fighting us and her skin tore. I think it was from the transfer not the fall. (V4) would never do that on purpose. (V4) is great and would never hurt anyone. On 10/15/25 at 12:30 PM, V1 (Administrator) and V2 (Director of Nursing) both verbally agreed R1's fall should have been investigated and the root cause for the skin tears determined and had not been. R1 should have been de-escalated prior to transfer by utilizing interventions as instructed on the care plan such as to use extra caution with manually transferring, notified the Physician for an as needed medication to calm R1, redirected with conversation or talked about family, offered to call V5 (R1's Family Member) to speak with R1 to assist with de-escalation and/or used a lifting device or draw sheet to reduce the risk of injury during transfer back to bed. 2. R3 was admitted to the facility on [DATE] with the following diagnoses: Guillain-Barre Syndrome, Parkinson's Disease, Alzheimer's Disease, Osteoporosis, Anxiety, Hypertension, left and right foot drop, and Peripheral Vascular Disease. R3's Minimum Data Set (MDS) dated [DATE] indicates R3 is cognitively intact. On 10/14/25 at 12:50 PM, R3 stated she fell recently (10/10/25) and cracked her knee cap. R3's Clinical Notes Report on 10/11/25 at 3:44 AM documents, At 0200, resident transferred from [NAME] Health Methodist emergency room back to the facility after being evaluated and treated for ground level fall. Diagnosed with Closed Displaced Fracture of Left Patella. R3's Care Plan intervention for falls with creation date of 10/11/25 documents the following: place call don't fall sign in resident's room to remind resident to call for assistance. R3's Clinical Notes Report does not contain documentation a fall occurred on 10/10/25 at 3:15 PM, a head to toe assessment was conducted by a nurse, required notifications were made or reason for transfer to the hospital. On 10/15/25 at 1:39 PM Call, don't fall sign not in place in R3's room. On 10/15/25 at 11:14 AM, V14 (Certified Nursing Assistant) reports she is not aware of any new interventions since R3's fall on 10/10/25. On 10/15/25 at 1:45 PM, V13 (Registered Nurse) reports the facility's Call, don't fall signs are placed in resident rooms where residents can see the sign. V13 verified R3 does not have a Call, don't fall sign in her room. On 10/15/25 at 2:02 PM, V2 (Director of Nursing) confirmed R3's fall on 10/10/25 at 3:15 PM is not documented in R3's medical record and a Call, don't fall sign should be posted in R3's room.

Based on interview and record review the facility failed to ensure residents were free of abuse/misappropriation of property for three of four residents (R1, R3, and R4) reviewed for theft in the sample of seven. Findings include: Facility Policy/Abuse/Neglect Prevention and Response date 7/29/21 documents: Residents and clients of (the facility) will live and be served in an environment that promotes dignity, respect and strives to be free from abuse, neglect and exploitation. Misappropriation of property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 1. Physician Orders indicate R1 was a resident at the facility from 11/15/24 to 12/19/24. Final Report of Financial Abuse dated 12/20/24 indicates that on 12/16/24 R1's credit card numbers were reported as compromised. Report indicates after investigation and video surveillance, evidence led to V7, CNA (Certified Nurse Assistant) as being involved. Report indicates V7, CNA was suspended on 12/16/24 and terminated on 12/18/24 with R1/Family filing a Police report on 12/17/24. Report indicates V7 had only been an employee at the facility since 11/4/24. Report indicates all other residents and families of the facility were interviewed regarding financial abuse and theft. Per investigation, it was found that three other residents were either missing cash from their room or there were fraudulent charges on their credit card. Report indicates all residents will be made whole financially from the credit card company or by the facility. All residents/families have been asked to remove monetary items from their rooms in order to prevent enabling another incident. Report indicates V1, Administrator will have a safe delivered on 12/27/24 for safe keeping any items residents want to keep at the facility. Report indicates Police investigation is ongoing. On 2/4/25 at 2:35pm, V1 (Administrator) stated that on 12/16/24, R1's family told her that R1's credit card had unauthorized charges, which occurred sometime in November (2024). V1 stated that someone had purchased items at two different local stores. V1 stated that later that same day, R1's family sent screenshots of deleted text messages from R1's cellular/cell phone - one for a Television Cable service provider and one was a request for digital payment through R1's telephone. V1 stated that V7 had also sent herself a text message from R1's phone so V7's phone number was in R1's cell phone. V1 stated, I thought I knew who had done it, and then it was confirmed when I saw (V7) going into (R1's) room on a night (V7) wasn't even assigned to that wing or room when I went back and looked at video footage from the hallway camera. V1 stated that R1's family had already contacted the Police and was told to contact them again when she returned to the facility. So R1's family came to the facility and myself, R1's family and R1 had a phone conference with the Police. V1 stated the fraudulent charges on R1's credit card were paid by the credit card company. V1 stated after the Electronic Mail (Email) message went out to all families alerting them to the theft, she received emails from V8, (R3 and R4's family) that they also had weird charges on their credit card. 2. Current Physician Orders indicate R3 was admitted to the facility on [DATE] and R4 (R3's Spouse) was admitted to the facility on [DATE]. Orders indicate R3 and R4 reside in the same room in the facility. Current Comprehensive Assessment indicate both R3 and R4 are both moderately cognitively impaired. On 2/4/25 at 10:15am V1, Administrator, stated that the other residents were R3 and R4 (husband and wife). V1 stated R3 and R4 had charges on their credit card. V1 stated these additional thefts were discovered upon interview with all residents and families. Electronic Mail (Email) correspondence dated 12/19/24 at 9am indicates V1 sent an email to all residents/families notifying them of a recent incident of theft at the facility. On 12/19/24 at 9:25am V8, (R3 and R4's Family Member) responded via email indicating R3 and R4's credit card was fraudulently used several times last month. Email dated 12/20/24 at 10:55am (from V8) to V1, Administrator indicates she received a photo of (R3 and R4's) bank statement with three fraudulent charges highlighted. Email indicates V8 put a freeze on (R3 and R4's) credit card with an attempt to charge nearly $500.00 at an Athletic Shoe store on 12/6/24 that was declined. Email indicates V8 then canceled R3 and R4's credit card and the bank turned the transactions over to the fraud division. Email indicates (R3 and R4) don't seemed rattled by it and mostly glad they didn't have to worry about it. Email response from V1 to V8 dated 12/22/24 at 11:12am indicates It had to be the same person and would send all correspondence on to the Police. Email response from V1 to V8 dated 1/5/25 at 9:09pm indicates V1 did speak with the Police about the theft and was told by the Police that V7, CNA was caught on camera by the Police using (R1's) credit card at a gas station, so we definitely got the correct person and she should be arrested and charged. Email response from V8 to V1 on 1/6/25 at 10:43pm indicates Fortunately for my parents, the credit card company covered the charges and the fraud division has it. I don't think my parents even know it happened and I don't think looping them in will be helpful. ==

Based on observation, interview and record review the facility failed to revise care plans for two residents (R5, R7) of three residents reviewed for swallowing difficulties in the sample of seven. Findings include: Facility Policy/Care Planning dated 1/1/23 documents: To ensure that care planning is individualized, interdisciplinary and based on the assessed needs of the patient. The care plan process includes structured assessment and documentation to include: Physical and psychological assessment, which addresses the current disease status, treatment options, functional status, expected prognosis, symptom burden and psychological coping. Care plan changes are based on the evolving needs and preferences of the patient and family over time, recognizing the complex, competing and shifting priorities in goals of care. 1. Nurse Note dated 7/12/24 at 12:10pm indicates R5 had a brief coughing spell at lunch on patty melt. Nurse did pat R5 on the back and remained with her during coughing. Note indicates R5 was encouraged to sip fluid after she was able to get her breath. R5 had no residual issues or complaints. Nurse Note dated 7/16/24 at 12:40pm indicates a Waiver was signed for dietary items R5 wants regardless of risk currently which are breads and ice cream. Note indicates R5 was aware of risk of aspiration pneumonia, choking, etc. Note indicates R5 was seen by Speech Therapist in AM. Note indicates R5 Family/POA (Power of Attorney) aware of R5 signing waiver and is ok with this. Informed Refusal Form dated 7/16/24 indicates R5 signed a document indicating she understood the probable risks of choking, aspiration pneumonia and death, however waived the risks by requesting breads and ice cream be included in her diet that would otherwise exclude those items due to the above risks. Nurse Note dated 1/13/25 at 11:34pm indicates staff alerted this nurse that R5 observed to be choking at dining room table. When this nurse arrived, R5 was cyanotic. Note indicates V4, CNA (Certified Nurse Assistant) reported they had used the Heimlich maneuver on R5 to dislodge the obstruction. and R5's color was no longer cyanotic and R5 was able to cough and spit up food and mucus. Note indicates Dietary staff notified EMS (Emergency Medical Services). Nurse Note dated 1/13/25 at 11:52am indicates R5's POA was notified regarding R5's choking episode Explained the incident and treatment given. Note indicates R5's POA declined to send R5 to the hospital stating that R5 no longer wanted to go to the hospital. Note indicates staff spoke with R5's POA regarding a speech evaluation or diet change from nectar thick liquids and mechanical soft diet and POA declined at this time. Nurse Note dated 1/27/25 at 2:05pm indicates Family and R5 considering Hospice Care and R5 no longer wants to be sent to the hospital. Nurse Note dated 1/31/25 at 1:45pm indicates Hospice elected for R5, requests comfort focused care and no hospitalization . R5's Current Care Plan indicates R5 receives a soft bite size diet with mildly thick liquids; waiver signed for bread and ice cream. Care Plan does not include two choking incidents (7/16/24 and 1/13/25) or revised interventions including, Hospice Care, no hospitalization s or subsequent interventions. 2. Nurse Note dated 1/31/25 indicates nurse was informed by staff that R7 appeared to have increased secretions and difficulty swallowing while in the dining room eating lunch. R7 was alert, oriented and verbalized that he was in distress. R7 was taken out of the dining room and further assessed by nursing staff with suctioning performed to remove excess secretions. No further airway obstruction noted upon assessment. R7 declined further hospital evaluation and requested that his son be contacted. Note indicates R7 was already being followed by Speech Therapy. Current Physician Orders indicate R7 has diet orders initiated 1/31/25 for Minced and Moist. R7's Current Care Plan indicates R7 receives a Regular diet with thin liquids, is at risk for aspiration; diet changes per SLP (Speech Language Pathologist). R7's Care Plan does not include change to Minced and Moist and does not include incident of choking and suctioning on 1/31/25 with revised interventions. On 2/5/25 at 1:45pm V1, Administrator and V2, DON (Director of Nursing) acknowledged R5 and R7's care plans should have been updated after the choking incidents.

Based on observation, interview and record review the facility failed to place the facility's annual State Survey Results in a readily accessible location for residents for viewing. This failure has the potential to affect all 69 Residents residing at the facility. Findings include: The facility's Resident Rights Policy, dated 1/30/24 document: Policy Statement: Staff shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of the (facility) community. These rights include the resident's right to: H. Be supported by the (facility) community in exercising their rights; M. Exercise rights not delegated to a legal representative; and W. Examine survey results. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) Form, dated 12/10/24, document 69 residents reside in the facility. On 12/11/24 at 1:00 p m, Residents R2, R6, R22, R25, and R53 attended the Resident Council Meeting. Residents confirmed they did not know where the State Survey Results/Binder was located. On 12/11/24 at 1:40 p.m., the facility's State Survey Results/Binder, white in color, was noted on the counter at the facility's nursing station; the counter was 42 inches in height from floor to counter top; and the Binder was placed inside a file folder holder (along with other miscellaneous binders, all white in color) so that the name of the Binder faced upward toward the ceiling. On 12/12/24 at 8:55 a.m., V8 Office Assistant stated that a resident had to ask (V8) to get the Survey Results Binder from the counter for the resident. On 12/11/24 at 1:40 p.m., V12 Activity Director stated that she organizes the Resident Council Meetings with the residents each month. V12 indicated that she was not sure if residents in wheelchairs would be able to reach the Binder. V12 also confirmed she was not sure if residents knew where the Survey Binder was located and residents should have access to the Binder. V12 stated, I will let them know at the next Resident Council Meeting where it is; I just got into this role a few months ago; that is one of their rights to know where the Survey Results are.

Based on observation, interview, and record review the facility failed to ensure a resident call light was in reach for two (R4 and R12) of 17 residents reviewed for call lights in the sample of 26. Findings include: The facility Call Light Response policy and procedure, dated 1/30/24, documents The policy statement To answer call lights and meet resident need(s) in a timely, dignified, and respectful manner. Call lights will be placed within reach of the resident. 1. On 12/12/24 at 8:15 am, R4 was lying in bed on her back with eyes closed. R4's call light noted resting on the floor behind R4's headboard and out of R4's reach. On 12/12/24 at 2:11 pm, R4 was lying in bed on her back and awake. R4's call light noted resting on the floor behind R4's headboard out of R4's reach. R4 mumbled she is unable to locate her call light. On 12/12/24 at 2:20 pm, V11 CNA (Certified Nursing Assistant) stated R4 has a sensitive touch call light and uses the call light at times. V11 CNA stated R4's call light should not be on the floor behind R4's headboard and should be placed where R4 can reach it. V11 CNA stated she would fix it. On 12/12/24 at 2:27 pm, V1 Administrator stated all resident call lights should be within the resident reach at all times whether they use them or not. 31285 2. R12's current Care Plan addresses R12's frequent bowel incontinence with an intervention stating Instruct [R12] to use call light. Answer call light promptly and keep nurse call light within easy reach; and R12's care plan addressing Risk for Falls, with a documented intervention to remind [R12] to call for assistance before attempting to get out of bed. 12/12/24 at 7:50 a.m. R12 was awake and laying in bed. R12 stated I am waiting to have a (bowel movement). At that time, R12's call light was clipped to the cord at the wall, out of her reach. On 12/12/24, at 8:00 a.m., V6/Registered Nurse verified R12's call light should be within her reach and not clipped on the wall.

Based on observation, interview, and record review the facility failed to ensure fall interventions were in place for one (R4) and failed to complete fall risk assessments and root cause analysis for two (R4 and R51) of ten residents reviewed for falls in the sample of 26. Findings include: The facility's Management of Fall Risk policy and procedure, dated 1/30/24, documents Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Each resident will be assessed for the risk factors for falling on admission, quarterly, with change in condition, and upon return from a health care facility. The facility Fall Log, documents R4 had a fall on 8/3/24 at 3:00 am and R51 had falls on 9/2/24 at 1:15 am, 9/27/24 at 6:45 am, and 10/24/24 at 12:30 am. 1. The current Care Plan for R4 documents R4 is at risk for falls and includes the following interventions as: Fall risk assessment to be completed on admission, quarterly, if significant changes, and with falls; Provide environmental adaptations - maintain bed in lowest position while (R4) is in bed; call light within reach; Use call light to ask for help instead of reach for object that is out of reach; Floor mats as indicated while resident is in bed. The Investigation Report for R4's 8/3/24 fall documents: Resident heard by staff yelling. Upon entry resident was noted to be lying on the floor between her bed and recliner chair on her right side. The bed was in the least position. Resident could not tell what happened due to dementia. Vitals obtained; skin assessment completed. ROM completed with grimacing noted to right shoulder. Resident was then helped back into bed by staff. Incontinence care provided. Bed in lowest position and call light within reach. Intervention documented to Provide (rolled edge) mattress for comfort and safety. This investigation does not include a root cause analysis that identifies the reason for R4's fall. The Fall Risk assessment for R4, was not completed until 19 days after R4's 8/3/24 fall on 8/22/24. This Fall Risk assessment documents R4 as a High Risk or falls. On 12/12/24 at 8:12 am, R4 was lying in a low bed with rolled edged mattress in place with her eyes closed. R4's call light was resting on the floor behind R4's headboard out of R4's reach. R4's fall mat was folded and resting against R4's closet and not in use. On 12/12/24 at 2:15 pm, R4 was lying in low bed with call light resting on the floor behind R4's headboard out of R4's reach. On 12/12/24 at 8:15 am, V6 RN (Registered Nurses) confirmed R4 is at risk for falls and should have the fall mat on the floor, on the left side of her bed when (R4) is in bed and the CNAs should place the mat on the floor when they leave her room. V6 also confirmed call lights should be within resident reach at all times. On 12/12/24 at 2:20 pm, V11 CNA (Certified Nursing Assistant) stated R4 has a sensitive touch call light and does use the call light at times. V11 CNA stated R4's call light should not be on the floor behind R4's headboard and should be placed where R4 can reach it. V11 CNA retrieved R4's call light from behind R4's headboard and placed it within R4's reach. 2. The current Care Plan for R51, documents R51 is at risk for falls/injury and documents an intervention as: Fall risk assessment to be completed on admission, quarterly, if significant changes, and with falls. The fall investigations for R51 dated 9/2/24, 9/27/24 and 10/24/24 do not include root cause analysis was completed to identify potential cause of R51's falls. The facility was unable to provide Fall Risk assessments for R51 after R51's falls on 9/2/24, 9/27/24, and 10/24/24. The Fall Investigation for R51's fall, dated 9/2/24 at 2:15 am, documents (R51) was on the call light at 2:15 am, sitting on the floor and calling out for her family to come get her back in bed. Resident was confused, not following commands, yelling, verbally abusive and paranoid. Intervention Offer to call son to speak with resident to help with de-escalation when resident expresses signs of heightened expressions. There is no Fall Risk assessment completed after this fall. The Fall Investigation for R51's fall dated, 9/27/24 at 6:45 am, documents R51 stated I had to pee really bad, so I shouted for help and when no one came, I pulled back the sheets and tried to grab the handlebar to get out of bed, but then I slid down on the floor and my back started hurting. There is no Fall Risk assessment completed after this fall. The Fall Investigation for R51's fall, dated 10/24/24 at 12:30 am, documents (R51) discovered on floor next to bed. (R51) noted with call light in hand. (R51) unable to answer questions about or to answer questions about events. (R51) noted alert to person and place - normal base line. (R51) able to move all extremities without difficulty. Floor mat next to bed while resident is in bed for safety. (R51) was just rounded on 30 minutes prior, call light within reach and noted sleeping. There is no Fall Risk assessment completed after this fall. On 12/11/24 at 2:45 pm, V2 DON (Director of Nursing) was unable to provide root cause analysis regarding R4 and R51's falls. V2 DON confirmed the resident fall investigations for R4 and R51 do not include root cause analysis to help determine why R4 and R51 fell . V2 DON stated, I understand what you are saying and confirmed not all the fall interventions are appropriate for each resident fall related to the root cause of the fall. V2 DON stated the facility discusses resident falls weekly on Thursdays and he will incorporate root cause analysis in future weekly meetings. V2 DON stated fall risk assessments are to be completed quarterly and after each resident fall and confirmed there were no fall assessments completed after R4 and R51's falls.

Based on observation, interview, and record review the facility failed to assess residents for the use of bedrails for two (R26 and R61) of six residents reviewed for bedrails in the sample of 26. Findings include: The facility's Proper Use of Bed Assistive Devices policy and procedure dated 1/30/24, documents The purposes of these guidelines are to ensure the safe use of bed Assistive devices as resident mobility aids and to prohibit the use of bed assistive devices as restraints unless necessary to treat a resident's medical symptoms. Bed assistive devices include side rails, assist rails, and other bed positioning devices. An assessment will be made to determine the resident's symptoms or reason for using the bed assistive device upon initiation, quarterly, and as needed. 1. On 12/10/24 at 10:46 am, there were quarter bed rails noted to each side of R26's bed in the up position. The Bed Assistive Device Assessment's for R26, dated 9/18/24 and 12/7/24 are blank and do not document an assessment having been completed for the use of R26's bed rails. Both assessments document no bed rails are being used for R26 and therefore, no consent is needed. 2. On 12/11/24 at 8:12 am, R61 was lying in bed with quarter bed rails in the upright position on bilateral sides of his bed. The Bed Assistive Device Assessments for R61, dated 11/4/24 and 12/5/24 are blank and do not document R61 being assessed for the use of bedrolls. On 12/12/24 at 11:30 am, V2 DON (Director of Nursing) confirmed bed rail assessments were not completed for R26 and R61 and stated he is unsure why they were not completed. On 12/12/24 at 12:23 pm, V2 DON confirmed that R61's bedrail assessment was not completed on 11/4/24 or 12/6/24 and is using this as an education opportunity for the Nurses.

Based on observation, interview and record review, the facility failed to monitor for identified target behaviors and failed to ensure that identified target behaviors were an indication for the use of an antipsychotic medication for seven of seven residents (R3, R17, R23, R34, R35, R50, and R119) reviewed for psychotropic medications in a sample of 32. Findings include: The facility's Psychotropic Medication Policy, revision date 2/14/20, documents, Residents will not receive psychotropic medications unless behavioral programming and/or environmental changes or other non-pharmacological interventions have failed to sufficiently address the resident's target behavioral goals. If antipsychotic medications are prescribed, documentation will show indication for the medication, attempts to implement care-planned, nonpharmacological approaches and ongoing evaluation of the effectiveness of these interventions. 6. Identified target behaviors will be monitored each shift along with individualized interventions as well as supporting documentation in the clinical record. 1. R3's Electronic medical record documents R3 has a physician order to receive Olanzapine 2.5 mg (milligrams) (antipsychotic medication) daily for Dementia with Behavioral Disturbance and Hallucinations that started on 2/16/22. R3's current care plan and Behavioral Monitoring Logs dated 10/1/22 to 1/24/23 do not include an individualized anti-psychotic plan of care addressing R3's specific behavioral signs/symptoms with interventions for the use of Olanzapine. R3's progress notes dated 10/1/22 to 1/25/23 do not include any adverse behaviors that warrant the use of an antipsychotic medication. On 1/23/23 at 9:50 AM and 1/25/23 at 11:08 AM, R3 was sitting in her room in her wheelchair alert and in a good mood. No behaviors displayed. R3's MDS (Minimum Data Set) Assessments dated 1/17/23, 10/19/22, and 7/20/22 documents R3 has no behavioral symptoms and receives an antipsychotic medication seven days a week. On 1/24/23 at 11:00 AM, V1/Administrator and V2 (DON/Director of Nursing) both stated R3 is not a danger or threat to herself or to other residents. On 1/26/23 at 11:30 AM, V2 and V10 (Registered Nurse) both confirmed the facility has no documentation of target/adverse behaviors/interventions for R3 documented in the medical record. 2. R34's Electronic Medical Record documents R34 has an order for Olanzapine 2.5 mg daily for Depression and Paranoia. R34's current care plan and Behavioral Monitoring Logs dated 10/1/22 to 1/24/23 do not include an individualized anti-psychotic plan of care addressing R34's specific behavioral signs/symptoms with interventions for the use of Olanzapine. R34's progress notes dated 10/1/22 to 1/25/23 do not include any behaviors that warrant the use of an antipsychotic medication. On 1/23/23 at 9:55 AM and 1/25/23 at 11:10 AM, R34 was sitting in her room in her wheelchair with no adverse behaviors displayed. On 1/24/23 at 11:00 AM, V1/Administrator and V2 (DON/Director of Nursing) both stated R34 is not a danger or threat to herself or to other residents. On 1/26/23 at 11:30 AM, V2 and V10 (Registered Nurse) both confirmed the facility has no documentation of target/adverse behaviors or interventions for R34 documented in the medical record. 3. R17 Physician's Orders, dated 1/1/2022, documents, Olanzapine (antipsychotic) 5MG (milligrams) by mouth daily. R17's medical record documents the following diagnosis: Dementia without behavioral disturbance, Depression, Anxiety, Insomnia, Psychotic Disturbance, Mood Disturbance and Bipolar Disorder. R17's current Care Plan report, documents the following problems: Antipsychotic use- (R17) is currently taking antipsychotic medication for Bipolar Disorder. Psychotropic drug use: (R17) uses psychotropic medications to manage Bipolar Disorder, Anxiety, Depression and Dementia. R17's Behavior Assessment, dated 12/11/2022, documents, Repetitive statements or issues, attention seeking through constant complaints of health, manipulates others, plays one against the other, repeatedly accuses staff of misplacing her items. R17's Behavior Monitoring form, dated 12/1/ 2022- 12/31/2022, documents. No behaviors, except on 12/5/22 days, refused cares. R17's Behavior Monitoring form dated 1/1-1/31/2023, documents, No behaviors are being tracked. On 1/23/2023 at 9AM, R17 was sitting in her room looking through her dresser drawers. R17 stated, I need to use the bathroom, I am waiting for assistance of two people. R17 did not display any adverse behaviors. On 1/26/2023 at 1:30 PM, V10/Care Plan Coordinator confirmed (R17) does not have the targeted/adverse behaviors for the use of the antipsychotic drug. 4. R23's Psychotropic Medication Consent, dated 12/5/2021, documents, Antipsychotic Drug name: Risperidone 0.25MG daily for Dementia. R23's medical record documents the following diagnosis: Alzheimer's Disease with late onset, Anxiety, Dementia without Behavioral Disturbances, Mood Disturbances and Depression. R23's Care Plan Report dated 8/23/2021, documents, R23 has other behavioral symptoms, not directed toward others. R23 will call out for help at times. R23 will pull her hair out and pick at her scabs, to make them bleed. R23's Resident Behavior Tracking Tool, dated 10/8/2022-12/2/2022, documents under Behavioral Symptoms: 0 none. R23's MDS (Minimum Data Set), dated 1/25/2023, documents the following: Section E Behavior Symptoms-Presence and Frequency, Behavior of this type occurred 1 to 3 days. C.) other behavioral symptoms not directed toward staff: Physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms, like screaming, disruptive sounds. On 1/23/2023 at 10:15AM, R23 was in her room lying in bed. R23 is alert, does not answer questions appropriately. R23 did not display any adverse behaviors. On 1/26/2023 at 1:30 PM V10/Care Plan Coordinator stated,R23 does not have the specific behavior symptoms to warrant the use of the antipsychotic drug. 5. R35's current Physician's Orders document the following medication orders: Sertraline (antidepressant) 25 milligrams one tablet every two days; Seroquel (antipsychotic)100 milligrams one time daily; Lorazepam (antianxiety) 0.5 milligrams by mouth daily in AM; Lorazepam 1 milligram by mouth daily in PM. R35's progress notes (dated 10/01/22 to 01/25/23) do not include any documentation of consistent adverse behaviors displayed. R35's Behavior Monitoring Sheets (dated 10/01/22 - 01/25/23) do not document any specific behaviors in which R35 is being monitored for or any consistent adverse behaviors displayed. On 01/23/23 at 09:40 AM, R35 was lying in a low bed asleep with two upper 1/2 side rails attached to bed and secured in the upright position. On 01/24/23 at 08:05 AM, R35 was sitting at the dining room table eating breakfast. R35 appeared to be cooperative and enjoying the meal. No adverse behaviors displayed by R35 at this time. On 01/26/23 at 12:30 PM, V10 (Registered Nurse) stated R35 displays the following adverse behaviors: Anger, Physical Aggression towards staff during cares, and Anxiety. V10 confirmed that there is no consistent documentation of any of these behaviors in R35's medical record. V10 stated that R35's Behavior Monitoring Sheets do not specifically mention R35's target behaviors, Staff is supposed to document any behaviors they observe. V10 also stated that none of these mentioned behaviors that R35 is currently monitored for displaying warrant the use of an antipsychotic medication. 6. R50's current Physician's Orders document the following medication orders: Sertraline (antidepressant) 100 milligram tablet one time daily take with 50 milligram tablet to equal 150 milligrams for Depression; Sertraline 50 milligrams tablet one time daily take with 100 milligram tablet to equal 150 milligrams for Depression. R50's progress notes (dated 10/01/22 to 01/25/23) do not include any documentation of consistent adverse behaviors displayed. R50's Behavior Monitoring Sheets (dated 10/01/22 - 01/25/23) do not document any specific behaviors in which R50 is being monitored for or any consistent adverse behaviors displayed. On 01/23/23 at 10:15 AM, R50 was sitting in a chair in the sitting area of the care center watching television with several other residents sitting nearby. No adverse behaviors were displayed by R50 at this time. On 01/26/23 at 12:30 PM, V10 (Registered Nurse) stated R50 displays the following adverse behaviors: Depression and Anxiety. V10 confirmed that there is no consistent documentation of any of these behaviors in R50's medical record. V10 stated that R50's Behavior Monitoring Sheets do not specifically mention R50's target behaviors, Staff is supposed to document any behaviors they observe. 7. R119's current Physician's Orders document the following medication order: Aripiprazole 5 milligram tablet one time daily for Psychosis. R119's progress notes (dated 10/1/22 to 01/25/23) do not include any documentation of consistent adverse behaviors displayed. R119's Behavior Monitoring Sheets (dated 10/01/22 - 01/25/23) do not document any specific behaviors in which R119 is being monitored for or any consistent adverse behaviors displayed. On 01/23/23 at 09:55 AM, R119 was sitting in a wheelchair in the sitting area near the nurse's station of the care center watching television. Several other residents were also present in the sitting area with R119. R119 appeared cooperative and did not display any adverse behaviors at this time. On 01/26/23 at 12:30 PM, V10 (Registered Nurse) stated R119 displays the following adverse behaviors: Sexually inappropriate towards staff; and Physical Aggression: hitting staff/throwing objects when agitated. V10 confirmed that there is no consistent documentation of any of these behaviors in R119's medical record. V10 stated that R119's Behavior Monitoring Sheets do not specifically mention R119's target behaviors, Staff is supposed to document any behaviors they observe.

Based on observation, interview and record review, the facility failed to follow a physician's order for wound dressings and treatments, transcribe a physician order's to the order sheet and the treatment administration record, develop a site-specific wound and wound vacuum care plan, revise a pressure ulcer care plan, sanitize scissors before and during pressure ulcer care, and perform hand hygiene and glove change during pressure ulcer care for two of two residents (R43, R60) reviewed for pressure ulcers in the sample of 32. Findings include: The facility's Standard Precautions policy, dated 9/23/22, documents Standard precautions will be used in the care of all residents regardless of their diagnosis or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. This same policy also documents Wash hands after removing gloves. Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. The facility's Handwashing/Hand Hygiene policy, dated 9/23/22, documents This organization considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Use an alcohol-based hand rub containing at least 60% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after direct contact with residents; Before and after performing any non-surgical invasive procedures; Before handling clean or soiled dressings, gauze pads etcetera; Before moving from contaminated body site to a clean body site during resident care; After contact with a resident's intact skin; After contact with blood or bodily fluids; After handling used dressings, contaminated equipment, After removing gloves. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing health care associated infections. This policy also documents Steps in the procedure, Washing Hands: Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of twenty seconds (or longer) under a moderate stream of running water, at a comfortable temperature. The facility's Care Plans- Comprehensive Person-Centered policy, dated 9/14/22, documents A comprehensive, person-centered care plan that includes measurable objects and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Services provided or arranged are culturally competent and trauma informed. In addition to the formal care plan document, the resident's individualized plan of care, as determined through the care planning process, will also be reflected in and communicated to the team via, but not limited to, the following tools: Current Physician Orders, Current Medication Record, Current Treatment record. This policy also documents The comprehensive, person-centered care will: Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; Aid in preventing or reducing decline in the resident's functional status and/or functional levels. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The facility's Physician Order policy (revised 09/16/22) documents the following: Orders for medications and treatments will be consistent with principles of safe and effective order writing. All orders will be transcribed and followed as directed. 1. On 1/23/23 at 10:35 AM, R60 was in her room sitting in chair. R60 stated she had a fall at home and developed a pressure ulcer to her heel and her foot while being hospitalized for the injury. R60 stated I was admitted here and had this pressure wound on my foot from the cast I was in. I now have a wound vacuum on it and I have a heel pressure ulcer. I have another wound on my thigh from a skin graft but my foot didn't take the graft. I've been on antibiotics for my foot infection and have this wound vacuum to help with healing. On 1/24/23 at 11:50 AM, V8 (Licensed Practical Nurse) and V9 (Registered Nurse/Wound Nurse) entered R60's room to perform pressure ulcer care. V8 and V9 did not perform any hand hygiene and then applied gloves. V8 then gathered dressing supplies and placed them on the R60's bed on top of R60's blanket. V8 removed the old clear bandage from the anterior portion of R60's left foot and removed the wound vacuum dressing using (un-cleansed) scissors from V8's pocket. V8 then removed her gloves and washed her hands for seven to eight seconds. R60's wound on the top of her foot was oozing and bleeding in some spots. V8 applied new gloves and cleansed the top of the wound with wound spray and gauze. V9 assisted with positioning the leg and assisting V8 with supplies. V8 removed her gloves and washed her hands for six seconds. V8 then applied new gloves. At this time V9, wearing her original gloves, took (un-cleansed) scissors from her waist supply pack and used them to cut a new clear dressing. V8 took her scissors once again from her pocket (without cleaning) and used them to cut the foam to fit the open wound on R60's foot and then placed them back in her pocket. V9 placed the foam on the wound to check the fit then continued to cut and trim around parts of the wound foam which had spots of blood and fluid from the open wound. V9 then put her (un-cleansed) scissors back in her waist supply pouch. V9 continued to dress the wound vacuum site and turned the machine on. With the same original gloves V9 then removed an old dressing from R60's left heel and placed a new square of yellow medicated gauze into the heel wound. V9 then pressed the treatment into the heel wound (still wearing her original gloves) and applied a bandaged tape to the top. On 1/24/23 at 3:02 PM, V8 (Licensed Practical Nurse) stated I clean my scissors between patients. Sometimes I clean them in the middle of a wound dressing if I am cutting multiple items. I didn't today. I normally wash my hands for 20 seconds but I probably didn't today. I think I was nervous. I don't always set my supplies on the bed or a not cleaned surface. You should always sanitize your hands and change gloves when going from one wound site to another site. (R60's) heel treatment is not in computer or on Physician Order Sheet. It should be. I am not sure why the order wasn't transcribed. I will make sure it gets put in today. R60's Current Physician Order Sheet and Treatment Administration record does not document an order for R60's pressure ulcer heel dressing until 1/24/23 at 4:45 PM. R60's Care Plan does not contain a plan of care for R60's anterior foot pressure ulcer with a wound vacuum. On 1/26/23 at 8:55 AM, V14 (Care Plan/Minimum Data Set assessment Coordinator) confirmed that R60's pressure ulcer with a wound vacuum is not on her care plan. V14 stated I don't see where the skin graft or the foot wound with wound vacuum is on the care plan. I am not sure why it didn't get put on there. We had two at the same time that got skin grafts so maybe I thought it was there, but missed it. I would normally put in on the care plan, it should be there. On 1/26/23 at 10:45 AM, V2 (Director of Nursing) stated When nurses go into a residents room they should perform hand hygiene before applying gloves. In-between wound sites gloves should be changed and hands should be washed or sanitized with alcohol. The scissors should be sanitized before and after use for each wound site. 2. On 01/23/23 at 09:45 AM, V2 (Director of Nursing) stated that R43 is currently receiving treatment for a pressure ulcer on his left shoulder. On 01/23/23 at 09:55 AM, R43 was lying supine in bed with a pillow positioned underneath his head. R43 was wearing a gown and was covered with a sheet from his chest down. A cup of orange juice was within R43's reach on a nearby bedside table. R43's skin was pale and he appeared extremely thin and gaunt. R43's lips appeared dry, and an indwelling urinary catheter drainage bag was hanging from the lower aspect of R43's bed with dark amber urine present in the bag. On 01/23/23 at 10:02 AM, V19 (Licensed Practical Nurse) stated R43 has an indwelling catheter that is changed monthly, and he is currently being treated for a wound on his shoulder. V19 stated R43 has poor intake, and refuses care and repositioning often, but he loves his orange juice. R43's current Physician's Orders document the following: Change dressing to back left shoulder to prevent skin breakdown three times weekly; Cleanse and pat dry left hip, place foam dressing for preventative care every three days; Stage IV pressure wound of the left, lateral knee. Cleanse area, pat dry, apply foam silicone border dressing three times per week. R43's current care plan has no mention of R43's physician ordered pressure ulcer prevention treatments for R43's left shoulder or left hip. On 01/25/23 at 02:00 PM, V19 (Licensed Practical Nurse) entered R43's room to perform pressure ulcer care. R43 was wearing a gown and was lying supine in bed with a pillow positioned underneath his head and neck. V19 applied gloves, approached R43, and assisted him to roll on to his right side. R43's left shoulder did not have a dressing in place, and V19 stated, We are not putting a dressing on his shoulder anymore. We just apply skin prep to the area. R43's left shoulder had scattered areas of redness present, and V19 proceeded to apply skin prep to R43's left shoulder area. V19 then pointed to a Stage 4 pressure ulcer on R43's left lateral knee. R43's left knee pressure ulcer did not have a dressing in place, and an oblong pressure ulcer was present on his left lateral knee measuring approximately 3 inches by 1 inch with a large amount of eschar tissue present. V19 then applied skin prep to R43's pressure ulcer, placed a foam border dressing over the wound, and proceeded to pick up R43's left foot to point out an area of redness present on his left heel. V19 stated, We put skin prep here as well for a preventative. Our preventative skin care is always skin prep. V19 then proceeded to apply skin prep to R43's left heel, and covered the area with a foam border dressing. V19 stated, He also has an area on his hip that we are just watching because the pressure ulcer has healed, and then removed the left side of R43's incontinent brief, exposing an approximately 3 inch linear area without a dressing in place on R43's left hip. This area was intact and was white in color. V19 then refastened R43's incontinence brief, and assisted R43 to roll back to a supine position in bed and covered R43 with a sheet. After assisting R43 to reposition, V19 removed her gloves, exited R43's room and approached the medication cart. V19 did not wash her hands or perform hand hygiene before, during or after R43's wound care. At this time, V19 stated it was not necessary to wash her hands or change gloves throughout R43's cares because, the skin prep sanitizes. On 01/25/23 at 03:00 PM, V2 (Director of Nursing) stated that R43's left shoulder and left hip should have had a dressing in place as stated in R43's current Physician's Orders. V2 stated that R43's left hip wound should have been cleaned with wound cleanser, and, Skin prep should not be applied unless there is a doctor's order. V2 also stated that R43's left heel currently does not have a physician's order in place for any type of treatment to be performed. V2 stated that V19 should have washed her hands before administering wound care, and should have changed her gloves and performed hand hygiene between each treatment. V2 also stated that he always expects physician's orders to be followed. On 01/26/23 at 09:00 AM, V14 (Care Plan Coordinator) confirmed that R43's current care plan does not mention R43's physician ordered pressure ulcer prevention treatments for R43's left shoulder or left hip. V14 stated, I haven't been putting preventative treatments on the care plan.

Based on interview, observation and record review, the facility failed to ensure an elopement deterrent device was monitored for functionality and placement for one resident (R50) reviewed for wandering/elopement in a sample of 32. Findings include: R50's Wandering/Elopement Risk Assessment (dated 09/20/22) documents R50 is at risk for wandering/elopement, and indicates the following: Elopement deterrent device implemented. R50's current Physician's Orders documents the following order: (Elopement deterrent device) check for functionality and placement every shift and PRN (as needed) placement left ankle. R50's current Care Plan documents the following problem: (R50) has exhibited wandering behavior. This same care plan documents the following intervention: Use (elopement deterrent device). Location: left lower extremity. Monitor every shift and PRN (as needed). On 01/23/23 at 10:15 AM, R50 was sitting in a chair in the sitting area watching television with several other residents sitting nearby. R50 was dressed and groomed and a nearby walker was within her reach. An Elopement deterrent device was in place around R50's left ankle. On 01/24/23 at 07:55 AM, R50 was ambulating in the hallway with the assistance of her walker. R50 seated herself in a chair near the medication cart, and V19 (Licensed Practical Nurse) prepared and administered R50's morning medications. R50 then stood and began ambulating in the hall towards the central nurse's station of the facility's care center. R50's current medical record including R50's Medication Administration Records and Treatment Administration records have no documentation of any monitoring of R50's (elopement deterrent device). On 01/25/23 at 11:20 AM, V2 (Director of Nursing) stated that R50's (elopement deterrent device) has not been monitored, We should be checking it for functionality and placement. It hasn't been checked daily, and it should have been.

Based on observation, interview and record review the facility failed to complete quarterly side rail assessments for one of one resident (R8) reviewed for side rails in the sample of 32. Findings include: The facility's Proper Use of Bed Assistive Devices policy, dated 9/16/22, documents The purpose of these guidelines are to ensure the safe use of bed assistive devices as resident mobility aides and to prohibit the use of bed assistive devices as restraints unless necessary to treat a resident's medical symptoms. Bed assistive devices include side rails, assist rails, and other bed positioning devices. This policy also documents An assessment will be made to determine the resident's symptoms or reason for using the bed assistive device upon initiation, quarterly and as needed. On 1/25/23 at 11:30 AM, R8's bed had bilateral 1/2 side rails in the upright position. R8's current medical record documents the most recent Bed Assistive Device Assessment was completed on 7/2/22. On 1/26/23 at 11:50 AM, V1 (Administrator) stated she does not have a side rail assessment for R8 since July of 2022. V1 stated The assessment should be done quarterly so (R8) should have two more assessments since July.

Based on observation, interview and record review, the facility failed to sanitize scissors before and during wound care, and perform adequate hand hygiene before and during wound care for one of seventeen residents (R60) reviewed for infection control in the sample of 32. Findings include: The facility's Standard Precautions policy, dated 9/23/22, documents Standard precautions will be used in the care of all residents regardless of their diagnosis or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. This same policy also documents Wash hands after removing gloves. Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. The facility's Handwashing/Hand Hygiene policy, dated 9/23/22, documents This organization considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Use an alcohol-based hand rub containing at least 60% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after direct contact with residents; Before and after performing any non-surgical invasive procedures; Before handling clean or soiled dressings, gauze pads etcetera; Before moving from contaminated body site to a clean body site during resident care; After contact with a resident's intact skin; After contact with blood or bodily fluids; After handling used dressings, contaminated equipment, After removing gloves. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing health care associated infections. This policy also documents Steps in the procedure, Washing Hands: Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of twenty seconds (or longer) under a moderate stream of running water, at a comfortable temperature. R60's Physician Order sheet, dated 1/24/23, documents an order started on 1/13/23 to Change dressing to right anterior thigh wound three times weekly. Apply single layer of (yellow medicated gauze) to open area and cover with four by eight border gauze. On 1/23/23 at 10:35 AM, R60 was her in room sitting in chair. R60 stated I have a wound on my thigh from a skin graft. I've been on antibiotics for my foot infection and have this wound vacuum to help with healing. On 1/24/23 at 11:50 AM, V8 (Licensed Practical Nurse) and V9 (Registered Nurse/Wound Nurse) entered R60's room to perform wound care. V8 and V9 did not perform any hand hygiene and then applied gloves. V8 and V9 completed R60's pressure ulcer care first. V8 then washed her hands for nine seconds and applied new gloves. V8 washed R60's skin graft wound on her right thigh with wound wash and gauze. V9 washed her hands and applied new gloves. V9 then took scissors that were previously used during pressure ulcer care (at which point they came in contact with blood and fluid from the pressure wounds and were not cleansed after use), from her waist supply pack and cut strips of yellow medicated gauze and applied them to the open areas on R60's thigh wound. V9 then placed her scissors on R60's bedside table, on top of her glasses case, and then picked them up again and continued to use them to cut the medicated gauze strips and place them on R60's wound. On 1/24/23 at 3:02 PM, V8 (Licensed Practical Nurse) stated I clean my scissors between patients. Sometimes I clean them in the middle of a wound dressing if I am cutting multiple items. I didn't today. I normally wash my hands for 20 seconds but I probably didn't today. I think I was nervous. On 1/26/23 at 10:45 AM, V2 (Director of Nursing) stated When nurses go into a residents room they should perform hand hygiene before applying gloves. In-between wound sites gloves should be changed and hands should be washed or sanitized with alcohol. The scissors should be sanitized before and after use for each wound site.

Based on interview, observation and record review, the facility failed to ensure a resident with limited range of motion was provided appropriate treatment and services to maintain and/or prevent a further decrease for three of six residents (R4, R43 and R49) reviewed for limited range of motion in the sample of 32. Findings include: 1. R4's current care plan documents the following: R4 has ADL (activities of daily living) self-care deficit, as evidenced by needing assistance with ADL's; weakness in lower extremities. R4's Minimum Data Set Assessment (dated 11/10/22) documents the following in Section G titled 'Functional Limitation in Range of Motion:' R4 has impairment on both sides of her lower extremities. R4's current medical record has no documentation of any type of range of motion program in place. On 01/23/23 at 09:15 AM, R4 was reclined in a recliner with a mechanical lift sling positioned in place underneath her. R4 nodded her head yes when asked is she is a full mechanical lift and when asked if she is unable to stand. On 01/25/23 at 02:15 PM, V2 (Director of Nursing) stated the facility does not currently have any type of range of motion program in place for residents with functional limitations. V2 also stated the facility does not have a policy specific to range of motion because they do not have a formal range of motion program in place. 2. R43's current medical record documents R43's diagnoses to include: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R43's Minimum Data Set Assessment (dated 11/03/22) documents in Section G titled 'Functional Limitation in Range of Motion:' R43 has impairment on one side of his upper extremities and impairment on both sides of his lower extremities. R43's current medical record has no documentation of any type of range of motion program in place. On 01/25/23 at 02:00 PM, V19 (Licensed Practical Nurse) entered R43's room to perform wound care. R43 was wearing a gown and was lying supine in bed with a pillow positioned underneath his head and neck. V19 approached R43, and provided assistance in order for R43 to roll on to his right side. On 01/25/23 at 02:15 PM, V2 (Director of Nursing) stated the facility does not currently have any type of range of motion program in place for residents with functional limitations. V2 also stated the facility does not have a policy specific to range of motion because they do not have a formal range of motion program in place. 3. On 1/23/2023 at 10AM, R49 was in her room sitting in her wheelchair. R49 is alert but is not able to answer questions appropriately. R49's MDS (Minimum Data Set), dated 11/2/2022, documents under Section G Functional Status, Functional Limitation in Range of Motion: Impairments on both sides: Lower extremity. R49's Physical Therapy Plan of Care, dated 2/3/2021, documents the following: Muscle Weakness, Difficulty in walking. Gross motor coordination left lower extremity: Moderately Impaired. Gross motor coordination, right lower extremity: Moderately Impaired. On 1/26/2023 at 2:35 PM, V2/DON (Director of Nurses) stated There is no formal ROM (Range of Motion) program in place, for R49.

Based on observation, interview and record review, the facility failed to properly secure and use the correct sling during a mechanical transfer for one (R1) of three residents reviewed for mechanical transfers in a sample of four. These failures resulted in (R1) slipping through the slit/hole in the back of the sling and suffering a left [CONDITION(S)]. Findings include: Facility Event Reporting, revised 7-29-2021, documents Events involving a resident, visitor, or other person (non-employee) that are outside of usual or normal happenings and present a potential liability, and events that are not in keeping with standards, policies, procedures or practices and may have an adverse outcome will be documented. An Adverse Event is defined as an undesired outcome or occurrence, not expected within the normal course of care or treatment, disease process, condition of the resident, or delivery of services. Facility Safe Lifting and Movement of Residents, revised 9/16/22, documents under Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this community uses appropriate techniques and devices to lift and move residents. Facility Positioning & Moving, reviewed 9/16/22, documents under Policy Statement: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. Center for Clinical Excellence Steps in the Procedure 1. Before using a lifting device, assess the resident's current condition. 2. Select a sling that is appropriate for the resident's size and the task. 9. Before resident is lifted, double check the security of the sling attachment. Facility report to state agency, dated 10/31/22 by V1 Administrator, documents During a (mechanical) transfer on 10/27/22 (by V3 and V4 CNAs/certified nursing assistants), (R1's) bottom slid out of the sling and (R1) slipped approximately one inch back into (R1's) recliner that (R1) was being lifted out of. (R1) has limited upper body strength for positioning. (V5 LPN/Licensed Practical Nurse) was summoned to the room and assisted with repositioning (R1's) arm which was positioned between the recliner chair cushion and recliner arm area crease. (R1) was admitted to (local hospital) on 11/1/22 for ORIF/Open reduction internal fixation of the left hip. R1's hospital record, dated 10/31/2022 at 6:15 pm by V7 MD/Medical Doctor, documents (R1) is [AGE] year old and presents to the ED/Emergency Department with a four day history of left hip pain. (R1) is immobile at baseline due to previous stroke. (R1) lives in a nursing home - she was being hoisted with a (mechanical) lift four days ago when she was dropped a few inches from the nursing home onto the bed. (R1) has been having pain to her left hip since that time, which worsened two days ago when she was being moved. Pain worsens with palpation and movement of left lower extremity. R1's hospital record, dated 10/31/22 at 11:47 pm to 11/01/22 12:47 am by V10 MD, documents EXAM: X-RAY LEFT HIP. HISTORY: Left hip pain. IMPRESSION: 1. Comminuted and displaced left intertrochanteric femur fracture. R1's hospital record, dated 11/1/22 at 12:05 pm by V12 PAC/Physician Assistant Certified, documents ORTHOPEDIC CONSULT Date of service: 11/1/2022 Chief Complaint: LEFT HIP PAIN. Musculoskeletal - Left lower extremity - leg is shortened and externally rotated. Pain with palpation of hip. Pain in hip with log rolling of the leg. Xray: Left hip/femur - Comminuted and displaced left intertrochanteric femur fracture. Plan: We will plan to go to the OR today for ORIF left IT (Intertrochanteric) fracture. R1's hospital record, dated 11/3/22 at 9:01 pm by V8 APRN/Advanced Practice Registered Nurse, documents (R1) was originally admitted on ,d+[DATE] with left femur intertrochanteric fracture. (R1) was dropped a couple of inches from her hoyer lift at the nursing home approximately four days prior to admission and had complained of persistent pain in the left hip since. (R1) underwent ORIF left intertrochanteric femur fracture on 11/1. R1's current facility careplan- documents (R1) will maintain current level of abilities including lift transfers. R1's facility MDS/Minimum Data Set, dated dated [DATE], documents R1 requires extensive assistance for transfers, and always incontinent of bowel and bladder. R1's 4/6/22 MDS documents R1 requires extensive assistance of two plus persons for transfers, impairment of both lower extremities, and always incontinent of bowel and bladder. V1 Administrator E-mail, dated 11/15/2022 at 4:49 PM, documents We use the following lifts: Hoyer (mechanical). We have Full Body Slings for the Hoyer-s/m/lg/xlarge; toileting slings for the Hoyer-s/m/lg/xlg; and shower slings for the Hoyer-s/m/large/xlarge. On 11/15/22 multiple residents were observed in the common area and their bedrooms with mechanical lift slings placed under the residents in their wheelchairs. Extra mechanical lift slings were observed in the weight room including shower/toileting slings, full body slings, and sit to stand slings. On 11/15/22 at 10:00 am, V1 Administrator stated I was notified by staff about (R1) and I was told (R1) came down about an inch onto her chair. (R1) did not fall. On 11/15/22 at 10:30 am, V6 APN/Advanced Practice Nurse RN/Registered Nurse, stated On 10/31/22 (R1) was lying in her recliner when I assessed her, she had hip pain and swelling, and left upper outer thigh pain. She did deny pain unless her leg was moved, her left lower extremity was shortened, yelled out in pain, and left lateral thigh was red. I ordered a left hip X-Ray. On 11/16/22 at 10:45 am, V5 LPN/Licensed Practical Nurse stated I was working on 10/27/22 as (R1's) nurse. I also worked with (R1) on 10/28/22 and 10/31/22 when she was sent to the hospital due to an increase in her pain to the left hip that was not controlled with Tylenol. (V3 and V4 CNAs) called me to (R1's) room where they had (R1) in the chair with a mechanical sling that was up under her that had slipped. They couldn't get the sling out from under her, and she was leaning to the left side. It was not a full body sling, it was a toilet sling that had slipped up under her arms, and the sling was the problem. The left arm pad of the toilet sling was up under her left arm and she was lying on her left arm. The sling they used was a toilet sling where you put your arms through the holes and then criss cross the sling across the thighs. After they took the sling off her I told them this sling is not what we use for transferring her. They used a toilet sling to transfer her but she does not get toileted so I am not sure why they used that sling on her. The toilet sling is small and not as much fabric to support the resident. We try to have a sling for each resident in their room unless it gets soiled then it is sent to laundry. The slings that are used go by their size from medium to xl. (R1) is incontinent of bowel and bladder at all times and wears incontinent briefs. (R1) has no trunk control and leans to the left side. All the extra slings are kept in the weight room where they are washed and air dried. On 11/15/22 at 12:00 pm, V15 and V16 both CNAs/Certified Nursing Assistants stated A toilet sling is where the arms go thru like a vest, the sling then gets pulled down and wraps around to fit under the hips and criss cross around the thighs to where your bottom is left out to toilet, and we use them when toileting. On 11/15/22 at 12:15 pm, V3 CNA via phone stated I was working on 10/27/22 and I was helping (V4 CNA) with a transfer of (R1). We were lifting her up and she fell through the bottom of the sling, and it was a shower or toilet sling we were using not a full body sling. The shower or toilet sling leaves a big gap where there is a hole where your bottom is, and it is easy to fall through because (R4) almost fell through it yesterday and she is a bigger lady. I have worked at (facility) since July 2022. There are multiple types of slings hanging in the weight closet. I was spotting (R1) while (V4) was using the controls on the lift, and (V4) put the lift under (R1) before I got in the room. On 11/16/22 at 10:17 am, V4 agency CNA via phone stated I was working as the CNA for (R1) on 10/27/22. It was a freak accident. The sling we (V3 and I) were using was the one in her room which had a slit in the back and buckles on the sling. One of the buckles came undone and (R1) then slipped through the slit/hole in the back of the sling. The buckles are plastic, it came unbuckled from the hoyer, and I had never used this type of sling before. I have been a CNA for 4 years. It is a newer hoyer lift with different slings and there are a bunch of different slings at (facility). I refrain from using the sling now. (R1) said it scared her.

Based on observation, interview and record review, the facility failed to ensure all nurse aides including agency nurse aides were provided training and were competent in their skills for mechanical lifts and different sling use for 1 of three residents (R1) reviewed for transfers. Findings include: Facility Positioning & Moving, reviewed 9/16/22, documents under Policy Statement: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. 5. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the community. Facility report to state agency, dated 10/31/22 by R1 Administrator, documents During a (mechanical) transfer on 10/27/22 (by V3 and V4 both CNAs/certified nursing assistants), (R1's) bottom slid out of the sling and (R1) slipped approximately one inch back into (R1's) recliner that (R1) was being lifted out of. (R1) has limited upper body strength for positioning. (V5 LPN/Licensed Practical Nurse) was summoned to the room and assisted with repositioning (R1's) arm which was positioned between the recliner chair cushion and recliner arm area crease. (R1) was admitted to (local hospital) on 11/1/22 for ORIF/Open reduction internal fixation of the left hip. V1 Administrator's E-mail, dated 11/15/2022 at 4:49 PM, documents We use the following lifts: Hoyer (mechanical). We have Full Body Slings for the Hoyer-s/m/lg/xlarge; toileting slings for the Hoyer-s/m/lg/xlg; and shower slings for the Hoyer-s/m/large/xlarge. Facility was unable to provide CNA training for V3 and V4 on the mechanical lifts and different sling use that was requested on 11/15/22 at 1:03 pm, and 11/16/22 at 12:03 pm and 12:42 pm. Facility training's that were provided by V1 did not have where V3 CNA and V4 agency CNA were provided mechanical lift training or different sling use. Training dated 11/15/22 (after the surveyor was in the building) did not include V3 and V4 in any of the training, and other training provided (undated) did not include any mechanical lift training or different sling use to V3 and V4. On 11/15/22 multiple residents were observed in the common area and their bedrooms with mechanical lift slings placed under the residents in their wheelchairs. Extra mechanical lift slings were observed in the weight room including shower/toileting slings, full body slings, and sit to stand slings. On 11/15/22 at 12:15 pm, V3 agency CNA via phone stated I was working on 10/27/22 and I was helping (V4) with a transfer of (R1) when she fell through the bottom of the toilet/shower sling. It is easy to fall through because (R4) almost fell through it yesterday. I have worked at (facility) since July 2022, and there are multiple different slings hanging in the weight closet. I do not use the shower/toilet sling anymore because I don't think it is safe. These slings are new. On 11/16/22 at 10:17 am, V4 agency CNA via phone stated I was working as the CNA for (R1) on 10/27/22, it was a freak accident, and the sling we were using was the one in her room which had a slit in the back and buckles on the sling. I had never used this type of sling before. I have been a CNA for 4 years. It is a newer (mechanical) lift with different slings and there are a bunch of different slings at (facility). I was trained on how to use the mechanical lift machine but never seen/used this sling before and I refrain from using the sling now.

Based on interview and record review the facility failed to ensure a resident's physician ordered antihypertensive medication was correctly transcribed and ordered for one of three residents (R1) reviewed for medications in the sample of three. This failure resulted in R1 receiving triple the dose of an antihypertensive medication at three different times. R1 became dizzy and hypotensive with altered level of consciousness. R1 required emergent transfer via ambulance to the local area hospital in which R1 received five doses of a reversal agent intravenously and was admitted to the Intensive Care Unit on blood pressure support medication. Findings include: The facility's Receiving and Transcribing Orders Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . All orders will be transcribed and followed as directed .The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. 2. A current list of orders must be maintained in the clinical record of each resident. The facility's Admissions, Transfers and Discharges policy, revised 4/26/21, Admission Assessment and Follow Up: Role of the Nurse. Steps in the Procedure: 5. Reconcile the list of medications from the medication history, admitting orders, the previous MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Administering Medication policy, revised 5/26/21, states, Policy Statement: Medication shall be administered in a safe and timely manner and as prescribed. The community shall provide residents with necessary medication(s) when they leave the community temporarily. 2. Medications must be administered in accordance with the orders, including any required time frame. 4. If a dosage is believed to be inappropriate or excessive for a resident, or medication has been identified as having potential adverse consequences for the resident, the person preparing or administering the medication shall contact the resident's physician to discuss the concerns. The facility's Reconciliation of Medication policy, revised 4/26/21, states, The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medication, route, and dosage upon admission or readmission to the community and transfers between levels of care. Preparation: 1. Gather the information needed to reconcile the medication list: a. Discharge Summary from referring hospital, MAR from other transferring facility. b. Admission Order Sheet c. All prescription and supplement information obtained from the resident/family during the medication history. d. Most recent MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Obtain a medication history from the resident and/or representative. 2. The information from the medication history should include: e. Dosage, route, frequency and last dose taken for all items 3. Review the list carefully to determine if there are any discrepancies/conflicts. 4. If there is a discrepancy or conflict in medication, dosage, route or frequency, contact the physician within 24 hours and document. The facility's (Name of Pharmacy) Remote Order Entry Process, not dated, states, (Name of facility Pharmacy) Remote Date Entry (RDE) Team will enter orders into (name of facility's electronic charting system) from the hospital discharge orders for medications and from (name of facility organization) Order Sets for additional orders. The community will fax the orders for the residents to the RDE Team for input. All orders will be put into (name of facility's electronic charting system) in DRAFT status so that once completed, the nurse can review, verify the orders, and then change to ACTIVE status in (name of facility's electronic charting system). Once the order is made active the order needs to be sent to (name of facility Pharmacy) electronically. R1's Adverse Event Documentation form, completed by V2 (Director of Nursing) on 2/14/22, documents the type of adverse event as Medication Event. The date and time of the event is documented as 2/13/22 at 3:00 P.M. The Brief Description of Medication Event (describe medications involved and any immediate actions taken) states, (R1) returned from LOA (Leave of Absence) post surgery. All medications were discontinued in the EMR (Electronic Medical Record) as (R1) was out of the facility for greater than 24 hours. (R1) arrived and AVS (After Visit Summary) was sent to (name of facility pharmacy). (Name of facility pharmacy) entered the medications into the EMR. [MEDICATION(S)] was transcribed at 0.3 (milligram) TID (three times a day) and should have been 0.1 mg TID. The RN (Registered Nurse/V4) then moved them to active and was an oversight in the 0.1 mg vs (versus) 0.3 mg during the review for medications for accuracy. One LPN (Licensed Practical Nurse/V10) did adjust the times (1700/5:00 P.M.-2000/8:00 P.M.) of administration but did not adjust the dosage. The medication ([MEDICATION(S)] 0.3 mg) was given (to R1) on 2/12/22 x (times) 1(one) dose and then on 2/13/22 x 2 (two) doses. (R1) c/o (complained of) dizziness and not feeling well. BP (Blood Pressure) noted 68/(no bottom number documented). Orders received to send (R1) to the ED (Emergency Department) for evaluation and possible treatment. This form documents the contributing factor as AVS reentry process. The facility's Serious Injury Incident Report to the local state agency on 2/14/22 documents the involved resident is R1, and the time of the incident is documented as 2/12/22-2/13/22. The Incident Category is marked as Other-Medication Error with Hospital Evaluation/Treatment. The Incident Description documents R1 was assessed by V3 (Licensed Practical Nurse) and V4 (Registered Nurse Supervisor) on 2/13/22 at 2:15 P.M. and R1 was sent to the local area hospital emergency room and admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Detailed Incident Summary states, R1 returned from inpatient hospital on 2/12/22 status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Vital signs obtained and R1 noted to be hypotensive (low blood pressure) .R1 sent to (local area hospital) for evaluation and treatment if indicated. Through the course of the report to the hospital it was noted that R1 had been discharged on [MEDICATION(S)] 0.1 mg (milligrams) TID (three times a day) but transcribed as 0.3 mg (three times a day). R1's change in condition attributed to low blood pressure secondary to the dose of [MEDICATION(S)]. R1's Emergency Services Report documents EMS (Emergency Medical Service) were dispatched to R1's skilled nursing facility on 2/13/22 at 3:13 P.M. for breathing problems. R1's Vital Signs at 3:25 P.M. are documented as BP 74/60, Pulse 57, Respirations 14 with an oxygen saturation of 97% (percent) on room air. R1's Vital Signs at 3:56 P.M. are documented as BP 72/46, Pulse 59, Respirations 14 with an oxygen saturation of 96% on room air. The Narrative of this report states, Medic 22 was dispatched to (name and city of skilled nursing facility) for a (age and sex of R1) with complaints of respiratory distress after returning from the hospital after having hernia surgery and was having tachypneic respirations and was reported as being pale in color. RN (unknown facility nurse) related that (R1) had returned from having hernia surgery the previous day and upon (R1's) family coming to visit (R1) was found to be extremely lethargic and altered. RN related obtaining a manual blood pressure of [CONDITION(S)] and contacted her PCP (Primary Care Physician) who advised for transport to the hospital for a medical evaluation. RN related that she followed (R1's) daily care and noted that (R1) was not behaving per (R1's) norm .RN and (R1's) family related that they (facility staff) discovered that PTA (prior to arrival) of EMS that (R1's) prescription for [MEDICATION(S)] had been changed since discharge from the hernia surgery after reviewing (R1's) records. RN related that (R1) had been given three times the prescribed dosage for [MEDICATION(S)] within 24 hours . R1's Critical Care History and Physical signed and dated 2/13/22 by V8 (R1's Hospital Physician) documents R1 presented to the Emergency Department from the skilled nursing facility for generalized weakness, lethargy, and [CONDITION(S)] (low blood pressure). Per the Nursing Home supervisor, (R1) was given three times her regular dose of [MEDICATION(S)]. This same form report states, Additional information received from nursing facility, (V9/R1's Family Member), and V6 (R1's Primary Care Physician) via phone. (R1) was recently admitted to (local area hospital) for urgent hernia repair. (V6) directly admitted (R1) herself for that admission. No medication changes were to be made during that hospitalization as they were not indicated. However, per nursing facility records, [MEDICATION(S)] has been administered at 0.3 mg (milligram) TID (three times a day) since discharge from (the local area hospital). Dosing prior to hospitalization was 0.1 mg TID. In the Emergency Department/ED, (R1) received 2 mg of [MEDICATION(S)] (reversal agent) x 5 doses. (R1) was also given 2 L (liter) fluid boluses. Initially started on [MEDICATION(S)] (blood pressure support medication) for [CONDITION(S)] which was discontinued while in ED due to BP response to [MEDICATION(S)] and fluids. Initially given [MEDICATION(S)] and [MEDICATION(S)] due to concern for septic shock. Discontinued after one time dose. R1's Progress Note signed and dated by V6 on 2/15/22 states, (R1) was admitted yesterday in the morning due to significant [CONDITION(S)]. It appears that when she was discharged from (local area hospital) on Saturday, February 12th following a left inguinal hernia repair on February 10th, she was discharged on her usual dose of [MEDICATION(S)] 0.1 mg TID. The nurse at (name of skilled nursing facility) where (R1) resides transferred the orders to the computer from the hospital discharge papers. She put in [MEDICATION(S)] at 0.3 mg 3 x daily, though the discharge med list has [MEDICATION(S)] 0.1 mg TID. (R1) received three doses of this incorrect dose of [MEDICATION(S)] after her discharge and then became hypotensive. (R1's) blood pressure dropped to 60/40. (R1) was transferred to the ED. (R1's) blood pressure was still very low. She was admitted to the ICU (Intensive Care Unit) due to her [CONDITION(S)], placed on fluids and pressors, and this did bring (R1's) blood pressure back to normal. (R1) was there overnight and came to the floor (general) today where I saw her. She suffered no acute injury to her vital organs as a result of the [CONDITION(S)]. This same note states, Impression: Significant [CONDITION(S)] secondary to [MEDICATION(S)] overdose. R1's Nursing Notes signed by V3 (Licensed Practical Nurse) on 2/12/22 at 7:15 P.M. documents R1 returned to the facility with family at 2:00 P.M. and R1's medications were verified and sent to the pharmacy. R1's Nursing Notes signed by V3 on 2/13/22 at 6:28 P.M., states, (R1) c/o (complained of) being dizzy and lightheaded, vitals taken, (R1) blood pressure very low, 60/46. Supervisor notified, family notified, attempt to notify (V6/R1's Physician) x 2. (R1) sent to (local area hospital) for eval (evaluation) and treat. R1's current Census Report documents R1 was discharged from the facility on 2/9/22 and readmitted back to the facility on [DATE] following an inpatient hospital stay. This same report documents R1 was again discharged from the facility on 2/13/22 on a hospital leave. R1's Diagnoses/Surgical Procedures report documents R1 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Brief Interview for Mental Status (BIMS) on 10/21/21 and 2/18/22 documents R1 as cognitively intact without memory impairments. R1's current Care Plan documents Cardiovascular: R1 has potential for complications related to R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Discharge After Visit Summary (AVS) from the local area hospital on 2/11/22 documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Fax Transmittal Sheet to the facility's Pharmacy for Remote Data Entry (RDE), dated 2/12/22, documents R1's AVS with the above [MEDICATION(S)] order was faxed to the facility pharmacy for entry. R1's Pharmacy Transaction History documents a new order for [MEDICATION(S)] HCL ([MEDICATION(S)]) 0.3 mg tablet on 2/12/22 at 9:01 P.M. This order documents [MEDICATION(S)] HCL 0.3 mg tablets were dispensed as written from the facility's pharmacy and that this order was approved by V4 (Registered Nurse Supervisor). The facility's Pharmacy Delivery Manifest, dated 2/12/22, documents the facility received 12 tablets of [MEDICATION(S)] HCL 0.3 mg tablets for R1. R1's February 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order has a start date of 2/12/22 and is documented as a telephone order read back by V4 (Registered Nurse Supervisor). R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This same MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Fax Cover Sheet documents R1's Medication Administration History was faxed to V8 (R1's Hospital Physician) at the local area hospital on 2/13/22 at 7:03 P.M. This Medication Administration History Form documents R1 received the [MEDICATION(S)] HCL 0.3 mg tablets on 2/12/22 at 9:29 P.M., on 2/13/22 at 9:19 A.M., and on 2/13/22 at 11:40 A.M. Handwritten vital signs are noted on the front of the fax cover sheet which V1 (Administrator) verified are R1's vital signs prior to R1 leaving for the hospital on 2/13/22. R1's vital signs are as follows: BP 68/42, Pulse 54, Respirations 24 and a Temperature of 97 Degrees Fahrenheit. On 2/22/22 at 9:50 A.M. R1 stated, I was recently in the hospital after hernia surgery. I came out and my meds were all mixed up. I usually take [MEDICATION(S)] 0.1 mg TID, and they gave me the wrong dose of 0.3 mg TID. My nurse in the morning (V3/Licensed Practical Nurse) had said she wanted to talk about my meds because some had increased. I was requesting [MEDICATION(S)] after my surgery and there was some problem with my prescription. It all got straightened out but (V3) seemed more worried about my [MEDICATION(S)] than my other meds. I don't get told what meds they are giving me. She gave me some pills before breakfast and then some more after. My son and daughter-in-law were here, and I couldn't stay awake .(V5/Certified Nursing Assistant) said she thought something was wrong, so she checked my blood pressure. (V5) kept trying to wake me up and couldn't. I was in the hospital for a day and a half. They gave me 10 mg of [MEDICATION(S)] to wake me up and to get my blood pressure up. I don't remember much else until I was awake. On 2/22/22 at 9:20 A.M., V1 (Administrator) and V2 (Director of Nursing) verified the Discharge After Visit Summary from the discharging facility is what current orders will resume once a resident arrives to the facility. On 2/22/22 at 12:00 P.M. V4 (RN/Registered Nurse Supervisor) stated, I was the RN supervisor when (R1) came back from the hospital (on 2/12/22). We faxed (R1's) orders to the pharmacy for entry. The pharmacy puts the orders in and the nurse reviews what was entered and then makes the order active. I don't know how I did it. It was a transcription error. I am charge nurse; I normally don't do the med check, but we got two admits within 30 minutes of each other on the same hall. This new way of Pharmacy entering the medications is a brand new process. If it had been caught prior, I would have changed the order to what the AVS (After Visit Summary) said. I caught a bunch of other discrepancies; I don't know how I missed this one. I was with V3 when we checked on R1. I did a manual blood pressure, and it was 60/40's. I said to (V3), what kind of blood pressure meds did you give her? When looking at it, we realized the [MEDICATION(S)] was 0.3 mg vs 0.1 mg (TID). At the time, I thought it was a dose increase from the hospital, I did not realize right away that it was a transcription error. On 2/22/22 at 3:22 P.M., V7 (Pharmacy Remote Data Entry Supervisor) stated that the medications are only dispensed after the facility nurse approves the draft entered by the Pharmacy Technician by changing the orders to active. V7 verified R1's [MEDICATION(S)] order was transcribed incorrectly by the Pharmacy Technician and that also the facility nurse (V4) missed the transcription error and approved the [MEDICATION(S)] 0.3 mg TID order erroneously. On 2/22/22 at 2:13 P.M., V6 (R1's Primary Care Physician) stated, I admitted (R1) myself for her hernia surgery and I saw her in the hospital before she left. I didn't discharge her on 0.3 mg (milligrams TID). She was on [MEDICATION(S)] 0.1 mg TID and the nurse approved an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Her blood pressure was stable on the 0.1 mg dose. I did not order any changes. It was an error. (R1's) hospitalization (on 2/13/22) was related to the error in the [MEDICATION(S)] dose.

Based on observation, interview, and record review, the facility failed to follow a plan of care for one of two residents (R25) reviewed for falls in the sample of 27. Findings include: The facility Falls and Fall Risk policy, review date 9/8/21, documents, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The facility Assessments and Care Planning policy, reviewed date 4/27/21, documents, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. R25's Fall Risk Assessments, dated 5/21/21 and 9/14/21 document R25 as a high risk for falls. R25's current Fall Care Plan documents R25 is at risk for falls/injury as evidenced by history of falls, cognitive status/behavior, imbalance. R25's Care Plan includes the following interventions: Provide line of sight monitoring while in (reclining) chair prn (As needed) and Call light within reach. On 12/7/21 at 11:00 am, 12/8/21 at 2:45 pm, and 12/10/21 at 11:00 am, R25 was sitting in the reclining wheelchair in R25's room with no visible staff in the area and R25's call light hanging over the headboard of R25's bed. On 12/10/21 at 11:00 am V5 CNA (Certified Nursing Assistant) stated R25 should have R25's call light in reach at all times.

Based on interview and record review, the facility failed to follow up on consultant pharmacist recommendations to the Physician for two (R53, R64) of five residents reviewed for unnecessary medications in a sample of 27. Findings include Facility Drug Regimen Review, reviewed 5/26/21, documents, It is the policy of the community that a licensed pharmacist will review the resident drug regimen including the resident chart at least once a month. The licensed pharmacist will report in writing, any irregularities to the attending Physician, the community's Medical Director and the Director of Nursing to be acted upon. Irregularities identified will be documented on a separate, written report and sent to the Physician, Medical Director, and Director of Nursing, listing the resident name, relevant drug and irregularity the pharmacist has identified. The Physician will document in the resident record the identified irregularity has been reviewed and any action taken to address it. If the Physician chooses not to act upon the pharmacy consultant recommendations, the Physician must document rationale as to why the change is not indicated in the resident record. 1. R53's Physician Order Sheet, dated December 2021, documents orders for Buproprion, [MEDICATION(S)], [MEDICATION(S)], and Lorazepam. R53's pharmacy Consultation Report dated 6/18/21 has no Physician response, Physician signature, or date acting upon the pharmacy request for R53's Buproprion's dose reduction. R53's pharmacy Consultation Report dated 8/19/21 has no Physician response, Physician signature, or date acting upon the pharmacy request for R53's [MEDICATION(S)] diagnoses/indication for use. R53's pharmacy Consultation Report, dated 5/23/21, 6/18/21, 8/19/21, and 10/17/21 has no Physician response, Physician signature, or date acting upon the pharmacy request for R53's [MEDICATION(S)]'s allowable diagnoses, a decrease in dose, or indication for use. R53's pharmacy Consultation Report, dated 8/19/21, 9/19/21, and 10/17/21 has no Physician response, Physician signature, or date acting upon the pharmacy request for R53's Lorazepam's PRN (as needed) stop date and rationale for use. R53's 9/19/21 request was signed on 12/9/21. On 12/9/21 at 9:15am, V1 Administrator stated (R53's) 9/19/21 request for her Lorazepam was signed today (12/9/21) after you asked about it. I sent it to the Physician and got him to sign the request, but I would have expected it to have been addressed before today. On 12/10/21 at 9:15am, V1 Administrator stated, Those should be addressed each month with a response, signature and date so we know they have been looked at and I don't see that there. On 12/10/21 at 11:30am, V4 MDS (Minimum Data Set)/CPC (Care plan Coordinator) stated, I have been working on the Physicians following up on the pharmacist recommendations, I email or fax them to the Physician unless they are in the building, and it has been difficult getting them to follow up on the recommendations. I am aware we are responsible for following up and getting a Physician response. I would expect them to respond within the week of them knowing of the pharmacy recommendation. 2. R64's Current Physician Order Sheet documents orders for [MEDICATION(S)] 10 milligram (mg) one time daily with an order date of 6/4/20, [MEDICATION(S)] 7.5 mg one time daily with an order date of 7/14/20 and [MEDICATION(S)] 3 mg one time daily with an order date of 1/23/21. R64's Consultant Pharmacist Recommendation to Physician form, dated 8/19/21 does not have a Physician/prescriber response to the pharmacist's recommendation to attempt a dose reduction of the [MEDICATION(S)] and/or [MEDICATION(S)] or the request to re-evaluate therapy for R64's [MEDICATION(S)] use. R64's Consultant Pharmacist Recommendation to Physician form dated 11/13/21 repeats the same request for [MEDICATION(S)] and [MEDICATION(S)] as the 8/19/21 recommendation. R64's medical record does not contain any documentation that the above recommendations were acknowledged by R64's Physician. On 12/10/21 at 11:20 A.M. V4 (Licensed Practical Nurse/Care Plan Coordinator) verified V4 is responsible for obtaining Physician follow-up on the Pharmacist Recommendation forms and verified R64's August 2021 and November 2021 Pharmacist Recommendation forms had not been responded to by R64's Physician.

Based on interview and record review, the facility failed to have an accurate diagnosis and PRN (as needed) Lorazepam stop date for one (R53) of five residents reviewed for [CONDITION(S)] medications in a sample of 27. Findings include: Facility [CONDITION(S)] Medication, review date 5/25/21, documents PRN (as needed) orders for [CONDITION(S)] drugs are limited for 14 days. If the Physician believes that the PRN order should be extended beyond the 14 days, the Physician must document rationale in the medical record. The indication for any [CONDITION(S)] medication will be thoroughly documented in the clinical record to include an appropriate supporting diagnosis. R53's Physician Order Sheet, dated December 2021, documents an order date of 9/9/21 for Lorazepam 0.5mg (milligram) every three hours as needed (PRN) for Dementia. R53's Physician orders for Lorazepam do not have the correct diagnosis or a stop date. On 12/10/21 at 11:30am, V4 MDS (Minimum Data Set)/CPC (Care plan Coordinator) stated (R53) is taking Lorazepam for Anxiety and I am aware it is extended past the 14 day PRN limit. I need to get that taken care of.

Based on observation, interview, and record review the facility failed to ensure one resident (R1) was removed from the bed pan in a timely manner. This failure resulted in R1 remaining on a bed pan for over five hours, resulting in a deteriorating stage IV pressure wound on the sacrum and the development of a new stage II pressure ulcer. R1 is one of three residents reviewed for skin injury in the sample of three. Findings include: The facility Skin and Wound Management Policy dated 1/11/2018 documents, General Guidelines: Pressure injuries are usually formed when a resident remains in the same position for an extended period of time, causing increased pressure or decreased circulation to that area and subsequent destruction of tissue. Pressure injuries are often made worse by continual pressure, heat, moisture, and irritating substances on the resident's skin. The policy further documents, Interventions and Preventative Measures: General for a person in bed 1. Change position at least every 2 hours or more frequently if needed. On 6/12/2018 at 5:58 PM, V3 CNA(Certified Nurse Aide) stated, I put (R1) on the bed pan at 9:45PM on (6/2/18) at R1s request. I told (V4 CNA) that (R1) was on the bed pan and I left. (R1) uses a 'fracture' bed pan (Mosby's Textbook for Nursing Assistants 8th Edition defines a 'fracture pan' as, A fracture pan has a thin rim. It is only about 1/2 inch deep at one end . The smaller end is placed under the buttocks. Fracture pans are used by person by persons with limited back mobility, [MEDICAL CONDITION], in casts, in traction.) R1 never refuses to be repositioned. I was off on Sunday (6/3/18) and returned on Monday. (R1) had a red line U-shaped on his bottom when I returned on Monday. On 6/12/2018 at 6:00PM, V4 CNA stated, No one told me (R1) was on the bed pan when I came onto the shift (on 6/2/18). I checked on (R1) at 11:00PM, 1:00AM and 3:00AM on (6/3/18). (R1) stated was comfortable at 11:00 PM and again at 1:00AM so I did not turn or reposition (R1). We (the nurse and V4) found him at 3:00AM. We are supposed to turn and reposition (R1) every 2 hours. Sometimes (R1) will say he is comfortable and does not want to reposition. We do not chart (R1s refusals). On 6/12/2018 at 6:30 PM, V5 Licensed Practical Nurse (LPN) stated, I found (R1) early Sunday morning (June 3, (YEAR)) around 3:30AM - 4:00AM when I usually do treatments. (R1) was lying on the bed pan when I found him. I went to get the V4 CNA because I wanted to know how long (R1) had been on the bed pan. (V4) said she was not aware (R1) was on the bed pan. There was an imprint of the bed pan on (R1s) skin. It was not blistered at that time but it was red. (R1) did not complain of pain or seem to know that he was on the bed pan. The bed pan had blood in it and was clean of BM ( a bowel movement). I asked (V3 CNA) the next day if she knew (R1) was left on the bed pan the night before (6/2/18 10:00PM). (V3) told me she forgot she put (R1) on the bedpan and remembered when she got home. V5 stated that V3 told V5 she was going to call back to the facility but did not because she assumed (R1) would be repositioned every 2 hours. V5 LPN states, (R1's) wound was clean and looked really good the last time I saw it, about 3 days before this happened. When I found (R1) that night the wound was full of eschar (non-viable) tissue. (R1) is supposed to be turned and repositioned every two hours. I have never seen (R1) refuse to turn. (R1) is always good and allows me to when I do his treatments. The Wound Specialist Physician's (V8) report on 6/1/2018 documented R1 has one lower sacral pressure ulcer wound Stage IV measuring 4.5 centimeters (cm) x 4.5 cm x 0.3 cm with heavy (clear) exudate and 100% granulation tissue. The wound progress is documented as unchanged from the previous visit. The Clinical Practice Guideline for the National Pressure Ulcer Advisory Panel (NPUAP) defines 'granulation tissue' as 'the pink/red, moist shiny tissue that glistens and is composed of new blood vessels, connective tissue, fibroblasts, and [MEDICAL CONDITION] cells that fills an open wound when it begins to heal. V8 Physician notes dated 6/8/18 document R1 has one Stage IV lower sacral wound measuring 6 cm x 3.2 cm x 0.3 cm with heavy clear drainage, thick adherent devitalized necrotic tissue at 75% of the wound bed and granulation tissue at 25% of the wound bed. V8 documented the necrosis (was) resulting from injury from recurring pressure injury. Nurse reports patient had extended time on (a) bed pan 4 or 5 days ago. V8 documented he cleansed the wound and used a curette to surgically excise the devitalized tissue, necrotic subcutaneous fat and surrounding connective tissue at a depth of 0.5 cm. Healthy bleeding tissue was observed. The wound progress is documented as deteriorated due to pressure. The same notes documents a new stage 2 pressure ulcer measuring 16.5 cm x 1 cm x not measurable. linear band with red areas of serous blistering. Result of prolonged time on bed pan. Red band noted in symmetric area to right buttock as well but is blanching. On 6/12/2018 at 6:15 PM, R1 was observed in bed lying on the left side. V6 LPN removed the sacral wound dressing to reveal a stage IV sacral wound with a defined and irregular shaped boarder. The irregular shape was circular with the exception of at 3 o'clock (using the face of a clock for reference) and 7 o'clock there were v-shaped wound extensions outward 1.5 centimeters (cm). The area at 7 o' clock had slough (non-viable) tissue in the wound bed. The wounds extended in a semi-circle 16 cm to R1's right buttock from the 3 o'clock extension. The 7 o'clock extension extended to the left side of R1's bottom in a semi-circular pattern . V6 stated she had not seen R1's wound in awhile but it was definately worse. On 6/13/2018 at 11:15AM V2 Director of Nursing stated she went down and assessed R1's wound on 6/3/2018. She found the red marks consistent with a bed pan. A fracture bed pan that had been placed in the backward position. V2 stated the areas were red at that point and had not blistered. On 6/15/2018 at 7:20 AM V8 Physician stated, (R1's) wound deteriorated from 6/1/18 to 6/8/18 resulting from the pressure of being left on the bed pan for an extended period of time. This is my 30th visit with (R1) and prior to last week we had finally achieved 100% granulation. Last week (6/8/2018) I had to debride the necrosis of the Stage IV wound. I had to debride it again this week. I staged the large semi-circular ring from the bed pan as a Stage II because there were fluid filled blisters in areas of that red ring.

Based on interview and record review the facility failed to provide treatment to a pressure area for 11 days from admission and failed to routinely assess per facility policy for one (R220) of four residents reviewed for pressure ulcers in a sample of 18. This failure resulted in R220's pressure ulcer worsening from a purple intact area on the left heel measuring 1.3 cm (centimeters) x 1.6 cm x 0.1 cm (1/12/2018) to a blackened, intact area measuring 6.0 cm x 4.0 cm x 0 cm (1/28/2018). Findings include: Facility Pressure Injury Treatment Policy, dated 1/10/18, documents: guidelines for care of existing pressure injuries and the prevention of additional pressure injuries; review of care plan and skin assessment (Braden Scale) to assess the resident's needs; and pressure injury treatment requires a comprehensive approach, including maximizing the potential for healing. Facility Prevention of Pressure Injuries Policy, dated 1/11/18, documents: change position at least every two hours, routinely assess and document the condition of the resident's skin per the weekly skin assessment for signs and symptoms of breakdown; and the care process should include efforts to stabilize/remove risk factors; and to monitor the impact of the interventions and modify the interventions as appropriate. R220's Admission Skin Risk Assessment, dated 1/12/18, documents that R220 is at moderate risk (score of ten) for pressure sores/skin breakdown. The Assessment also documents that R220 is confined to bed and cannot bear weight. R220's Admission Wound Assessment, dated 1/12/18, documents that R220's left heel is purple, intact, no drainage and measures 1.3 centimeters/cm X 1.6 cm X 0.1 cm. R220's Nursing History and Assessment, dated 1/12/18, documents that R220's skin is purple area on left heel is unstageable and does not document a treatment. R220's Wound Care Specialist Evaluation, dated 1/19/18, documents an unstageable deep tissue injury ulcer, measuring 3.5cm X 5.5cm X not measurable. The Evaluation also documents a treatment order of a skin adhesive (skin prep) once daily and prevalon boot while in bed. R220's Wound Assessment, dated 1/28/18, documents that R220's left heel is blackened, intact, no drainage and measures 6.0cm X 4.0cm X 0 cm. R220's Baseline Care Plan, dated 1/12/18, documents a left heel pressure ulcer. The Care Plan also documents the following interventions: Braden on admission, weekly skin assessments, treatment as ordered, assist to reposition and float heels in bed. R2220's Care Plan, dated 2/1/18, documents that skin problems and interventions were created on 1/22/18 and effective on 1/15/18. R220's Section M0300 and M0700 of the Minimum Data Set (MDS), with assessment reference (ARD) dated 1/19/18 and 1/26/18, documents a Stage Four (4), unstageable deep tissue injury. The MDS, dated [DATE], documents pressure ulcer care under Section 1200 (Skin/Ulcer Treatments). R220's Nursing Assessment and Physician order [REDACTED]. R220's Wound Care Specialist Evaluation, dated 1/19/18, documents an order for [REDACTED]. R220's POS, dated dated 1/13/18, documents an order for [REDACTED].>R220's POS, dated 1/23/18, documents an order for [REDACTED]. R220's January 2018 Treatment Record (TAR), dated 2/1/18, documents a weekly skin assessment was ordered on [DATE]. The TAR documents two weekly skin assessments, 1/22/18 and 1/29/18, for R220. R220's TAR also documents a treatment for [REDACTED]. On 2/1/18, at 2:05 pm, V9 (Assistant Director of Nursing/ADON/Wound Nurse) stated, (R220) admitted late at night on 1/12/18. The staff should have initiated a left heel treatment upon admission. The treatment should have been put on the TAR upon admission and they should have initiated the weekly skin assessments starting on 1/13/18. I do not see any documentation of any treatment being started until 1/23/18. On 2/1/18, at 4:00 pm, V6 (Wound Doctor) stated, (R220) admitted to the facility on [DATE], with a 1.3 cm X 1.6 cm X 01.cm wound/blister, and I did not see the wound until 1/19/18. I ordered skin prep and prevalon boots for the left heel at that time. I would expect the facility to follow the policy and doctor orders to help improve the wound (providing treatment and assessing).

Based on interview and record review, the facility failed to accurately transcribe a physician's order for one of 15 residents (R27) reviewed for medications in the sample of 15. As a result, R27 was administered an excessive dosage of R27's [MEDICATION NAME] (diuretic) medication causing weakness, dehydration and [DIAGNOSES REDACTED], and subsequently requiring R27 to be hospitalized . Findings include: The facility's Medication and Treatment Orders policy (Revised April 2014) documents the following: Orders for medications and treatments will be consistent with principles of safe and effective order writing. R27's electronic facesheet indicates that R27 was readmitted to the facility on [DATE], and R27's electronic [DIAGNOSES REDACTED]. R27's Five Day Final Investigation report dated 2/24/17 documents the following: (E1, Administrator) notified by (E2, Director of Nursing) that during this morning's (2/16/17) medication pass, it was noted that there had been a transcription error of a physician's order on 2/15/17, for (R27's) [MEDICATION NAME] dose. Fax order received .for the following: give additional 40 mg (milligrams) daily x 3 days .Transcribed as [MEDICATION NAME] 40 mg t.i.d. (three times daily) x 3 days. R27's faxed order dated 2/15/17 received from (Z4, Advanced Practice Nurse) documents the following: Noted weight gain. Give additional 40 mg (milligrams) daily x 3 days (in addition to her 80 mg). Continue daily weights. R27's Physician Order dated 2/9/17 documents the following order: [MEDICATION NAME] 80 mg tablet one tab daily at 8:00 AM. R27's February 2017 Medication Administration Record [REDACTED]. R27's Physician order dated 2/10/17 documents the following order: [MEDICATION NAME] (diuretic) 2.5 mg tablet one time daily starting 2/10/17. R27's February 2017 Medication Administration Record [REDACTED]. R27's mistranscribed Physician Order dated 2/16/17 and documents the following: [MEDICATION NAME] 40 mg three times daily for three days starting 2/16/17 at 9:00 AM, 1:00 PM and 5:00 PM. R27's February 2017 Medication Administration Record [REDACTED]. R27's Clinical Notes dated 2/16/17 and timed 5:57 PM documents, (R27) back from appointment and eating in the dining room. Vitals are stable, denies pain at this time. Alert and Oriented, able to make needs known. No complaints at this time. R27's Clinical Notes dated 2/17/17 at 4:06 AM documents, Resting comfortably in bed. Went to see lung doctor says she is not feeling good. R27's Clinical Notes dated 2/17/17 at 9:42 AM documents, Hospital called with lab values Potassium 2.7 milliEquivalents per liter (mEq/L, indication of a critically low value) .(Z5, R27's Physician) advised us to send (R27) to hospital. (R27) received [MEDICATION NAME] 80 mg yesterday AM and 40 mg t.i.d. (three times daily) yesterday in addition to [MEDICATION NAME] this morning .Weight down to 149 pounds from 159 pounds two days ago. (R27) very weak. Shaky. Sending to (local emergency room ). R27's local Emergency Department documentation dated 2/17/17 documents the following: (R27) complains of generalized weakness and fatigue. (R27) also states she has dizziness and lightheadedness .Clinical Impression: [DIAGNOSES REDACTED] (low potassium), Weakness .Potassium was 2.7 mEq/L on labs obtained prior to ER (emergency room ) visit. With high dose of diuretics, this would explain her [DIAGNOSES REDACTED]. R27's local hospital laboratory results form documents the following: On 2/8/17, R27's potassium was 4.6 mEq/L with the following parameters: normal range 3.5 - 5.1 mEq/L. On 2/17/17, R27's potassium was 2.7 mEq/L. On 2/8/17, R27's BUN (Blood Urea Nitrogen) was 29 milligrams per deciliter (mg/dL) with the following normal parameters: 7 - 25 mg/dL. On 2/17/17, R27's BUN was 47 mg/dL. According Tietz Textbook of Clinical Chemistry (4th Ed.) (2006). Blood Urea Nitrogen (BUN), Serum. Retrieved on 3/9/17 from http://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/ , Increased blood urea nitrogen (BUN) may be due to prerenal causes (cardiac decompensation, water depletion due to decreased intake and excessive loss). On 3/8/17 at 10:12 AM, E1 Administrator, stated that R27 is still hospitalized and E18, Registered Nurse, who incorrectly transcribed R27's [MEDICATION NAME] order, no longer works at the facility. On 3/8/17 at 11:01 AM, Z5, R27's Physician, stated that R27 was admitted to the hospital as a result of the medication error that occurred on 2/16/17. Z5 stated, She received two extra doses of [MEDICATION NAME] which caused dehydration and a significant weight loss, and that caused her weakness. The morning after (the medication error) she couldn't even stand up. The weakness and dehydration was related to the extra [MEDICATION NAME] doses over-diuresing her. Z5 then verified that on 2/17/17, R27's serum potassium level was 2.7 mEq/L (normal range 3.5 - 5.1 mEq/L), a critically low level, and stated, [MEDICATION NAME] is widely known to cause a fall in a resident's potassium.

Based on observation, record review, and interview the facility failed to document, assess, and investigate an incident and failed to implement new fall interventions and complete a fall assessment after each fall for three of three residents (R1-R3) reviewed for falls in a sample of three. This failure resulted in R1 sustaining a Mildly displaced, acute right femoral neck fracture on 11/27/17. Findings include: The facility's Fall Prevention and Management Program policy dated 8/13/2012 documents: Each resident will be assessed for the risk factors for falling at move in, quarterly, with a change in condition, upon return from a health care facility and after a fall .On the day of move in each resident will be assessed for risk for falls by a licensed nurse using the community approved fall risk assessment tool .the interdisciplinary team will develop a plan for services to improve or maintain the resident's standing or sitting balance and other interventions to reduce the resident's risk for falls. The plan will include specific information about the resident's routine. 1. R1's electronic Nursing Admission Assessment documents R1 was admitted to the facility on [DATE]. The same assessment documents for R1 unable to orient .resident is very confused and alert only to self. R1's electronic medical record documents that R1 has had only one Fall Assessment completed on 11/10/16 which documented that R1 was at a high risk for falls. R1's Fall Investigation Report documents R1 had a fall on 11/12/16 at 6:00 a.m. The same form under a section titled Fall Team Meeting Notes is blank. A new fall assessment was not completed for R1 after this fall. R1's electronic clinical note entry dated 11/24/16 at 11:05 a.m. documents (R1) was sitting in his w/c (wheelchair) .(R1)fell from chair landing on his left side .(R1) did hit his head and c/o (complain of) head hurting, 911 called . R1's clinical note dated 11/24/16 at 11:09 a.m. documents (R1) has two skin tears to left elbow measuring 1 cm (centimeter) x 1 cm . (R1) has rug burn to his left eye brow measuring 4 cm x 1 cm. R1's local emergency department record dated 11/24/16 documents: [DIAGNOSES REDACTED]. R1's electronic medical record has no evidence of the facility investigating, determining root cause, implementing an intervention to prevent further falls or completing a new fall assessment for R1's fall on 11/24/17. R1's clinical note entry dated 11/27/16 at 7:15 a.m. documents (R1) stood up from wheelchair and fell to the ground .(R1) c/o head pain .(R1) c/o pain in the hip/pelvic area. local ambulance called for transport to hospital. R1's result report from the local hospital dated 11/27/17 at 9:27 a.m. XR (picture) Hip 2 views bilateral .clinical history: .(R1) fell out of wheelchair .Impression: Mildly displaced, acute right femoral neck fracture. R1's electronic fall care plan, dated 11/12/16, documents that the care plan and its current interventions were created on 11/12/16. R1's care plan has no documentation of new fall interventions being updated following R1's falls on 11/24/16 and 11/27/16. The facility's Accident/Incident Report documents that R1 had one fall from the time of admission on 11/10/16 to R1's discharge on 11/27/16. The report also documents that the one fall incident occurred on 11/24/16 at 11:05 a.m. in the dining room. On 2/1/17 at 11:15 p.m. E1 (Administrator) and E2 DON (Director of Nursing) stated a fall assessment was not completed after each of R1's falls on 11/12/17, 11/24/17 and 11/27/16, and on 11/24/16 the fall investigation was not completed nor was a new intervention implemented. E1 and E2 also stated that R1's intervention for the fall on 11/27/16 was to send R1 to the hospital. 2. R2's Nursing Admission assessment dated [DATE] documents R2 was admitted on [DATE]. The fall assessment portion of R2's nursing admission assessment was not completed and did not indicate a fall risk. R2's clinical note entry dated 1/28/17 at 3:05 p.m. documents R2 was found sitting on the foot pedal of R2's wheelchair and sustained a skin tear. R2's clinical note entry dated 1/28/17 at 5:30 p.m. documents R2 slid out of wheelchair while being pushed down the hall. R2's electronic medical record has no evidence of the facility investigating or determining root cause, for R2's falls on 1/28/17. The facility's Accident/Incident Report documents that R2 had one fall on 1/28/17 at 3:05 p.m. The additional fall on 1/28/17 at 5:30 p.m. was not documented on the accident/incident report. On 2/1/17 at 10:45 a.m. R2 was sitting in a wheelchair in R2's room and was unable to recall the details of R2's falls on 1/28/17. On 2/1/17 at 11:15 a.m. E1 Administrator and E2 DON (Director of Nursing) confirmed R2's admission fall assessment indicating fall risk was not completed and that investigations to both falls on 1/28/17 were not completed. 3. R3's electronic medical record documents that R3 has had only one Fall Assessment completed on 11/11/16 which documented that R3 was at a low risk for falls. The facility's Accident/Incident log documents R3 sustained a fall on 11/19/16 at 9:30 a.m R3's Fall Scene Investigation Report dated 11/19/16 does not document an intervention for R3's fall. R3's electronic fall care plan, dated 11/21/16, documents that the care plan and its current interventions were created on 11/21/16. R1's care plan has no documentation of new fall interventions being updated following R1's fall on 11/19/16. On 2/1/17 at 8:50 a.m. R3 was sitting in R3's wheelchair in R3's bathroom. R3 stated when R3 fell on [DATE] R3 had a urinary tract infection and was kind of out of it. On 2/1/17 at 11:15 a.m. E1 Administrator and E2 DON verified R3's fall scene investigation report dated 11/19/16 did not document an intervention to prevent further falls and a fall assessment was not completed after R3's 11/19/16 fall.

Based on record review and interview, facility staff knowingly failed to act upon the facility Abuse Protocol to ensure staff protected residents from potential sexual abuse after witnessing sexual abuse for one of three residents (R1) reviewed for abuse in a sample of three. This failure resulted in a total of two staff (E13 C.N.A./Certified Nurse Aid and E18 C.N.A.) neglecting to report witnessed sexual abuse against a cognitively impaired resident (R1) until five hours after the incident occurred, neglecting to protect R1 once the abuse occurred, and allowing the alleged perpetrator to remain in the facility for the remainder of the shift and the potential for ongoing abuse to occur. This failure also resulted in a third staff member (E14 C.N.A.) neglecting to report alleged sexual abuse once told by the two staff members who witnessed it. This failure has the potential to affect R1, 5, 8, 12, 14, 15,16,19, 21, 22, 24, 31 and 32 as these residents reside on hallways accessible to the alleged staff perpetrator, are cognitively impaired and dependent on staff. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 1/22/16, the facility remains out of compliance at a Severity Level II as the facility revises operational policies and procedures on Abuse, continues to conduct ongoing re-education of all staff, including a pre-testing and post-testing all direct care staff, regarding reporting abuse and resident protection from abuse, and random audits to determine staff proficiency and compliance with the revised Abuse Policy. Findings include: On 1/14/15 at 7:45 a.m., E13 (Certified Nursing Assistant) stated she was doing rounds with E18 on 12/28/15 at approximately 1:45 a.m. E13 stated she was standing in R1's doorway when she observed E19 (Licensed Practical Nurse) holding his penis in R1's mouth with his left hand. Immediately following this incident, E13 stated she went into another resident room with E18 and E19, to assist in a resident treatment. According to E13, after completing the treatment, she and E18 left that hall to do rounds on another hall. E13 stated, when we left the hall, (E19) was left alone with the residents (on Clover). At 4:29 a.m., E13 stated she attempted to call the State Hotline to report what she had witnessed, but was unsuccessful. E13 stated she then continued to do rounds with E18 and the remainder of the night we just worked our shift. E13 indicated she had received training on 11/13/15 on Abuse and was instructed to call the Administrator if you suspect or see abuse. E13 stated, I would call what (E19) did sexual abuse. In that case, we were supposed to call the Administrator, but I didn't because the building does not have any confidentiality. At that time, I wasn't thinking about the resident. On 1/12/16 at 1:58 p.m., E18 stated she and E13 were doing rounds at approximately 2:00 a.m. on 12/28/15, when they noticed R1's door was almost completely closed. E18 stated they opened R1's door and observed E19 with his penis in R1's mouth. E18 stated she was too scared to confront (E19) and she, along with E13 and E19 went into another resident room to complete a treatment. After completing the treatment, E18 stated she avoided E19 for the remainder of the shift by going to another hall with E13. At approximately 4:00 a.m., E18 stated she and E13 left the facility and went out to her car to call the State hotline. After returning to the facility, E18 stated she approached E12 (Nurse Supervisor) and asked a hypothetical question about who she would report abuse to. According to E18, E12 told her all abuse should be reported to E1 (Administrator) right away. E18 stated she never went back to check on R1, because she felt (R1) was fine. E18 stated, I knew I needed to report the abuse, but I was afraid of what (E19) would do .I knew it was abuse. E18 stated she waited until approximately 7:30 a.m., after she had left the facility and contacted the Administrator by phone to report what she witnessed between R1 and E19. On 1/12/16 at 9:15 a.m., E12 (Registered Nurse) stated she was the Supervising Nurse on the early morning of 12/28/15. E12 stated E18 approached her at approximately 4:00 a.m. and stated hypothetically, if a resident was abused by staff, who would I need to report to? E12 advised E18 that all allegations of abuse are to be reported to (E1) as soon as possible. On 1/12/16 at 1:44 p.m., E14 (Certified Nursing Assistant) stated, on 12/28/15 at approximately 2:00 a.m., she overheard E13 and E18 talking about R1 and E19 in the hallway, but didn't want to get involved. E14 stated at approximately 4:00 a.m. on 12/28/15, E13 told her that she observed E19's penis in R1's mouth, but was waiting for (E1) to come in to report the incident. After being told about the alleged sexual abuse at 4:00 a.m., E14 stated she did not report the allegation to anyone on 12/28/15 as she thought E13 was handling it. However, E14 stated she was aware that abuse needed to be reported to E1 as soon as possible. On 1/12/16 at 10:50 a.m., E1 (Administrator) stated he received a phone call from E18 at 7:41 a.m. on 12/28/15, alleging E19 had engaged in sexually inappropriate behavior with R1. E1 stated E18 and E13 reported that the incident occurred at 2:00 a.m. on 12/28/15 and E19 worked the remainder of his shift ending at 6:38 a.m. as documented in E19 ' s time sheet. E1 indicated E19 would have been sent home immediately if the allegation had been reported sooner. E1 stated E19 was immediately placed on unpaid leave, effective 12/28/15. E1 stated staff are expected to immediately report any incident that could be considered potential abuse to himself (Administrator and Abuse Coordinator) to ensure the protection of the residents. On 1/13/16 at 3:43 p.m., Z2 (Police Detective) stated E19 was arrested on 12/30/15 and remains in police custody, charged with Aggravated Criminal Sexual Assault. An Abuse Investigation, dated 12/31/15, documents E13 (Certified Nursing Assistant) and E18 (Certified Nursing Assistant) reported to E1 (Administrator) on 12/28/15 an allegation of sexual abuse. The Abuse Investigation documents E13 and E18 observed E19 (Licensed Practical Nurse) engage in sexual activity with R1 on 12/18/15 at approximately 1:45 a.m. and waited until 7:41 a.m. to report the allegation to E1. According to the Abuse Investigation, E19 was placed on suspension from his position at the facility on 12/28/15, immediately after the allegation was reported and the local Police Department was notified. The Abuse Investigation documents E19 was arrested on 12/30/15. A Minimum Data Set, dated dated [DATE], documents R1 as being cognitively impaired, having short term and long term memory impairment and requiring total staff assistance for all activities of daily living. R1's current Plan of Care, dated 1/12/16, documents R1 as having difficulty remembering things and difficulty communicating and making my needs known. A training certificate dated 7/30/15, documents E13 completed one hour of Continuing Education on Preventing, Recognizing and Reporting Resident Abuse. This Continuing Education course advises staff, As a caring person and employee of your long term care facility, you want to make sure that residents feel safe and secure and are protected from physical, emotional, or other kinds of abuse .If your facility does not protect residents by reporting any suspected abuse, it could be heavily fined or lose its operating license .You should report all suspected abuse to you immediate supervisor, the supervisor in charge during your shift, a manager on duty, and/or your facility's administrator. On 1/20/16 at 9:00 a.m., E1 (Administrator) stated he and E2 (Director of Nursing) participated in educating staff at the Abuse Reporting and Education inservice on 11/13/15 and immediate reporting of abuse to the Administrator was discussed, along with what constitutes abuse/neglect. On 1/20/16 at 11:10 a.m., E2 (Director of Nursing) stated the 11/13/15 Abuse Inservice included information on the different types of abuse, staff's expectation to notify E1 immediately of any suspected abuse/neglect, and a review of the facility Policy and Procedure on Abuse. E2 stated resident protection was included in the inservice, including the importance of immediately notifying the Administrator of abuse so we (E1 and E2) can come into the facility to remove the alleged abuser and initiate an investigation. A Training/Inservice Sheet dated 11/13/15, documents E13, E14 and E18 were in attendance for the Abuse Reporting and Education training provided by E1 and E2. The facility policy, titled Abuse/Neglect Prevention and Response (revised 5/04/13), documents Purpose: To prevent abuse and neglect of residents and clients and establish an organized response to possible incidents of abuse and neglect. The Abuse/Neglect Prevention and Response policy defines sexual abuse as sexual harassment, sexual coercion and sexual assault and advises In licensed care centers (licensed nursing homes), reports of abuse or neglect are to be made to the Administrator. Additionally, under Response to Allegations of Abuse/Neglect, the policy documents Investigation .Any time an allegation of abuse or neglect involves an employee, that individual will be suspended from duty until an investigation is completed. A Health Center Room Occupancy Chart, provided by E1 on 1/20/16, documents R1 through R32 reside on the units E19 had access to. On the Health Center Room Occupancy Chart, E1 identified the following residents on those halls as being completely dependent on staff for all cares and cognitively impaired: R1, R5, R8, R12, R14, R15, R16, R19, R21, R22, R24, R31 and R32. On 01/22/16 at 11:30AM an Immediate Jeoardy was identified to have begun on 12/28/15 when E13, E14, and E18 neglected to report the sexual abuse. E1/Administrator and E2/Director of Nursing were notified of the Immediate Jeopardy on 01/22/16 at 11:30AM. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. The facility provided in-service training by the facility's Director of Nursing and Clinical Nurse Educator to all staff at the nursing home regarding staff obligation to immediately report any allegation, accusation, or suspicion of abuse or neglect to the facility Administrator. 2. The facility has reviewed its Policy and Procedure on Abuse/Neglect Prevention and Response to explicitly instruct that an alleged perpetrator of abuse or neglect is to be immediately removed from resident contact, as soon as an allegation, accusation, or suspicion of abuse or neglect is made and suspended until the conclusion of the facility's investigation. 3. A plan to monitor for continued compliance has been developed. The Administrator and Clinical Nurse Educator are performing a re-training of all RN, LPN, and CNA staff on the updated Policy and Procedure on Abuse/Neglect Prevention and Response. The re-training entails a pre-test to determine baseline knowledge, an in-person education program, and then a post-test exam for each RN, LPN, and CNA. Thereafter, the Administrator will conduct random audits to determine staff proficiency and compliance with the updated Abuse/Neglect Prevention and Response policy and procedure; the audits will be done daily on each shift for the next two weeks, and then once per week per shift for the following two weeks. Additionally, the facility's Risk Manager will perform an audit of every allegation, accusation, or suspicion of abuse or neglect at the facility, weekly for the next six weeks, to verify that the policy and procedure for identifying, reporting, and investigation is properly followed by staff and Administration.

Based on record review and interview, the facility failed to ensure staff reported an allegation of sexual abuse immediately to the Administrator, for one of three residents (R1) reviewed for abuse in a sample of three. Staff failed to report an allegation of sexual abuse against a cognitively impaired resident (R1) until five hours after the incident occurred, allowing the alleged perpetrator to remain in the facility for the remainder of the shift. This failure potentially placed R1, 5, 8, 12, 14, 15,16,19, 21, 22, 24, 31 and 32 at risk, as these residents reside on hallways accessible to the alleged staff perpetrator. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 1/22/16, the facility remains out of compliance at a Severity Level II as the facility revises operational policies and procedures on Abuse, continues to conduct ongoing re-education of all staff, including a pre-testing and post-testing all direct care staff, regarding reporting abuse and resident protection from abuse, and random audits to determine staff proficiency and compliance with the revised Abuse Policy. Findings include: The facility policy, titled Abuse/Neglect Prevention and Response (revised 5/04/13), documents Purpose: To prevent abuse and neglect of residents and clients and establish an organized response to possible incidents of abuse and neglect. The Abuse/Neglect Prevention and Response policy defines sexual abuse as sexual harassment, sexual coercion and sexual assault and advises In licensed care centers (licensed nursing homes), reports of abuse or neglect are to be made to the Administrator. A Minimum Data Set, dated dated [DATE], documents R1 as being cognitively impaired, having short term and long term memory impairment and requiring total staff assistance for all activities of daily living. R1's current Plan of Care, dated 1/12/16, documents R1 as having difficulty remembering things and difficulty communicating and making my needs known. An Abuse Investigation, dated 12/31/15 (final report), documents E13 (Certified Nursing Assistant) and E18 (Certified Nursing Assistant) reported to E1 (Administrator) on 12/28/15 an allegation of sexual abuse. The Abuse Investigation documents E13 and E18 observed E19 (Licensed Practical Nurse) exposing his penis to a female resident and one of these CNAs (Certified Nursing Assistants) reported seeing (E19) removing his penis from the resident's mouth at approximately 2:00 a.m. The Abuse Investigation documents E18 reported the incident to E1 at 7:41 a.m., five hours and 41 minutes after the incident occurred. On 1/12/16 at 1:58 p.m., E18 stated she and E13 were doing rounds at approximately 2:00 a.m. on 12/28/15, when they noticed R1's door was almost completely closed. E18 stated they opened R1's door and observed E19 with his penis in R1's mouth. E18 stated she was too scared to confront (E19) and she kept doing rounds with E13. E18 stated she continued to avoid E19 for the remainder of the shift. E18 stated she was aware she needed to report the incident, but waited until approximately 7:30 a.m. to inform the Administrator. On 1/14/15 at 7:45 a.m., E13 (Certified Nursing Assistant) stated she was doing rounds with E18 on 12/28/15 at approximately 1:45 a.m. E13 stated she was standing in R1's doorway when she observed E19 holding his penis in R1's mouth with his left hand. Immediately following this incident, E13 stated she went into another resident room, with E18 and E19, to assist in a resident treatment. E13 stated she continued to do rounds with E18 and we just worked our shift. E18 stated she did not report the incident to anyone until she called E1 (Administrator) at approximately 8:15 a.m. on 12/28/15 to talk to him about what she witnessed. On 1/12/16 at 1:44 p.m., E14 (Certified Nursing Assistant) stated, on 12/28/15 at approximately 2:00 a.m., she overheard E13 and E18 talking about R1 and E19 in the hallway, but didn't want to get involved. E14 stated at approximately 4:00 a.m. on 12/28/15, E13 told her that she observed E19's penis in R1's mouth, but was waiting for (E1) to come in to report the incident. E14 stated she did not report the allegation to anyone on 12/28/15. On 1/12/16 at 9:15 a.m., E12 (Registered Nurse) stated she was the Charge Nurse for the facility from 6:30 p.m. on 12/27/15 to 7:00 a.m. on 12/28/15 and R19 was working the halls Clover Court and Dogwood during that time. E19 ' s time card for 12/27- 12/28/2015 documents E19 punched in to work at 6:25pm on 12/27/2015 and punched out at 6:38am on 12/28/2015. The facility Job description for Licensed Practical Nurse/Staff Nurse documents, in part, Nursing Care: .Make periodic checks to assure that prescribed treatments are being properly administered by nursing assistants and to evaluate the residents physical emotional status. Administer professional services such as: cauterization, tube feedings, suction, applying and changing dressings /bandages, packs, [MEDICAL CONDITION] and drainage bags, initiate and maintain IV therapy with doctor ' s orders Obtain sputum, urine and other lab tests as ordered. Take TRPs (temperatures, pulse and respirations), blood pressure, weights (etcetera), in accordance with our facilities policy and procedure . On 1/12/16 at 10:50 a.m., E1 (Administrator) stated he received a phone call from E18 at 7:41 a.m. on 12/28/15, alleging E19 had engaged in sexually inappropriate behavior with R1. E1 stated E18 and E19 reported that the incident occurred at 2:00 a.m. on 12/28/15. E1 stated staff are expected to immediately report any incident that could be considered potential abuse to himself (Administrator and Abuse Coordinator) to ensure the protection of the residents. On 1/20/16 at 9:00 a.m., E1 (Administrator) stated he participated in educating staff at the Abuse Reporting and Education inservice on 11/13/15 and immediate reporting of abuse to the Administrator was discussed, along with what constitutes abuse/neglect. On 1/20/16 at 11:10 a.m., E2 (Director of Nursing) stated the 11/13/15 Abuse Inservice included information on the different types of abuse, staff's expectation to notify E1 immediately of any suspected abuse/neglect, and a review of the facility Policy and Procedure on Abuse. A Training/Inservice Sheet dated 11/13/15, documents E13, E14 and E18 were in attendance for the Abuse Reporting and Education training. A Health Center Room Occupancy Chart, provided by E1 on 1/20/16, documents R1 through R32 reside on units where E19 had access. On the Health Center Room Occupancy Chart, E1 identified the following residents on those halls as being completely dependent on staff for all cares and cognitively impaired: R1, R5, R8, R12, R14, R15, R16, R19, R21, R22, R24, R31 and R32. On 01/22/16 at 11:30AM an Immediate Jeoardy was identified to have begun on 12/28/15 when E13, E14, and E18 failed to report the sexual abuse immediately to their supervisor. E1/Administrator and E2/Director of Nursing were notified of the Immediate Jeopardy on 01/22/16 at 11:30AM. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. The facility provided in-service training by the facility's Director of Nursing and Clinical Nurse Educator to all staff at the nursing home regarding staff obligation to immediately report any allegation, accusation, or suspicion of abuse or neglect to the facility Administrator. 2. The facility has reviewed its Policy and Procedure on Abuse/Neglect Prevention and Response to explicitly instruct that an alleged perpetrator of abuse or neglect is to be immediately removed from resident contact, as soon as an allegation, accusation, or suspicion of abuse or neglect is made and suspended until the conclusion of the facility's investigation. 3. A plan to monitor for continued compliance has been developed. The Administrator and Clinical Nurse Educator are performing a re-training of all RN, LPN, and CNA staff on the updated Policy and Procedure on Abuse/Neglect Prevention and Response. The re-training entails a pre-test to determine baseline knowledge, an in-person education program, and then a post-test exam for each RN, LPN, and CNA. Thereafter, the Administrator will conduct random audits to determine staff proficiency and compliance with the updated Abuse/Neglect Prevention and Response policy and procedure; the audits will be done daily on each shift for the next two weeks, and then once per week per shift for the following two weeks. Additionally, the facility's Risk Manager will perform an audit of every allegation, accusation, or suspicion of abuse or neglect at the facility, weekly for the next six weeks, to verify that the policy and procedure for identifying, reporting, and investigation is properly followed by staff and Administration.

Based on record review and interview, the facility failed to protect a resident from sexual abuse by a staff member, for one of three residents (R1) reviewed for abuse, in a sample of three. This failure resulted in R1 being sexually violated in her own room in the early morning hours while she was laying in her own bed. Findings include: An Abuse Investigation (final report), dated 12/31/15, documents E13 (Certified Nursing Assistant) and E18 (Certified Nursing Assistant) reported to E1 (Administrator) on 12/28/15 an allegation of sexual abuse. The Abuse Investigation documents E13 and E18 observed E19 (Licensed Practical Nurse) exposing his penis to a female resident and one of these CNAs (Certified Nursing Assistants) reported seeing (E19) removing his penis from the resident's mouth at approximately 2:00 a.m. The female resident was prone in her bed in her room. The CNAs believed the resident to be asleep .(E13) and (E18) witnessed (E19's) actions upon entry into the doorway of the resident's room. (E13) immediately alerted (E19) to their presence, at which point it was reported that (E19) quickly stopped, adjusted his pants and exited the room. On 1/14/15 at 7:45 a.m., E13 (Certified Nursing Assistant) stated she was doing rounds with E18 (Certified Nursing Assistant) on 12/28/15 at approximately 1:45 a.m., when they determined they needed assistance from E19 (Licensed Practical Nurse). E13 stated she went to multiple rooms looking for E19 and noted R1's door was kinda closed. E13 stated, I had to push the door open to get in the room, but I could see in to (R1) from the hallway .When I went into the room (E18) was right behind me .I saw (E19) with his right knee on the edge of the bed, near the head of the bed and standing on his left leg. He was holding his penis in her mouth with his left hand. I saw her face. E13 called out E19's name, causing E19 to turn. E13 stated, as E19 came out of the the room his white button down shirt and both shirt tails were tucked into (his) boxers, and white pants (were) hanging under his belly. On 1/12/16 at 1:58 p.m., E18 stated she and E13 were doing rounds at approximately 2:00 a.m. on 12/28/15, when they were in a resident room completing cares and decided they needed E19's assistance for a treatment. E13 left that resident's room to look for E19. When E13 didn't come back, E18 went out to the hall and helped E13 look for E19. E13 stated they noticed R1's door was almost completely closed. E18 stated they opened R1's door and observed E19 standing at the head of R1's bed. E18 stated, she could see (R1's) head hanging down off the edge of the bed. (E19's) right knee was on the edge of the bed. E18 stated E19 jumped back when E13 called his name and that was when she noted E19 had his penis in R1's mouth. E18 observed E19 adjust his pants and could see that he was wearing checked boxers. E18 stated she was too scared to confront (E19) and she kept doing rounds with E13. On 1/12/16 at 1:44 p.m., E14 (Certified Nursing Assistant) stated, on 12/28/15 at approximately 2:00 a.m., she overheard E13 and E18 talking about R1 and E19 in the hallway, but didn't want to get involved. E14 stated at approximately 4:00 a.m. on 12/28/15, E13 told her that she observed E19's penis in R1's mouth, but was waiting for (E1-Administrator) to come in to report the incident. On 1/12/16 at 10:50 a.m., E1 (Administrator) stated he received a phone call from E18 at 7:41 a.m. on 12/28/15, alleging E19 had engaged in sexually inappropriate behavior with R1. E1 stated E18 and E13 reported that the incident occurred at 2:00 a.m. on 12/28/15 and E19 worked the remainder of his shift (ending at approximately 6:30 a.m.). E1 stated staff are expected to immediately report any incident that could be considered potential abuse to himself (Administrator and Abuse Coordinator) to ensure the protection of the residents. On 1/12/16 at 9:50 a.m., R1 was interviewed regarding the alleged incident on 12/28/15. R1 denied any staff member doing anything sexually inappropriate to her and denied any complaints with the staff. A Minimum Data Set, dated dated [DATE], documents R1 as being cognitively impaired, having short term and long term memory impairment and requiring total staff assistance for all activities of daily living. R1's current Plan of Care, dated 1/12/16, documents R1 as having difficulty remembering things and difficulty communicating and making my needs known.

Based on interview and record review the facility failed to follow fall interventions outlined in the care plan for one (R1) of three residents for falls. This failure resulted in R1 falling and sustaining a hip fracture that required surgical repair. Findings include: R1's care plan dated 11/18/15 documents one of the interventions as, I am unable to pull cord in bathroom for assistant due to my decreased cognition. Please do not leave me in the bathroom unattended. The facility's Incident Review Form dated 12/08/15, notes that on 12/08/15, (R1) was found on bathroom floor after an unwitnessed fall. R1's Radiology Report dated 12/08/15, and signed by Z2(Radiologist), documents, Reason: Pain in right hip from a fall; Conclusion: Fracture of the right hip. On 12/23/15 at 11:45 AM, R4(R1's roommate), stated, (R1) was taken to the bathroom and staff left the room. I heard (R1) yell and I turned on my call light and the nurse and CNA came running in the room into the bathroom. No one was in the room or bathroom with (R1). R4's Admission MDS (Minimum Data Set) Assessment, documents that R4 has no cognitive impairment. On 12/23/15 at 10:00 AM, Z1(R1's family), stated, (R1) and (R4) both told me what happened the morning of the fall. Both confirmed that (R1) was left on the toilet unattended and fell when (R1) stood up. (R4) turned on the call light when (R4) heard (R1) yell, and a nurse and Certified Nurses Assistant/CNA came running into the room. (R4) confirmed no one was in the room or bathroom with (R1) when the fall occurred. (R1) had an xray that showed a right hip fracture, (R1) was transferred to a local hospital and had a surgical repair to the right hip on 12/10/15. On 12/23/15 at 2:08 PM, E2(Registered Nurse/RN), confirmed R1's fall on 12/08/15 was reported as an unwitnessed fall. On 12/23/15 at 12:15 PM, E1(Administrator), stated, If I remember correctly, (R1) fell while trying to self transfer. The CNA that was with (R1) heard another fall alarm across the hall and went to check on it.

Based on interview and record review, the facility failed to safely transfer for one of three residents (R1) reviewed for transfers in a sample of three. This failure resulted in R1 sustaining fractures of the tibia and fibula. Findings include: Facility document "Using Mechanical Lift", dated 2005, states "Residents who are unable to bear their own weight will be transferred using a mechanical device....Use of a mechanical lift will be determined by the residents individualized plan for care." Facility document "Using a Transfer Belt to Assist in Transferring a Resident between Two Surfaces", dated 2005, states "when a resident requires assistance in transferring between two surfaces the team member assisting the resident will review the resident plan of care to determine if there is an individualized plan noting specific requirements related to transfer." R1's Minimum Data Set (MDS), dated [DATE], documents under Section G-Functional Status B. Transfer as "total dependence and two plus person physical assist." R1's facility "Order Audit and electronic Signature-By Resident" dated 5/1/15-5/19/15 documents R1 as non-weight bearing and a mechanical lift. R1's care plan dated 3/10/15 documents R1 uses a mechanical lift for transfers. R1's "closet care plan", no date, documents R1 as a mechanical lift with a bed and chair alarm. On 5/15/15 at 12:50p.m., E11 CNA, verified R1 bears no weight and was "2 man lifted" by E11 CNA and E8 CNA from R1's reclining wheelchair to R1's bed. E11 and E8 noticed the bed alarm cord wrapped around R1's leg when R1 was in bed. E11 also stated R1 immediately complained of right leg pain and stated (R1's) leg was broke. On 5/15/15 at 12:20p.m., E2 DON, stated the following: E11 CNA and E8 CNA performed an improper transfer of a "stand pivot" with R1 instead of a mechanical lift transfer from R1's reclining wheelchair to R1's bed, and R1 got wrapped up in R1's chair alarm. E8 CNA told E2 that E8 transferred R1 without a mechanical lift because E8 wanted R1 in bed right away so E8 CNA had E11 CNA assist E8. R1's leg was x-rayed at the facility, and a fracture was found. R1 was then sent to the emergency room at the local hospital. On 5/19/15 at 3:00p.m., E9 RN (Registered Nurse) stated E8 CNA told E9 "we 2 man lifted (R1) to bed and (R1's) leg got caught in the alarm cord." On 5/20/15 at 6a.m., Z2 APN (Advanced Practice Nurse), stated "I think R1's spiral fracture was caused by the wheelchair and bed. When the CNA's picked up R1 and turned R1 to the bed, R1's leg did not turn with the body. I would assume it (leg) got caught where it did not move with the body. There were no ligaments/cord marks on R1's leg so I don't believe the (alarm) cord made the spiral fracture. R1 had significant swelling, bruising, and definite deformity of the right leg. R1's leg could have gotten caught between the bed and the wheelchair." Radiology report, dated 5/14/15, documents R1 has a "Spiral fracture of the distal tibial shaft. Nondisplaced fracture of the distal fibula shaft. Mild swelling." R1's local hospital emergency department notes, dated 5/15/15 at 5:53a.m., by Z2 APN (Advanced Practice Nurse) documents E10 LPN, stated, "R1 got the alarm cord tangled around (R1's) leg. R1 was being transferred to R1's bed." Orthopedic Consultation Note, dated 5/15/15, by Z3 PA-C (Physician Assistant-Certified) documents R1's "Radiology Review: Spiral fracture of the tibia and fibula which extends cranially to the level of midshaft. Mild angulation. Not significantly displaced........to place patient in long leg splint."

Based on interview and record review, the facility failed to follow policies related to transfers and mechanical lifts that require staff to transfer a resident according to the individualized care plan for one of three residents (R1) reviewed for transfers in a sample of three. This failure resulted in R1 sustaining fractures of the tibia and fibula. Findings include: Facility document "Abuse/Neglect Prevention and Response", dated 5/4/13, documents under "Procedures...Definitions...Neglect is defined as withholding services that are necessary to maintain physical, mental, or spiritual health." Facility document "Using Mechanical Lift", dated 2005, states "Residents who are unable to bear their own weight will be transferred using a mechanical device....Use of a mechanical lift will be determined by the residents individualized plan for care." Facility document "Using a Transfer Belt to Assist in Transferring a Resident between Two Surfaces", dated 2005, states "when a resident requires assistance in transferring between two surfaces the team member assisting the resident will review the resident plan of care to determine if there is an individualized plan noting specific requirements related to transfer." R1's Minimum Data Set (MDS), dated [DATE], documents under Section G-Functional Status B. Transfer as "total dependence and two plus person physical assist." R1's facility "Order Audit and electronic Signature-By Resident" dated 5/1/15-5/19/15 documents R1 as non-weight bearing and a mechanical lift. R1's care plan dated 3/10/15 documents R1 uses a mechanical lift for transfers. R1's "closet care plan", no date, documents R1 as a mechanical lift with a bed and chair alarm. On 5/15/15 at 12:50p.m., E11 CNA, verified R1 bears no weight and was "2 man lifted" by E11 CNA and E8 CNA from R1's reclining wheelchair to R1's bed. E11 and E8 noticed the bed alarm cord wrapped around R1's leg when R1 was in bed. E11 also stated R1 immediately complained of right leg pain and stated (R1's) leg was broke. On 5/15/15 at 12:20p.m., E2 DON, stated the following: E11 CNA and E8 CNA performed an improper transfer of a "stand pivot" with R1 instead of a mechanical lift transfer from R1's reclining wheelchair to R1's bed, and R1 got wrapped up in R1's chair alarm. E8 CNA told E2 that E8 transferred R1 without a mechanical lift because E8 wanted R1 in bed right away so E8 CNA had E11 CNA assist E8. R1's leg was x-rayed at the facility, and a fracture was found. R1 was then sent to the emergency room at the local hospital. On 5/19/15 at 8:40a.m., E2 DON, stated E8 CNA had education on how to determine a residents transfer status and how to use the mechanical lifts at the facility prior to the incident. E2 DON verified that E8 CNA regularly works with R1 and has previously transferred R1 with a mechanical lift prior to the 5-14-15 incident. On 5/19/15 at 3:00p.m., E9 RN (Registered Nurse) stated E8 CNA told E9 "we 2 man lifted (R1) to bed and (R1's) leg got caught in the alarm cord." On 5/20/15 at 6a.m., Z2 APN (Advanced Practice Nurse), stated "I think R1's spiral fracture was caused by the wheelchair and bed. When the CNA's picked up R1 and turned R1 to the bed, R1's leg did not turn with the body. I would assume it (leg) got caught where it did not move with the body. There were no ligaments/cord marks on R1's leg so I don't believe the (alarm) cord made the spiral fracture. R1 had significant swelling, bruising, and definite deformity of the right leg. R1's leg could have gotten caught between the bed and the wheelchair." Radiology report, dated 5/14/15, documents R1 has a "Spiral [MEDICAL CONDITION] tibial shaft. Nondisplaced [MEDICAL CONDITION] fibula shaft. Mild swelling." R1's local hospital emergency department notes, dated 5/15/15 at 5:53a.m., by Z2 APN (Advanced Practice Nurse) documents E10 LPN, stated, "R1 got the alarm cord tangled around (R1's) leg. R1 was being transferred to R1's bed." Orthopedic Consultation Note, dated 5/15/15, by Z3 PA-C (Physician Assistant-Certified) documents R1's "Radiology Review: Spiral [MEDICAL CONDITION] and fibula which extends cranially to the level of midshaft. Mild angulation. Not significantly displaced........to place patient in long leg splint."

Based on interviews, observation and record reviews the facility failed to safely serve coffee to one of three sampled residents. (R1) On 9/13/14 R1 spilled coffee on his legs, which resulted in second degree burns on both posterior thighs. Findings include: R1's Minimum (MDS) data set [DATE] notes R1 to have a [DIAGNOSES REDACTED]. Incident report dated 9/13/14 at 7:30 A.M. notes that R1 had spillled coffee on both legs. Incident report reads, "Resident (R1) spilt coffee on his left upper thigh, Resident was given 650 mg of Tylenol for the pain and cold compress for 15 minutes to left upper thigh. Has some redness to it but no blisters or welps present at this time. Skin intact. Will continue to monitor." Note on incident report at 4:27 P.M. reads, "Daughter here and noticed a blister to left back upper thigh and opened blisters to the right upper back thigh." Patient Wound Care Sheet dated 9/16/14 notes R1 to have a 9.5 centimeter x 3.0 centimeter full thickness burn to the right posterior thigh and a 9.3 centimeter x 5.2 centimeter partial thickness burn to the left posterior thigh. On 10/2/14 at 9:05 A.M. Z2 (R1's Daughter) stated that R1 has been having an issue with spilling his drinks for the past several months. Z2 stated the facility staff and herself tried sippy cups and cups with lids on them, but R1 was not receptive to these ideas. Z2 stated she then told staff R1 should have an ice cube in his coffee and only fill it half way. This way if he was to spill it on himself he would not burn himself. Z2 stated she assumed that the information had been passed on to all departments. Z2 stated that she was surprised to find out that R1 had second degree burns to the backs of both thighs. On 10/3/14 at 9:53 A.M. E6 (Homemaker) stated that she was told about a month ago that R1 was to have an ice cube in his coffee and only half full. E6 stated that R1 has had trouble with spilling his coffee and that's when they first tried the cups with lids on them. E6 said she thought all the staff knew this information. On 10/2/14 at 10:18 A.M. E4 (Household Coordinator) stated that she is the Coordinator of the Unit in which R1 resides. E4 stated that she was not made aware of the intervention of putting an ice cube in a half cup of coffee for R1. E4 stated the information needs to be passed on to management in order to get on R1's care plan and Dietary card. On 10/2/14 at 1:57 P.M. Z1 (R1's Attending Physician) stated that R1 did acquire second degree burns to both posterior thighs as a result of spilled coffee on 9/13/14.