Every finding on record at Mackinac Straits Long Term Care Unit

Based on observation, interview and record review, the facility failed to follow proper infection control practices including: 1) adhering to Personal Protective Equipment (PPE) requirements in accordance with facility policy and CDC recommendation for one Resident (#37) of one reviewed for transmission based precautions and 2) failing to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility.Findings Include: Resident #37 (R37) The medical record revealed R37 was admitted to the facility on [DATE]. On 6/22/26 the physician ordered Contact Precautions (steps taken to prevent the spread of infection) r/t (related to) rash on right arm at elbow and right side of back by shoulder. The order was current and had not been discontinued by the physician. On 6/30/2026 at 8:01 AM, a receptacle of various types of PPE including gloves, gowns etc. and a contact precaution sign was observed on R37's door. Certified Nurse Aide (CNA) K walked into R37's room without donning any PPE and delivered a meal tray. CNA K adjusted R37's bed and asked, Can I help you with your clothing protector? R37 agreed and CNA K put it on him. CNA K exited the room and when asked about the contact precaution sign and equipment, she stated, I only follow the instructions on the door when providing care like feeding or bathing. CNA K agreed that she made contact with R37 when donning his clothing protector for breakfast. During an interview on 6/30/2026 at 10:15 AM, Licensed Practical Nurse (LPN) L stated R37 has been on contact precautions and was evaluated by the Director of Nursing (DON) and was taken off today. On 6/30/2026 at approximately 10:30 AM, CNA J was observed entering and exiting the room of R37. When questioned CNA J stated R37 places his call light on multiple times each shift and sometimes each hour. CNA J stated R37 will request his bed be adjusted up and then down and then up and confirmed he must adjust R37's bed covers frequently. CNA J stated R37 has been on contact precautions for the past two weeks or so. CNA J stated he did not wear PPE upon entering the room for just adjusting the bed or covers for the last two weeks. During an interview on 6/30/2026 at 10:39 AM, the DON stated, (R37) was on contact precautions and now he is back on EBP (Enhanced Barrier Precautions). The DON stated the expectations would be all staff would wear gowns and gloves to enter and interact with residents with contact precautions. The medical chart for R37 was observed and the order for contact precautions had not been changed and still indicated contact precautions were in effect. The DON stated, Nursing can initiate an order but technically it would require a physician's order to discontinue (the contact precautions) The DON confirmed there was still an order for contact precautions. The CDC recommendations as accessed on their website on 6/30/26 read in part, Use Personal Protective Equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. On 6/30/2026 at 9:04 AM, the water management plan, dated 1/2020, was reviewed with the Director of Facilities C and Maintenance Tech (MT) D and it places all fixtures on a regular flushing schedule. While reviewing the chart showing which rooms are getting flushed on which dates and by whom, N/A was noted on the line for the North Tub Room. MT D was asked what the N/A meant and stated the tub had been removed from that room and was no longer in use to be able to sample. When asked, MT D thought the plumbing had been removed completely. MT D stated the South Tub Room was used for most of the time for bathing residents. On 6/30/2026 at 9:30 AM, MT D and the surveyor then began the facility tour and went into the North Tub Room which is now used for storage. The bathtub was observed having been removed and the room was full of equipment. MT D stated this room is now used for storage only. When equipment was moved out of the way, the cold-water fill line for a removed toilet was observed sticking out of the wall with a small shut off valve. To the left of the former toilet, additional hot and cold-water lines with shut off valves extending out of the wall were observed. MT D stated neither of these areas are on the sampling or flushing schedule. On 6/30/2026 at 9:40 AM, a tour of the Main Health Spa showed the shower in this room was being used as storage; the shower contained personal care equipment for bathing, bags of resident socks and 28 empty clothes hangers hanging on the shower curtain rod. Certified Nursing Assistant (CNA) E entered the room and said the shower never gets used anymore, and that they use it for storage of socks and personal items. MT D confirmed the water lines were not on the current flushing schedule.

Based on observation, interview, and record review, the facility failed to maintain proper food safety and equipment in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 6/29/2026 at 10:45 AM, observed the slicer was covered with a clear protective cover. During this observation, when asked, Long-Term Care [NAME] F said that the protective cover means that the slicer has been cleaned and sanitized and is ready for use again. The exterior of the slicer was observed with dried tomato debris and seeds stuck to the slicer. Dietary cook for Hospital Acute Care G, stated Dietary [NAME] (DC) I normally cuts all the tomatoes on the slicer. DC I was not working at the time of the observation. On 6/29/2026 at 12:10 PM, Licensed Practical Nurse (LPN) H stated that Non-Certified Aides check the personal room refrigerators every Tuesday and fill the logs out on the front of each refrigerator and they let the nurses know if there are any problems. On 6/29/2026 at 12:14 PM, the thermometer in the personal refrigerator in room [ROOM NUMBER] was observed to read that the ambient air temperature was 45 degrees. This refrigerator was observed to contain an open container of home canned relish, canned beer and canned soda pop. The temperature of the relish was noted at 45 degrees when checked with a probe thermometer. On 6/30/2026 at 3:08 PM, the exhaust filter in the vent hood over the dish machine in the hospital kitchen was observed soiled with an accumulation of dust and the top of the dish machine was soiled with an accumulation of mineral and chemical build-up.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.According to the 2022 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54C (130F) or above; or (2) At 5C (41F) or less.

Based on interview and record review, the facility failed to: (1) implement individualized fall interventions based on an identified root cause to prevent recurrent falls and (2) supervise a dependent resident during toileting for two Residents (R3 and R28) of three residents reviewed for falls.Findings include: Resident #28 (R28) was admitted most recently to the facility on 1/23/2026 with a primary diagnosis of dementia and other diagnoses including a history of multiple falls. During an interview on 6/29/26 at 3:30 PM, R28's Family Member (FM) M explained that R28 had a recent fall and had to go to the hospital. R28 then returned to the facility but still had pain. When asked about the fall, FM M stated R28 was being assisted by the CNA (Certified Nurse Aide) who the left her alone in the bathroom and R28 fell. FM M stated, She (R28) just went out to the hospital for more x-rays. She has been in pain. The medical record contained a progress note regarding the fall on 6/27/26: [Recorded as Late Entry on 06/28/2026 01:09] Tabs were sounding and CNA said resident was on the floor and needed help to get resident up. Resident was sitting on her bottom on the floor with her back to the wall after trying to get up from the toilet, She had bumped the back of her head on the toilet in the process. During an interview on 6/30/2026 at 2:09 PM, CNA O stated (R28)'s tab alarm was going off and she had toileted herself. I had been bouncing back from her room to the hallway. She wanted to get ready for bed and did not have any gowns in her room, so I stepped into the hallway to get her a gown. I was heading back into the room when I heard 'help me help me'. (R28) was sitting on the floor. During an interview on 6/29/2026 at 3:33 PM, Licensed Practical Nurse (LPN) N said, Yes I was here that evening working 7:00 PM to 1:00 AM and the aide took (R28) to the bathroom. The aide had left the room. We are not supposed to do that. During an interview on 6/30/2026 at 3:01 PM, the event was reviewed with the director of Nursing (DON). The DON agreed the CNA should not have left a dependent resident unsupervised. The care plan for R28 included: Problem start Date 9/4/2025 Cognitive Loss / Dementia I have a Dx (diagnosis) of Neurocognitive Disorder with Lewy Bodies, Dx. of Dementia, moderate with psychotic disturbance. I exhibit cognitive deficits. I benefit from assistance, cues and reminders for safe decision making and organization. Edited: 05/19/2026 And Problem Start Date: 03/05/2025 Category: Falls Resident is at risk for falls due to; history of falls, weakness, medication side effects, and use of lift chair. Resident #3 (R3) During a telephone interview on 6/29/26 at 11:47 a.m., the resident representative stated R3 fell while at the facility and sustained a head injury requiring hospitalization. Review of the electronic medical record (EMR) revealed R3 experienced an unwitnessed fall on 1/24/26 while independently attempting to toilet. Staff found R3 on the bathroom floor with a skull laceration. R3 was transferred to the emergency department and subsequently to another hospital with a higher level of care, and diagnostic testing identified a subdural hematoma (a potentially life-threatening condition that causes increased pressure on the brain due to a collection of blood between the brain and its outer covering). R3 was admitted to the intensive care unit before returning to the facility on 1/27/26. A falls care plan identified R3 as being at risk for falls related to a history of falls, unsteady gait, weakness, and cognitive impairment. Following the 1/24/26 fall, the documented intervention added to the care plan was: Grippy socks [gripper socks – socks with a textured surface] to be on while in bed. The EMR documented R3 had another unwitnessed fall while trying to use the bathroom on 5/29/26. The subsequent incident report documented Resident was trying to take self to the restroom. The report documented, in part: .Resident has a dementia diagnosis and has had falls in the past self transferring self [sic] and forgetting to use his call light. A Minimum Data Set (MDS) assessment dated [DATE], prior to the fall event on 1/24/26, documented R3 had severe cognitive impairment and had experienced two or more falls since admission to the facility or prior assessment. The MDS indicated R3 required staff supervision for toilet transfers but was not on a toileting program. The most recent MDS dated [DATE] documented R3 continued to require staff assistance with toilet transfers and was dependent on staff for toileting hygiene. The MDS indicated R3 was not on a toileting program to assist R3 to the bathroom at regular intervals since the resident had a history of falls while trying to toilet. A skilled therapy evaluation was completed by the facility Physical Therapist on 1/28/26. The evaluation documented R3 was at increased risk for falls due to unsafe independent transfers. The evaluation indicated R3 had dementia with fluctuating levels of alertness contingent on the time of day. The physical therapist documented, in part: .patient has been non-ambulatory for a long time .fall risk if patient does not have assistance with transfers . The Director of Nursing (DON) was interviewed on 6/30/26 at 12:49 PM. The DON was asked how interventions were developed when a resident falls. The DON said the interventions were based on the reason the resident fell to minimize the risk of fall recurrence. When asked about the fall of R3 and the reason for the intervention of gripper socks on 1/24/26, the DON referred to the nurse manager, Registered Nurse (RN) A. During an interview on 6/30/26 at 12:53 p.m., Registered Nurse (RN) A confirmed the fall on 1/24/26 occurred when R3 independently transferred to the bathroom. RN A stated it was not uncommon for R3 to self-transfer. RN A acknowledged R3 was inconsistent with using the call light and confirmed R3 did not reliably request staff assistance before toileting. When asked whether it was reasonable to expect a resident with severe cognitive impairment to consistently remember to use the call light, RN A responded, No. When asked what intervention had been implemented to address the identified cause of the fall, RN A reviewed the EMR and stated the intervention was gripper socks while in bed. When asked how gripper socks addressed the risk associated with the resident independently attempting to toilet, RN A stated, Gripper socks aren't going to help with a fall based on this root cause because he fell going to the bathroom. [R3] should be helped to the bathroom on a routine basis. RN A confirmed Resident 3 was not on a scheduled toileting program and was not routinely assisted to the bathroom. When asked what was being done for R3 to provide supervision for safe toileting, RN A said she did not know. The facility's policy titled Incident Reporting dated as revised 3/2024 read, in part: .Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences.

This citation pertains to intakes 2638726 and 2641135.Based on observation, interview and record review the facility failed to provide safe transport to an outside appointment for one Resident (#10) of three residents reviewed for accidents/hazards. This deficient practice resulted in harm when R10 sustained a fractured left hip from being improperly secured during transport and fell from her seat when the transport van hit an obstacle in the road. Findings include:Resident #10 (R10)Review of the Minimum Data Set (MDS) assessment, dated 9/10/2025, revealed R10 was admitted to the facility on [DATE] and had diagnoses including diabetes and heart failure. Section GG of the MDS indicated R10 required substantial/maximal assistance with lower body dressing, was dependent on staff for transfers and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating cognition was intact.On 10/15/2025 at 12:45 p.m., R10 could be heard yelling out in pain from her room. Upon entering the room, R10 was observed seated in bed with a troubled expression on her face. When asked if she was ok, R10 reported yes but she had just been repositioned by staff and that movement made her bones hurt. When asked where her pain was originating from, R10 placed her hand on her left thigh and stated, it's my bones. R10 was queried about prior injury and reported she recently fractured her left thigh and underwent surgical repair after a fall in the facility van while being transported to an appointment. When asked to describe the incident, R10 reported she was seated in her wheelchair in the back of the van and when the van hit a bump in a construction zone, she went flying from her wheelchair into the back of the seat in front of her, jamming her left knee into the back of the seat. R10 stated, my bone cracked, and I knew something was wrong right away. R10 reported she had significant pain in her left leg following the event. When asked if she had been wearing a seatbelt, R10 reported her wheelchair was tied down but she was not wearing a seatbelt, and the facility did not have any type of safety belt device for use during transport that would fit her wheelchair.Review of the incident report and investigation summary provided by the Director of Nursing (DON), dated 10/1/2025, revealed the following: Nursing supervisor was notified by CNA [Certified Nursing Assistant] what had happened. CNA informed [sic] that a bump was hit and [R10's] left knee hit the back of the seat and she c/o [complained of] pain in her leg. CNA asked for guidance and was instructed to take her to her [appointment] and then come back to facility. Once back to facility, order for x-rays was already obtained and she went down for x-rays and results came back that she had a fracture . 911 was called and she was sent to [acute care hospital] for treatment.Review of the Incident Summary, submitted to the State Agency (SA) on 10/1/2025 at 12:34 p.m., revealed the following: [R10] was on a transport in our wheelchair accessible van . she was accompanied by CNA [ A] and Activity Aide [AA B] (who was driving). Per [CNA A] during the transport, the van stopped due to oncoming construction, which caused [R10] to slump in her wheelchair. [R10's] knee hit the seat in front of her. When she returned from the appointment, she began to complain of pain.Review of the Investigation Summary, submitted to the SA on 10/8/2025 at 9:54 a.m., revealed the following: Director of Nursing [DON] interviewed both staff members, [CNA A and AA B], who were with [R10] during the transport at the time of the incident. Both staff members confirmed that the slow down the van needed to make was not a severe or harsh stop that caused significant force when the resident slid from her wheelchair and her left leg moved into the car seat in front of her. [CNA A] stated during interview with DON that she felt [R10's] leg lightly hit the front seat .It was noted there was no mention of whether R10 was provided with a seatbelt during the transport on 10/1/2025 per the documents submitted by the facility to the SA on 10/1/2025 and 10/8/2025.During an interview on 10/15/025 at 1:00 p.m., CNA A recalled the incident involving R10 which occurred during transport on 10/1/2025. CNA A reported R10 was seated in her wheelchair while being lifted into the back of the transport van. CNA A reported securing the wheelchair in the van using the tie-downs and hooks on the floor of the van and proceeded to take a seat in the first passenger row of the van, with R10 in her wheelchair seated behind her. CNA A reported AA B was driving the van and hit a bump while going through construction at which time R10 started to yell out. CNA A reported upon hearing R10 yell out she turned around to find the Resident slid partially out of her chair with her left foot off the foot pedal of the wheelchair, bent over with her left shoulder and knee up against the back of the passenger row of seats. CNA A was queried as to whether or not R10 expressed pain after the incident to which she reported she [R10] said her leg [left] hurt and that R10 expressed worry about the pain when arriving to her appointment and again when arriving back at the facility. When asked if she witnessed R10 slide out of the chair, CNA A reported she did not witness R10 come out of the chair and only turned around when R10 yelled out after hitting a bump. When asked if R10 was provided with a seatbelt or lap belt while seated in the wheelchair, CNA A reported the facility did not have a safety belt that would fit R10's wheelchair, therefore, R10 was without any type of safety belt to ensure she would remain seated if the vehicle experienced hazardous movements. When asked if she and AA B were aware there was not safety belt available to secure R10 in her seat for protection against harmful movement while being transported in the van, CNA A answered yes both she and AA B were aware there was no protective device available for R10 to use during transport.Review of AA B's written statement, signed and dated on 10/01/2025, revealed the following: While taking resident to a [physician appointment] . we hit a bump that of which [R10] was informed of. She went forward into the seat, her knee pressed against the back of the seat. [R10] was not in chair, her bottom was on the edge. She would not help. I did have to help [CNA A] boost her . Upon driving home she had no complaints until she seen [the facility]. Then she began to yell, cry and seatbelt does not fit large people [sic]. [CNA A] was in second seat back.Review of R10's hospital History and Physical, dated 10/01/2025 at 11:34 p.m., revealed the following: [R10] presents to [emergency department] as a level 2 activated trauma following an aggressive ride in her wheelchair on a wheelchair van . [the facility] was transporting her to an appointment when they went through a construction zone. Apparently the driver had to stop suddenly. She lurched forward in her wheelchair. It is unclear whether she tilted forward and struck her leg or she struck her leg on something . she had continued pain. There was shortening and rotation of the left lower extremity . Patient is screaming out in pain with any movement of the left lower extremity . X-ray of femur shows a periprosthetic proximal third femur fracture . CT Lower Extremity [without] Contrast Left: Acute comminuted fracture left femoral mid diaphysis surrounding the distal end of the femoral component left total hip arthroplasty . Assessment/Plan: Femur fracture: Left-sided femur fracture after falling out of wheelchair. Patient was in a van which stopped suddenly causing her to be ejected from her wheelchair .Review of R10's Critical Care Progress Note, dated 10/4/2025 at 2:47 p.m., revealed R10 underwent surgical repair of her left femur fracture on 10/4/2025.Review of R10's electronic medical record (EMR) revealed the following progress note, dated 10/5/2025 at 10:26 a.m.: This nurse call [acute care hospital] to get an update on [R10]. She continues to be in the ICU [Intensive Care Unit]. She had surgery yesterday (10/4/25) to repair her femur. She did receive 3 units of blood during her surgical procedure .Further review of R10's EMR revealed the Resident returned to the facility from hospitalization on 10/8/2025.During an interview on 10/15/2025 at 1:20 p.m., the Nursing Home Administrator (NHA) reported he was aware R10 was not provided with a safety belt during transport to her appointment on 10/1/2025. The NHA stated the facility investigation into the incident found that R10's wheelchair was not rated for use in the van and they were unable to find a safety belt or harness that would fit the wheelchair. When asked to provide documentation of CNA A's and AA B's training on transporting residents in wheelchairs, the NHA reported he was unable to provide the documentation. The NHA stated the facility had ordered four new wheelchairs for use during transportation and all transport staff would be educated and required to provide a return demonstration for competency when the chairs arrived. The NHA reported the facility had discontinued transports for wheelchair bound resident in the facility van until training could be completed.Review of the facility policy titled, Transporting a Resident (Facility Van), dated 10/2/2025, revealed the following: Each resident will be secured in a seat with a seatbelt or in their wheelchair secured with wheelchair tie-downs and a wheelchair seat belt. No resident will be allowed to be transported in the facility van if their wheelchair cannot be safely secured and/or utilize a seat belt while in their wheelchair.

Based on interview and record review, the facility failed to consistently identify targeted behavior and implement non-pharmacological interventions prior to the administration of PRN (as-needed) anti-anxiety medication for one resident (#28) of five resident reviewed for unnecessary psychotropic medication, resulting in the potential for oversedation, dependency on controlled medication and decreased quality of life. Findings include: Resident #28 (R28) Review of the Minimum Data Set (MDS) assessment, dated 3/19/2025, revealed R28 was admitted to the facility on [DATE] and had diagnoses including anxiety disorder and depression. Further review of the MDS assessment, revealed R28 required substantial/maximal assistance with most Activities of Daily Living (ADLs) and was dependent on staff for transfers. Review of R28's physician orders revealed an order for lorazepam [a controlled anti-anxiety medication] 0.5mg [milligrams] every 8 hours - PRN [as needed] . Special Instructions: May give 0.25, [one-half] 0.5mg tab no closer than [every] 8 hours for increased anxiety . Please monitor [R28] and call [provider] if [R28] shows signs or symptoms of increased confusion or over-sedation. Review of R28's Medication Administration Record (MAR) for 5/01/25 through 5/28/2025 revealed R28 was administered the PRN lorazepam on 32 occasions. Further review of the MAR revealed indications for administration of the PRN lorazepam were listed on the MAR as Other Anxiety for 19 of the 28 administrations, Sleep for eight administrations, and Behavior Issue for one administration. It was noted in review of the MAR, documentation did not include specific target behaviors, or the sign and symptoms of anxiety warranting administration for each dose of the PRN lorazepam. Review of R28's electronic medical record (EMR) revealed no documentation of behavior or signs and symptoms of anxiety targeting by administration of the PRN lorazepam or the use of non-pharmacological interventions attempted prior to 25 of 28 administrations of the medication from 5/01/2025 through 5/28/2025. During an interview on 05/29/25 at 12:55 p.m., the Director of Nursing (DON) was queried about the process for administration of PRN psychotropic medication, including lorazepam. The DON reported staff were expected to document specific behavior, signs and symptoms targeted by administration of PRN anti-anxiety medication. The DON reported she was aware of staff administering PRN lorazepam to R28 without identifying the specific need for the medication. The DON stated, I keep telling them you can't just give it to him because he asks for it, there has to be a reason. The DON reported non-pharmacological interventions should be utilized in an attempt to alleviate R28's anxiety prior to administration of the PRN lorazepam to ensure the Resident is not administered unnecessary medication. The DON acknowledged the need for accurate and complete documentation related to administration of the medication to determine effectiveness of R28's medication regimen and if changes to the Resident's plan of care were warranted. Review of the facility policy titled, Psychotropic Medications, revised 5/2024, revealed the following: Physician will order psychotropic medications only for the treatment of specific medical and/or psychiatric conditions or when the medication meets the needs of the resident to alleviate significant distress for the resident not met by the use of non-pharmacological approaches . Orders for PRN psychotropic medications will be time limited and only for specific, clearly documented circumstances.

Based on observation, interview, and record review, the facility failed to revise and update care plans for three Residents (#3, #29, and #28) of twelve residents reviewed for care plan accuracy and revision. Findings include: Resident #3 (R3) On 5/27/25 at 2:16 PM, R3 said she fell but could not recall when the fall occurred. Pressure sensor alarms were observed on R3's bed and wheelchair. Review of the electronic medical record (EMR) revealed R3 fell and sustained a right hip fracture while in the bathroom on 4/10/25 at 8:30 AM. A nurse progress note dated 4/10/25 at 9:15 a.m. documented a tab alarm and safety checks every 30 minutes would be implemented. A nurse progress note dated 4/10/25 at 10:30 AM documented, in part: . tab alarm in place and 30 minutes [sic] safety checks have begun. An incident report dated as completed 5/2/25 for the fall event of 4/10/25 documented, in part: .INTERVENTIONS/TREATMENTS - Immediate measures taken. Tab alarm; 30 minute checks . The care plan for R3 was reviewed on 5/28/25. The fall care plan contained an intervention documented as created on 5/2/25 that read: was put on 30 minute checks 4/10/24 [sic]. The care plans did not include alarming devices to the bed and wheelchair. The Director of Nursing (DON) was interviewed on 5/29/25 at 10:48 AM. The DON said updates or revisions to fall care plan interventions should be completed the day of the fall or as soon as possible after fall occurrences. The DON acknowledged the care plan intervention for 30-minute safety checks was not entered as a care plan intervention until 5/2/25. The DON confirmed the bed and wheelchair alarms had not been added to R3's care plans. The DON reviewed and updated the care plan on 5/29/25 to include the intervention for the bed and wheelchair alarms. Resident #29 (R29) On 5/27/25 at 11:06 AM, R29 was observed lying in bed with both hands on his abdomen. R29 said he did not feel well and said he experienced pain when going to the bathroom. A bladder scanner was noted to be in the room next to R29's bed. Review of the EMR revealed R29 was admitted to the facility 4/28/25. An admission Minimum Data Set (MDS) assessment dated [DATE] documented R29 was incontinent of bladder, and dependent on staff for toileting hygiene and personal hygiene. A physician's progress note dated 5/13/25 at 3:19 PM documented, in part: .Physician notes from prior facility indicated that he was treated for MRSA [Methicillin Resistant Staphylococcus Aureus - a contagious, antibiotic-resistant bacteria that can cause serious infections, sepsis, or death] UTI [urinary tract infection] in March 2025 .The patient is minimally conversive and intermittently cries, admitting to lower abdominal pain . has a hx [history] of UTI .Concern for current UTI .lower urinary symptoms and history of UTI: patient with pustular drainage from his urethra and history of MRSA UTI. Recommend STAT straight cath UA sample, antibiotics will likely be needed . A urine culture was obtained on R29 on 5/14/25 and identified MRSA in the urine. The care plans for R29 did not include a plan of care for MRSA or the implementation of precautions to minimize the risk of spreading the bacteria to others. The care plans did not mention a history of UTI or contain interventions to provide staff with direction for minimizing the risks of infection. The DON was interviewed on 5/29/25 at 10:48 AM. The current care plan and care plan history of R29 were reviewed with the DON. The DON acknowledged the UTI, MRSA, and infection history were not in R29's care plans. The DON said R29 should be in Enhanced Barrier Precautions (EBP - a type of infection control intervention designed to reduce transmission of multidrug-resistant organisms such as MRSA) due to having MRSA in the urine. The DON reviewed the care plan and confirmed the EBP was not included in the plan of care. 41978 Resident #28 (R28) Review of the MDS assessment, dated 3/19/2025, revealed R28 was admitted to the facility on [DATE] and had diagnoses including anxiety disorder and depression. Further review of the MDS assessment, revealed R28 required substantial/maximal assistance with most Activities of Daily Living (ADLs) and was dependent on staff for transfers. Review of R28's physician orders revealed an order for lorazepam [a controlled anti-anxiety medication] 0.5mg [milligrams] every 8 hours - PRN [as needed] . Special Instructions: May give 0.25, [one-half] 0.5mg tab no closer than [every] 8 hours for increased anxiety . Please monitor [R28] and call [provider] if [R28] shows signs or symptoms of increased confusion or over-sedation. Review of R28's Medication Administration Record (MAR) for 5/01/25 through 5/28/2025 revealed R28 was administered the PRN lorazepam on 32 occasions. Further review of the MAR revealed indications for administration of the PRN lorazepam were listed on the MAR as Other Anxiety for 19 of the 28 administrations, Sleep for eight administrations, and Behavior Issue for one administration. It was noted in review of the MAR, documentation did not include specific target behaviors, or the sign and symptoms of anxiety warranting administration for each dose of the PRN lorazepam. Review of R28's care plan revealed a focus area for Psychotropic Drug Use. Resident receives antianxiety medication [related to] anxiety, initiated 3/26/2025 with the goal of Resident will be prescribed the lowest effective dose of medication. Further review revealed the interventions were not updated to include precipitating factors, targeted behavior or signs and symptoms of anxiety to assist staff in recognizing the need for the antianxiety medication. It was also noted R28's care plan did not include non-pharmacological interventions to be utilized in targeting R28's anxiety and ultimately to determine the need for administration of the PRN lorazepam. During an interview on 05/29/25 at 12:55 p.m., the DON was queried about the process for administration of PRN psychotropic medication, including lorazepam. The DON reported staff were expected to document specific behavior, signs and symptoms targeted by administration of PRN anti-anxiety medication. The DON reported behaviors along with sign and symptoms of anxiety should be included in R28's care plan along with non-pharmacological interventions to be utilized in attempts to prevent or alleviate the Resident's anxiety. The DON confirmed the use of non-pharmacological interventions prior to administration of PRN lorazepam was a standard of practice. Review of the facility policy titled, Comprehensive Care Plan, revised 10/2023, revealed the following: Each resident's comprehensive care plan will describe the following: Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The comprehensive care plan will: Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Aid in preventing or reducing declines in the resident's functional status and/or functional levels; Promote resident safety; Reflect currently recognized standards of practice for the problem areas and conditions . The care planning/interdisciplinary team is responsible for review and updating of care plans: When there is a significant change in the resident's condition; When the outcome is not met .

Based on observation, interview and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two Residents (#24 and #46) of twelve Residents reviewed for accuracy of MDS assessments. Findings include: Resident #24 (R24) R24 was admitted to the facility 12/19/24. The diagnoses list reviewed in R24's electronic medical record (EMR) included a diagnosis of Post-Traumatic Stress Disorder (PTSD). Review of the EMR revealed a care plan dated 12/19/24 for past physical and emotional trauma experienced by R24. A form titled Initial Trauma Informed assessment dated [DATE] reiterated the information contained in the care plan. Review of section I - Active Diagnoses on an admission MDS dated [DATE] and a quarterly MDS dated [DATE] revealed the PTSD was not documented in either MDS assessment. The PTSD, as assessed on admission and care planned, was not coded on the MDS. Resident #46 (R46) On 5/27/25 at 12:38 PM, R46 was observed with bed rails on both sides of the bed. R46 was unable to answer questions regarding the bed rails due to confusion and cognitive impairment. Review of the EMR revealed R46 was admitted to the facility on [DATE] with a primary medical diagnosis of severe vascular dementia. The MDS assessment dated [DATE] documented R46 was dependent on staff for Activities of Daily Living (ADLs) including but not limited to bed mobility, turning, and repositioning. An admission MDS dated [DATE], an MDS for significant change dated 2/11/25, and the quarterly MDS dated [DATE] were reviewed. None of the MDS documented the use of bed rails. The MDS coded bed rail use as 0 (not in use). The MDS Nurse, Registered Nurse (RN) C, was interviewed via telephone in the presence of the Director of Nursing (DON) on 5/29/25 at 2:50 PM. RN C acknowledged coding MDS information. When asked why the MDS did not accurately code the status of R24 and R46, RN C said, I can't tell you why the information isn't coded - I don't have a good answer to your question. RN C acknowledged the information should have been included in the MDS assessments of both residents but had been erroneously omitted from the MDS assessments.

Based on observation, interview, and record review, the facility failed to ensure infection control precautions were implemented and hand hygiene and glove changes were performed after touching potentially contaminated items for two Residents (#46 and #29) of six residents reviewed for infection prevention and control. Findings include: Resident #46 (R46) On 5/27/25 at 12:38 PM, R46 was observed lying in bed with urinary catheter drainage tubing extending from under a blanket into a drainage bag attached to the bedframe of the bed. The urine in the drainage tubing was observed to be dark yellow and cloudy with sediment. R46 was unable to answer questions regarding urinary tract infection (UTI) or the presence of the urinary catheter due to confusion and impaired cognition. Signage was posted outside the door or R46's room indicating R46 was in Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of multidrug-resistant organisms [MDRO - pathogens that resist most available antimicrobial medications]). The posting directed staff to perform hand hygiene and wear gloves and gowns when performing high-contact resident care activities including the provision of personal hygiene to the resident. Review of the Electronic Medical Record (EMR) revealed R46 was admitted to the facility 1/14/25 with a primary medical diagnosis of severe vascular dementia. R46 required an indwelling urinary catheter due to urinary retention. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS - a test for cognitive status) score of 99 indicating R46 was unable to complete the BIMS due to having severely impaired cognition. Further review of the MDS divulged R46 was dependent on staff for Activities of Daily (ADL), including but not limited to personal hygiene and toileting hygiene. A care plan for the urinary catheter reflected R46 required the use of EBP and included an intervention dated 4/10/25 that read: Please provide me assistance with maintaining my indwelling urinary catheter including good urinary catheter hygiene. On 5/29/25 at 10:03 AM, Certified Nurse Aide (CNA) D was observed preparing items to provide urinary catheter hygiene to R46. CNA D performed hand hygiene and donned a gown and gloves prior to entering R46's room. CNA D moved two waste baskets containing refuse next to the bedside of R46 then removed the plastic waste bags of refuse from the containers and tied them up before setting them aside and obtaining new plastic waste bags to place in the containers. CNA D did not change gloves or perform hand hygiene after touching the bags of refuse and before starting catheter care on R46. The Director of Nursing (DON) was interviewed on 5/29/25 at 10:38 AM. The DON conveyed the expectation that staff remove gloves, cleanse hands, and put on new gloves after touching soiled and potentially contaminated items. The DON reiterated CNA D should have removed the gloves after touching the waste containers, then performed hand hygiene and put on another pair of gloves before providing catheter care to R46. Resident #29 (R29) On 5/27/25 at 11:06 AM, R29 was observed lying in bed with both hands on his abdomen. R29 said he did not feel well and said he experienced pain when going to the bathroom. A bladder scanner was noted to be in the room next to R29's bed. Review of the EMR revealed R29 was admitted to the facility 4/28/25. An admission Minimum Data Set (MDS) assessment dated [DATE] documented R29 was incontinent of bladder, and dependent on staff for toileting hygiene and personal hygiene. A physician's progress note dated 5/13/25 at 3:19 PM documented, in part: .Physician notes from prior facility indicated that he was treated for MRSA [Methicillin Resistant Staphylococcus Aureus - a contagious, antibiotic-resistant bacteria that can cause serious infections, sepsis, or death] UTI [urinary tract infection] in March 2025 .The patient is minimally conversive and intermittently cries, admitting to lower abdominal pain . has a hx [history] of UTI .Concern for current UTI .lower urinary symptoms and history of UTI: patient with pustular drainage from his urethra and history of MRSA UTI. Recommend STAT straight cath UA sample, antibiotics will likely be needed . A urine culture was obtained on R29 on 5/14/25 and identified MRSA in the urine. The EMR did not contain a physician's order for R29 to be in infection prevention and control precautions. The care plans for R29 did not include a plan of care for MRSA or the implementation of precautions to minimize the risk of spreading the bacteria to others. The care plans did not mention a history of UTI or contain interventions to provide staff with direction for minimizing the risks of infection. The DON was interviewed on 5/29/25 at 10:48 AM. The DON said residents with MDROs were placed in EBP or Transmission-Based Precautions (TBP - safety measures implemented to prevent the transmission of infectious organisms). When asked if R29 was placed in TBP or EBP, the DON said R29 was placed in TBP through the completion of antibiotic therapy when the MRSA was identified. The DON said R29 should have been placed in EBP after antibiotics were completed. R29's current care plan, care plan history, and physician orders were reviewed with the DON. The DON acknowledged the UTI, MRSA, and infection history were not in R29's care plans. The DON confirmed no physician's order had been obtained for R29 to be in TBP or EBP when MRSA was identified. The DON said, [R29] should be in enhanced barrier precautions - I will get on that today. The policy Transmission-Based Precautions dated as last revised 12/2023 read, in part: .All [name of facility] employees .will use the Transmission-based Precautions (TBP) outlined in the policy on all patients requiring extra protection to interrupt the transmission of pathogens . The policy Enhanced Barrier Precautions dated as effective 4/1/24 documented, in part: .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . An order for enhanced barrier precautions will be obtained for residents with any of the following: urinary catheters .infection or colonization with a CDC [Centers for Disease Control]-targeted MDRO with Contact Precautions [type of TBP] do not otherwise apply . epidemiologically important MDROs may include, but are not limited to: a. Methicillin-resistant Staphylococcus aureus (MRSA) .

Based on observation, interview, and record review, the facility failed to provide drinks, including water and other liquids consistent with resident needs for one resident requiring thickened liquids (#16) of one resident reviewed for fluid needs. Findings include: On 5/27/25 at 10:38 AM, Resident #16 (R16) was observed lying in bed. Her lips were observed as dry and flaky. When asked if she was drinking enough fluids, R16 responded, I have to have that thick stuff, and I hate it so probably not. R16 stated the thermal 12 ounce covered mug on her bedside table was water with a straw inserted that had just been delivered. Upon inspection and discovery that the thermal cup contained non-thickened ice water, R16 exclaimed, Oh good! During meal observations on 5/28/25 at 12:30 PM, R16 was eating lunch in her room. Her meal included two thermal 12 ounce covered mugs with lids. R16 was sipping from one mug which she stated was coffee. She stated she hated thick coffee and thick water. When the lids were removed and checked for consistency and content, the coffee was discovered without thickener. R16 did not receive nectar thick liquids per the physician order. On 5/28/25 at 12:35 PM, Registered Dietitian RD A observed the beverages received by R16 and confirmed they were not thickened beverages. RD A said to R16, You should not have received the (unthickened) coffee. RD A indicated R16 was waiting to see the Speech Therapist (SLP) for an evaluation. R16 said, She (the SLP) was supposed to be here last Friday. The medical record for R16 included a nursing progress note on 5/16/2025 at 12:42 PM which read as follows, This nurse was approached by dietary aide and speech therapist was talking with this nurse. Dietary aide informed that she hears (R16) coughing everyday at lunch time when she is drinking her liquids. Speech therapist informed that liquids can be downgraded until she can see the person and screen them. This nurse then went and sat with (R16) and her husband in the dining room. Asked (R16) if she notices that she coughs at mealtime. (R16) replied, Yes, I do cough when I drink liquids. Asked her if we could try a glass of nectar thick liquids and she agreed. Gave her a glass of cranberry juice nectar thick and she drank it with no coughing noted. She agreed to have her liquids nectar thick until speech can see her. Informed nursing supervisor and NP [Nurse Practitioner] and order written for her to be seen by speech next week. The medical record included a nursing progress note written on 5/17/2025 at 7:40 AM which read in part, Order obtained for speech screen/eval r/t (related to) coughing when drinking thin liquids . The medical record included a physician order dated 5/16/25 Diet: Regular diet, Nectar thick liquids. The care plan for R16: included, Please provide my diet as ordered, regular with nectar liquids. Edited: 05/162025.

Based on observation, interview, and record review, the facility failed to ensure bed rail assessments were completed to evaluate entrapment risk prior to the use of bed rails, obtain a physician's order for the use of bed rails, attempt alternatives prior to the use of bed rails, provide medical reason for the use of bed rails, and document the risks and benefits of bed rails for one Resident (#46) of one resident reviewed for accident hazards. Findings include: Resident #46 (R46) On 5/27/25 at 12:38 PM, R46 was observed with bed rails on both sides of the bed. R46 was unable to answer questions regarding the bed rails due to confusion and cognitive impairment. Review of the Electronic Medical Record (EMR) revealed R46 was admitted to the facility on [DATE] with a primary medical diagnosis of severe vascular dementia. A Minimum Data Set (MDS) assessment dated [DATE] documented R46 was dependent on staff for Activities of Daily Living (ADL) including but not limited to bed mobility, turning, and repositioning. The MDS documented a Brief Interview for Mental Status (BIMS - a test for cognitive status) score of 99 indicating R46 was unable to complete the BIMS due to having severely impaired cognition. The EMR did not contain an assessment of the risk of entrapment prior to application of the bedrails. The physician orders for R46 did not contain an order for the bedrails. No documentation was found regarding alternatives that were attempted prior to installing bedrails. No medical symptoms or bedrail measurements were in the medical record. A form Side Rail assessment dated [DATE] was present in the EMR of R46. The form read, in part: .in addition to this signed form authorizing the use of bed rails for this resident, a written order from the resident's attending Physician, specifying the medical rationale and circumstances for use, must be obtained prior to the installation of this medical treatment device. It is also my understanding that the Facility will periodically review and re-evaluate the resident's need for bed rails and that the resident, responsible party and attending Physician will be consulted in this matter . The form was signed by the Resident Representative (RR) of R46 on 1/14/25. A question on the Side Rail Assessment form asked, Why is side rail being used? The written response was When in bed. The form did not include the indication for use or the risks and benefits for the use of the side rails. An additional area of the form: Specific medical symptoms which require side rail use was blank and did not provide the medical symptoms to justify the use of the bed rails. The Side Rail Assessment form did not document a review of the risks and benefits of side rail use to ensure the RR of R46 was provided sufficient information to make an informed decision regarding bed rail utilization. Documentation of the bed's dimensions and measurements to ensure appropriateness for R46's size and weight were not found in the medical record. On 5/29/25 at 10:03 AM, Certified Nurse Aide (CNA) D was observed providing hygiene to R46 with Registered Nurse (RN) E present. CNA D and RN E rolled R46 onto her right side. R46 did not utilize the bed rail to assist with the turning. RN E held R46 onto her right side until CNA D completed cleansing R46's back side. R46 made no attempt to utilize the bed rail to assist with turning and repositioning. RN E was observed completing dressing changes to R46's pressure injuries on 5/29/25 at 10:18 AM. CNA D assisted RN E with turning and positioning R46 during the treatment completion. After the dressing changes, CNA D and RN E repositioned R46 onto her left side. R46 made no attempt to utilize the bed rail to assist with the turning and repositioning. The Director of Nursing (DON) was interviewed on 5/29/25 at 10:38 AM. The DON said R46 should have a physician's order for bedrails because a physician's order was required to utilize bed rails. The DON reviewed the medical record of R46 and acknowledged there was not physician's order for the bed rails. The DON confirmed the medical reason and indication for use of bed rails were not documented in the medical record. The DON admitted no alternatives were attempted prior to installing the bedrails, and there were no documented risks or benefits to bed rail usage. The DON confirmed there was no assessment for bed rail usage aside from the modified assessment documented on the Side Rail Assessment form. The DON said bed and rail measurements were completed by another department and were not maintained in R46's medical record. The DON said she would obtain the documented measurements for perusal. The bed and rail measurements were not provided by the end of survey. The policy Bed Rails dated as effective 7/2024 documented, in part: .the resident or resident's legal guardian, advocate or other legal representative will be informed of the risks of bed rail use and the alternatives to bed rail use . an assessment will be performed by members of the Interdisciplinary Team to determine if bed rails are appropriate for this resident . An order must be obtained from the physician. The order must contain statements and determinations regarding medical symptoms, and it must specify the circumstances under which the bed rails are to be used . Bed rails applied to the bed must be individually selected for the resident based on their body weight, body size, head measurement, bed, rail, and mattress configurations . During the first five (5) days following initial use, the resident, bed frame, bed rails, and mattress must be monitored by each shift . Continued use of side rails must be reviewed quarterly by nursing .

Based on observation, interview, and record review the facility failed to ensure timely interventions to prevent facility acquired pressure injuries for one resident (#16) and failed to ensure comprehensive wound documentation for two residents (#16 and #6), per professional standards of practice. This deficient practice resulted in harm when resident #16 developed two Stage 2 pressure injuries and the potential for worsening and delayed healing of Stage 3 pressure injury for resident #6. Resident #16 (R16) A review of the Electronic Medical Record (EMR) for R16 revealed admission to the facility on [DATE] with diagnoses of Alzheimer's disease (progressive memory disorder), Down Syndrome (intellectual and developmental delay condition), and seizures. R16's face sheet had a note which read, R16 is unable to answer questions appropriately. Hearing is adequate and does not require hearing aids. A review of the MDS (Minimum Data Set) Braden Scale for Prediction of a Pressure Sore Risk for R16 dated 10/17/23 was scored at a 13/18, indicating a moderate risk for a pressure sore. Factors included having very moist skin, being chair fast, and having very limited mobility. The MDS indicated R16 was totally dependent on helpers for all activities of daily living. On 11/10/23, the Weekly (head to toe) Skin Assessment indicated R16 had the following skin observations: neck area reddened and superficial open area on buttocks. In the section titled skin condition: reddened neck was indicated, but there was nothing about the open area on the buttocks, and the remainder of the assessment was not completed. On 12/15/23, the Weekly (head to toe) Skin Assessment indicated R16 read in part: skin to buttock with existing area, treatment in place. In the section titled skin condition: other- treatment in place to buttocks, with the remainder of the assessment incomplete. A progress note, from 12/31/24 indicated R16 had a 1.5cm (centimeters) x 0.2cm open area on her left buttock, near the coccyx area. Some bleeding noted when cleansed/assessed. (R16) also has existing areas of sheared (when forces moving in opposite directions are applied to tissues in the body) skin near the same area. There was not a part in R16's care plan which addressed shearing. Progress Notes reviewed revealed the following: 1/17/24: R16 had excoriated/skin sloughing to bilateral upper buttocks with a slit in the crevice of buttocks. 3/3/24: read in part, R16's wound measured R (right) buttocks: 2cm x 2cm of sheared skin, with a 0.5cm x 0.5cm open area. L (left) buttocks: 2cm x 1.5cm of redness with a 1.5cm x 1cm open area. 3/16/24: read in part, R16 had redness and excoriation observed to bilateral buttocks, blanchable. 3/23/24: read in part, R16 had redness and excoriation observed to bilateral buttocks, blanchable. 3/27/24: read in part, R16's Right buttock darker purplish area measuring 0.2cm x 4cm with intact skin. Left buttock had 4 areas of concern .The area at 3 o'clock on left buttocks measures 1cm x 0.5cm and is identified as skin shearing with the area superficial but center of area shiny red in appearance. The other 3 areas of concern are a darker purplish red in color on the left buttocks. The 12 o'clock area measures 0.7cm x 0.3cm. The two just below in on the left buttocks (6 o'clock) are very close to each other but not connected and each measure 0.6cm x0.3cm. 3/30/24: read in part, Area on left buttock open. Skin surface only. 3/31/24: read in part, right and left buttocks cheeks reddened with open areas noted calazime (skin protectant) applied. Areas do not seem to be improving, will suggest magic butt cream to speed up healing process to supervisor. 4/1/24: read in part, BL (bilateral) buttocks assessed and no yeast present. Magic Butt Cream is not appropriate at this time. 4/3/24: read in part, superficial opening/stage 2 PI (pressure injury) measuring 0.4.cm x 0.5cm the wound bed is red with crusted dry skin edges and bloody drainage. The left buttocks stage 2 PI measures 2.7cm x 1.3cm and has bright red wound bed with dry crusted skin surrounding and bloody drainage. The areas are dried out and in need of moisture to aid healing. At this time wound order are changed back to Mepilex dressings. 4/9/24: read in part, Left buttocks stage 2 pressure injury measures 5cm x 5cm, right buttocks stage 2 pressure injury measures 1.7cm x 4cm. The pressure injuries are beefy red in appearance and raised. 4/10/24: read in part, wounds have improved significantly overnight with use of A&D ointment and calazime mixture. 4/16/24: read in part Right PI measures 6.7cm x4.5cm. Left PI measures 6cm x 4.3cm. Also recommend continuing to offload pressure to buttocks frequent repositioning . 4/21/24: a late entry progress note, read in part, Pressure injuries remain the same, superficial, no change in size or appearance of dull reddish-purple color, slowly blanchable Wound measurements to continue weekly on Tuesday. No measurements to substantiate the documentation of no change in size or appearance noted in progress note. 4/23/24: a late entry progress note, read in part, Right pressure injuries measure 6.5cm x 5cm and has evidence of excoriation with superficial deep red purplish wound bed. The left pressure injury measures 7.0cm x 5cm and is superficial deep red purplish wound bed .the pressure injuries are slow to blanch. Wound order is to cleanse entire buttocks with warm water and no foam soap, and pat dry. Cleanse with NS (normal saline) and pat dry with 4x4 (4 inch x 4 inch) gauze. Apply thin layer of mixture of 1 packet A&D with 6 grams of calazime to pressure injuries. Skin prep surrounding pressure injuries. Mepilex dressing to secure. Change every 3 days and PRN (as needed) >50% saturation. Strongly encourage frequent repositioning to offload pressure from areas. CN (Charge Nurse) and CNAs (Certified Nursing Assistant) aware. 5/3/24: read in part, The left PI measures 6cm x 4.5cm with excoriation in the wound bed, surrounding tissue normal. The right PI measures 6cm x5.3cm with normal tissue surrounding. The wound care order has been changed to cleanse bilateral buttocks with warm water and mild soap, pat dry. Apply skin prep surrounding pressure injuries and let dry, apply new duoderm to each PI and change q (each, every) 5 days and prn >50% saturated. 5/16/24: read in part, Stage 2 PI left buttock measures 8cm x 3.5cm. Stage 2 PI right buttock measures 7cm x 3cm with lower part having excoriation within the wound bed. The wound beds are dark red and blanchable. 5/20/24: read in part, R (right) buttocks PI measures 6.8cm x 6cm with scant amount of excoriation within wound bed and surrounding. Left buttocks PI measures 8cm x 5cm with small amount of excoriation on edges .There is evidence of the duoderm dressing causing more excoriation from the adhesive as the pressure injuries are becoming wider in nature with excoriation. Therefore, the wound order is discontinued at this time and a new order is entered: cleanse entire buttocks with warm water and soap, pat dry. Cleanse pressure injury areas with NS and gauze 4 x 4, pat dry. Mix 1 packet A&D ointment with 6 grams of calazime, skin protectant and apply thin layer to bilateral buttocks pressure injuries. Skin prep surrounding pressure injuries where adhesive will be. Secure 2 separate small Mepilex dressings or sacral Mepilex dressing. 5/26/24: read in part, Stage 2 PI left buttocks measures 8cm x 5 cm purplish-red with 1.2cm x 1cm area of superficial red excoriation within. Right buttocks Stage 2 PI measures 8cm x 5cm and is light purplish in color . Order is updated .secure left buttocks with Mepilex dressing change q 3 days or PRN 50% saturated. Utilize body pillow to reposition and offload pressure from buttocks and bony prominences. 6/5/24: read in part, Right buttocks have 2 areas of shearing within red quickly blanchable area. Right superior area of shearing measures 1.2cm x 1.3cm, inferior area of shearing measures 0.6cm x 0.6cm. The left buttocks have 1 area of shearing measuring 0.4cm x 0.4cm. The left buttocks PI is observed to have too much moisture r/t (related to) Mepilex dressing and there is an attempt at healing with some loose scabbing. At this time, treatment is changed to cleanse buttocks with mild soap and water, pat dry. Apply thin layer of calazime to bilateral buttocks pressure injuries. Treatment BID (two times a day) and PRN brief changes. 6/11/24: read in part, Right buttocks Stage 2 PI has red sheared area measuring 1.2cm x 1cm. Left buttocks Stage 2 PI measures 1.2cm x 1cm and is scabbed. 6/19/24: read in part, Evidence of increased pressure to buttocks as right buttocks has deep red discoloration measuring 6.7cm x 3.5cm with area of dark purple shiny sheared skin measuring 0.7cm x 3cm. Left buttocks Stage 2 PI has red discoloration measuring 5cm x 3cm with excoriation within and superior area of excoriation measuring 2.2cm x 0.7cm. R16's care plan last updated 5/11/24 stated: Pressure Ulcer/Injury I am at risk for skin breakdown and developing a pressure ulcer related to incontinence, impaired mobility, decreased sensory perception and a history of multiple cysts and infections. Please apply my blue pressure relieving boots to both feet when I am in bed to avoid pressure on my bony prominences and prevent skin break down (initiated 5/11/24). I have a Stage II pressure ulcer on my right and left buttock, please complete treatments as ordered (initiated 4/6/24). Please provide me with an air mattress for pressure injury care and prevention (initiated 4/5/24). On 6/25/24 at 10:17 AM, during observation of morning care, resident has Stage 2 pressure ulcer to left and right buttocks, that was red, with uneven boarders, elongated in shape. On 6/25/24 at 4:15 PM, during an interview with the Director of Nursing (DON), who reviewed R16's chart and agreed nursing needed to put measurements when they assessed the wounds on R16's buttocks. The DON stated nurses were expected to fill out the weekly skin assessment completely. The DON acknowledged while looking through progress notes, the wound started in March and the resident was not given an air mattress until 4/5/24. The DON acknowledged the air mattress took too long to implement based on R16's wound assessments and when they began. A review of the EMR revealed an order for the air mattress dated 4/5/24. On 6/26/24 at 9:30 AM, during observation of Registered Nurse (RN) C who performed wound measurements, indicated the wound was looking ruddier. RN C noted a small new wound on sacral area. RN C then applied a sacral Mepilex dressing due to this added area of concern. The new area was located on the sacrum, was small, oblong, and had uneven wound edges. On 6/26/24 at 9:48 AM, a follow up interview was conducted with the DON, to discuss what might have caused the wounds on R16. The DON stated she did not see it when it first started but did thought it looked like the wounds were caused by shearing (mechanism of action in which uneven forces upon the skin increases the chance for skin tears, pressure injuries, and other wounds). 45123 Resident #6 (R6) Review of the facility's resident matrix revealed R6 had a facility acquired stage III pressure ulcer. On 6/24/24 at 11:15 AM, an interview was conducted with the Director of Nursing (DON) and asked if R6 had any pressure ulcers or wounds and replied, R6 has a right ankle stage III pressure injury that he was admitted with. The DON was asked if he required any type of dressing changes and replied, No. He is observation only and open to air. Review of R6's medical record revealed he was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, chronic obstructive pulmonary disease (COPD), and pressure ulcer of right ankle (stage 3). Review of R6's admission and body assessment, date 4/19/24, revealed under the skin section a stage II right lower extremity pressure ulcer. Review of R6's MDS assessment, dated 7/26/23 revealed he scored a 10/15 on the Brief Interview for Mental Status (BIMS) assessment indicating moderate cognitive impairment. This MDS also revealed he had one pressure ulcer stage III that was facility acquired and none that were present on admission. Review of R6's care plan, dated 4/19/22, read in part .Problem: I am at risk for developing pressure ulcers, I have had pressure ulcers in the past .Approach .Please complete dressing order per MD (medical doctor) to my right malleolus (outer ankle area) .Please assess my skin . Review of R6's physician order, dated 4/21/24 read in part, Pressure sore: Measure and Document progress weekly . Review of R6's wound progress notes, dated between 4/19/22 through 6/26/24, revealed that the original pressure ulcer stage III on his right ankle had not healed and remained open. Review of R6's wound progress notes, dated between 8/1/23 through 6/26/24, revealed the lack of weekly wound measurements as follows: a.) between 8/20/23 through 9/9/23, b.) between 9/25/23 through 10/21/23, c.) between 10/23/23 through 11/25/23, d.) between 11/27/23 through 12/23/23, e.) between 1/15/24 through 3/2/24 and, f.) between 3/4/24 through 3/22/24. On 6/25/24 at 10:00 AM, an observation was made of R6 in his room sitting in his wheelchair and playing solitaire. R6 was asked about his right ankle pressure ulcer and replied, You can look at it if you want to. I have had that sore since 1987. I hit my ankle on a rock when I was walking down a sidewalk and ever since then it has not healed. R6's right ankle was observed to have a pressure ulcer to the right malleolus with an area the size of a nickel. No dressing was present, and the wound was open to air. On 6/25/24 at 3:10 PM, an interview was conducted with the DON and asked if R6 had a facility acquired pressure ulcer stage III and replied, No. He was admitted to the facility with that pressure ulcer, and it has not healed yet. The DON was asked how often R6 has his wound measurements and replied, They are completed weekly by the nurse managers or me. The DON was asked if R6 should have any weekly wound measurements incomplete and replied, No. The DON was asked where the documentation was kept and if there were any other place wound measurements were charted in the electronic medical record and replied, The wound measurements are documented under the wound progress notes and that is the only place they are documented. Review of policy titled, Decub/Skin Protocol, dated 3/31/17, read in part, .3. The program will be overseen by assigned Nursing Supervisor. All resident skin issues will be followed weekly by Nursing Supervisor .5 .a weekly skin assessment will be made out .6 .The care plan will be updated according to the resident's condition .

Based on observation, interview, and record review, the facility failed to ensure that the Minimal Data Set (MDS) assessment was accurate for two residents (Resident #6 and Resident #22) of 12 sampled residents reviewed for comprehensive assessments. Findings include: Resident #6 (R6) Review of the facility's resident matrix revealed R6 had a facility acquired stage III pressure ulcer. On 6/24/24 at 11:15 AM, an interview was conducted with the Director of Nursing (DON) and asked if R6 had any pressure ulcers or wounds and replied, R6 has a right ankle stage III pressure injury that he was admitted with. The DON was asked if he required any type of dressing changes and replied, No. He is observation only and open to air. Review of R6's medical record revealed he was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, chronic obstructive pulmonary disease (COPD), and pressure ulcer of right ankle (stage 3). Review of R6's admission and body assessment, date 4/19/24, revealed under the skin section a stage II right lower extremity pressure ulcer. Review of R6's MDS assessment, dated 7/26/23 revealed he scored a 10/15 on the Brief Interview for Mental Status (BIMS) assessment indicating moderate cognitive impairment. This MDS also revealed he had one pressure ulcer stage III that was facility acquired and none that were present on admission. Review of R6's MDS assessment, dated 10/24/23 revealed he had one pressure ulcer stage III that was facility acquired and none that were present on admission. Review of R6's MDS assessment, dated 1/23/24 revealed he had one pressure ulcer stage III that was facility acquired and none that were present on admission. Review of R6's MDS assessment, dated 4/15/24 revealed he had one pressure ulcer stage III that was facility acquired and none that were present on admission. Review of R6's wound progress notes, dated between 4/19/22 through 6/26/24 revealed that the original pressure ulcer stage III on his right ankle had not healed and remained open. On 6/25/24 at 10:00 AM, an observation was made of R6 in his room sitting in his wheelchair and playing solitaire. R6 was asked about his right ankle pressure ulcer and replied, You can look at it if you want to. I have had that sore since 1987. I hit my ankle on a rock when I was walking down a sidewalk and ever since then it has not healed. R6's right ankle was observed to have a pressure ulcer to the right malleolus with an area the size of a nickel that lacked a dressing and was open to air. On 6/25/24 at 11:05 AM, an interview was conducted with the DON and asked if R6 had a facility acquired pressure ulcer stage III and replied, No. He was admitted to the facility with that pressure ulcer, and it has not healed yet. The DON was asked why R6's MDS was coded to reflect a facility acquired pressure ulcer stage III and replied, The MDS is coded incorrectly. R6's MDS assessment should be coded as being present on admission. Resident #22 (R22) On 6/26/24 at 11:00 AM, an observation was made of R22 sitting in his wheelchair in the North Hall. R22 had a urinary catheter bag hanging from the bottom of his wheelchair. Review of R22's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Lewy bodies, neuromuscular dysfunction of bladder, and retention of urine. Review of R22's physician order, dated 4/18/24 revealed an order that read, insert a 16F (French) Coude (rigid tip for narrow difficult catheter insertions) catheter for urinary retention. Review of R22's progress note, dated 5/23/24 read in part, .Foley patent to DD (dependent drainage) urine concentrated with sediment. Review of R22's quarterly MDS, dated ,d+[DATE] revealed under section H, bowel and bladder no indication of having an indwelling catheter. Review of R22's progress note, dated 5/26/24 read in part, .Urinary catheter has not being (sic) leaking since supervisor made adjustments. Review of R22's care plan, dated 4/24/24 read in part, .Problem: I require an indwelling catheter for obstructive uropathy . On 6/25/24 at 11:05 AM, an interview was conducted with the DON and was asked if R22's MDS was coded correctly to reflect he had an indwelling urinary catheter and replied, I would have to check. The DON reviewed R22's quarterly MDS, dated [DATE] and stated, No. His MDS is not coded correctly. I will call the MDS nurse to have her correct the coding. The DON was asked if the MDS nurse was involved in morning meetings and how frequently these occurred and replied, Every morning during the week we have them Monday through Friday and the MDS nurse is on the calls as she works remotely. The DON was asked if there was any reason why the MDS for R6 and R22 were coded incorrectly and replied, No. I will call her and have her correct them.

Based on interview and record review the facility failed to identify, evaluate, and implement interventions to prevent an avoidable accident when bath aides failed to transport one Resident #3 (R3) of two residents reviewed for safety, safely to the bath via the bath lift in the tub room. This deficient practice resulted in bath lift tipping over while R3 aboard, causing a laceration to his left shin which required sutures. Resident #3 (R3) Review of R3's medical record indicated R3 was admitted to facility on 2/27/24 with diagnoses of age-related osteoporosis (when mineral density and bone mass decreases), Type II diabetes, muscle weakness, and traumatic brain injury. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R3 had a BIMS (Brief Interview for Mental Status) score of 15/15, indicating R3 was cognitively intact. Review of R3's orders indicated clopidogrel (blood thinner) 75 mg (milligrams) was prescribed to R3 once a day at 9:00 AM. Clopidogrel is an antiplatelet medication that can cause increased potential for bruising and bleeding. A review of R3's care plan initiated on 2/27/24 indicated at risk for falls related to impaired mobility, disease process, and possible side effects of medication. Please assist me (R3) with transferring and toileting as needed. I use a full mechanical lift. I use a blue sling. A review of R3's progress notes dated 3/6/24 at 3:30 PM revealed the following: approximately 1520 (3:20 PM) in to get this nursing supervisor and provider for resident fall. This nurse went into tub room between north and south hall where resident was observed on the floor near tub with head against the wall facing the tub in supine position with bath trolley (bath lift) on top of resident. The resident was alert and oriented at baseline, reporting no pain anywhere during assessment. Vitals BP (Blood Pressure) 156/72, HR (Heart Rate) 95, T (Temperature) 98.2, R (respirations) 20, SpO2 (Oxygen Saturation) 97% on RA (Room Air). The bath aides reported they were getting ready to lower the resident into the tub when the trolley quickly tipped over resulting in the resident falling to the floor. Initially the resident is observed to have a laceration to anterior left shin and scant amount of bleeding form an abrasion to the posterior head. The provider evaluated the resident and determined need to transfer to the ER (emergency room ) for a head CT (Computed Tomography) due to the resident on anticoagulant Plavix (clopidogrel) as well as need to repair leg laceration. Administrator advised of occurrence and resident's emergency contact notified. A progress note from the Physician Assistant (PA) dated 3/6/24 at 3:30 PM, read in part fell from lift to hard floor during transfer to bath . just fell off lift during transfer to receive a bath. He struck his head and lacerated R (right) anterior leg (incorrectly identified by PA in note). Denies LOC . denies any pain, SOB (shortness of breath) or chest discomfort. Denies cervical, thoracic, or lumbar spine pain. Denies headache A review of nursing progress notes on 3/6/24 at 6:43 PM, read in part, (R3) returned from the ER with sutures to the lower left leg laceration, tetanus shot updated, CT of head/C-Spine (cervical spine)/chest/pelvis/left leg with no acute injury or abnormalities. Resident has generalized pain from fall. An interview with R3 on 6/26/24 at 7:48 AM, revealed the following: R3 stated that during the fall it all happened too quick for him to alert staff something was wrong but felt something was not quite right while on the bath lift. R3 felt there was too much weight at one end. During an interview conducted with the Director of Nursing (DON) on 6/26/24 at 9:02 AM, she stated that the R3's fall was investigated and the lift had been taken out of commission until it was evaluated by the external vendor, stating that they ' . fixed it'. She indicated the external vendor informed the facility the lift was nearing the end of its life and was being replaced. The DON stated the facility had determined that the resident was too heavy for the bath lift. Review of manufacturers bath lift instructions for use, from medical supplier, indicated the maximum safe operating weight was 352 pounds for the bath lift. R3's chart indicated his weight at 309.5 pounds, which is under the safe operating weight. A review of the medical supplier's Inspection Report indicated that an incident report was completed and sent to complaints. Lift inspection completed no fault found, all functions working properly. Pictures of lift attached. A review of the Event Report Safety Events - LTC (Long Term Care) Fall Occurrence Report explanation of incident read in part as R3 seat belt in with safety bar over legs of bath/gurney trolley. Trolley completely knocked over with R3 down on floor. R3's upper torso partially off end of trolley on floor, head propped up on stack of towels. Left shin up against safety bar with laceration noted. Bleeding noted from posterior head. Unbuckled from trolley and trolley pulled away per three staff. On 6/26/24 10:16 AM, an interview was conducted with shower aide (SA) E, who was present at time of fall on 3/6/24. SA E stated she had resident sitting up with the bar over his leg, per bath lift protocol, brought R3 into the shower room, had R3 next to the bath and the apparatus just tipped over. SA E then proceeded to lean on the end of bath lift to show how hard it was to get it to lean. SA E stated she knew that R3 was not over the weight limit but after thinking about it she feels that R3's body makeup made him heavier on one side than the other and that is why it tipped. A follow-up interview was conducted with the DON and the NHA (Nursing Home Administrator) in attendance on 6/26/24 at 10:30 AM, where they indicated they had reenacted the fall, and could not figure out why the bath lift had fallen over, calling it a freak accident.

Based on observation, interview and record review, the facility failed to provide preventative care consistent with professional standards of practice, for 1 resident (Resident #5) reviewed for the risk of the development of pressure injuries, resulting in impaired skin integrity, inaccurate/incomplete documentation, and the potential for the delay in treatment, the worsening of a wound, infection, and the overall deterioration in health status. Findings: Resident #5 (R5) Review of an Admission Record revealed R5 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: Stroke and Alzheimer's Disease. Review of a Minimum Data Set (MDS) assessment for R5, with a reference date of 5/4/23 revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated R5 was severely cognitively impaired. Review of the Functional Status revealed that R5 required extensive 2 person assist for bed mobility. Review of R5's Braden Scale For Prediction of Pressure Sore Risk dated 5/4/23 revealed a score of 15, indicating R5 was at risk for pressure injury/skin breakdown. Review of R5's pressure injury prevention Care Plan revealed, I have decreased mobility, decreased ability to reposition independently, incontinence, and poor nutritional status therefore I am at risk for developing a pressure ulcer .Please turn and reposition Q2-3 (every 2-3) hours, as I allow, please note I cannot lay flat for 1 hour after my tube feedings . dated 3/1/23. During an observation on 7/20/23 at 8:56 AM, R5 was in bed on her back with no offloading devices in place. R5's body pillow was on top of the chifforobe, folded in half, with no pillowcase. During an observation on 7/20/23 at 10:21 AM, R5 was in bed on her back with no offloading devices in place. R5's body pillow was on top of the chifforobe, folded in half, with no pillowcase. During an observation on 07/20/23 at 11:51 AM, R5 was in bed on her back with no offloading devices in place. R5's body pillow was on top of the chifforobe, folded in half, with no pillowcase. During an observation on 07/20/23 at 1:00 PM, R5 was in bed on her back with no offloading devices in place. R5's body pillow was on top of the chifforobe, folded in half, with no pillowcase. During an observation and interview on 07/20/23 at 2:34 PM, R5 was in bed on her back with no offloading devices in place. R5's body pillow was on top of the chifforobe, folded in half, with no pillowcase. Registered Nurse (RN) A had just completed the administration of R5's formula into R5's feeding tube. RN A reported that R5 should be repositioned with every check and change (brief assessment/change) at least every couple hours. RN A reported that R5's skin on her buttocks was fragile and the facility staff had been implementing new treatments and interventions for open/excoriated areas. RN A reported R5's buttock skin was improving but the skin breakdown/injury had not yet fully resolved. At that time RN A and Certified Nursing Assistant (CNA) B completed pericare for R5. The entirety of R5's buttocks was deep red, with areas of superficial and partial-thickness areas of breakdown surrounded by macerated tissue. There were 2 ruddy red, deep, intact linear indentations on the back of R5's bilateral thighs. On the front of R5's right thigh there was a ruddy red, deep, intact linear indentation. CNA B reported the deep, intact, linear indentions were due to R5's brief and reported the indentation on the front of R5's right thing was the result of incorrect placement of the brief. CNA B reported that R5 required assistance with repositioning and was to be turned/repositioned every couple hours to prevent the worsening of her skin breakdown. At approximately 3:00 PM, RN A directed CNA B to keep R5's head of bed up higher than 30 degrees for 30 more minutes before repositioning due to the recent administration of the formula into R5's feeding tube. During an observation on 7/20/23 at 3:51 PM, R5 was in bed on her back with no offloading devices in place. The body pillow was on top of the chifforobe, folded in half, with no pillowcase. During an observation and interview on 7/20/23 at 4:26 PM, R5 was in bed on her back with no offloading devices in place. CNA B reported R5 was to be repositioned using the body pillow (pointed to the body pillow on top of the chifforobe with no pillowcase). CNA B reported she was going to get new pillowcases for the body pillow. CNA B reported she had not repositioned R5 since she was last changed (at 2:34 PM) as RN A wanted her to wait because R5 had just had a bolus feeding through her feeding tube. During an observation on 7/21/23 at 7:33 AM, R5 was in bed on her back with no offloading devices in place. The body pillow was on top of the chifforobe, folded in half, with no pillowcase. Review of R5's Skin assessment dated [DATE] revealed R5's skin was intact/no problems. There was no Skin Assessment completed on 7/7/23. Review of R5's Skin assessment dated [DATE] revealed R5's skin was intact/no problems. Review of R5's Skin assessment dated [DATE] revealed R5's skin was intact/no problems and .skin intact with no concerns signed by RN D as completed. During an interview on 7/21/23 at 12:00 PM, RN D reported she did not complete a skin assessment on (R5) that morning. RN D reported R5 had a history of redness on her bottom and was receiving treatment. During an interview on 7/21/23 at 12:04 PM, DON was notified that RN D reported she had not completed a Skin Assessment on R5 but had documented that a Skin Assessment had been completed on R5's electronic health record the morning of 7/21/23. DON was notified that RN D documented that R5's skin was intact. DON reported that all licensed nurses would be educated on complete and accurate documentation and an order would be written/implemented to ensure the licensed nurse providing care for R5 would ensure R5 was turned and repositioned every 2 hours. Review of R5's Order Summary dated 7/21/23 revealed, CN (charge nurse) to ensure that (R5) is turned frequently when in bed and nurse to visual turning and repositioning. Please chart in progress notes if she refuses to be turned. Twice A Day. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The presence and duration of moisture on the skin increases the risk of pressure injury. Moisture reduces the resistance of the skin to other physical factors such as pressure, friction, or shear. Prolonged moisture softens skin, making it more susceptible to damage. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1238). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Repositioning (turning) patients is a consistent element of evidence-based pressure injury prevention (EPUAP, NPIAP, PPPIA, 2019a). The twofold aim of repositioning should be to reduce or relieve pressure at the interface between bony prominence and support surface (bed or chair) and to limit the amount of time the tissue is exposed to pressure (Maklebust and [NAME], 2016). Elevating the head of the bed to 30 degrees or less decreases the chance of pressure injury development from shearing forces (WOCN, 2016). Change the immobilized patient's position according to tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort (EPUAP, NPIAP, PPPIA, 2019a). A standard turning interval of 1.5 to 2 hours does not always prevent pressure injury development; repositioning intervals are based on patient assessment. Some patients may need more frequent position changes, while other patients can tolerate every-2-hour position changes without tissue injury. When repositioning, use positioning devices to protect bony prominences (WOCN, 2016). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1255). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the facility failed to ensure annual performance reviews were conducted and education based on the outcome of the reviews were completed for two Certified Nurse Aides (CNA's), resulting in the potential for diminished quality and/or inadequate provision of care for all residents living at the facility. Findings: Review of the facility assessment last updated on 5/16/23 reflected Staff Competencies: Our Director of Nursing, in consultation with the Interdisciplinary Team as needed, determines what topics of training and competencies are offered and completed for our staff. We may also determine educational needs as identified through our QAPI process. In addition to the mandatory training topic, such as annual resident abuse awareness, other topics for training and competencies this year have included: a) Interacting and caring for Residents with Dementia b) Proper Hand Washing (infection prevention) c) Medication Administration d) Proper Documentation Techniques e) Fall Prevention and Interventions f) Residents Rights and Abuse Policies g) Emergency Preparedness Education is provided through lecture/ presentations, on-line based learning, and hands on competency review. A review of the employee file for CNA F revealed CNA F was hired in June of 2022. CNA F did not have an annual performance review. Review of the employee file for CNA G reflected CNA G was hired to work at the facility as a nurse aide on 4/27/2020. CNA G had never had an annual skills evaluation and had never been given an annual performance evaluation. During an interview on 7/21/23 at 9:45 AM, the NHA said the facility does not have a policy for annual skills evaluation or performance reviews. During a follow-up interview on 7/21/23 at 10:36 AM, the NHA confirmed that CNA G did not have an annual competency skills check. No other records awaiting verification were discovered by the NHA who reported that it is clear the facility needs to correct annual reviews and ensure staff have skills checks and annual in-service to meet the standard.

Based on interview and record review, the facility failed to ensure one nurse aide completed required in-service training to evaluate nurse aide competence, resulting in the potential for inadequate and substandard quality of care for residents living at the facility. Findings: Review of the employee file for CNA G reflected CNA G was hired to work at the facility as a nurse aide on 4/27/2020. CNA G had not completed the required 12 hours of mandatory in-service training since hiring into the facility. During an interview on 7/21/23 at 9:45 AM, the NHA reported there is not a policy for the requirement for 12 hours of in-service training for nurse aids. The NHA reported the requirement is not mentioned in the employee handbook it is just understood. During a follow-up interview on 7/21/23 at 10:36 AM, the NHA reported that it is clear the facility needs to correct the lack of annual reviews and ensure staff have skills checks and annual in-service to meet the standard.

Based on interview and record review, the facility failed to report an allegation of sexual abuse, for one Resident (#12) from five reviewed for abuse. This deficient practice resulted in the potential for continued abuse and trauma. Findings include: According to the electronic medical record (EMR), Resident #12 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment, dated 6/2/22, Resident #12 was cognitively intact and required extensive assistance with all care. On 8/15/22 at 2:05 p.m., Resident #12 was observed in a room in a wheel chair. Resident #12 was asked about his care, the reply was very difficult to understand. This Surveyor then moved to yes/no questions. The Resident confirmed he had a problem with his care. When asked if anyone hurt him, Resident #12 responded yes. When asked if he could explain, this Surveyor could not understand the Resident's speech. When asked if a trusted staff could accompany the interview, Resident #12 agreed to have the Activity Director present. When that also failed, Activity Director (Staff) C suggested the Resident's representative be included as she was able to better understand him. The Resident agreed and Family Member (FM) Q joined the interview by phone. Family member Q explained Resident #12 could spell out his words. One letter at a time, Resident #12 said he was sexually abused days prior, by his Certified Nurse Aide (CNA) R, who was working that very day. During an interview on 8/15/22 at 3:00 p.m., CNA R confirmed she was assigned to Resident #12 that day. During an interview on 8/15/22 at 3:06 p.m., Staff C confirmed she learned in the facility morning meeting that Resident #12 alleged a CNA kissed him inappropriately on the ear. During an interview on 8/15/22 at 3:10 p.m., the Director of Nursing (DON) said the allegation arose initially on 8/11/22, while interviewing residents regarding a different allegation. When asked if Resident #12's allegation was reported to the State Agency (SA), the DON said it was not because the police were in the building and spoke with the Resident and was not initiating an investigation around the allegation. The Administrator (NHA) joined the interview and confirmed Resident #12 did not use the word abuse, and therefore he did not consider it an abuse allegation. During an interview on 8/17/22 at 10:50 a.m., Staff S confirmed she assisted with the investigation of a different allegation by interviewing residents regarding abuse and safety on 8/11/22, including Resident #12. Staff S said the Resident was asked if anyone sexually abused him and he responded 'yes'. Staff S said she documented the interview and gave it to the NHA, who requested she write a witness statement. The Witness Statement, dated 8/12/22, confirmed Staff S's interview above. The incident was then reported to the SA on 8/15/22 at 3:55 p.m., with the date/time incident discovered box entered as 8/11/22 at 3:30 p.m., 4 days later. The policy Abuse Policy, dated 5/12/22, revealed, .[facility] prohibits the .abuse of residents .by anyone .[facility] has designed and implemented processes, which strive to ensure the prevention and reporting of resident abuse .All allegations that meet the definition of abuse .will be reported to state agencies .as required .

Based on interview and record review, the facility failed to thoroughly investigate an allegation of sexual abuse, and protect the Resident from further potential abuse, for one Resident (#12) from five reviewed for abuse. This deficient practice resulted in the potential for continued abuse and trauma. Findings include: According to the electronic medical record (EMR), Resident #12 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment, dated 6/2/22, Resident #12 was cognitively intact and required extensive assistance with all care. On 8/15/22 at 2:05 p.m., Resident #12 was observed in the room in a wheel chair. The Resident was asked about his care, but was very difficult to understand. This Surveyor then moved to yes/no questions. The Resident confirmed he had a problem with his care. When asked if anyone hurt him, Resident #12 responded yes. When asked if he could explain, this Surveyor could not understand the Resident's speech. When asked if a trusted staff could accompany the interview, Resident #12 agreed to have the Activity Director present. When that also failed, Activity Director (Staff) C suggested the Resident's representative be included as she was able to better understand him. The Resident agreed and Family Member (FM) Q joined the interview by phone. Family member Q explained Resident #12 could spell out his words. One letter at a time, Resident #12 said he was sexually abused days prior, by his Certified Nurse Aide (CNA) R, who was working that very day. During an interview on 8/15/22 at 3:00 p.m., CNA R confirmed she was assigned to Resident #12 that day. During an interview on 8/15/22 at 3:06 p.m., Staff C confirmed she learned in the facility morning meeting that Resident #12 alleged a CNA kissed him inappropriately on the ear. During an interview on 8/15/22 at 3:10 p.m., the Director of Nursing (DON) said the allegation arose initially on 8/11/22, while interviewing residents regarding a different allegation. When asked if Resident #12's allegation was reported to the State Agency (SA), the DON said it was not because the police were in the building and spoke with the Resident and was not initiating an investigation around the allegation. The Administrator (NHA) joined the interview and confirmed Resident #12 did not use the word abuse, and therefore he did not consider it an abuse allegation. Both the NHA and DON confirmed no investigation was initiated for the same reason. During an interview on 8/15/22 at 4:14 p.m., the DON confirmed she began an investigation that day and suspended CNA R that same day. During an interview on 8/16/22 at 4:53 p.m., the DON said she interviewed Resident #12 as part of her investigation, that day, and he did name CNA R as the potential perpetrator. The DON confirmed this should have been known if the investigation was started immediately on 8/11/22, and that CNA R should have been suspended then. The policy Abuse Policy, dated 5/12/22, revealed, .[facility] prohibits the .abuse of residents .by anyone .[facility] has designed and implemented processes, which strive to ensure the prevention .of resident abuse .Protection .Provide for the immediate safety of the resident upon identification of potential abuse .suspend identified employee(s) immediately pending outcome of the investigation .Investigation .Compile details of the investigation .

Based on observation, interview, and record review, the facility failed to prevent resident to resident physical abuse for two Residents (#25 and #32) of five Residents reviewed for abuse. This deficient practice resulted in the potential for physical injury and pain and the potential for fear, based on a reasonable person standard. Findings include: A review of an incident report submitted to the State Agency (SA) on 8/12/2022 at 8:00 a.m., revealed a resident-to-resident altercation occurred on 8/11/2022 at 7:57 p.m. Further review of the incident report revealed Resident #32 struck Resident #25 on the right upper arm. Resident #25 Resident #25 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #25's most recent Minimum Data Set (MDS) assessment, dated 6/27/2022, revealed Resident #25 was independent with ambulation and had severe cognitive impairment. Further review of Section E - Behavior, of Resident #25's MDS assessment revealed the Resident exhibited, Physical behavioral symptoms direct toward others (e.g., hitting, kicking, pushing, scratching, grabbing .) on 1 to 3 days during the seven-day observation period. An observation on 8/16/2022 at 8:54 a.m., revealed a mesh door guard stop sign banner (a banner attached across a door frame to deter wandering residents from entering a room) attached across Resident #25's door frame and the door to the Resident's room was closed. Upon entering the room, a jigsaw puzzle in a hard, cardboard box and a book were observed to be laying on the floor directly inside Resident #25's doorway. Resident #25 was sitting on the edge of her bed and reported she became angry and threw the puzzle and the book at the closed door. A review of Resident #25's Event Reports, from 6/01/2022 through 8/17/2022, revealed the following: 6/06/2022 . (Resident #25) hit another resident . 8/12/2022 . (Resident #25) was hit by another resident . A review of Resident #25's progress notes from 4/01/2022 through 8/17/2022, revealed the following: 8/12/2022 (7:35 a.m.) . (Resident #25) informed this nurse this morning that (Resident #32) hit her on the shoulder last night . Administrator and this nurse viewed the video camera from last night and (Resident #25) was sitting in a chair in the north alcove and (Resident #32) was sitting in her (wheelchair) in north alcove. It appears (Resident #32) was trying to get (Resident #25's) attention and reached out to her. (Resident #25) swung at (Resident #32) and did not make contact. (Resident #32) then swung at (Resident #25) and hit her on the right upper arm/shoulder area . A review of Resident #25's care plan revealed the following, in part: Problem Start Date: 3/08/2021. Category: Behavioral Symptoms. (Resident #25) can become combative with other residents . (Resident #25) will not have an increase in behaviors (through) next review as evidenced by no incidents with other residents. Approach Start Date: 6/13/2022 . had a stop sign placed further out from the entrance to her door to allow for other resident to not get too close to her space as she does not like others in her space. Staff to . remind her that she should not hit other residents . Approach Start Date: 3/08/2021 . encourage and educate (Resident #25) to ask staff for help or yell out for help when other residents are entering her personal space. Further review of Resident #25's care plan revealed the following, in part: Problem Start Date: 8/17/2020. Category: Behavioral Symptoms. (Resident #25) can become combative at times; attempting to strike out at staff and other residents. These behaviors generally occur during attempts at care or when she is having pain or when someone is attempting to enter her personal space . Resident #32 Resident #32 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #32's most recent MDS assessment, dated 7/11/2022, revealed Resident #32 required one-person, physical assistance with locomotion (how resident moves between locations) on and off the unit. Further review of Resident #32's MDS assessment revealed the Resident had severe cognitive impairment and exhibited physical (e.g., hitting, kicking, pushing, scratching, grabbing .) and verbal (e.g., threatening others, screaming at others, cursing at others .) behavior symptoms on 1 to 3 days, during the seven-day observation period. An observation on 8/17/2022 at approximately 4:30 p.m., revealed Resident #32 sitting in a wheelchair adjacent to the north hall nurse's station. Resident #32 was heard repeatedly calling help, help, are we safe? A review of Resident #32's care plan revealed the following, in part: Problem Start Dated: 12/23/2019. Category: Behavioral Symptoms . (Resident #32) can refuse assistance with cares and can be argumentative and make rude/sexually inappropriate comments/gestures to staff and other residents, as well as be socially inappropriate to staff/residents (foul language). [Resident #32] can also be combative. 8/11 - she hit another resident on the right shoulder. Goal: (Resident #32) will interact in a positive and safe manner with peers. She will not have unwanted physical contact with peers. Approach Start Date: 1/04/2020 . provide redirection to (Resident #32) from residents when (Resident #32) is becoming, upset, argumentative, or socially inappropriate . Approach Start Dated: 12/23/2019 . Staff to encourage (Resident #32) to inform staff when other residents bother her. Staff can then redirect resident away from her . A review of video surveillance on 8/17/2022 at 4:59 p.m., with the Nursing Home Administrator (NHA), revealed on 8/11/2022 at 7:55 p.m., Resident #25 was seated sideways in an armchair in the north hall alcove. Resident #25's back was facing the north hallway. Resident #32 was observed to be sitting in a wheelchair behind and to the right of Resident #25. Registered Nurse (RN) T approached Resident #25 from the left to administer medication. It was noted at the time RN T was observed administering Resident #25's medication, Resident #32 was facing the back of Resident #25, within approximately one foot distance. RN T did not separate the residents at that time. At 7:56 p.m., Resident #32 was observed to reach out and touch the right arm of the chair in which Resident #25 was seated. At 7:57 p.m. Resident #32 reached out and grabbed Resident #25's right arm. Resident #25 immediately swung her right fist at Resident #32 but did not make contact. Resident #32 responded by swinging her right fist and hitting Resident #25 on the right upper arm. At approximately 7:58 p.m., RN T was observed separating Resident #25 and Resident #32 by moving Resident #32 in her wheelchair to the middle of the alcove, approximately three feet from Resident #25. A review of the incident investigation file, provided by the NHA, revealed a statement dated 8/12/2022 and signed by the Director of Nursing (DON). Further review of the DON's signed statement revealed the following, in part: I talked to (RN T) . on 8/12/22 as she was the charge nurse who was in the building with (Resident #32) and (Resident #25) had their interaction with each other. (RN T) told me she did not witness any physical contact with either resident but heard the commotion with each other and went over to move (Resident #32) away from (Resident #25), she said to prevent them from hitting each other . A review of the Investigation Summary/Actions Taken, portion of the incident summary submitted to the SA on 8/12/2022 at 8:00 a.m., revealed the following, in part: 5) DON met with (RN T) via telephone, who was charge nurse at the time of the incident and she heard them (Residents #25 and #32) interacting with each other. Per interview, (RN T) said she did not witness any physical contact between (Residents #25 and #32), only that they were verbally interacting with each other. On 8/18/2022 at 9:00 a.m., the DON stated Resident #32 and Resident #25 had histories of aggressive behavior toward staff and other residents. The DON reported that she reviewed the video footage of the altercation between Resident #25 and Resident #32 that took place on 8/11/2022 at 7:57 p.m. The DON confirmed that Resident #32 and Resident #25 were sitting too close to each other. The DON reported concern that RN T did not separating the Residents prior to the altercation. The DON stated she re-educated RN T about Resident #25's and Resident #32's need for personal space. A review of the facility policy titled Abuse Policy, effective 5/12/2022, revealed the following, in part: (Facility name redacted) prohibits the mistreatment, neglect and abuse of residents . Physical Abuse includes hitting, slapping . Prevention: C. Ensure implementation of prevention techniques in the center, including, but not limited to: Ongoing supervision of residents . observation and recognition of signs of resident-to-resident . frustration or stress.

Based on observation, interview and record review, the facility failed to prevent an unnecessary physical restraint for one Resident (#16) from one reviewed for restraints. This deficient practice resulted in the potential for falls, depression and psychosocial decline. Findings include: Resident #16 A Minimum Data Set (MDS) assessment, dated 8/4/22, revealed Resident #16 was moderately cognitively impaired, with hallucinations, delusions, and verbal behaviors for 4-6 of the last seven days. The Resident rejected care with no impact to the Resident, according to the assessment. The Resident was non-ambulatory and required extensive assistance for most activities of daily living (ADLs) including bed mobility, transfers and dressing. The Resident required supervision after setup with locomotion in a wheel chair. The assessment was coded as having no restraints in use. Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the electronic medical record (EMR), Resident #16 was a retired nurse. On 8/15/22 at 2:35 p.m., Resident #16 was observed in bed in the lowest position, no more than 16 inches from the floor, a lipped mattress was in place. The Resident had a scab with faint bruising to the right forehead and said she fell about a month prior. On 8/16/22 at 8:01 a.m., Resident #16 was observed in bed with her legs hanging over the lipped mattress. The Resident was trying to get out of the bed and stated that she needed to find her husband. On 8/16/22 at 8:36 a.m., Resident #16 was observed in the bed at the lowest position, not more than 16 inches from the floor, with her legs swung over the bed to the side. A fall mat was on the floor next to the bed, which was up against the wall. The mattress was lipped creating a barrier to exit the bed. At that same time, Certified Nurse Aide (CNA) N was asked about what Resident #16 had for breakfast. CNA N said that Resident #16 ate a few bites of french toast and a few sips of orange juice. When asked why Resident #16 did not get out of bed for breakfast, CNA N said the Resident did not get out of bed because she would wheel to the exits and try to escape or wander into others' rooms or try to stand and fall. CNA N confirmed the reason Resident #16 did not get out of bed was to keep her from eloping or falling, and confirmed the Resident was unable to get up from the bed. On 8/16/22 at 9:39 a.m., Resident #16 was observed in the bed with both legs hanging sideways off the bed. On 8/16/22 at 2:05 p.m., Resident #16 was heard yelling for help. This Surveyor entered the room to find the Resident trying to pull up her pants and yelling for help to get up and pull up her pants. The Resident's legs were hanging off the bed and she was completely sideways in the bed. This Surveyor called to the nursing station where Registered Nurse (RN) O was standing. RN O came to the room and the Resident yelled, Help, I want to get up. RN O stated, You can't do that anymore. You'll go boom boom. Resident #16 became more upset, crying out and yelling, I'm gonna die. RN O continue to contradict what the Resident said, insisting she calm down. CNA N entered the room to assist and checked Resident #16's brief. The Resident screamed, Don't take my pants! RN O told the Resident, 'You're saturated. We have to change your brief. RN O continued to argue with Resident #16, using clinical terms like brief and saturated and skin breakdown, causing the Resident to cry and become combative with the care attempt. RN O several times called the Resident Sweetie. The Resident said, You're not helping. I can't take it. I'm gonna die. They're taking my clean clothes. RN O just continued to argue with the Resident and stated, You're making us work for this one, not as nicely as I want. Resident #16 stated, I've been laying here too long, trying to get someone to help me. CNA N raised and lowered the bed without telling the Resident prior. The two staff finished the care and left the Resident in the bed and left the room. No fluid was offered. The EMR was absent any order for a bed restraint or bedrest. There was an order, dated 8/3/22, for [MEDICATION(S)] (an anti anxiety medication) as needed for extreme behaviors. Resident #16's care plan revealed she developed a urinary tract infection ([CONDITION(S)]), dated 8/10/22, with interventions including encouraging fluids. The care plan also included interventions for anxiety, delusions and hallucinations which included assuring safety and re-attempting cares when calm, approaching in a calm manner, offering a snack, bathroom, change in environment, television and music, dated, 12/17/22. On 8/5/22 an intervention indicated Resident #16 should be allowed to make her own decisions. The ADL care plan, dated 3/8/22, indicated toilet use with assistance of two staff and a wheel chair, and telling the Resident what was happening prior to starting a task. The care plan indicated Resident #16's preference for being up in the wheel chair twice daily, dated 12/7/21, and encouraging her to do as much as possible, dated 12/1/21. The care plan also indicated increased mobility, as tolerated, dated 12/1/21. During an interview on 8/16/22 at 3:28 p.m., Social Worker (Staff) J confirmed Resident #16 had a [CONDITION(S)] for about 10 days. Staff J also confirmed the behavior log for the Resident had only two entries in August 2022, on 8/10, which were not effective. Staff J said the logs weren't always filled out. Staff J confirmed all residents had a behavior log and all logs listed the same behaviors and same interventions and was used as a standard form. Staff J confirmed no behaviors with interventions were specifically documented for Resident #16, and therefore were not appropriately monitored. Staff J did confirm the order, dated 8/3/22 for [MEDICATION(S)] use as needed. During an interview on 8/16/22 at 3:55 p.m., RN P confirmed Resident #16 was recently diagnosed with a [CONDITION(S)], and was treated with two courses of antibiotics, but was not back to her baseline status. RN P confirmed Resident #16 had not been up in her wheelchair for at least one week, but could propel herself when she was. RN P said Resident #16 was in better moods and less anxious when she was up in the wheel chair. RN P said when Resident #16 was up in her chair she would watch the birds or sit in the hallway by the nursing station, but did not see the Resident exit seeking. On 8/16/22 at 4:16 p.m., RN O peeked into Resident #16's room, but did not enter the room or offer the Resident anything. Resident #16 was in the low bed with her drinks out of reach, across the floor mat. On 8/17/22 at 7:16 a.m., Resident #16 was observed in bed. The policy Use of Restraints in Health Care Facilities, date 7/31/14, revealed, .It is the policy of [facility] to provide each resident with a safe place to reside .The use of any .restraint on a resident .must be in compliance with licensure rules and/or certification regulations and there must be in the resident's clinical record information sufficient to support the use of that restraint and responsive to minimum requirements .When properly used, the restraint should not be the least restrictive approach . On 8/16/22 at 3:55 p.m., both the Administrator (NHA) and Director of Nursing (DON) confirmed the above statement, When properly used, the restraint should not be the least restrictive approach was a typed error in the policy and should absolutely be the least restrictive.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE MISTREATMENT (PHYSICALLY RESTRICTING RESIDENT'S HANDS AND FREEDOM OF MOVEMENT AGAINST HIS WILL) FOR ONE RESIDENT (#101) OF FOUR COGNITIVELY IMPAIRED ELDERLY RESIDENTS REVIEWED FOR ABUSE, NEGLECT AND MISTREATMENT FROM A TOTAL OF 48 RESIDENTS IN THE FACILITY, PLACING RESIDENT #101 IN IMMEDIATE JEOPARDY TO HIS HEALTH AND SAFETY. THE FACILITY ALSO FAILED TO IMPLEMENT THEIR OWN "ABUSE INVESTIGATION" POLICY/PROCEDURE. THIS INCIDENT OF MISTREATMENT WAS WITNESSED AND PARTICIPATED IN BY THE DIRECTOR OF NURSING WHO THEN FAILED TO RECOGNIZE THE ACT AS MISTREATMENT AND FAILED TO PUT IN PLACE INTERVENTIONS TO PREVENT FURTHER MIStreatment of [REDACTED]. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 10/26/12 AT 4:30 P.M. THE IMMEDIATE JEOPARDY BEGAN ON 10/22/12 AT 2:54 P.M., WHEN THE DIRECTOR OF NURSING (DON), REGISTERED NURSE (RN) "A" AND SOCIAL WORKER (SW) "X" TRIED TO TAKE RESIDENT #101 TO HIS ROOM TO CHANGE HIS CLOTHING BECAUSE HE HAD FECES OR BOWEL MOVEMENT (BM) ON HIS SHIRT AND SUSPENDERS. WHEN RESIDENT #101 REFUSED, RN "A" (WHILE USING HIS BODY WEIGHT ON RESIDENT #101) HELD RESIDENT #101'S HANDS DOWN FORCIBLY IN RESIDENT #101'S LAP. RN "A" WAS VISUALIZED BRACING HIS LEFT LEG IN ORDER TO HOLD AND CONTROL RESIDENT #101. RESIDENT #101 STRUGGLED WITH FORCE TO FREE HIMSELF AND IN DOING SO, HE MOVED THE CHAIR HE WAS SITTING IN AND OTHER FURNITURE IN HIS PATH. THE DON PARTICIPATED IN THIS INCIDENT WITHOUT ATTEMPTS TO HALT RN "A". THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 10/26/12 AT 4:30 P.M. VIA SPEAKERPHONE, ALONG WITH THE DON. THE DON THEN SIGNED FOR THE ADMINISTRATOR, ACKNOWLEDGING THE IMMEDIATE JEOPARDY. THE IMMEDIATE JEOPARDY WAS REMOVED ON 10/29/12 AT 12:30 P.M., AFTER THIS SURVEYOR VERIFIED THE FOLLOWING: 1. ON 10/26/12, THE THREE STAFF MEMBERS (DON, RN "A" AND SW "X") WERE SUSPENDED PENDING THE OUTCOME OF THE INVESTIGATION. 2. LONG TERM CARE STAFF WERE MONITORING EACH RESIDENT IN THE FACILITY FOR ANY EFFECT FROM WITNESSING THIS INCIDENT AND DOCUMENTING IN THE NURSE NOTES ANY FINDINGS. STAFF WILL CONTACT THE HOSPITAL SOCIAL WORKER IF ANY RESIDENT NEEDS ASSISTANCE. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT AN ISOLATED LEVEL, WITH POTENTIAL HARM TO ALL RESIDENTS PENDING: 1. ALL LONG TERM CARE STAFF WILL COMPLETE INSERVICE TRAINING BY 10/31/12 ON ABUSE, NEGLECT AND MISTREATMENT PREVENTION, WITH FULL UNDERSTANDING OF THE "IMMEDIATE" REPORTING PROCESS TO THE ADMINISTRATOR AND DIRECTOR OF NURSING. 2. THE FACILITY PLANS TO MONITOR ITS' CORRECTIVE ACTION AT THEIR WEEKLY VARIANCE CONCERN MEETING, WITH RESULTS TO THE QUALITY ASSURANCE COMMITTEE; AND STAFF WILL BE EDUCATED FOR THE NEXT SIX MONTHS AT THE MANDATORY MONTHLY INSERVICE MEETINGS. 3. VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH PROTECTING RESIDENTS FROM MISTREATMENT, ABUSE AND NEGLECT. FINDINGS INCLUDE: A REVIEW OF A COMPLAINT INTAKE RECEIVED 10/24/12 READS, "ON 10/22/12, (RESIDENT #101) WAS SITTING IN A PUBLIC ALCOVE IN THE FACILITY WHEN HE WAS ASSAULTED BY 3 STAFF MEMBERS. THE RESIDENT HAS BM ON HIS SHIRT AND DIRECTOR OF NURSING, SOCIAL WORKER AND RN ("A"), TRIED TO TAKE RESIDENT TO HIS ROOM. RESIDENT REFUSED SO THEY HELD HIM DOWN AND REMOVED HIS SHIRT AND SUSPENDERS. RESIDENT WAS SCREAMING FOR HELP. RESIDENT HAS DEMENTIA AND MAY NOT REMEMBER THE INCIDENT. FACILITY IS TRYING TO COVER IT UP." ACCORDING TO THE FACE SHEET, RESIDENT #101 IS AN [AGE] year OLD MAN admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. ACCORDING TO THE QUARTERLY MINIMUM DATA SET (MDS) assessment dated [DATE], RESIDENT #101 SCORED "3" ON HIS BIMS (BRIEF INTERVIEW OF MENTAL STATUS), REFLECTING "SEVERELY IMPAIRED COGNITION". HE WAS INDEPENDENT IN AMBULATION, TRANSFER, DRESSING AND EATING, BUT REQUIRED EXTENSIVE 1-2 ASSIST FOR HYGIENE AND BATHING. RESIDENT #101 WAS OCCASIONALLY INCONTINENT OF BLADDER AND CONTINENT OF BOWEL. ON 10/26/12 AT 12:55 P.M. AND ON 10/29/12 AT 11:21 A.M., A VIDEO TAPE OF AN OCCURRENCE DATED 10/22/12 WAS REVIEWED. THE VIDEO SHOWED RESIDENT #101 SITTING IN A HIGH BACK CUSHIONED CHAIR OUTSIDE THE SOCIAL WORKER'S (SW "X") OFFICE IN THE ALCOVE AREA AT 14:54 (2:54) P.M. ON 10/22/12. ON THE VIDEO, SW "X" IS VISUALIZED LEAVING HER OFFICE AND GOING INTO THE DON'S OFFICE. THE DON AND SW "X" RE-ENTER THE ALCOVE AREA AND ARE VISUALIZED PUTTING ON GLOVES AND REMOVING THE HIGH BACK DINING ROOM CHAIR FROM BEHIND RESIDENT #101. THE DON AND SW "X" WERE TALKING TO RESIDENT #101. THE SW "X" IS SEEN REACHING BEHIND RESIDENT #101'S BACK TO UNHOOK THE SUSPENDER FROM THE BACK WAIST BAND OF HIS PANTS. RESIDENT #101 WAS SWINGING HIS LEFT ARM TOWARD SW "X" AND LOOKED IN HER DIRECTION. AT 15:03 (3:03) P.M., RESIDENT #101 WAS VISUALIZED KICKING AND SWINGING HIS ARMS AT THE DON. HE SCOOTED FORWARD IN THE CHAIR AND PUSHED HIS WALKER AT THE DON AS WELL. CERITIFIED NURSE AIDE (CNA) "R" REACHED BEHIND RESIDENT #101'S BACK (RIGHT SIDE) AND ATTEMPTED TO UNHOOK HIS SUSPENDER FROM HIS PANTS. RESIDENT #101 STOOD UP, SWINGING HIS ARMS AND GRABBED A PLANT FROM THE END TABLE AND THREW IT AT CNA "R". WITH THE CONTINUED REVIEW OF THE VIDEO TAPE, IT SHOWED RESIDENT #101 HAD MOVED TO ANOTHER CHAIR OFF CAMERA. RESIDENT #101 WAS NEVER LEFT ALONE TO CALM DOWN, AND STAFF ARE VISUALIZED CONTINUALLY WALKING IN AND OUT OF THE CAMERA VIEW AND TALKING WITH HIM. AT 15:24 (3:24) P.M., RESIDENT #101 TRIED TO WALK AWAY FROM THE SITUATION AND WAS FOLLOWED DOWN THE HALLWAY (OFF CAMERA) TOWARDS THE DINING ROOM AREA AND HIS ROOM. THE VIDEO SHOWED HE WAS FOLLOWED BY RN "A" AND THEN RETURNED TO THE ALCOVE WITH STAFF, SPECIFICALLY RN "A" AND THE DON. RESIDENT #101 SAT IN A DIFFERENT CHAIR THAN THE PREVIOUS ONE (HIGH BACK DINING ROOM CHAIR). AT 15:28 (3:28) P.M., RN "A" IS VISUALIZED PHYSICALLY HOLDING RESIDENT #101'S HANDS IN HIS LAP AND RN "A" IS SEEN BRACING HIS LEFT LEG OUTWARD IN ATTEMPT TO CONTROL RESIDENT #101. RESIDENT #101 WAS STRUGGLING TO RELEASE RN "A"'S GRIP AND PUSHED HIMSELF FORCIBLY (CHAIR AND ALL) BACKWARDS, THROUGH 2 END TABLES AND 2 STUFFED HIGH BACK CHAIRS. RESIDENT #101 WAS NOW OFF CAMERA VIEW. AT 15:29 (3:29) P.M., THE DON IS VISUALIZED WALKING BY THE CAMERA VIEW WITH RESIDENT #101'S SHIRT AND SUSPENDERS IN HER HAND. AT 15:45 (3:45) P.M., RESIDENT #101 WAS SHOWN WALKING WITH CNA "F" INTO CAMERA VIEW WEARING A NEW SHIRT AND THEN CONTINUED TO WALK OFF CAMERA WITH CNA "F". RN "A" IS VISUALIZED AT THE DON'S DOOR AT 15:58 (3:58) P.M., AND THEN EXITED THE BUILDING AT 16:00 (4:00) P.M. A REVIEW OF NURSES NOTES IN RESIDENT #101'S MEDICAL RECORD DATED 10/22/12 AT 4:20 P.M. (APPROXIMATELY 50 MINUTES AFTER THE INCIDENT) READ, "RESIDENT (#101) IS SITTING BY THE BIRD AVIARY NEAR SOUTH HALL NURSES STATION, VISIBLY SHAKEN & TEARY EYED. WENT TO TOUCH HIS ARM AND HE QUICKLY PULLED HIS ARM BACK. I ASKED IF HE WAS OK. HE SAID 'THEY RIPPED MY SHIRT & SUSPENDERS OFF! I'M NOT A 2 YEAR OLD.' I ASKED IF HE WAS OK AND HE NODDED 'YES'. ASKED IF HE NEEDED ANYTHING & HE SHOOK HIS HEAD 'NO'. THIS NURSE LEFT HIM TO WATCH THE BIRDS." THIS ENTRY WAS SIGNED BY RN "B". A REVIEW OF NURSES NOTES IN RESIDENT #101'S MEDICAL RECORD DATED 10/22/12 AT 6:42 P.M., READ: "AT APPROXIMATELY 17:30 (5:30) P.M. (2 HOURS POST INCIDENT) RESIDENT (#101) IS STILL UPSET ABOUT EARLIER INCIDENT, STATING 'THEY RIPPED MY SHIRT AND SUSPENDERS OFF OF ME', ASKING IF I KNOW WHO DID THIS. RESIDENT IS CALMER AT THIS TIME. MESSAGE LEFT FOR FAMILY IN REGARDS TO THIS INCIDENT." THIS ENTRY WAS SIGNED BY LICENSED PRACTICAL NURSE (LPN) "I". AN INTERVIEW WAS CONDUCTED WITH SW "X" ON 10/26/12 AT 12:40 P.M. SW "X" STATED, "I CAME OUT OF MY OFFICE AND COULD SEE (RESIDENT #101) HAD FECES ON HIS SHIRT AND SUSPENDERS... I WENT INTO THE DIRECTOR OF NURSING'S (DON) OFFICE AND INFORMED HER OF THE SITUATION...WE CAME BACK OUT AND PUT ON GLOVES AND STARTED TALKING TO (RESIDENT #101). I TOLD HIM HE HAD BM (FECES) ON HIS SHIRT AND WE NEEDED TO CHANGE IT... (RESIDENT #101) STATED, 'IT'S YOU WHO STINKS'." A TELEPHONE INTERVIEW WAS CONDUCTED WITH RN "A" ON 10/29/12 AT APPROXIMATELY 1:30 P.M. RN "A" STATED: "I WAS COMING BACK FROM THE HOSPITAL CLINIC AND I SAW (CNA "J") ON THE FLOOR, SHE HAD BEEN PUSHED OVER BY (RESIDENT #101). (RESIDENT #101) WAS SITTING IN A CHAIR. HE WAS AGITATED... THE DON WAS TRYING TO PERSUADE HIM TO CHANGE HIS CLOTHES... (RESIDENT #101) WAS SWEARING AND SAYING THE F-WORD AND, 'I'M NOT GOING TO MY ROOM YOU S.O.B.' I LET HIM RANT AND RAVE FOR A FEW MINUTES... I DON'T KNOW IF HE (RESIDENT #101) COULD UNDERSTAND WHAT WAS GOING ON... THE CNAS WERE TRYING TO PERSUADE HIM TO GO TO HIS ROOM AND CHANGE HIS CLOTHES... HE GETS UP AND I WAS HOPING HE WAS GOING TO HIS ROOM, BUT HE DIDN'T, I COULDN'T LET HIM GO INTO THE DINING ROOM... I GOT IN FRONT OF HIM AND TOLD HIM HE COULDN'T GO IN THERE, IT (BM) WAS AN INFECTION CONTROL ISSUE... I TOLD HIM HE NEEDED TO CHANGE HIS SHIRT BEFORE HE COULD GO IN THE DINING ROOM... HE WAS VERY AGITATED AGAIN, I DON'T THINK HE REALLY UNDERSTANDS US... HE TURNED AROUND AND WENT BACK TO THE ALCOVE AREA AND SAT IN A CHAIR THERE. I ASKED THE DON AND SW, IF WE CAN'T GET HIM TO GO TO HIS ROOM WHAT OPTION DO WE HAVE? WE (DON, SW "X" AND MYSELF) DISCUSSED IT AND THE CONSENSUS WAS THE SHIRT NEEDED TO BE REMOVED... I THINK IF (RESIDENT #101) WOULD HAVE STAYED IN THE CHAIR, HE WOULD HAVE CHANGED HIS MIND, BUT WHEN HE WENT INTO THE DINING ROOM, WE (RN, DON AND SW) KNEW THE SHIRT NEEDED TO COME OFF." RN "A" WAS ASKED BY THIS SURVEYOR IF HE LAID HIS HANDS ON RESIDENT #101 AND HE REPLIED, "YES, I WAS HOLDING HIS HANDS DOWN, AND (RESIDENT #101) WAS YELLING, 'LEAVE ME ALONE'." AN INTERVIEW WAS CONDUCTED WITH THE DON ON 10/26/12 AT 2:45 P.M. THE DON INDICATED SHE HAD JUST TAKEN THE POSITION AS DON AT THE FACILITY ON 10/09/12. SHE STATED: "I DON'T HAVE A WHOLE LOT OF HISTORY IN RESIDENT'S RIGHTS... I KNOW A RESIDENT HAS THE RIGHT TO EAT OR NOT EAT, TO GET UP OR STAY IN BED, TO BATHE OR NOT TO BATHE." THE DON WAS ASKED ABOUT THE INCIDENT THAT OCCURRED WITH RESIDENT #101 ON 10/22/12. SHE REPLIED, "I KNOW STAFF THINK I HURT THIS MAN, BUT I THINK WE DID THE RIGHT THING, WE COULDN'T LET HIM GO AROUND WITH DRIED BM ON HIS CLOTHES, IT WAS A DIGNITY ISSUE FOR HIM AND AN INFECTION CONTROL ISSUE FOR US... NOBODY TRIED TO STOP US." THE DON WAS ASKED IF SHE REALLY THOUGHT A CNA OR HOUSEKEEPER WOULD CHALLENGE THE AUTHORITY OF THE DON, SW OR AN RN SUPERVISOR? THE DON REPLIED, "YES, I THINK THEY WOULD HAVE." THE DON WAS THEN ASKED WHAT THE DEFINITION OF ABUSE/MISTREATMENT WAS. SHE REPLIED, "FORCING A RESIDENT TO DO SOMETHING HE DOESN'T WANT TO DO, LAYING HANDS ON SOMEONE... STAFF WERE RIGHT, I MADE A MISTAKE, IT WON'T HAPPEN AGAIN." IN AN INTERVIEW WITH HOUSEKEEPER (STAFF) "L" ON 10/29/12 AT 2:15 P.M., SHE CONFIRMED HER WRITTEN STATEMENT THAT WAS PROVIDED TO THE FACILITY. STAFF "L" STATED: "I WITNESSED AN INCIDENT THAT TOOK PLACE IN THE NORTH SIDE SITTING AREA (ALCOVE) ON 10/22/12. I WAS CLEANING THE TUB ROOM ON THE NORTH HALLWAY AND SAW THE DON, (SW "X") AND TWO CNAS (UNIDENTIFIED) FROM AFTERNOONS AND ONE CNA (UNIDENTIFIED) FROM DAYS AROUND (RESIDENT #101) IN THE SITTING AREA JUST OUTSIDE (SW "X")'S OFFICE. I COULD SEE THEY (STAFF) WERE WEARING GLOVES AND COULD HEAR THE SITUATION GETTING VERBALLY LOUD AND OUT OF CONTROL. I HEARD (SW "X") SAY TO (RESIDENT #101) THAT HE SMELLED AND SHE TOLD HIM OTHER RESIDENTS COULD SMELL HIM AND WERE OFFENDED BY IT...YOU COULD SEE (RESIDENT #101) FELT TRAPPED AND OUT NUMBERED. HE GOT UP AND WALKED AWAY... OTHER RESIDENTS WERE AROUND AND WERE VERY DISTURBED BY WHAT THEY WERE WATCHING, AND FELT [MEDICATION NAME] FOR (RESIDENT #101) BECAUSE OF HOW HE WAS BEING TREATED IN THIS PUBLIC AREA. I'M A HOUSEKEEPER AND I KNOW THE FIRST THING YOU DO IN THESE SITUATIONS IS TO DE-FUSE, WALK AWAY AND RE-APPROACH LATER IN A DIFFERENT WAY. (RESIDENT #101) HAD MORE SENSE THAN THE DON DID, HE TRIED WALKING AWAY, ONLY TO BE PUBLICLY ATTACKED IN HIS HOME IN FRONT OF SO MANY PEOPLE... I HOPE MY INTERVIEW/STATEMENT HELPS IN DEALING WITH THE SITUATION APPROPRIATELY AND WITHOUT REPERCUSSION TO ANY OF US WHO WERE WITNESS TO THIS SAD, UNNECESSARY INCIDENT." IN AN INTERVIEW ON 10/29/12 AT 3:50 P.M., CNA "M" CONFIRMED HER WRITTEN STATEMENT DATED 10/22/12. CNA "M" STATED: "I DID NOT WITNESS THE BEGINNING OF THE OCCURRENCE, BUT AFTER I HAD FINISHED MAKING ROUNDS WITH A CO-WORKER (UNIDENTIFIED), I WAS ASKED BY THE DON TO PUT GLOVES ON AND ASSIST WITH (RESIDENT #101). I WAS TOLD HE HAD BM ON HIS CLOTHES AND THEY NEEDED TO COME OFF... I CALMLY WALKED IN FRONT OF (RESIDENT #101), AND KNELT DOWN IN FRONT OF HIM... I ASKED IF HE WOULD WALK WITH ME TO HIS ROOM TO GET CHANGED, HE SAID 'NO'... AT THIS TIME, HE WAS ALREADY UPSET AND STARTED TO BE COMBATIVE, SO I TOOK MY GLOVES OFF AND WALKED AWAY. THE SW ("X"), DON AND (RN "A") WERE STILL SURROUNDING HIM... I WENT AND PASSED SNACKS TO THE RESIDENTS... I CAME BACK A FEW MINUTES LATER AND HE (RESIDENT #101) WAS STILL SITTING IN THE ALCOVE AREA... AS HE (RESIDENT #101) WAS BEING HELD DOWN BY (RN "A") AND SCREAMING 'LET ME GO'. THE DON TOOK (RESIDENT #101)'S SHIRT OFF IN FRONT OF OTHER RESIDENTS ...I GRABBED HIS CLEAN T-SHIRT AND PUT IT ON HIM, DUE TO IT BEING A DIGNITY ISSUE. THIS SITUATION GOT NOT ONLY MYSELF ALL WORKED UP AND VERY UNCOMFORTABLE, BUT OTHER RESIDENTS AS WELL. I DIDN'T WANT TO EVEN BE PART OF THE SITUATION, BUT I ALSO DIDN'T WANT TO GET IN TROUBLE WITH MY DON." DURING AN INTERVIEW WITH RN "B" ON 10/29/12 AT 2:38 P.M., RN "B" CONFIRMED HER WRITTEN STATEMENT RECALLING THE OCCURRENCE OF 10/22/12. RN "B" STATED: "I WAS WORKING WITH (RN "S") ENTERING ORDERS INTO THE COMPUTER SYSTEM... I HEARD LOUD VOICES AND ASKED THE SW ("X") WHAT WAS GOING ON. SHE (SW) RESPONDED BY SAYING (RESIDENT #101) HAD BM ON HIS CLOTHES AND THEY NEED TO COME OFF, IT'S AN INFECTION CONTROL ISSUE... I ASKED, 'CAN'T YOU LEAVE HIM & COME BACK', AND THE SW ("X") STATES 'NO... IT STINKS AND IT'S AN INFECTION CONTROL PROBLEM'... IT (SITUATION) SEEMED CALMER SO I WENT TO THE OTHER HALL TO DO SOME MORE WORK, I HEARD SOME YELLING AND ASKED WHAT WAS GOING ON & WAS TOLD (RESIDENT #101) WAS TACKLED AND HAD HIS SHIRT & SUSPENDERS REMOVED AT THE MAIN ENTRANCE. HE WAS STILL YELLING AFTERWARDS... I CONFERRED WITH (RESIDENT #101)'S PHYSICIAN (MD1) AND HE SAID DO WHAT I NEED TO DO. I CONTACTED THE ADMINISTRATOR BEFORE I LEFT THE BUILDING AT 4:30 P.M." AN INTERVIEW WAS CONDUCTED WITH CNA "J" ON 10/26/12 AT 11:15 A.M. CNA "J" STATED SHE WAS WORKING IN THE ACTIVITY ROOM ON THE AFTERNOON OF 10/22/12. CNA "J" STATED: "I COULD HEAR SHOUTING GOING ON IN THE ALCOVE, AND I LOOKED UP AND SEEN (RESIDENT #103), STANDING IN THE ACTIVITY ROOM DOORWAY, HE APPEARED UPSET, BUT BECAUSE OF HIS DEMENTIA, HE CAN'T ALWAYS SAY WHAT HE WANTS TO... I COULD TELL HE WANTED ME TO FOLLOW HIM... WE WENT OUT INTO THE HALLWAY AND I COULD SEE THE DON AND THE SW ("X") TALKING WITH (RESIDENT #101) AND TRYING TO GET HIM TO TAKE HIS SHIRT AND SUSPENDERS OFF... I HAVE A GOOD RELATIONSHIP WITH HIM (RESIDENT #101) SO I THOUGHT I WOULD TRY... I KNELT DOWN IN FRONT OF (RESIDENT #101) AND ASKED HIM IF HE WOULD COME WITH ME TO HIS ROOM... HE (RESIDENT #101) TOLD ME 'NO' AND THEN PUSHED ME OVER... THE SW ("X") KEPT TELLING (RESIDENT #101) HE NEEDED TO TAKE A SHOWER... I KEPT THINKING 'OH, DON'T TELL HIM THAT HE DOESN'T LIKE SHOWERS'... I WENT BACK TO THE RESIDENTS IN THE ACTIVITY ROOM." AN INTERVIEW WAS CONDUCTED WITH CNA "O" ON 10/26/12 AT 3:40 P.M. CNA "O" STATED SHE ENTERED THE BUILDING THROUGH THE FRONT DOOR WITH RESIDENT #103. THEY HAD BEEN OUTSIDE FOR A WALK LIKE THEY DO EVERYDAY. CNA "O" STATED RESIDENT #101 WAS IN THE ALCOVE AREA AND SEVERAL STAFF WERE AROUND HIM, 'LIKE A PACK OF ANIMALS'. THIS SURVEYOR ASKED CNA "O" WHY SHE DID NOT INTERVENE ON BEHALF OF RESIDENT #101. CNA "O" REPLIED, "DON IS HARD TO APPROACH, IF I WOULD HAVE TOLD HER TO STOP, SHE WOULD HAVE TOLD ME TO MIND MY OWN BUSINESS, SHE'S (DON) VERY UNAPPROACHABLE." AN INTERVIEW WAS CONDUCTED WITH THE DON ON 10/26/12 AT 2:45 P.M. THE DON WAS ASKED WHEN SHE KNEW THIS WAS A REPORTABLE EVENT. SHE REPLIED, "AFTER STAFF WERE SUBMITTING THEIR WRITTEN STATEMENTS TO THE RISK MANAGER ON 10/23/12 {THE DAY AFTER THE MISTREATMENT OCCURRED}... (LICENSED PRACTICAL NURSE (LPN) "I") TOLD ME, 'YOU (DON, REGISTERED NURSE "A" AND SOCIAL WORKER "X") ABUSED HIM (RESIDENT #101), YOU PUT YOUR HANDS ON HIM AND HELD HIM DOWN, THAT'S ABUSE!' I GUESS SHE (LPN "I") WAS RIGHT." AT THE TIME OF THE SURVEY BEGINNING ON 10/26/12, THE FACILITY HAD NOT PROTECTED RESIDENT #101 OR OTHER RESIDENTS FROM THE THREE ALLEGED PERPERTRATORS. THE DON AND SW "X" WERE ON DUTY AT THE FACILITY AND WERE INTERVIEWED BY THIS SURVEYOR. INTERVIEWS WITH OTHER FACILITY STAFF REFLECTED RN "A" WAS SEEN IN THE FACILITY EARLIER THAT SAME DAY. INTERVIEW WITH RN "B" ON 10/29/12 AT 2:38 P.M., REFLECTED THE ADMINISTRATOR WAS NOTIFIED OF THE INCIDENT APPROXIMATELY 1 1/2 HOURS AFTER IT OCCURRED BY THIS REGISTERED NURSE. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY RESIDENT CARE AND SERVICES RESULTING IN HARMFUL NEGLECT OF ONE PHYSICALLY AND MENTALLY DISABLED RESIDENT (#1) OF FIVE SAMPLED RESIDENTS REVIEWED FOR THE USE OF MOIST HOT PACKS FROM A [MEDICATION NAME] FROM THE FACILITY'S RESIDENT POPULATION OF 47. THE FACILITY'S DEFICIENT PRACTICE RESULTED IN RESIDENT #1 DEVELOPING A SECOND DEGREE BURN TO THE TOP OF HIS RIGHT SHOULDER WHEN THE FACILITY NEGLECTED TO DEVELOP AND IMPLEMENT A MOIST HOT PACK POLICY FOLLOWING THE MANUFACTURER'S SAFE OPERATION RECOMMENDATIONS AND THEN FAILED TO ADHERE TO PROFESSIONAL STANDARDS OF PRACTICE AND MONITOR THE CONDITION OF RESIDENT #1'S SKIN WHEN OCCUPATIONAL THERAPIST (OT) "A" PLACED A MOIST HOT PACK ON RESIDENT #1'S RIGHT SHOULDER PLACING RESIDENT #1 IN IMMEDIATE JEOPARDY TO HIS HEALTH AND SAFETY. FINDINGS INCLUDE: THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 12/28/11 AT 1:30 P.M. THE IMMEDIATE JEOPARDY BEGAN ON 12/20/11 AT APPROXIMATELY 10 A.M., WHEN OT "A" PLACED A MOIST HOT PACK ON RESIDENT #1'S RIGHT SHOULDER AND FAILED TO APPROPRIATELY MONITOR THE CONDITION OF HIS SKIN DURING AND/OR AFTER THE PRESCRIBED TREATMENT. THE FACILITY'S LACK OF DEVELOPING AND IMPLEMENTING A MOIST HOT PACK POLICY BASED ON MANUFACTURERS SAFE OPERATION RECOMMENDATION AND THE LACK OF OT "A"'S ADHERENCE TO PROFESSIONAL STANDARDS OF PRACTICE, RESULTED IN RESIDENT #1 RECEIVING A 9 CENTIMETER (CM) BY 5 CM SECOND DEGREE BURN TO THE TOP OF HIS RIGHT SHOULDER, AS EVIDENCED BY A BLISTER. THE LAST DOCUMENTED [MEDICATION NAME] WATER TEMPERATURE CHECK WAS CONDUCTED ON 12/13/11 AND SHOWED A TEMPERATURE OF 175 DEGREES FAHRENHEIT (?F). THE FACILITY STAFF DID NOT RECHECK THE [MEDICATION NAME] TEMPERATURE ON 12/20/11, PRIOR TO PROVIDING RESIDENT #1'S MOIST HOT PACK TREATMENT. THE MOIST HOT PACK REMAINED ON RESIDENT #1'S SHOULDER UNTIL APPROXIMATELY 10:10 A.M. A COMPLETE ASSESSMENT OR MONITORING OF RESIDENT #1'S SKIN DID NOT OCCUR DURING OR FOLLOWING THE MOIST HOT PACK TREATMENT. DUE TO RESIDENT #1'S REFUSAL FOR ASSISTANCE WITH UPPER BODY CARES AFTER RECEIVING THE MOIST HOT PACK TREATMENT, THE SECOND DEGREE BURN WAS NOT IDENTIFIED UNTIL APPROXIMATELY 2:30 P.M. ON 12/21/11. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 12/28/11 AT 1:53 P.M. ON 12/28/11 AT 4 P.M., THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THIS SURVEYOR VERIFIED THE FOLLOWING: - DURING THE 12/28/11 INTERVIEWS WITH OT "A" AT 9:45 A.M. AND RESTORATIVE AIDE "B" AT 2 P.M., THEY STATED THEY WERE THE STAFF THAT PERFORM MOIST HOT PACK TREATMENTS. THEY SAID THE MOIST HOT PACK TREATMENTS WERE STOPPED ON 12/28/11, UNTIL THE FACILITY REVIEWED THE MOIST HOT PACK PROCESS. - DURING AN INTERVIEW ON 12/28/11 AT 3 P.M. WITH THE DIRECTOR OF NURSING (DON), SHE PRODUCED A DOCUMENT FOR ALL STAFF, EXPLAINING THE USE OF ALL HOT PACK TREATMENTS HAD BEEN STOPPED UNTIL FURTHER NOTICE FROM THE ADMINISTRATOR. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT AN ISOLATED LEVEL WITH ACTUAL HARM TO RESIDENT #1 AND POTENTIAL FOR HARM TO OTHER RESIDENTS DUE TO: - AWAITING COMPLETION OF ASSESSMENTS WITH ALL RESIDENTS THAT HAD RECEIVED THE HOT PACK TREATMENTS AND TO DETERMINE WHAT ALTERNATIVE PAIN RELIEF MEASURE(S) WILL BE PROVIDED. - THE NEED TO REVIEW ALL RESIDENT CARE PROCEDURES TO ENSURE THEY INCLUDE ALL INFORMATION NEEDED TO DIRECT STAFF IN THE APPROPRIATE USE OF ALL RESIDENT CARE DEVICES. - DEMONSTRATION THAT STAFF HAVE BEEN TRAINED AND ARE COMPETENT IN PROVIDING CARE PROCEDURES FOR ANY RESIDENT CARE DEVICES AND IN PROVIDING TREATMENTS. - THE REVIEW AND REVISIONS OF THE HOT PACK POLICY AND PROCEDURES WHICH WILL INCLUDE THE [MEDICATION NAME]'S MANUFACTURING CAUTION RECOMMENDATIONS FOR THE [MEDICATION NAME] WATER TEMPERATURE AND THE [MEDICATION NAME] TEMPERATURE CHECKS OCCURRING JUST PRIOR TO USE. FINDINGS INCLUDE: A REVIEW OF THE FACILITY'S INVESTIGATION REPORT REVEALED ON 12/20/11 AT APPROXIMATELY 10 A.M., OT "A" PLACED A MOIST HOT PACK FROM A [MEDICATION NAME] ON RESIDENT #1'S SHOULDER WHILE HE WAS IN HIS ROOM. THE REPORT DOCUMENTED THE MOIST HOT PACK WAS APPLIED FOR 10 MINUTES. AFTER THE REMOVAL OF THE MOIST HOT PACK, PER THE REPORT, RESIDENT #1 HAD REFUSED ASSISTANCE WITH UPPER BODY CARES UNTIL THE NEXT AFTERNOON. AT THAT TIME, CNA "C" REPORTED TO REGISTERED NURSE (RN) "D" THAT RESIDENT #1 HAD A BURN ON HIS RIGHT SHOULDER. THE REPORT DOCUMENTED A 9 CM BY 5 CM BLISTER WAS INTACT WHEN IT WAS DISCOVERED. RESIDENT #1'S CLINICAL CHART WAS REVIEWED. THE FACE SHEET SHOWED RESIDENT #1 IS [AGE] years OLD AND HAS RESIDED AT THE FACILITY SINCE 2005. HIS [DIAGNOSES REDACTED]. RESIDENT #1'S 11/13/11 MINIMUM DATA SET (MDS) ASSESSMENT DOCUMENTED HIS COGNITION AS MODERATELY IMPAIRED. THE MDS ASSESSMENT SHOWED HE SOMETIMES UNDERSTANDS WHAT IS SAID TO HIM AND IS SOMETIMES UNDERSTOOD WHEN HE SPEAKS. THE MDS ASSESSMENT AND THE 11/11 UPDATED CARE PLAN SHOWED HE CAN ASK FOR WHAT HE WANTS. THE 11/11 PAIN ASSESSMENT AND CARE PLAN DOCUMENTED RESIDENT #1 HAS "ALMOST" CONSTANT JOINT AND/OR NERVE PAIN THAT WAS RATED AS MODERATE TO SOMETIMES SEVERE. THE MDS ASSESSMENT AND CARE PLAN DOCUMENTED HIM TAKING SCHEDULED AND AS NEEDED (PRN) PAIN MEDICATIONS AND ALSO USING NON-MEDICINE PAIN RELIEF INCLUDING THE USE OF MOIST HOT PACKS FROM A [MEDICATION NAME]. THE FACILITY DOCUMENT TITLED "WEEKLY SKIN PROGRESS REPORT" (REVISED 1/11), SHOWED A SKIN ASSESSMENT TO RESIDENT #1'S RIGHT SHOULDER IDENTIFIED AS A "BURN". THE REPORT DOCUMENTED ON 12/23/11, "MOST OF BLISTER POPPED WITH MODERATE SEROSANG DRAINAGE. RED AROUND BLISTER..." THE AREA MEASURED "7 CM BY 5 CM" WITH THE CURRENT TREATMENT DOCUMENTED AS BEING "[MEDICATION NAME] DRSG (DRESSING)". THE 12/23/11 PHYSICIAN ORDER [REDACTED]. ON 12/28/11 AT 1:30 P.M., AN INTERVIEW TOOK PLACE WITH RESIDENT #1 IN HIS ROOM AND INCLUDED AN OBSERVATION OF HIS RIGHT SHOULDER BURN. THE BURN MEASURED APPROXIMATELY 7 CM BY 5 CM. THE BLISTER WAS NOT INTACT. THE BLISTERED SKIN WAS GONE AND THE AREA WAS PINK. RESIDENT #1 SAID HE WAS IN NO PAIN. WHEN ASKED IF HE REMEMBERED HOW HE RECEIVED THE BURN, HE SAID IT WAS FROM A HOT PACK. RESIDENT #1 SAID, HE DID NOT THINK THE BURN HURT WHEN HE GOT IT BUT ALSO STATED, HE WAS IN PAIN IN HIS NECK AND SHOULDER AREA "MOST OF THE TIME". AN INTERVIEW WAS CONDUCTED WITH OT "A" ON 12/28/11 AT 9:45 A.M. SHE EXPLAINED SHE HAD DELIVERED THE MOIST HOT PACK TREATMENT TO RESIDENT #1. OT "A" SAID SHE HAD NOT CHECKED THE TEMPERATURE OF THE MOIST HOT PACK PRIOR TO WRAPPING IT IN THE EQUIVALENT OF 8 TOWEL LAYERS. SHE THEN PLACED THE MOIST HOT PACK ON THE TOP OF RESIDENT #1'S "LIGHT T-SHIRT" COVERING HIS RIGHT SHOULDER AT THE BASE OF HIS NECK. OT "A" STATED, PER THE HOT PACK TREATMENT POLICY, THE [MEDICATION NAME] TEMPERATURE WAS LOGGED ONCE A WEEK AND THE TEMPERATURES WERE NOT CHECKED EACH TIME PRIOR TO THEIR USE ON A RESIDENT. THE FACILITY'S POLICY TITLED, "HOT PACK" (DATED 9/2/10), DOCUMENTS "...POLICY 1. WEEKLY TEMPERATURE CHECKS MUST BE COMPLETED AND DOCUMENTED IN THE LOG. WATER TEMPERATURE SHOULD BE BETWEEN 150?F AND 175?F..." THE FACILITY'S DOCUMENT TITLED "[MEDICATION NAME] TEMPERATURE CHECKS, YEAR: 2011" WAS REVIEWED. THE LAST TIME THE [MEDICATION NAME] TEMPERATURE WAS DOCUMENTED AS BEING CHECKED PRIOR TO THE 12/20/11 INCIDENT WAS 12/13/11. THE TEMPERATURE WAS RECORDED AT 175?F. THE OPERATIONS MANUAL TITLED, "[MEDICATION NAME] MASTER HEATING UNITS" (NO DATE), READ "...PRECAUTIONARY INSTRUCTIONS... 2. CAUTION: THE THERMOSTAT IS EXTREMELY SENSITIVE AND THE SLIGHTEST ADJUSTMENT WILL ALTER THE TEMPERATURE SEVERAL DEGREES. THE RECOMMENDED OPERATING TEMPERATURE IS 160?F TO 166?F." THE DON WAS INTERVIEWED ON 12/28/11 AT 2 P.M. CNA "C" WAS INTERVIEWED ON 12/28/11 AT 2:30 P.M. BOTH STAFF SAID THEY HAD OBSERVED THE BURN ON RESIDENT #1'S RIGHT SHOULDER ON 12/21/11. CNA "C" STATED, RESIDENT #1 OFTEN WILL ACCEPT CARES TO HIS UPPER BODY ONLY ONE TIME A DAY. SHE EXPLAINED, SHE KNEW HE HAD CARES PRIOR TO THE HOT PACK TREATMENT ON 12/20/11, SO IT WAS NOT UNUSUAL FOR HIM NOT TO WANT ASSISTANCE WITH CHANGING HIS SHIRT UNTIL 12/21/11. CNA "C" SAID, RESIDENT #1 STAYS UP LATE AT NIGHT AND HAD SLEPT IN ON 12/21/11, SO SHE HAD NOT REMOVED HIS SHIRT UNTIL ABOUT 1:30 P.M. ON 12/21/11. SHE SAID SHE OBSERVED A BLISTER WITH MINIMAL DRAINING COMING FROM A "SMALL SCABBED AREA AT THE BOTTOM OF THE BURN TOWARD HIS CHEST..." CNA "C" EXPLAINED, RESIDENT #1 SAID IT DID NOT HURT. SHE SAID RESIDENT #1 HAS PAIN IN HIS SHOULDERS "MOST OF THE TIME, SO HE MAY NOT KNOW WHAT EXACTLY HURTS... HE IS NOT A COMPLAINER... HE DOESN'T WANT TO MAKE WORK FOR ANYBODY..." DURING THE INTERVIEW WITH THE DON, SHE STATED THE FACILITY'S INVESTIGATION REPORT WAS CORRECT. THE DON EXPLAINED SHE ASSESSED RESIDENT #1'S BURN AT APPROXIMATELY 3 P.M. ON 12/21/11. SHE SAID, SHE ASSESSED IT TO BE A SECOND DEGREE BURN AND THE PHYSICIAN ORDERED THE treatment for [REDACTED]. SHE WAS ALSO ASKED WHY THE HOT PACK TEMPERATURE WAS NOT CHECKED PRIOR TO RESIDENT USE. THE DON SAID, THE FACILITY USED THE HOSPITAL'S OUTPATIENT POLICY AND FAILED TO REVIEW IT AND REVISE IT, TAKING INTO CONSIDERATION THE SPECIAL ASSESSMENT AND CARE NEEDS OF THE RESIDENTS. DURING THE INTERVIEW WITH OT "A", SHE WAS ALSO ASKED WHY THE FACILITY WAS NOT FOLLOWING THE RECOMMENDED TEMPERATURE READINGS FOUND IN THE [MEDICATION NAME] MANUAL. SHE WAS ASKED WHY THE FACILITY WAS NOT CHECKING THE [MEDICATION NAME] HEATED MOIST HOT PACK TEMPERATURES PRIOR TO EACH USE. OT "A" SAID THE FACILITY ADOPTED THE POLICY THAT WAS ESTABLISHED FOR OUTPATIENT TREATMENT SETTINGS. SHE EXPLAINED OUTPATIENT PATIENTS CAN TELL YOU IF SOMETHING IS TOO HOT. OT "A" SAID, "WE SHOULD'VE TAKEN INTO CONSIDERATION THE SPECIFIC POPULATION OF THE LONG TERM CARE FACILITY AND THEIR SENSITIVE SKIN CONDITIONS AND ABILITIES TO COMMUNICATE... I ALSO SHOULD'VE FELT (RESIDENT #1)'S SKIN TO SEE HOW WARM IT WAS DURING AND AFTER THE (HOT PACK) TREATMENT..." RESIDENTS #2, #3, #4 AND #5'S CLINICAL RECORDS WERE REVIEWED. THEIR INDIVIDUAL CARE PLANS DOCUMENTED THEIR ISSUES WITH PAIN AND THE USE OF MOIST HOT PACK TREATMENTS TO HELP ALLEVIATE THE PAIN. THE THERAPY ROOM AND RESIDENTS' INDIVIDUAL ROOMS WERE IDENTIFIED DURING THE INTERVIEW WITH OT "A", AS THE LOCATIONS WHERE RESIDENTS COULD RECEIVE THESES MOIST HOT PACK TREATMENTS. ON 12/28/11 BETWEEN 11 A.M. AND 4 P.M. AND ON 12/29/11 BETWEEN 8:10 A.M. AND 9:15 A.M., OBSERVATIONS WERE MADE OF THE THERAPY ROOM AND OF RESIDENTS #2, #3, #4 AND #5 WHILE THEY WERE IN THEIR RESPECTIVE ROOMS. DURING THESE OBSERVATIONS, NO HOT PACKS TREATMENTS WERE BEING PROVIDED. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT RESIDENT ELOPEMENT RESULTING IN AN IMMEDIATE JEOPARDY FOR ONE (#1) OF FOUR RESIDENTS KNOWN TO BE AT RISK FOR ELOPEMENT, WHO SUSTAINED INJURIES DURING AN ELOPEMENT FROM THE FACILITY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 2/22/11 AT 4:15 P.M. THE IMMEDIATE JEOPARDY BEGAN ON 2/20/11 AT 9:53 A.M. WHEN RESIDENT #1, EFFECTIVELY LEFT THE FACILITY THROUGH THE MAIN LOBBY DOOR, REMAINED AT LARGE IN SUB-FREEZING TEMPERATURES FOR 27 MINUTES, AND WAS RETURNED TO THE FACILITY HAVING SUSTAINED AN INJURY INCLUDING A FRACTURE OF THE 3RD METACARPAL OF THE RIGHT FOOT. THE DIRECTOR OF NURSING (DON) WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 2/22/11 AT 5:00 P.M. THE IMMEDIATE JEOPARDY WAS REMOVED ON 2/22/11 AT 7:00 P.M., WHEN A NEW ALARM WAS INSTALLED FOR THE MAIN LOBBY DOOR AND A PLAN FOR INSERVICE TRAINING FOR ALL STAFF ON ELOPEMENT PREVENTION AND EMERGENCY MISSING RESIDENT PROCEDURE WAS INITIATED. HOWEVER, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT THE LEVEL OF ISOLATED ACTUAL HARM PENDING COMPLETION OF TRAINING FOR ALL STAFF, REASSESSMENT AND CARE PLANNING FOR RESIDENT #1 AND OTHER ALL OTHER RESIDENTS IDENTIFIED AS ELOPEMENT RISKS, CONFIRMATION THAT ALL ALARMS USED TO ENSURE RESIDENT SAFETY ARE IN WORKING ORDER, AND VERIFICATION BY THE STATE AGENCY. FINDINGS INCLUDE: A REVIEW OF RESIDENT #1'S MEDICAL RECORD REFLECTS RESIDENT #1 IS [AGE] years OLD. HIS PRIMARY [DIAGNOSES REDACTED]. RESIDENT #1'S PLAN OF CARE DATED 1/11/11, REFLECTS HE HAS BEHAVIORAL DIFFICULTIES RELATED TO DEMENTIA AND DEMONSTRATES "LIMITED ABILITY TO UNDERSTAND" AND "ATTEMPTS TO GO FIND HIS TRUCK". THE "FUNCTIONAL CARE PLAN" REVIEWED BY FACILITY STAFF ON 2/17/11, IDENTIFIES RESIDENT #1 AS BEING A "HIGH FALL RISK". RESIDENT #1 WAS ALSO IDENTIFIED WITH SHORT AND LONG TERM MEMORY IMPAIRMENTS. BOTH PLANS OF CARE DIRECT STAFF TO USE A "HOME FREE WATCH" SAFETY DEVICE, WHICH ALLOWS RESIDENT #1'S WHEREABOUTS TO BE TRACKED VIA A WIRELESS MONITORING SYSTEM. A REVIEW OF THE MEDICAL RECORD REVEALED RESIDENT #1 IS RESTLESS AND OFTEN "ON THE MOVE", PROPELLING HIMSELF AROUND THE FACILITY IN HIS WHEELCHAIR. HOWEVER, RESIDENT #1 IS ABLE TO WALK SHORT DISTANCES BY HIMSELF. RESIDENT #1, A COGNITIVELY IMPAIRED RESIDENT WITH KNOWN ELOPEMENT ATTEMPTS, LEFT THE FACILITY UNSUPERVISED, THROUGH THE MAIN LOBBY DOOR. THE FACILITY'S COMPUTER MONITORING RECORDS SHOWED THE MAIN DOOR ALARM WAS ACTIVATED AT 9:52:50 A.M. ON 2/20/11 BY RESIDENT #1 AND RANG FOR SEVEN MINUTES BEFORE IT WAS TURNED OFF BY FACILITY STAFF. THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED ON 2/22/11 AT 1:00 P.M. THE DON STATED THERE ARE TWO SETS OF ALARMS ON THE FRONT DOORS: THE FIRST ONE NECESSITATED PUNCHING A KEYPAD TO ENTER/EXIT THE LOBBY, OR AN ALARM WOULD SOUND. THE SECOND ALARM IS ON THE DOORS LEADING FROM THE LOBBY TO THE HALLWAY. THIS ALARM IS ONLY ACTIVATED WHEN A PERSON WEARING A WATCH WITH AN ELECTRONIC TRANSMITTER IN IT COMES NEAR THE DOOR. THE DON EXPLAINED FOUR RESIDENTS IN THE FACILITY, INCLUDING RESIDENT #1, WEAR THE ELECTRONIC WATCHES BECAUSE THEY ARE RESIDENTS WITH DEMENTIA, WHO HAVE BEEN IDENTIFIED AS "HIGH RISK" TO LEAVE THE FACILITY UNSUPERVISED. BASED ON SURVEYOR OBSERVATION DONE ON 2/22/11 AT 2:00 P.M. AND STAFF INTERVIEWS CONDUCTED DURING THE ABBREVIATED SURVEY ON 2/22/11 AND 2/23/11, THE MAIN DOOR ALARM WAS NOT AUDIBLE WHEN tested BY THIS SURVEYOR ON 2/22/11, OR TO STAFF ON "UNIT ONE" WHO WERE ASSIGNED THE RESPONSIBILITY OF MONITORING THE FRONT DOOR ON 2/20/11 AT 9:53 A.M. AS A RESULT OF THE DOOR ALARM NOT BEING AUDIBLE, THERE WAS A DELAY IN THE FACILITY'S AWARENESS AND RESPONSE TIME THAT RESIDENT #1 HAD ELOPED. IN ADDITION TO THE DELAY OF THE FACILITY'S RESPONSE TO THE FRONT DOOR ALARM, THE FACILITY FAILED TO FOLLOW THEIR DISASTER PLAN - "CODE GREEN" - MISSING RESIDENT/ELOPEMENT. BY FAILING TO FOLLOW THEIR "CODE GREEN" POLICY, RESIDENT #1 REMAINED OUTSIDE, UNDETECTED, FOR ANOTHER 20 MINUTES, UNTIL RESIDENT #1'S EMPTY WHEELCHAIR WAS SEEN BY ANOTHER STAFF IN THE SIDE PARKING LOT. TWO CERTIFIED NURSE AIDES (CNAS) ("I" AND "E") DID NOT FOLLOW THE "CODE GREEN" PROCEDURES BY FAILING TO SEARCH FOR RESIDENT #1, EVEN THOUGH THEY KNEW HE WAS NOT IN HIS ROOM. THEN, CNAS "E" AND "I" ALLOWED THE FIRST "CODE GREEN" (MISSING PERSON'S ALARM) TO BE CANCELLED, WITHOUT REPORTING TO THE NURSE OR CONFIRMING RESIDENT #1 WAS IN THE BUILDING. BY THE TIME THE SECOND "CODE GREEN" WAS CALLED AND STAFF LOCATED RESIDENT #1, RESIDENT #1 HAD BEEN OUTSIDE FOR 27 MINUTES. DURING THE TIME RESIDENT #1 WAS OUTSIDE, HE HAD AN UNWITNESSED ACCIDENT, WHICH RESULTED IN PAIN IN ONE HAND AND A BROKEN BONE IN ONE FOOT. A HISTORICAL WEATHER SEARCH WAS DONE ON 2/22/11, VIA THE INTERNET AT WWW.WUNDERGROUND.COM. THE SEARCH REVEALED ON 2/20/11 AT 9:53 A.M., WHEN RESIDENT #1 WAS OUTSIDE, THE RECORDED TEMPERATURE WAS 26.6? (DEGREES) FAHRENHEIT AT THE WEATHER STATION CLOSEST TO THE FACILITY, FIVE MILES AWAY, ON MACKINAC ISLAND. IN AN INTERVIEW WITH THE DON ON 2/22/11 AT 1:00 P.M., THE DON SUMMARIZED HER INVESTIGATION OF RESIDENT #1'S ELOPEMENT ON 2/20/11. SHE EXPLAINED SHE HAD DISCOVERED THERE WERE TWO PARTS TO RESIDENT #1'S ELOPEMENT. ? PART ONE: THE DON STATED DUE TO THE ELECTRONIC MONITORING SYSTEM, THEY HAD COMPUTER PRINTOUTS THAT CONFIRMED RESIDENT #1 WAS BY THE FRONT DOOR AT 9:53 A.M. ON 2/20/11. THE FRONT DOOR ALARM WAS ACTIVATED AT THAT TIME. HOWEVER, THE ALARM WAS NOT TURNED OFF FOR 7 MINUTES, BY WHICH TIME, RESIDENT #1 WHO HAD GONE OUTSIDE, WAS NO LONGER VISIBLE TO STAFF FROM THE FRONT DOOR. A VIDEO CAMERA AIMED AT THE FRONT PARKING LOT, RECORDED RESIDENT #1 IN HIS WHEELCHAIR NEAR THE END OF THE MAIN SIDEWALK. ? ? DURING THE INTERVIEW WITH THE DON ON 2/22/11 AT 1:00 P.M., A WRITTEN STATEMENT BY DIETARY AIDE "K", DATED 2/21/11, WAS PROVIDED. THIS STATEMENT REFLECTS DIETARY AIDE "K" CAME INTO THE MAIN FRONT HALL FROM THE KITCHEN AROUND 10:00 A.M. ON 2/20/11 AND HEARD THE MAIN DOOR ALARM SOUNDING. SHE INFORMED THE "UNIT ONE" NURSE AND TOGETHER THEY WENT TO THE FRONT DOOR AND TURNED OFF THE ALARM. SINCE THEY SAW NO RESIDENT IN THE VICINITY, THE NURSE THEN ANNOUNCED "CODE GREEN" OVER THE LOUDSPEAKER. ACCORDING TO FACILITY POLICY, THE DON STATED, WHEN "CODE GREEN" IS ANNOUNCED, STAFF ARE TO CHECK ALL RESIDENT ROOMS AND ADJACENT AREAS UNTIL THEY HAVE LOCATED ALL THE RESIDENTS ASSIGNED TO THEIR CARE. ON 2/20/11, THE DON REPORTED A MISTAKE WAS MADE WHEN THE "ALL CLEAR" SIGNAL WAS GIVEN, INDICATING ALL RESIDENTS HAD BEEN LOCATED, WHEN IN FACT, RESIDENT #1 WAS NOT ACCOUNTED FOR. THIS LED TO PART TWO. ? ? PART TWO: RESIDENT #1 REMAINED OUTSIDE ANOTHER 15 MINUTES, UNTIL A CNA IN THE SOILED UTILITY ROOM, LOOKING OUT A WINDOW, SPIED AN EMPTY WHEELCHAIR IN THE SIDE PARKING LOT. THE WHEELCHAIR WAS IDENTIFIED AS BELONGING TO RESIDENT #1. AT 10:15 A.M., A SECOND "CODE GREEN" WAS ANNOUNCED, THIS TIME IDENTIFYING THE RESIDENT'S ROOM NUMBER. THREE STAFF WENT OUTSIDE TO SEARCH FOR RESIDENT #1, WHO WAS FOUND IN THE SIDE PARKING LOT, 4 CARS DOWN FROM WHERE HIS WHEELCHAIR WAS SPOTTED. RESIDENT #1 WAS RETURNED TO THE FACILITY AT 10:20 A.M. ON 2/20/11. AT 12:50 P.M. ON 2/23/11, AN INTERVIEW WAS CONDUCTED WITH NURSE "G" WHO FOUND RESIDENT #1 IN THE PARKING LOT, AND WHO CONDUCTED THE PHYSICAL CHECK AFTERWARDS. NURSE "G" REPORTED RESIDENT #1 WAS WEARING SWEATPANTS, A LONG-SLEEVE SHIRT, AND "GRIPPY" SOCKS WHEN HE LEFT THE BUILDING. HE HAD NO SHOES OR COAT ON. NURSE "G" STATED SHE FOUND RESIDENT #1 STANDING BESIDE A TRUCK IN THE PARKING LOT, WITH THE DOOR OPEN. RESIDENT #1 STATED TO HER, "I'M GOING FOR A RIDE." NURSE "G" REPORTED RESIDENT #1 WAS PLEASANT AND AGREED TO LET HER PUSH HIM IN HIS WHEELCHAIR BACK INTO THE FACILITY. NURSE "G" REPORTED ONE KNEE OF RESIDENT #1'S SWEATPANTS WAS DIRTY AND WET, SO SHE INSPECTED THE KNEE, BUT FOUND NO ABRASION ON THE KNEE. NURSE "G" STATED SHE ASKED RESIDENT #1 IF HE HAD FALLEN AND HE RESPONDED "NO." SHE REPORTED RESIDENT #1'S FEET WERE NOT COLD AND HIS BODY TEMPERATURE WAS NORMAL. SHE COULD FIND NO INJURIES. DURING AN INTERVIEW WITH THE DON CONDUCTED ON 2/23/11 AT 11:30 A.M., THE DON REPORTED, "(RESIDENT #1) HAS A BROKEN FOOT. HE MUST HAVE FALLEN WHEN OUTSIDE (ON 2/20/11)." SHE EXPLAINED ON 2/21/11, A BRUISE WAS NOTED ON TOP OF HIS FOOT AND RESIDENT #1 COMPLAINED OF PAIN IN HIS HAND. A NURSES NOTE, FOUND IN RESIDENT #1'S MEDICAL RECORD, DATED 2/21/11 AT 12:20 P.M. READS, "...SWELLING NOTED IN (R) RIGHT HAND AND (R) FOOT. X-RAYS ORDERED FOR BOTH...". THE X-RAY REPORTS, DATED 2/22/11 AND ALSO FOUND IN THE MEDICAL RECORD, SHOW X-RAYS OF RESIDENT #1'S RIGHT HAND AND RIGHT FOOT WERE TAKEN ON 2/22/11 AT 2:38 P.M., DUE TO "PAIN AND SWELLING". THE X-RAY REPORT RESULTS READ, "THREE VIEWS OF THE RIGHT FOOT WERE OBTAINED AND REVEAL EVIDENCE OF TRANSVERSE FRACTURE OF THE 3RD METACARPAL...THIS APPEARS TO BE A MORE ACUTE INJURY...". ALTHOUGH NO ONE WITNESSED ANY ACCIDENT, THE DON STATED THE FACILITY HAD CONCLUDED THE INJURY OCCURRED WHILE RESIDENT #1 WAS OUTSIDE ON 2/20/11. THE DON STATED NO STAFF WITNESSED ANY FALL OR ACCIDENT BY RESIDENT #1 IN THE 24-HOURS AFTER HE RETURNED TO THE FACILITY, AND BEFORE THE BRUISE APPEARED. AT 2:00 P.M. ON 2/22/11, AN AUDITORY TEST ON THE FRONT DOOR ALARMS WAS CONDUCTED BY THIS SURVEYOR. STAFF WAS INSTRUCTED TO SET OFF THE FRONT DOOR ALARMS AND LEAVE THEM ON. STANDING IN THE DINING ROOM, ADJACENT TO THE FRONT LOBBY AND THUS CLOSE TO THE ALARMS, THE ALARMS COULD BE HEARD, BUT THE SOUND WAS SOFT TO FAINT. STANDING AT THE "UNIT ONE" NURSE'S STATION, IT WAS EXTREMELY DIFFICULT TO HEAR THE ALARMS, EVEN WHEN TRYING TO HEAR THEM, AND EVEN THOUGH THE AREA WAS QUIET. THIS SURVEYOR COULD NOT DISTINGUISH BETWEEN THE TWO ALARMS, ALTHOUGH STAFF REPORTED THEY WERE BOTH ON, AND ONE WAS SLIGHTLY HIGHER PITCHED THAN THE OTHER. THE ALARMS WERE NOT LOUD ENOUGH TO COMMAND ONE'S ATTENTION. AT 3:25 P.M. ON 2/23/11, CERTIFIED NURSE AIDE (CNA) "A" WAS INTERVIEWED. CNA "A" STATED IT WAS VERY DIFFICULT TO HEAR THE DOOR ALARMS WHEN IN RESIDENT ROOMS, ESPECIALLY IF THE DOOR TO THE HALL OR THE BATHROOM DOOR WAS CLOSED FOR PRIVACY WHILE GIVING CARES. CNA "D" WAS INTERVIEWED ON 2/23/11 AT 3:05 P.M. SHE STATED SHE COULD HEAR THE DOOR ALARMS AT TIMES, BUT admitted SHE HAD BECOME "IMMUNE AND USED TO IT." SHE STATED AT THE TIME OF RESIDENT #1'S ELOPEMENT ON 2/20/11, SHE WAS IN A ROOM PROVIDING CARES AND DID NOT HEAR THE ALARM. NURSE "B" WAS INTERVIEWED AT 2:45 P.M. ON 2/23/11. NURSE "B" REPORTED THE FRONT DOOR ALARMS SOUND VERY SIMILAR TO THE BED ALARMS AND CHAIR ALARMS. SHE STATED ALARMS FREQUENTLY GO OFF AND IT IS DIFFICULT TO DISTINGUISH BETWEEN THE DIFFERENT ALARMS. SHE STATED SHE COULD HEAR THE FRONT DOOR ALARMS ONLY WHEN SHE WAS IN THE DINING ROOM. NURSE "G" IN HER INTERVIEW AT 12:50 P.M. ON 2/23/11, ALSO REPORTED SHE COULD NOT HEAR THE ALARMS WHEN IN A RESIDENT'S ROOM AND STATED SHE COULD BARELY HEAR THEM WHEN IN THE HALL. NURSE "G" ADDED "UNIT ONE" WAS A VERY BUSY UNIT WITH A LOT OF COMMOTION WHICH MADE IT DIFFICULT TO HEAR THE ALARMS. IN DISCUSSION WITH THE DON ON 2/23/11 AT 5:45 P.M., THE DON ACKNOWLEDGED THE FACILITY HAD NOT CONDUCTED "ELOPEMENT DRILLS" TO PRACTICE THEIR "CODE GREEN" PROCEDURES. THE DON ALSO ACKNOWLEDGED THE STAFF NEEDED FURTHER TRAINING IN ELOPEMENT PROCEDURES, TO ENSURE ALL STAFF RECOGNIZED THE HIGH PRIORITY OF A "CODE GREEN" AND THE NECESSITY TO LOCATE ALL RESIDENTS AS STATED IN THE POLICY AND PROCEDURES. ( ) --

BASED ON INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO EFFECTIVELY TRAIN ALL EMPLOYEES IN EMERGENCY DISASTER PROCEDURES THAT ADDRESSED MISSING RESIDENTS AND DOOR ALARMS, RESULTING IN ONE (#1) OF FOUR HIGH RISK RESIDENTS ELOPING FROM THE FACILITY, WITHOUT STAFF KNOWLEDGE, IN COLD WEATHER, FOR 27 MINUTES, DURING WHICH TIME, AN UNWITNESSED ACCIDENT OCCURRED, WITH RESIDENT #1 SUSTAINING A BROKEN FOOT BONE. FINDINGS INCLUDE: A FACILITY REPORTED INCIDENT (FRI) DATED 2/21/11 READS, "FACILITY REPORTS ON 2/20/11 AT 10:20 A.M., EMPTY WHEELCHAIR NOTED IN PARKING LOT IDENTIFIED AS (RESIDENT #1). SEARCH CODE INITIATED. RESIDENT FOUND SITTING IN A VEHICLE IN PARKING LOT. DON (DIRECTOR OF NURSING) NOTIFIED... RESIDENT WEARS A WANDER GUARD WATCH WHICH WAS FUNCTIONAL AT TIME OF INCIDENT...". AN IDENTIFIED IMMEDIATE JEOPARDY BEGAN ON 2/20/11, DUE TO FAILURE OF THE FACILITY TO PROVIDE APPROPRIATE SUPERVISION TO PREVENT AN ELOPEMENT OF ONE (#1) RESIDENT KNOWN TO BE AT RISK FOR ELOPEMENT. DURING AN INTERVIEW WITH THE DON CONDUCTED ON 2/23/11 AT 11:30 A.M., THE DON REPORTED, "(RESIDENT #1) HAS A BROKEN FOOT. HE MUST HAVE FALLEN WHEN OUTSIDE (ON 2/20/11)." SHE EXPLAINED ON 2/21/11, A BRUISE WAS NOTED ON TOP OF HIS FOOT AND RESIDENT #1 COMPLAINED OF PAIN IN HIS HAND. A NURSES NOTE FOUND IN RESIDENT #1'S MEDICAL RECORD, DATED 2/21/11 AT 12:20 P.M. READS, "...SWELLING NOTED IN (R) RIGHT HAND AND (R) FOOT. X-RAYS ORDERED FOR BOTH...". THE X-RAY REPORTS DATED 2/22/11, AND ALSO FOUND IN THE MEDICAL RECORD, SHOW X-RAYS OF RESIDENT #1'S RIGHT HAND AND RIGHT FOOT WERE TAKEN ON 2/22/11 AT 2:38 P.M., DUE TO "PAIN AND SWELLING". THE X-RAY REPORT RESULTS READ, "THREE VIEWS OF THE RIGHT FOOT WERE OBTAINED AND REVEAL EVIDENCE OF [MEDICATION NAME] METACARPAL... THIS APPEARS TO BE A MORE ACUTE INJURY...". ALTHOUGH NO ONE WITNESSED ANY ACCIDENT, THE DON STATED THE FACILITY HAD CONCLUDED THE INJURY OCCURRED WHILE RESIDENT #1 WAS OUTSIDE ON 2/20/11. THE DON STATED NO STAFF WITNESSED ANY FALL OR ACCIDENT BY RESIDENT #1 IN THE 24-HOURS AFTER HE RETURNED TO THE FACILITY, AND BEFORE THE BRUISE APPEARED. THE FACILITY'S INVESTIGATION OF THIS INCIDENT REVEALED TWO CERTIFIED NURSE AIDES (CNAS) ("I" AND "E") HAD NOT FOLLOWED THE FACILITY'S "CODE GREEN" PROCEDURE FOR LOCATING A MISSING RESIDENT. THE FAILURE OF THESE TWO CNAS TO FOLLOW THE "CODE GREEN" PROCEDURES LED TO RESIDENT #1 REMAINING OUTSIDE, IN COLD WEATHER, WITHOUT SHOES AND A COAT, FOR 20 MINUTES AFTER FACILITY STAFF TURNED OFF THE ALARMING EXIT DOOR. ON 2/23/11, INTERVIEWS WERE CONDUCTED WITH NURSE "G" AT 12:50 P.M., NURSE "B" AT 2:45 P.M., CNA "D" AT 3:05 P.M. AND CNA "A" AT 3:25 P.M. CNA "I" WAS INTERVIEWED BY PHONE ON 2/24/11AT 10:20 A.M. STAFF "G", "B", "D", "A" AND "I" REPORTED THEY HAD RECEIVED ANNUAL TRAINING IN DISASTER PREPAREDNESS, INCLUDING WHAT TO DO IF A RESIDENT WAS IDENTIFIED AS "MISSING" (THE FACILITY'S "CODE GREEN" PROCEDURE). STAFF "G", "B", "D", "A" AND "I" REPORTED THIS TRAINING WAS PRIMARILY PROVIDED VIA A COMPUTERIZED EDUCATIONAL SESSION. STAFF "G", "B", "D", "A" AND "I" STATED THEY COULD NOT REMEMBER PARTICIPATING IN AN ACTUAL PRACTICE OR "TRAINING DRILL" FOR THE "CODE GREEN" PROCEDURE.. ON 2/23/11 AT 5:30 P.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED. THE DON STATED IT WAS MANDATORY FOR ALL STAFF TO HAVE DISASTER TRAINING ON AN ANNUAL BASIS. UPON QUESTIONING, THE DON REPORTED THIS TRAINING WAS DONE IN THE CLASSROOM AND WAS COMPUTER-BASED. SHE STATED THE FACILITY HAD NOT CONDUCTED A "CODE GREEN - MISSING PERSON" DRILL, BUT STATED SHE ALREADY HAD PLANS TO DO SO. IN DISCUSSION WITH THE DON, SHE AGREED THE TRAINING WITH STAFF NEEDED TO EMPHASIZE THE IMPORTANCE OF RESPONDING TO CRISIS SITUATIONS (IN THIS CASE, LOOKING FOR A MISSING RESIDENT) ABOVE ALL OTHER ACTIVITIES. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO DEVELOP, IMPLEMENT AND EVALUATE AN APPROPRIATE PLAN OF ACTION TO CORRECT IDENTIFIED QUALITY OF CARE DEFICIENCIES RESULTING IN A REPEATED FAILURE TO EFFECTIVELY SUPERVISE ONE (#1) OF FOUR RESIDENTS KNOWN TO BE AT RISK FOR ELOPEMENT, RESULTING IN RESIDENT #1 LEAVING THE FACILITY FOR 27 MINUTES, IN COLD WEATHER, WITHOUT APPROPRIATE SUPERVISION AND SUSTAINING AN INJURY (BROKEN FOOT BONE) OF UNKNOWN ORIGIN. FINDINGS INCLUDE: A FACILITY REPORTED INCIDENT (FRI) DATED 2/21/11 READS, "FACILITY REPORTS ON 2/20/11 AT 10:20 A.M., EMPTY WHEELCHAIR NOTED IN PARKING LOT IDENTIFIED AS (RESIDENT #1). SEARCH CODE INITIATED. RESIDENT FOUND SITTING IN A VEHICLE IN PARKING LOT. DON (DIRECTOR OF NURSING) NOTIFIED. ASSESSMENT COMPLETED - VITAL SIGN NORMAL, SKIN WARM TO TOUCH... RESIDENT WEARS A WANDER GUARD WATCH WHICH WAS FUNCTIONAL AT TIME OF INCIDENT...". AN IDENTIFIED IMMEDIATE JEOPARDY BEGAN ON 2/20/11 DUE TO FAILURE OF THE FACILITY TO PROVIDE APPROPRIATE SUPERVISION TO PREVENT AN ELOPEMENT OF ONE (#1) RESIDENT KNOWN TO BE AT RISK FOR ELOPEMENT. DURING AN INTERVIEW WITH THE DON CONDUCTED ON 2/23/11 AT 11:30 A.M., THE DON REPORTED, "(RESIDENT #1) HAS A BROKEN FOOT. HE MUST HAVE FALLEN WHEN OUTSIDE (ON 2/20/11)." SHE EXPLAINED, ON 2/21/11, A BRUISE WAS NOTED ON TOP OF HIS FOOT AND RESIDENT #1 COMPLAINED OF PAIN IN HIS HAND. A NURSES NOTE, FOUND IN RESIDENT #1'S MEDICAL RECORD, DATED 2/21/11 AT 12:20 P.M. READS, "...SWELLING NOTED IN (R) RIGHT HAND AND (R) FOOT. X-RAYS ORDERED FOR BOTH...". THE X-RAY REPORTS DATED 2/22/11, AND ALSO FOUND IN THE MEDICAL RECORD, SHOW X-RAYS OF RESIDENT #1'S RIGHT HAND AND RIGHT FOOT WERE TAKEN ON 2/22/11 AT 2:38 P.M., DUE TO "PAIN AND SWELLING". THE X-RAY REPORT RESULTS READ, "THREE VIEWS OF THE RIGHT FOOT WERE OBTAINED AND REVEAL EVIDENCE OF [MEDICATION NAME] METACARPAL... THIS APPEARS TO BE A MORE ACUTE INJURY...". ALTHOUGH NO ONE WITNESSED ANY ACCIDENT, THE DON STATED THE FACILITY HAD CONCLUDED THE INJURY OCCURRED WHILE RESIDENT #1 WAS OUTSIDE ON 2/20/11. THE DON STATED NO STAFF WITNESSED ANY FALL OR ACCIDENT BY RESIDENT #1 IN THE 24-HOURS AFTER HE RETURNED TO THE FACILITY, AND BEFORE THE BRUISE APPEARED. ON 2/23/11, INTERVIEWS WERE CONDUCTED WITH NURSE "G" AT 12:50 P.M., NURSE "B" AT 2:45 P.M., CNA (CERTIFIED NURSE AIDE) "D" AT 3:05 P.M. AND CNA "A" AT 3:25 P.M. ALL OF THESE STAFF REPORTED DURING INTERVIEW, THEY HAD DIFFICULTY HEARING THE "BACK-UP ALARM" WHEN WORKING IN RESIDENT ROOMS. IN ADDITION, ALL STATED THEY HAD NOT REPORTED THEY WERE UNABLE TO HEAR THE FRONT DOOR ALARMS WHEN THEY WERE IN RESIDENT ROOMS PROVIDING CARES. DURING THE ABOVE-MENTIONED INTERVIEWS WITH STAFF "A", "B", "D" AND "G" ON 2/23/11, THEY WERE ASKED IF ANYONE FROM THE FACILITY'S QUALITY ASSESSMENT/ASSURANCE (QAA) COMMITTEE OR MANAGEMENT TEAM HAD ASKED HOW THE NEW "BACK-UP ALARM SYSTEM" WAS WORKING. EACH STAFF MEMBER STATED THEY WERE NOT ASKED. ON 2/23/11 AT 5:30 P.M., AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSING (DON). THE DON VERIFIED SHE IS A MEMBER OF THE FACILITY'S QAA COMMITTEE. THE DON WAS THEN ASKED IF THE EFFECTIVENESS OF THE "BACK-UP ALARM SYSTEM", WHICH THE FACILITY INSTALLED AFTER THE ABBREVIATED SURVEY DONE IN JULY 2010, WAS EVALUATED BY THE QAA COMMITTEE. THE DON REPLIED, "NO, WE REALLY DIDN'T." THE INTERVIEW WITH THE DON ALSO REVEALED NO STAFF INPUT REGARDING THE EFFECTIVENESS OF THE "BACK-UP" ALARM SYSTEM HAD BEEN SOLICITED. IN ADDITION TO THE IMMEDIATE JEOPARDY IDENTIFIED ON 2/22/11 INVOLVING RESIDENT #1, FEDERAL TAG 323 (FAILURE OF FACILITY TO PROVIDE SERVICES TO PREVENT ACCIDENTS INVOLVING A MALFUNCTIONING DOOR ALARM SYSTEM), RESULTED IN HARM ON 6/10/10 AND WAS CITED DURING AN ABBREVIATED SURVEY ON 7/27/10. THE IMMEDIATE JEOPARDY OF 2/20/11 IS THE SECOND TIME IN 12 MONTHS, THAT THE FACILITY'S QUALITY ASSESSMENT/ ASSURANCE COMMITTEE HAS FAILED TO EFFECTIVELY IDENTIFY THE ROOT CAUSES REQUIRED FOR THE DEVELOPMENT AND IMPLEMENTATION OF ACTION PLANS FOR AREAS NEEDING IMPROVEMENT. FEDERAL TAG 520 (FAILURE TO MONITOR EFFECTIVENESS OF ACTION PLANS IDENTIFIED FOR INFECTION CONTROL QUALITY INDICATORS) WAS CITED DURING THE ANNUAL SURVEY ON 3/10/10. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT DEVELOPMENT OF AN AVOIDABLE PRESSURE ULCER COVERED WITH NECROTIC, BLACK, DEAD TISSUE, IN 1 RESIDENT (#4), AND FAILED TO PROVIDE NECESSARY CARE & TREATMENT TO PROMOTE HEALING FOR 1 RESIDENT (#2) WITH A PRESSURE ULCER, FROM A SAMPLE OF 6 RESIDENTS WITH PRESSURE ULCERS IN A TOTAL SAMPLE OF 11 RESIDENTS. FINDINGS INCLUDE: DURING THE SURVEY PERIOD OF 1/10/11 THROUGH 1/13/11, THE CLINICAL RECORD OF RESIDENT #4 WAS REVIEWED. THE FACE SHEET REVEALED RESIDENT #4 IS A [AGE] year-old FEMALE WHO WAS RE-admitted to the facility on [DATE] WITH A [MEDICAL CONDITION] TIBIA AND FIBULA, DEBILITY, [MEDICAL CONDITIONS] AND [MEDICAL CONDITION]. THE MINIMUM DATA SET (MDS) assessment dated [DATE] REVEALED THE RESIDENT WAS ALERT AND ORIENTED AND WAS ABLE TO UNDERSTAND AND TO BE UNDERSTOOD. THE PHYSICAL ASSESSMENT FOR RESIDENT #4 DATED 11/19/10 REVEALED RESIDENT #4 HAD NO SKIN BREAKDOWN ON HER FEET AT THE TIME OF HER RE-ADMISSION. A PHYSICIAN'S PROGRESS NOTE DATED 12/07/10 READS, "EXAM OF THE LEFT (LT) HEEL REVEALS AN AREA OF SUBCUTANEOUS PURPURA OVERLYING THE POSTERIOR ASPECT OF THE LT HEEL... I FEEL THAT THE PURPURA OVER THE LT HEEL IS PROBABLY RELATED TO PRESSURE OR BANGING THE HEEL AND THE ANTI-COAG EFFECT OF THE ASPIRIN. I HAVE DISCONTINUED THE ASPIRIN." "NURSING NOTES" ON 12/7/10 READ, "WOUND TO LEFT HEEL INTACT - DISCOLORED AREA - ELEVATE (HEEL) WHILE IN BED... DECREASE PRESSURE". THE "MONTHLY RESIDENT SUMMARY" SHEET DATED 12/20/10, REVEALED RESIDENT #4 HAD A BLISTER TO THE LEFT HEEL AND UNDER "TREATMENT" WAS WRITTEN "FLOAT HEELS". THE RESIDENT'S "ADL (ACTIVITY OF DAILY LIVING)/RESTORATIVE" SHEET DATED 12/2010 REVEALED THE RESIDENT'S HEELS WERE TO BE ELEVATED. THERE WAS NO DOCUMENTATION TO SHOW THE RESIDENT'S HEELS WERE ELEVATED PRIOR TO 12/25/10, 18 DAYS AFTER THE PRESSURE ULCER WAS IDENTIFIED. IN ADDITION, THE "RESIDENT ADL/RESTORATIVE" SHEET DOCUMENTING THE INTERVENTION SHOWS BLANKS, INDICATING THE HEELS WERE NOT ELEVATED, ON 12/25/10, 12/26/10 AND 12/28/10 ON THE MIDNIGHT SHIFT. A REVIEW OF THE RESIDENT'S PLAN OF CARE FOR, "POTENTIAL FOR SKIN BREAKDOWN", INITIATED ON 11/05/10, SHOWED A GENERIC APPROACH, "#7 PRESSURE RELIEVING DEVICES AS NEEDED TO PREVENT SKIN BREAKDOWN - IE: ROHO CUSHION, AIR MATTRESS, HEEL LIFT, ETC." NO EVIDENCE WAS PROVIDED TO SHOW ANY SPECIFIC MEASURES HAD BEEN IMPLEMENTED TO PROTECT THE HEELS OF RESIDENT #4 FROM SKIN BREAKDOWN. AN OBSERVATION OF THE RESIDENT'S PRESSURE ULCER TOOK PLACE ON 1/11/11 AT 9:55 A.M., WITH LICENSED PRACTICAL NURSE (LPN) "A". THE LPN STATED, "I'M ASSUMING THAT THE PRESSURE ULCER DEVELOPED WHEN SHE WAS IN BED WITH HER FRACTURES... AND WAS NOT MOVING." OBSERVATION AT THAT TIME SHOWED THE ULCER WAS LOCATED ON THE LEFT SIDE OF THE HEEL. IT WAS BLACK, NECROTIC TISSUE APPROXIMATELY THE SIZE OF A HALF DOLLAR. THERE WAS NO DRAINAGE OR ODOR PRESENT. RESIDENT #4 STATED SHE WAS EXPERIENCING PAIN AT, "A '10' WHEN (THE PRESSURE ULCER WAS) TOUCHED". DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 1/11/11 AT 2:10 P.M., THE DON STATED, "SHE (RESIDENT #4) WAS AT HIGH RISK FOR SKIN BREAKDOWN RELATED TO HER IMMOBILITY AND HER SEVERE [MEDICAL CONDITION] WE SHOULD HAVE DONE SOME KIND OF INTERVENTIONS TO PREVENT A PRESSURE ULCER FROM OCCURRING." DURING ANOTHER INTERVIEW WITH THE DON ON 1/12/11 AT 9:05 A.M., THE DON STATED, "I HAVE TO BE HONEST... I CAN'T FIND ANYTHING TO SUPPORT INTERVENTIONS THAT WE HAD DONE TO PREVENT THE PRESSURE ULCER TO THE HEEL." DURING AN INTERVIEW WITH RESIDENT #4 ON 1/11/11 AT 12:15 P.M., SHE STATED, "THE HEEL CUSHION (CURRENTLY ON HER BED) WAS PUT IN... JUST A LITTLE WHILE AGO... AFTER MY SORE DEVELOPED... THEY HAVEN'T SAID ANYTHING EXCEPT THAT WHEN I'M IN BED TO PUT MY LEG ACROSS THE PILLOW CUSHION THEY JUST PUT ON THE BED. BUT NO, THEY SAID NOTHING BEFORE THAT ABOUT MY FEET AND LEGS." DURING THE SURVEY PROCESS OF 1/10/11 THROUGH 1/13/11, THE CLINICAL RECORD OF RESIDENT #2 WAS REVIEWED. THE RECORD REVEALED RESIDENT #2 IS AN [AGE] year-old FEMALE WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) assessment dated [DATE] INDICATED RESIDENT #2 NEEDED EXTENSIVE ASSIST WITH AMBULATION AND TRANSFERS, AND HER PRIMARY MEANS OF MOBILITY WAS A WHEELCHAIR. A CURRENT PHYSICIAN ORDER [REDACTED]." ON 1/10/11, A REVIEW OF THE "TREATMENT SHEET" FOR RESIDENT #2 SHOWED THE TREATMENT WAS DONE ON 1/5/11 IN THE MORNING, TWICE A DAY ON 1/6/11 AND 1/7/11, AND ONLY IN THE MORNING ON 1/8/11. NO FURTHER DOCUMENTATION OF treatment for [REDACTED]. DURING AN OBSERVATION OF RESIDENT #2 ON 1/10/11 AT 4:30 P.M., RESIDENT #2 WAS UP IN A WHEELCHAIR AT THE NURSING STATION AND THERE WAS NO DRESSING ON HER LEFT HEEL. ON 1/11/11 AT 8:30 A.M., RESIDENT #2 WAS LYING IN BED. HER FEET WERE ELEVATED ON A CUSHION AND HER HEELS WERE "FREE FLOATING". THERE WAS NO DRESSING ON HER LEFT HEEL. DURING AN OBSERVATION OF THE LEFT FOOT WITH LPN "A" ON 1/11/11 AT 10:05 A.M., THE HEEL OF RESIDENT #2 HAD NO DRESSING IN PLACE. THE HEEL HAD A QUARTER SIZE AREA OF NECROTIC TISSUE. IT APPEARED AS BLACK, DRY TISSUE. NO DRAINAGE OR ODOR WAS PRESENT. UPON IMMEDIATELY LEAVING THE ROOM, LPN "A" WAS ASKED WHY THERE WAS NO DRESSING ON THE HEEL AS ORDERED. THE NURSE REVIEWED THE MOST CURRENT PHYSICIan order for [REDACTED]." ( ) --