Every finding on record at Marquette County Medical Care Facility

Based on interview and record review, the facility failed to ensure the Long-Term Care (LTC) Ombudsman was notified of a resident's discharge from the facility for one Resident (#137) of one resident reviewed for discharge practices. This deficient practice has the potential to limit oversight and advocacy services intended to protect residents' rights during the transfer and discharge process.Findings include:Resident #137 (R137)Review of R137's Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance) and syncope (fainting).Review of a facility census report revealed R137 was discharged from the facility on 6/9/26.Review of the documentation provided to the (LTC) Ombudsman in June 2026 revealed they were not notified of the resident's discharge from the facility.On 8/12/26 at 10:35 AM, an interview was conducted with Admissions Coordinator/Registered Nurse (RN) A who verified she was responsible for Ombudsman notifications. RN A stated she had been trained to only notify the Ombudsman of emergent transfers from the facility, either to an acute care hospital or a mental health facility. RN A confirmed the Ombudsman was not notified of R137's discharge on [DATE].Review of the facility policy titled, Transfer and Discharge (including AMA [against medical advice]), dated 01/23, read, in part: .Generally, the notice must be provided at least 30 days prior to a facility-initiated transfer or discharge of the resident. Exceptions to the 30-day requirement apply when . b. The resident's health improves sufficiently to allow a more immediate transfer or discharge. or d. A resident has not resided in the facility for 30 days. In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC ombudsman as soon as practicable before the transfer or discharge.

Based on observation, interview, and record review, the facility failed to develop a care plan and offer/recommend diagnostic testing or consultation with a Gastroenterologist or Physician Specialist to determine the source of prolonged nausea and vomiting for one Resident (R16) of one Resident reviewed for change of condition. This deficient practice resulted in R16 sustaining a 27.3% weight loss in 6 months, a decline in activities of daily living (ADL), a significant change of condition, and the development of multiple pressure injuries. Findings include: Resident #16 (R16) R16 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) Assessment, dated 9/26/23, coded R16 as requiring staff assistance for activities of daily living (ADL), including partial staff assistance with ambulating, toileting, standing, and transfers. The MDS documented a Brief Interview for Mental Status (BIMS) Score of 15, indicating R16 was cognitively intact. The quarterly MDS did not code R16 with weight loss. A Significant Change MDS, dated [DATE], coded R16 as being fully dependent on staff for all ADL except eating. The MDS coded R16 as being dependent on staff for ambulating, toileting, standing, and transfers. The MDS documented a BIMS score of 13, indicated R16 remained cognitively intact. The Significant Change MDS coded R16 with weight loss. On 6/4/24 at 8:27 a.m., R16 was observed lying in bed holding an emesis basin with an untouched plate of breakfast on her bedside table. R16 said she was nauseated and was unable to move because of nausea and vomiting. R16 said she had experienced nausea and vomiting for so long that she lost weight due to inability to eat. A review of the medical record for R16 revealed a weight loss of 69.9 pounds from 12/6/23 until 6/2/24, a 27.3% loss of body weight. The care plan for R16 did not indicate the weight loss as desirable by R16. The nutritional care plan documented R16 was diagnosed with protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function) starting 3/1/24 due to prolonged low appetite/intakes/weight loss. Progress notes for R16 revealed numerous documentation entries of nausea and vomiting. R16 was documented as experiencing intermittent nausea in August, September, and October 2023. From 11/17/23 through 11/27/23, there were 13 progress note entries detailing R16 experiencing nausea and vomiting with limited ability to eat. The medical record documented a 16.6-pound weight loss from 11/15/23 through 11/30/23, a 9.4% loss of body weight. In December 2023, R16 was transferred and subsequently admitted to the hospital with venous stasis ulcers (wounds that result from blood flow problems in the veins) and cellulitis (a skin infection that can spread rapidly and cause serious complications). R16 returned to the facility from the hospital on 12/24/24. There were seven progress notes in January 2024 regarding R16 enduring nausea and vomiting. A progress note by the Registered Dietician (RD) on 1/12/24 described R16's intake as very poor. The note documented R16 was declining most meals and reporting lack of appetite despite the use of an appetite stimulant. The progress note documented, Noted MD is aware of continued poor appetite despite initiation of (a medication used to stimulate appetite) . Nausea and/or vomiting were documented fifteen times for R16 in February 2024, ten times in March 2024, nine times in April 2024, and twenty-eight times in May 2024. A progress note on 5/6/24 documented, in part: .very shaky, increased RR (respiratory rate) and heavy breathing .promethazine given at 10:00 a.m. which provided little to no relief. Stating 'I'm sick of being nauseous, I'm dry heaving, I'm so tired. Why can't I have something else for this nausea?' . Physician visit documentation for September 2023, October 2023, November 2023, December 2023, and January 2024 did not contain documentation of R16 experiencing nausea and vomiting. A physician visit note dated 2/7/24 read, in part: .she has occasional nausea .Reviewing the notes over the last month she has had really a fair amount of GI (gastrointestinal) upset .She is having a lot of nausea, is vomiting, unclear why .The weight loss at this rate is not good and she is getting a lot of (a medication used to treat nausea and vomiting) and having a lot of problems so we will get the labs and then decide . The documentation did not include any discussion with R16 regarding diagnostic testing or consultation with a physician specializing in disorders of the gastrointestinal (GI) system. A physician visit note dated 3/6/24 read, in part: .she has been having ongoing nausea . The documentation did not include a plan to address the nausea by offering to conduct diagnostic testing or referring R16 to a physician specializing in disorders of the GI system. On 4/5/24 the physician documented R16 had an episode of nausea, vomiting and diarrhea but that resolved . The documentation did not include a plan to address the nausea or offering R16 the opportunity for diagnostic testing or referral to a Gastroenterologist. The most recent physician's visit note in R16's record was dated 5/1/24 and read, in part: .reading the notes there is intermittent nausea although it seems, today anyway, being related to being moved in her bed and turned .Will treat her vertigo, which hopefully will help the nausea . The documentation did not document any discussion with R16 regarding consultation with a Gastroenterologist or obtaining diagnostic testing. R16's care plans did not contain a care plan for nausea and vomiting to provide staff with interventions to implement when R16 experienced nausea and vomiting. The medical record did not reveal a discussion with R16 regarding consultation with a specialist to determine and potentially treat the source of the nausea and vomiting, nor was R16 provided with an offer for diagnostic testing to potentially determine the source of the nausea and vomiting. The Director of Nursing (DON) and the Registered Nurse (RN) Supervisor L were interviewed on 6/5/24 at 8:05 a.m. The DON confirmed she was aware of R16 experiencing recurrent nausea and vomiting. The DON said R16's physician had ordered antiemetic medications, but admitted she was unaware if diagnostic testing or consultation with a specialist had been discussed with R16. RN L confirmed she was aware of R16 enduring persistent, intermittent nausea and vomiting and weight loss. When asked if consultation options or diagnostic testing was offered to R16, RN L said, I don't know. I'll have to look in the record. R16 was interviewed on 6/5/24 at 8:29 a.m. R16 was lying in bed with an emesis basin next to her. R16 said she was nauseated and said, I've been nauseated for so long. I just wish this was all over. R16 said her physician was in the facility today and had offered to conduct some testing. When asked if she was considering the testing, R16 said, It probably won't do any good because they'd have to move me and that would cause even more nausea. On 6/5/24 at 10:22 a.m., RN M and RN N were observed completing treatments to pressure injuries and moisture-associated skin damage (MASD) on R16's bilateral buttocks. R16 was rolled onto her left side to reveal two Stage 2 pressure injuries (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) on the right gluteal cleft and one Stage 2 pressure injury on the left gluteal cleft. R16's bilateral buttocks were reddened and inflamed with skin erosion due to MASD. RN L was interviewed on 6/5/24 at 10:46 a.m. When asked if she had the opportunity to review R16's medical record to determine if R16 was offered consultation with a specialist or diagnostic testing to determine the root-cause of the nausea and vomiting, RN L said they had obtained labs and adjusted the medications for R16. RN L said they obtained lab results last week. A progress note of 5/25/24 at 2:06 p.m. was reviewed and read, in part: .Labs recently done WNL (within normal limits). When asked if the labs or medication adjustments had determined the source of the recurrent nausea and vomiting, RN L replied, The doctor is monitoring. RN L said R16's physician had spoken with R16 this morning and the physician said further diagnostic testing was not indicated. RN L said R16 declined any further actions to determine the source of the nausea and vomiting when the offer for diagnostic testing was offered to R16 on 6/5/24. When asked why diagnostic testing was not offered to R16 prior to 6/5/24, RN L said an overall decline had been experienced by R16. RN L said the decline included a change in appetite. She wasn't eating or thriving. When asked if R16 wasn't eating because of nausea and vomiting, RN L said, We were trying to deal with that with medications. When asked if the Medical Director had been made aware of the prolonged amount of time R16 had endured nausea and vomiting of an unknown cause, RN L replied, No, I don't think so. The Registered Dietician (RD) was interviewed on 6/5/24 at 11:08 a.m. The RD confirmed R16 had lost a significant amount of weight due to not eating. The RD said R16 had nausea and vomiting so she would refuse food, or eating would result in R16 vomiting. The RD said the interdisciplinary team had been discussing R16 going on comfort care measures or hospice. The RD said R16 started experiencing significant weight loss from nausea and vomiting in January 2024. R16's physician was interviewed on 6/5/24 at 11:22 a.m. The physician was asked what had been done to address R16's prolonged nausea and vomiting. The physician said she had made medication adjustments and said R16 had been on most of the available antiemetic medications. When the physician was asked what was causing the nausea and vomiting, she replied, I'll be honest with you - I don't know. She might have gastroparesis or a tumor or it could be anything. When asked if R16 had been afforded the opportunity for consultation with a Gastroenterologist or other specialist, or if diagnostic testing was offered, the physician said she offered R16 those options today, 6/5/24, and R16 had declined the offer. When asked why R16 was not provided with those options prior to 6/5/24 despite many months of nausea and vomiting with subsequent weight loss and wound development, the physician said, I think I did - I actually know I did - I don't know why I didn't document it. The physician reiterated R16's declination on 6/5/24 of further testing or consultations. The facility policy Significant Change Notification dated 1/4/23 read, in part: .Purpose: To assure that residents and/or their legal representative has the right to make choices about aspects of his/her care that will affect the quality of life of each resident .If the RN Supervisor or Charge Nurse is not satisfied that the physician's response will meet the resident's needs, then he/she may move up the chain of command to: .Medical Director . The DON was interviewed on 6/5/24 at 1:05 p.m. The DON was asked if the Medical Director had been made aware of the concerns with R16 and the prolonged duration of nausea and vomiting without being afforded the opportunity to find out the cause of the nausea and vomiting, the DON replied, No, not to my knowledge.

Based on observation, interview, and record review, the facility failed to implement and maintain interventions to prevent the development and progression of pressure ulcers (a wound affecting skin, fat, and muscle tissues) for two Residents (#62, #113) of three residents reviewed for pressure injuries. This deficient practice resulted in the development of three stage II pressure ulcers and worsening of pressure ulcers. Findings include: Resident #62 (R62): Review of R62's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including a collapsed vertebra, muscle weakness, peripheral vascular disease, and diabetes. Review of R62's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of being cognitively intact. Further review of the MDS, section M, revealed R62 did not have pressure ulcers present upon admission. Review of R62's Braden Scale admission assessment (a standardized assessment which calculates risk of pressure injury) on 5/2/24, revealed a score of 13.0, indicating R62 was at risk [for pressure ulcer]. An interview was conducted with R62 on 6/4/24 at 4:30 p.m. R62 stated that he has two pressure ulcers on his buttock that he did not have when he was admitted just over a month ago. R62 expressed frustration that he needs staff assistance to turn and reposition, his wheelchair is uncomfortable, and his feet cannot reach the floor causing pressure on his lower back and buttocks. R62 was currently lying on his back in his bed. On 6/5/24 at 10:40 a.m., R62 was observed sitting in his wheelchair requesting to use the restroom. R62's legs were noted to not be able to touch the ground with his right lower leg rubbing and pushing against the metal of his wheelchair. R62 stated that this causes him immense pain. R62 was transferred to the toilet and an observation of his wheelchair showed that his Roho cushion (device used on wheelchair seats to promote skin integrity) was noted to be deflated. An interview was conducted with Occupational Therapist (OT) S on 6/5/24 at 11:00 a.m., concerning R62's wheelchair. OT S stated that Roho cushions are checked every day but that R62's wheelchair was not the best fit for him. An interview was conducted with Physical Therapist (PT) T on 6/5/24 at 11:05 a.m. PT T stated that R62's wheelchair is lowered as far as it will go, but that his legs will still not touch the ground. PT T stated that R62 did have a smaller wheelchair at the time of admission, but it was too tight and causing pain and discomfort. R62 did have a power wheelchair and was assessed for safety from OT, but since R62 is requiring supplemental oxygen, this power wheelchair is not best suited for him. PT T explained that there are no custom wheelchair companies in the region and that R62 would either need to purchase a wheelchair for himself or that the therapy department could possibly ask the facility to purchase one. PT T observed the Roho cushion and stated that it was not inflated to the correct pressure. Review of R62's plan of care revealed the following problem: At risk for skin breakdown R/t (related to): Nicotine dependence, Pacemaker, Type 2 DM (diabetes), Pain, Constipation, Sleep Apnea, Atherosclerotic heart disease, HTN (hypertension) A Fib (Atrial fibrillation), collapsed vertebra of lumbar region. Interventions were listed as: 1. BED: oversized width [NAME] air, keep linen clean, dry, and wrinkle free. Date Initiated: 5/2/24 2.Calmoseptine to scrotum, buttocks (slit), and glutes with cares and episodes of incontinence for protection, [medication name] pump lotion to dry areas w/ (with) cares. Date Initiated: 5/2/24 3.Elevate heels with dermasaver over foam pillow, derma boots to feet when in bed, oversized ROHO to recliner, blue heel protections to be on when in recliner, bedder foot pad to end of bed between mattress and sheet. Date Initiated: 5/2/24 4.Repositioning: Reposition every 2-3 hours when in bed or chair, avoid shearing residents' skin during positioning, transferring, and turning, elevate heels w/ derma over pillow. Date Initiated: 5/2/24 5. Weekly skin assessment to be completed for 4 weeks to observe skin for changes to the skin's integrity. Date Initiated: 5/2/24 Review of R62's Progress Notes revealed the following data: 1. 5/2/24: a) Mid buttock 8.5 cm(centimeter) scar with slight indentation noted. b) Buttock into rectum region: 6.5x3.5 cm blanching redness. 2. 5/6/24: a) No new skin issues or concerns b) Sacral slit area measuring .8 cm with red/blanching area. 3. 5/7/24: a) No new reported skin issues or concerns 4. 5/8/24: a) No new skin issues or concerns 5. 5/9/24: a) Location of Wound - L (left) gluteal cleft. b) Type of Wound - Pressure c) Wound Stage: Stage II d) Wound Measurement - Length 1 cm, Width 1 cm e) Any Changes to Care Plan Interventions? No 6. 5/13/24: a) Location of Wound - L gluteal cleft b) Type of Wound - Pressure c) Wound Stage: Stage II d) Wound Measurement - Length 1.5 cm, Width 0.5 cm e) Any Changes to Care Plan Interventions? No 7. 5/20/24: a) Location of Wound - L gluteal cleft b) Type of Wound - Pressure c) Wound Stage: Stage II d) Wound Measurement - Length 1.1 cm, Width 1 cm e) Any Changes to Care Plan Interventions? No 8. 5/27/24: a) Location of Wound- L gluteal cleft b) Type of Wound - Pressure c) Wound Stage: Stage II d) Wound Measurement - Length 1.1 cm, Width 1 cm and superficial area .9 cm x .6 cm e) Any Changes to Care Plan Interventions? No 9. 5/29/24: a) Location of Wound - Rt (right) gluteal cleft, medial #1 b) Type of Wound - Pressure c) Wound Stage: Stage II d) Wound Measurement - Length 2 cm x 1 cm, Depth .1 cm e) Any Changes to Care Plan Interventions? No 10. 5/29/24: a) Location of Wound - Rt Gluteal Cleft, lateral #1 b) Type of Wound - Pressure c) Wound Stage: Stage II d) Wound Measurement - Length 2 cm, Depth .1 cm, Width 1 cm e) Any Changes to Care Plan Interventions? No 11. 5/29/24: a) Location of Wound - L Gluteal Cleft b) Type of Wound - Pressure c) Wound Stage: Stage II d) Wound Measurement - Length 2 cm, Depth .1 cm, Width 1 cm e) Any Changes to Care Plan Interventions? No 12. 6/3/24: a) Location of Wound - Rt Gluteal Cleft Lateral #1 b) Type of Wound - Pressure c) Wound Stage: Stage II d) Wound Measurement - Length 1 cm, Depth .1 cm, Width .9 cm e) Any Changes to Care Plan Interventions? No 13. 6/3/24 a) Location of Wound - Rt Gluteal Cleft medial #1 b) Type of Wound - Pressure c) Wound Stage: Stage II d) Wound Measurement - Length 1.5 cm, Depth .1 cm, Width 1.2 cm e) Any Changes to Care Plan Interventions? No 45123 On 6/5/24 at 9:30 AM, an observation was made of R62 during wound dressing changes completed by Registered Nurse Q. Wound measurements were as follows: a.) Right buttocks one open area (stage II) measuring 1.0-centimeter (cm) x 1.0 cm with surrounding redness 3.0 cm x 3.0 cm, b.) Left buttocks two open areas (stage II) measuring upper 1.0 cm x 0.5 cm and lower 1.0 cm x 0.4 cm with surrounding redness measuring 7.5 cm x 4.0 cm, c.) Intergluteal cleft from the coccyx to the anus open area (stage II) measuring 3.0 cm x 0.2 cm, d.) Right malleolus (unstageable) with eschar in the center measuring 1.6 cm x 0.6 cm and with surrounding redness measuring 4.9 cm x 4.2, e.) Left heel (deep tissue injury) measuring 2.7 cm x 0.6 cm with mild redness surrounding the area with a scab in the center and light purple in color. On 6/5/24 at 9:45 AM, R62 was asked if any of the wounds hurt or were tender to touch and replied, The one on my right ankle is sore to touch and my butt is really sore. I need to rest now and stabilize. On 6/5/24 at 10:00 AM, an interview was conducted with RN M in charge of wound care and was asked if R62 was admitted to the facility with all of his current open wounds and replied, No. He originally just had the one on his left heel and acquired the others after he was admitted to the facility. 49302 Resident #113 (R113) Review of R113's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including a left femur fracture, history of transient ischemic attack (a temporary blockage of blood flow to the brain), and encephalopathy (a type of brain injury contributing to an altered mental status). Review of R113's Brief Interview for Mental Status (BIMS) assessment, dated 4/3/24, revealed a score of 3, indicative of severe cognitive impairment. Review of Minimum Data Set (MDS) Section M, Skin Conditions, revealed R113 admitted to the facility with 2 stage II (tissue damage that affects the first two layers of skin) pressure ulcers and 1 unstageable deep pressure injury. Review of a Skin Assessment, dated 3/29/24, indicated R113 had two open stage II ulcers on the anterior left leg which measured 1.5 cm (centimeters) x 1.7 cm and 1 cm x 1.2 cm, respectively, and a deep tissue to the left heel measuring 2.6 cm x 3.5 cm. On 6/3/24 at 2:17 PM, an interview was conducted with R113 who was asked about the status of his wounds. R113 stated, It hurts. Review of a Wound Treatment Note dated 5/14/24 read, in part: .Location of Wound: Lt [left] heel . Signs of Symptoms of Infection: Odor, Increased Drainage . Any Change in Wound:? Worsened larger, blister popped, small drainage . .Lt shin with mild odor today, foul smelling . Lt heel-now opened d/t [due to] drainage noted on dressing . Review of a Wound Treatment Note dated 5/24/24 read, in part: .At this time, left shin now Stage 4 [pressure ulcer] down to what is perceived to be exposed tendon, shiny and white . Review of R113's EMR revealed no indication of physician follow-up after identification of R113's worsening wounds as indicated by Wound Treatment Notes on 5/14/24 and 5/24/24. On 6/5/24 at 11:30 AM, an interview was conducted with Wound Care Treatment Coordinator, Registered Nurse (RN) M who verified the worsening of R113's wounds since admission. RN M indicated a foul-smelling odor and/or increased drainage from a wound could be a sign of infection. When asked the reasoning behind the lack of physician follow-up in reference to the worsening of R113's wounds, RN M stated, I asked for an order for a wound care consultation referral from [Physician R] on 5/14/24 but never got a response. I asked again [for a wound care consultation referral] on 5/23/24 with no response . He [Physician R] is notorious for not coming in [to the facility] to sign orders and he doesn't like them faxed . I eventually had my supervisor contact him [Physician R] to forward it [wound care consult referral request] on . Review of email correspondence sent by RN M to Physician R revealed the following: 1. 5/14/24: PLEASE DICTATE ON THE FOLLOWING SKIN ISSUE: .Location of wound: lt heel . Type of Wound: Pressure . Pinpoint area to center of heel DTI [deep tissue injury] opened and drained scant serosanguinous drainage . Would you agree with a Wound Care Consult? 2. 5/23/24: PLEASE DICTATE ON THE FOLLOWING SKIN ISSUE: .Location of wound: left heel . Type of Wound: Pressure . Would you agree with a Wound Care Consult? Review of physician documentation did not address a wound care consult following the email communications from RN M on 5/14/24 and 5/23/24. Review of Nursing Progress Note dated 5/24/28, read: Skin: In to assess resident at this time. D/T not hearing a reply from multiple attempts to MD regarding Wound Care Consult, reached out to supervisor who will be contacting MD directly to discuss referral which family and treatment team is in favor of. Review of R113's Wound Care Consultation, dated 5/28/24, 14 days after initial identification of R113's wound progression, read, in part: .Wound #1 is located on left lower leg (distal shin). The aide with the patient is not sure how long the wound has been present for, just states that per [facility] nurses, that since developing the wound it has worsened . Wound #2 is located on left heel. The aide with the patient again is not sure how long this wound has been present for. This wound was not even listed on the paperwork brought in by the CNA [certified nursing assistant] from the facility . The aide wasn't sure with that (sic) the wound has been treated with; there is no mention in the accompanying documentation of what it's been being treated with .Wound #1/left distal shin .I suspect this is an arterial ulcer .non-pressure chronic ulcer .with unspecified severity . On 6/5/24 at 12:15 PM, an interview was conducted with the Director of Nursing (DON) regarding expectations for interdisciplinary communication regarding wound care/management. The DON stated the physician should be notified and should respond to progression of a wound in terms of size and signs and symptoms of infection including odor. The DON stated she was unsure why Physician R did not respond to the Wound Care Consult request despite rounding on R113 on 5/14/24. The DON was questioned regarding the facility protocol if the interdisciplinary team was unsatisfied with the physician's response. The DON stated, the medical director would be responsible for assisting but indicated the medical director was not notified in this case. The DON confirmed the 14-day lapse from the initial wound care consultation request on 5/14/24 to the wound care consult visit on 5/28/24 was considered a delay in treatment. Review of facility policy titled, Significant Change Notification, dated 1/4/23, read, in part: STANDARD: To ensure that a system exists for immediate notification for the resident's physician and legal representative when there is a change in psychosocial status, life threatening conditions, clinical complications, or a need to alter treatment significantly . The RN Supervisor/Charge Nurse may at any time prompt a clarification of orders. If the RN Supervisor or Charge Nurse is not satisfied that the physician's response will meet the resident's needs, then he/she may move up the chain of command: a. On-call RN b. DON/ADON [assistant director of nursing] or designee c. Medical Director d. Administrator . Review of facility policy titled, Skin Integrity Program, dated 7/18/23, read, in part: .This facility is committed to reducing the risk of pressure injuries and the promotion of healing of existing pressure injuries . The MD [medical doctor] will be updated, following a nursing assessment, for changes in preexisting or new onset of co-morbid conditions affecting skin integrity . The attending physician will be notified of the presence or lack of healing of any pressure injuries .

Based on observation, interview, and record review the facility failed to implement, update and revise comprehensive care plans to prevent falls for three Residents (#9, #26, #29) of three residents reviewed for falls. This deficient practice resulted in falls with major injury. Findings include: Resident #26 (R26) Review of R26's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including dementia, left femur fracture, and history of falling. Review of R26's 9/21/23 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 11/15, indicative of mild cognitive impairment. Further review of R26's MDS revealed she had a fall with fracture prior to admission to the facility. Review of R26's Fall Risk Assessment, dated 9/15/23 and completed on 9/20/23 revealed R26 scored a 19 presenting as a high risk for falls. Plan of Care for R26 read, in part, Resident has a fall risk score of 19. She has a history of 1 fall within the past month resulting in current fracture. No falls since admission, she has not shown any impulsive behaviors. She is working with skilled therapy and remains capable of making her own independent decisions. She will be changed from a risk closely monitor, to a potential monitor for falls. Care plan updated. Review of R26's Plan of Care in October 2023 revealed the following problems: Alteration in cognition secondary to some underlying memory loss that is present - start date: 9/18/23. Potential Alteration in performing activities of daily living resulting in risk of self-care deficit and potential falls .start date: 9/15/23. Approaches for R26 included the following interventions: I am known to self-transfer despite reminders and encouragement to call for assistance - start date 10/5/23. Potential for falls, monitor - start date 9/20/23. Review of R26's Incident and Accident Reports revealed the following entry: 10/14/23 .Floor staff heard resident yelling for help while they were assisting another resident. Upon entering the room res (resident) was laying on the floor on her left side with her head towards the door and her legs toward her bed. WC (wheelchair) was next to armoire and walker was next to the foot of her bed. Res had been noted to be ambulating without walker this shift .Res ROM (Range of Motion) WNL (within normal limits) with all extremities with the exception of her LLE (Left Lower Extremity), LLE rotated outward and shortened. Res unable to move without pain and was guarding the lateral side of her left thigh about her knee where a mass was felt by writer upon assessment .Res agreed to be sent out to hospital for further evaluation . Review of R26's Hospital Discharge Summary dated 10/19/23 read, in part, Discharge Diagnosis: Oblique left periprosthetic distal femur fracture, s/p (status post) ORIF (open reduction internal fixation [surgical repair method]) on 10/15/23 . R26 returned to the facility on [DATE]. Review of R26's Current Plan of Care revealed the following problems: Alteration in cognition secondary to diagnosis of dementia with a recent progression of disease progress. Worsening insight, judgment and recall ability's .start date: 9/18/23. Alteration in performing activities of daily living resulting in risk of self-care deficit and potential falls .start date: 9/15/23. Approaches for R26 included the following interventions: Transfers and ambulates independently with a walker. Please encourage walker usage if seen walking without her assistive devices .start date: 4/19/24. Potential for falls, monitors, signs to encourage resident to use her walker by TV and bed in room .start date: 4/19/24. An interview was conducted with R26 and her daughter on 6/3/24 at 3:29 p.m. R26 stated that she has attempted most recently to not use her walker when getting out of bed to see if she, still can do it. An interview was conducted with the Director of Nursing (DON) on 6/5/24 at 11:17 a.m. The DON confirmed that when R26 had returned to the facility after her fall in October 2023, the facility's fall watch program was either not initiated or not documented correctly. The DON stated that the facility would normally do more interventions for residents who are at high risk for falls which would include 15-minute checks stating, They could have done more. The DON agreed that the pre and post fall interventions for R26 were not appropriate or adequate. 49735 Resident 9 (R9) Review of R9's Minimum Data Set (MDS) assessment, dated 5/9/24, revealed an admission to the facility on [DATE], with active diagnoses that included: urinary tract infection, dementia, anxiety, chronic obstructive pulmonary disease (COPD), and chronic kidney disease. R9 scored 11 of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderate cognitive impairment. Review of Resident Incident Report, dated 4/29/24, reflected R9 was found sitting on the bathroom toilet at 1:15 a.m. The staff were alerted by roommate that R9 had fallen and assisted self to a standing position and ambulated to the bathroom. R9 sustained a skin tear to left arm. A review of R9's care plan, revealed no interventions to reduce accidents/falls were added to R9's care plan. During an interview on 6/5/24 at 8:45 a.m., RN (Registered Nurse)/Rehab Coordinator K stated, The care plan was not updated as it was a Urinary Tract Infection (UTI) that caused the fall ., We don't update with each fall. During an interview on 6/5/24 at 11:25 a.m., the Director of Nursing (DON) acknowledged the care plan was not revised after R9's fall to prevent further accidents. Resident 29 (R29) Review of R29's MDS assessment, dated 3/14/24, revealed an admission to the facility on [DATE], with active diagnoses that included: diabetes mellitus, hypertension, heart failure, chronic kidney disease, and depression. R29 scored a 13 of 15 on the BIMS reflective of intact cognition. Review of R29's Incident Report, dated 2/12/24, revealed R29 was found on the floor in her room, and she fell trying to get out of bed. A review of R29's care plan, revealed no intervention to reduce accidents was added to R29's care plan. During an interview on 6/5/24 at 8:03 a.m., RN/Rehab coordinator K confirmed no interventions were added to R29's care plan . Review of R29's Incident Report, dated 4/16/24, revealed R29 rang call light and stated that R29 slid out of bed and fell to the floor. During an interview on 6/5/24 at 8:03 a.m., RN/Rehab Coordinator K stated, a treatment was added . and should have been added to her care plan, but it was not done. Review of Resident Incident Report, dated 4/23/24, revealed R29 fell in the doorway of another resident's room. R29 reported a head injury and a bump was noted to the back of R29's head. A review of R29's care plan, revealed no intervention to reduce accidents was added to R29's care plan. During an interview on 6/5/24 at 8:03 a.m., RN/Rehab coordinator K said, Changes are in the notes but not in the care plan. During an interview on 6/5/24 at 11:25 a.m., the DON acknowledged the care plan was not revised after R29's multiple falls to prevent further accidents. Review of policy titled, Fall/Fall Risk Program, read in part, .The facility will identify residents at risk for falls and develop interventions along with a plan of care to prevent falls. The facility will respond to resident's experiencing a fall by analysis/assessment, establishment of a plan of care, and monitoring of the effectiveness of the care plan. The Rehab Coordinator/designee will identify and initiate fall interventions with staff, resident, and or family input which will be reflected in the plan of care. Interventions will be monitored for effectiveness and adjusted as necessary .

Based on observation, interview, and record review, the facility failed to provide activities of daily living (ADL) care in a dignified manner to one Resident (R17) of twenty-five residents reviewed for dignity. Finding include: On 6/3/24 at 3:10 PM, an observation was made of CNA (certified nurse aide) D assisting R17 in his room to his bathroom on the toilet. On 6/3/24 at 3:15 PM an observation was made of R17 in his bathroom with the door open to the bathroom and the room door open. R17 was using the bathroom toilet. R17 was left unattended with both the bathroom door and room door open. On 6/3/24 at 3:17 PM, an observation was made of R57 entering R17's room in her wheelchair. Approximately one minute later CNA G redirected R57 out the room door of R17. On 6/3/24 at 3:20 PM, an interview was conducted with CNA G, and was asked if R17's door should be closed and replied, The other CNA could have, yeah. The other CNA should have closed it part way because R17 is a fall risk and if it was partially closed then she [R57] would not have gone in. On 6/3/24 at 3:25 PM, an interview was conducted with CNA D, and was asked why he left R17 in his bathroom with both the bathroom door and room door open and replied, I had to go get a brief. CNA D was asked why he did not ask for assistance and replied, I don't know. CNA D was asked why he left the door open to R17's bathroom and room entry door and replied, I guess I should have closed it and left it open a little. He is a fall risk. CNA D was asked if R17 had privacy while using the bathroom and replied, No. I should have done that differently. On 6/5/24 at 10:30 AM, an interview was conducted with the Nursing Home Administrator (NHA) and was asked about closing doors to provide privacy when residents were using the bathroom and to prevent wandering residents from entering other resident's rooms and replied, I would expect for bathroom doors to be closed by staff to allow for privacy and wandering residents should not be entering rooms when others are using the bathroom. The CNA should have closed the door and not allowed the wandering resident to enter the room. Wandering residents should be redirected.

Based on observation, interview, and record review, the facility failed to ensure appropriate and safe use of bedrails for nine Residents (R25, R31, R78, R84, R313, R314, R315, R501, and R502) beds, out of nine Residents reviewed for bed safety. This deficient practice resulted in the potential for inappropriate bedrail usage and bedrail entrapment. Findings include: During an observation on 6/27/23 at approximately 1:50 p.m., the following Resident beds were observed with bedrails: R25 - bilateral mobility bars. R31 - bilateral mobility bars. R78 - bilateral mobility bars. R84 - bilateral mobility bars. During an interview on 6/28/23 at 3:05 p.m., Physical Plant Manager (Staff) G was asked about bed entrapment zone measurements for residents with bedrails. Staff G said the facility did not perform entrapment zone gap measurements on resident beds if they did not have half bedrails on their beds. Residents with mobility bedrails did not have entrapment zone gap measurements performed as required per the facility policy. On 6/28/23 at 3:05 p.m., Staff G provided a form used for bed safety inspections entitled, Bedrail/Mattress Safety Assessment, for an unidentified resident, which included a one-time Pass/Fail with no documented measurements for the following areas: ZONE: Right side of bed between mattress and lowermost portion of bedrail. Right side of bed between inside surface of the bedrail and mattress. Left side of bed between mattress and lowermost portion of bedrail. Left side of bed between inside surface of the bedrail and mattress. Staff G said that was the only form completed related to entrapment zone gap measurements for facility beds. Review of the EMR on 6/28/23 found no individualized resident assessments related to the need, safety, and use of bedrails prior to installation of the bedrails on R25, R31, R78 and R84's beds. On 6/28/23 at 3:00 p.m., the DON, Nursing Home Administrator (NHA), Assistant Director of Nursing (ADON) L, Staff G, and Rehab Coordinator H were interviewed regarding the use of bedrails in the facility. The DON confirmed no documentation was present in resident medical records for any alternative approaches to bedrails prior to installation/initiation of bedrails on facility resident beds. When asked if the DON was aware of the reason for concern related to the use of bedrails within the facility, including mobility bedrails, the DON stated, We are not doing a bedrail assessment (to determine individual need and safety of bedrail use). Rehab Coordinator (Staff) H also acknowledged no individualized resident bedrail assessments were completed to ensure bedrails were appropriate and safe for each resident. Because the facility had transitioned to mobility bars (bedrails) the NHA stated, We thought we did not have to do bedrail assessments. We didn't need to do the measurements. We didn't need to do anything because they were not bedrails. ADON L expressed understanding of the facets of a bedrail assessment that must be performed to determine the resident is safe with the use of bedrails. On 6/28/23 at 3:26 p.m., Certified Nurse Aide (CNA) J and CNA I confirmed with this Surveyor, bilateral mobility bars were in use on beds for R25, R31, R78, and R84. Review of the Assessment of Bed Rails policy, dated 1/31/23, revealed the following, in part: .To ensure resident's safety, all bed frames, mattresses and rails will be assessed according to safety guidelines, findings documented, and corrective action documented and implemented as needed. The facility will measure and monitor potential gaps on bed rails, mattresses, headboards, and footboards to maintain resident safety and prevent entrapment and injury . On each of the first 5 days following initial use, the resident bedframe, bed rails, and mattress will be monitored by the maintenance department to document proper fit of and to ensure that the maximum distance between components for that resident as recorded on assessment form . Review of the Bed Device Safety policy, dated 1/31/23, revealed the following, in part: .Education and training for maintenance and housekeeping staff will be provided related to installation, maintenance, functional safety checks and measurement of gaps for bed rails, beds, BMADs (bed mobility assistive devices) and mattresses. Review of the Guidance for Industry and FDA (Food and Drug Administration) Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated March 10, 2006, revealed the following, in part: The seven areas in the bed system where there is a potential for entrapment are identified in the drawing below. Zone 1: Within the Rail Zone 2: Under the Rail, Between the Rail supports or Next to a Single Rail Support Zone 3: Between the Rail and the Mattress Zone 4: Under the Rail, at the Ends of the Rail Zone 5: Between Split Bed Rails Zone 6: Between the End of the Rail and the side Edge of the Head or Foot Board Zone 7: Between the Head or Foot Board and the Mattress End. During an interview on 6/29/23 at 7:01 a.m., the NHA acknowledged maintenance staff should have been completing the entrapment zone measurements for five days following initial installation of bedrails, per the facility policy, for new admission beds. The NHA agreed that bedrail alternatives were not implemented, nor was an individualized assessment of resident physical and mental status being performed prior to the initiation of bedrails on facility resident beds. During an interview on 6/29/23 at 8:50 a.m., the DON and ADON both confirmed no bedrails alternatives were being attempted, and no individualized bedrail assessments were being completed prior to installation of bedrails for facility residents. On 6/29/23 at approximately 9:00 a.m., five completed Bedrail/Mattress Safety Assessment forms were provided by Staff G for review for R313, R314, R315, R501, and R502. Staff G said the forms were all completed that day (6/29/23) by Maintenance Staff M. Review of the forms revealed the following, in part: R313, Date of Assessment: 6/26/23 (date of admission, not date of assessment) . Staff signature and title: signed by Staff M, Date: 6/26/23 (date of admission, not assessment). R314, Date of Assessment: 6/27/23 (date of admission, not date of assessment) . Staff signature and title: signed by Staff M, Date: 6/27/23 (date of admission, not assessment). R315, Date of Assessment: 6/15/23 (date of admission, not date of assessment) . Staff signature and title: signed by Staff M, Date: 6/15/23 (date of admission, not assessment). R501, Date of Assessment: 6/28/23 (date of admission, not date of assessment) . Staff signature and title: signed by Staff M, Date: 6/28/23 (date of admission, not assessment). R502, Date of Assessment: 5/23/23 (date of admission, not date of assessment) . Staff signature and title: signed by Staff M, Date: 5/23/23 (date of admission, not assessment). During an interview on 6/29/23 at 10:15 a.m., Staff M confirmed he had completed all the above Bedrail/Mattress Safety Assessment forms that day (6/29/23). Staff M stated, I was given a piece of paper from Staff G that had their arrival (admission) date and I just put that date on there (the forms) . There is (sic) a few that were missing. I am not sure why they didn't get done.

Based on observation, interview, and record review, the facility failed to prevent the development of avoidable pressure ulcers for one Resident (R32) of three residents reviewed for pressure ulcers. This deficient practice resulted in the development of two pressure ulcers for R32, and the potential for complications such as infection and rehospitalization , related to pressure injuries. Findings include: Resident #32 (R32) R32 was admitted to the facility on [DATE] and had diagnoses including generalized weakness, fracture of lower end of the left humerus (upper arm bone), fracture of left pubis (front pelvis area), dementia, diabetes mellitus, peripheral vascular disease (PVD), and need for assistance with personal care. Review of R32's admission Minimum Data Set (MDS) assessment, dated 6/7/23, revealed the following: R32 required extensive, two-person physical assistance with bed mobility and was totally dependent on staff for transfers. Section M- Skin Conditions, revealed R32 was at risk for developing pressure ulcers and had three unstageable pressure ulcers (wound bed covered by slough [dead tissue]and /or eschar [dried brown slough]), and one unstageable pressure ulcer, not present upon admission. Further review of Section M, revealed a fourth pressure ulcer, deep tissue injury (DTI), not present on admission. R32's admission MDS assessment also revealed, a Brief Interview for Mental Status (BIMS) assessment of 4 out of 15, indicating severe cognitive impairment. On 6/27/23 at 3:40 PM, an observation was made of R32 in his room. R32 was lying in his bed with his heels on his mattress, not elevated on a pillow, and was wearing gripper socks. R32 was wearing a left arm sling, with his left arm resting on his left side, and his elbow and upper arm resting on his mattress. On 6/28/23 at 12:05 PM, an interview was conducted with Licensed Practical Nurse (LPN) F. LPN F was asked how R32 developed two pressure ulcers after admission to the facility. LPN F replied, [R32's] left arm is heavy in his sling, and we have not been able to find extra pillows but did order some more. LPN F was asked about what care plan interventions should be in place. LPN F replied, All interventions should be in place, and he should have derma saver pad, boots and heels elevated. On 6/29/23 at 8:05 AM, an observation was made of R32. R32 was lying in his bed in his room and talking with an unidentified staff member. R32's heels were observed resting directly on the bed. R32 did not have derma saver boots on and was wearing gripper socks. R32 was also not wearing a left arm sling located in the room. On 6/29/23 at 8:15 AM, an interview was conducted with LPN A. LPN A was asked why R32 did not have feet elevated, derma saver boots on or the left arm sling. LPN A replied, I have to look at his care plan. LPN A reviewed R32's care plan and then stated, [R32] should be . and immediately went to see R32. An observation of R32's wound care, provided by LPN F on 6/29/23 at 12:25 PM, revealed an intact dressing located on his left posterior heel and his left elbow. Upon entry to the room, R32 was up in his wheelchair wearing socks and shoes and his left arm sling was not in place. The left arm sling was observed located on top of a dresser in his room. Upon removal of R32's wound dressings, the following was observed: One round pressure ulcer, approximately 2 centimeters (cm) in diameter, over R32's left elbow. The wound was 20 % covered with yellow colored slough (dead tissue) and pink remaining wound bed with scant serosanguinous (clear liquid mixed with blood) drainage. R32's left heel DTI was light purple/pink, blanchable and without drainage. A light skin colored small scab was noted forming over the center of the left heel area, measuring approximately 0.5 cm. A review of R32's electronic medical record (EMR) revealed wound care documentation of R32's left heel DTI and left elbow began on 6/07/23. Further review revealed the following: 06/07/2023, 09:50 AM, Treatment Note: . Left Elbow . Pressure . Unstageable, Wound Measurement . Length 2.7 cm (centimeters), Width 1.4 cm, Wound bed: Slough 90 % (percent), Appearance Red/Blanchable outward 1.5 cm, . Any Change in Wound?: Worsened new unstageable wound to elbow . 06/07/2023, 02:36 PM, Treatment Note: . Left Posterior Heel . Pressure . DTI, Wound Measurement . Length 0.8 cm, Width 1.1 cm, Wound bed: Appearance Red/Blanchable outward to the lateral 4 cm, outward to the medial, distal and proximal 1 cm each area, . Any Change in Wound?: Worsened new, Description of Change: new wound . 06/11/2023, 03:26 PM, Treatment Note: SKIN: writer and additional nurse . in to reassess R [right] fourth digit, L [left] heel, Sacral region dressing, and LUE [left upper extremity] . No need for further intervention/monitor of areas. Sacral region and L heel dressing dry and intact at this time. LUE continues with dark purple/yellow bruising. Writer noting L elbow dressing with 50% drainage. Area cleansed, rinsed, pat dried with . dressing placed. No additional breakdown to LUE noted at this time . will monitor. 06/13/2023, 03:42 PM, Treatment Note: Skin: MDS admission assessment completed for . end date of 6/8/23 . Braden scale score is 13, which is an indication that he is at a moderate risk for developing pressure injuries . There is also a DTI to the left posterior heel. And an unstageable PrI [prior to admission] to the left elbow as slough is covering wound bed and it is r/t [related to] a medical device. Please refer to the treatment notes and measurements on 6/8/23 . He is an assist of 2 for transfers via a hoyer lift and non-ambulatory and an assist of 1-2 prn for bed mobility . There are orders in place for repositioning and heel elevation and daily observation of the skin to the left arm and right side of the neck r/t to the medical device in place to support the left arm. The care plan has been initiated. *Note: EMR Progress notes and/or treatment notes lacked any measurements to wounds on 6/8/2023. 06/14/2023, 03:31 PM, Treatment Note: . Left Elbow . Pressure . Unstageable (medical device), Wound Measurement . Length 2.2 cm (centimeters), Width 1.4 cm, Wound bed: Slough 100 % (percent), Appearance Red/Blanchable 75 %, Pink/Normal 25 %, . Drainage: Serosanguinous . 06/14/2023, 03:37 PM, Treatment Note: . Left Posterior Heel . Pressure . DTI, Wound Measurement . Length 0.7 cm (centimeters), Width 1.0 cm, Wound bed: Appearance dark/red/purple, Red/Blanchable 100 %, . Any Change in Wound?: Stable appearance remains unchanged . 06/15/2023, 03:12 PM, Treatment Note: SKIN: writer in to assess dressings to sacrum, L heel, and L elbow. Writer noting sling removed to LUE. Writer noting L elbow dressing dry and intact at this time . [R32] with moderate discomfort with LUE movement that seized with rest. Sacral and L heel dressings dry and intact . 06/16/2023, 03:18 PM, Treatment Note: SKIN: writer in to assess L heel, L elbow, and buttock dressing. Writer noting dressing dry and intact at this time . 06/20/2023, 04:03 PM, Treatment Note: Skin: Sacral dressing and left elbow dressing dry and intact . *Note: Wound measurements lacked documentation in the EMR after 6/14/23. Review of R32's care plan for the problem area, Resident is at risk for developing pressure injuries or other skin breakdown R/T [related to]: Diabetes, PVD, other displaced fracture of lower end left humerous (sic) . Revealed the approach for the care plan, initiated on 6/02/23, was Derma Saver boots to be in place to BLE [bilateral lower extremities] at all times while resident is in bed . ; Elevate heels off mattress at all time while in bed using a pillow with a Derma Saver footpad over it, placing both under bilateral calves so heels are not in contact with mattress r/t aiding in pressure redistribution; Observations, monitors and treatment applications as per Physician's or nursing orders; Please refer to the standards of care. A review of R32's Physician Orders revealed, Monitor left arm and neck area for any skin concerns daily r/t sling placement. (Dated 6/3/23) A review of R32's Treatment Administration Record (TAR), revealed, Chart daily: For Medicare Part A residents: if resident has any skin issues (skin tear, bruise, pressure injury, surgical wound, etc.): What is skin ., Frequency: Once A Day, start date 6/03/23. A review of R32's progress notes dated 6/3/23 through 6/28/23, revealed lack of skin condition being addressed on dates as follows: 6/03/23, 6/05/23, 6/10/23, 6/18/23, 6/19/23, 6/25/23, 6/26/23, 6/27/23, and 6/28/23. A review of R32's Observation History in the EMR, revealed a nursing admission assessment completed on 6/1/23 and a skin risk assessment with Braden scale completed on 6/13/23. R32's EMR lacked any other type of skin assessment or skin risk assessments. During an interview on 6/29/23 at 11:00 AM, with the Director of Nursing (DON). The DON confirmed, per facility policy, a Braden scale skin assessment should have been completed on admission to the facility for R32. The DON also acknowledged a second Braden skin assessment should have been completed prior to the seventh day of R32's stay at the facility. The DON stated care plan interventions should have been followed for R32. The DON stated the expectation was care plan interventions were to be in place. The DON confirmed anyone admitted to the facility with pressure ulcers would be considered a high risk for developing further pressure ulcers. The DON confirmed nursing should have been charting in the EMR daily on skin color, movement, and sensation with a medical device. During an interview on 6/29/23 at 1:30 PM, LPN F reported being responsible for wound care. LPN F confirmed R32's pressure ulcers on his left heel and left elbow were acquired after he was admitted to the facility. LPN F also confirmed that an off-loading intervention for R32's left arm should have been an intervention to assist with the prevention of the left elbow pressure ulcer. A review of the facility policy titled, Pressure Injury Prevention and Management, last reviewed 3/27/19, revealed the following in part: This facility is committed to reducing the risk of pressure injuries and the promotion of healing of existing pressure injuries .3. Assessment of Pressure Injury Risk .b. Licensed nurses will conduct a pressure injury risk assessment, using the Braden Scale on all residents upon admission/re-admission, with a change of condition, and quarterly. A review of facility policy titled, Skin Integrity Program, last reviewed 1/31/23, revealed the following in part: .Facility will initiate a program to reduce the risk of skin breakdown/skin injuries in all at risk residents. Residents experiencing skin breakdown will be assessed and evaluated with appropriate interventions initiated and monitored for effectiveness. This facility is committed to reducing the risk of pressure injuries and the promotion of healing of exiting pressure injuries .4. Risk factors and co-morbid conditions contributing to skin breakdown will be identified and modified or eliminated if current condition warrants. A. The Braden Risk Assessment Scale will be used. The risk assessment will be completed within 7 days of admission or readmission, quarterly, and with a significant change in condition. At risk residents will be assessed for skin breakdown at least weekly for four weeks following admission. Appropriate interventions will be initiated .

Based on observation, interview, and record review, the facility failed to ensure a medication error rate less that 5 percent with seven medication errors observed out of 26 opportunities during medication pass. This deficient practice resulted in a medication error rate of 26.92 percent and the potential for undesirable effects related to omission of medications for Resident #45 [R45]. Findings include: During an interview and observation on 6/28/23 at 7:36 a.m., Registered Nurse (RN) K, prepared the following medications for R45: Risperdal (liquid), 1 mg (milligram), once daily Valproic Acid (liquid) 2.5 MLs (milliliters), Miralax [Polyethylene glycol (bulk laxative)], 17 grams, mixed in (120 MLs) approximately four ounces of cranberry juice. All three medications were mixed together. RN K walked the cup of juice, mixed with medications, into R45's room and placed it on the Residents' overbed table. RN K walked out of the room and left the cup of all liquid medications at the bedside. When RN K was asked if R45 had an assessment completed for self-administration of medications, RN K stated, No. She won't drink them if I try to get her to take them (while in the room). RN K said her morning medications were left on R45's overbed table until she had breakfast. When RN K was asked if she was able to leave medications at the bedside of R45, RN K stated No. RN K contacted the Director of Nursing (DON) via telephone and asked for guidance regarding the medications left in the cranberry juice at R45's bedside. On 06/28/23 at 7:48 a.m., RN K entered R45's room and encouraged R45 to continue to drink the cranberry juice with added medications. R45 refused and RN K removed the plastic cup of cranberry juice from R45's room. On 6/28/23 at 7:50 a.m., RN K entered R45's room and removed an insulated, foam cup and a small can (approximately eight ounces) of diet root beer; both with straws inserted and placed them on top of the medication cart. When asked why she had removed additional beverages from R45's room, RN K stated, These are the rest of her morning liquid medications. The diet root beer (with liquid medications) was poured into another insulated foam cup. They (beverages with liquid medications) were prepared by RN K and were sitting in R45's room waiting for breakfast. At 06/28/23 at 7:53 a.m., the DON arrived at the 100 Hall medication cart with a medication storage policy. RN K disposed of the medications that she had previously prepared and started over and began to prepare the following additional morning medications for R45: Acetaminophen (cherry flavored), 640 ML - 20 ML. Lasix 10 mg/per ML, 40 mg dose. Potassium Chloride (liquid,) 20 [NAME] (milliequivalents)/15 ML, dose 15 ML Vitamin D (liquid), 10 mcg/1mL - dose 2 ML (20 mcg). On 6/28/23 at 8:01 am., RN K entered R45's room. R45 refused the acetaminophen liquid, and all the other medications prepared. RN K stated, I know she isn't going to drink it (beverages with medication mixed in). On 6/28/23 at 8:06 a.m., RN K went to the clean utility room and retrieved two, small, insulated, foam cups. RN K emptied the medication cup contents into the two cups, applied cup covers, labeled the cups, and stored the cups in the medication cart. RN K said she would try to have R45 take the valproic acid, Risperdal, and polyethylene glycol in the cranberry juice with her breakfast tray. During an interview on 6/28/23 at 8:12 a.m., RN K acknowledged the liquid medications should not have been left in R45's room when there was not an assessment completed for R45 that authorized self-administration of medication. RN K stated she understood the concern of leaving medications in the room. On 6/28/23 at 8:13 a.m., R45's meal tray arrived in the Residents' room. RN K placed the cranberry juice with liquid medications on the over-bed table near the meal tray. RN K questioned, If I drop (cup with medications and juice) off and stand here and watch her eat, is that ok? On 6/28/23 at 8:17 a.m., R45 was observed eating breakfast and repeatedly picked up the coffee, not the juice (with liquid medications) during her meal. No observation of consumption of the medications was observed by this Surveyor. Review of the facility Administration of Medication, policy, dated 1/31/23, provided on 6/28/23 at 9:02 a.m., revealed the following, in part: .The Licensed Nurse will safeguard all medications by always locking medication carts and medication rooms when not in direct vision of nurse . The Licensed Nurse will label the medication cup with resident's name and date of medication administration if resident is not readily available or refuses the medication. The medication will be properly disposed if the medication is not administered . Dispense the medications to appropriate resident. Remain with resident until medication is swallowed with sufficient fluids . During an interview on 6/28/23 at approximately 9:05 a.m., The DON acknowledged R45 did not have an authorization for self-administration of medications. The DON said the facility would immediately begin development of an individualized plan for safe, observed administration of R45's medications.

Based on observation, interview, and record review, the facility failed to implement the comprehensive, resident-centered risk for skin breakdown for two Residents (R32 and R93) of twenty-three residents reviewed for care plans. This deficient practice resulted in the development of two pressure injuries for R32 and the potential for R93 to develop a pressure injury. Findings include: Resident #32 (R32) R32 was admitted to the facility on [DATE] and had diagnoses including generalized weakness, fracture of lower end of the left humerus (upper arm bone), fracture of left pubis (front pelvic area), dementia, diabetes mellitus, peripheral vascular disease (PVD), and need for assistance with personal care. Review of R32's admission Minimum Data Set (MDS) assessment, dated 6/7/23, revealed the following: R32 required extensive, two-person physical assistance with bed mobility and was totally dependent on staff for transfers. Section M- Skin Conditions, revealed R32 was at risk for developing pressure ulcers and had three unstageable pressure ulcers (wound bed covered by slough [dead tissue] and /or eschar [dried brown slough] ), and one unstageable pressure ulcer, not present upon admission. Further review of Section M, revealed a fourth pressure ulcer, deep tissue injury (DTI), not present on admission. R32's admission MDS assessment also revealed a Brief Interview for Mental Status (BIMS) assessment of 4 out of 15, indicating severe cognitive impairment. On 6/27/23 at 3:40 PM, an observation was made of R32 in his room. R32 was lying in his bed with his heels resting on the mattress, not elevated on a pillow, and was wearing gripper socks. R32 was wearing a left arm sling, with his left arm resting on his left side, and his elbow and upper arm were resting on his mattress. On 6/28/23 at 12:05 PM, an interview was conducted with Licensed Practical Nurse (LPN) F. LPN F was asked how R32 developed two pressure ulcers after admission to the facility. LPN F replied, [R32's] left arm is heavy in his sling, and we have not been able to find extra pillows but did order some more. LPN F was asked about what care plan interventions should be in place. LPN F replied, All interventions should be in place, and he should have derma saver pad, boots and heels elevated. On 6/29/23 at 8:05 AM, an observation was made of R32. R32 was lying in his bed in his room and talking with an unidentified staff member. R32's heels were observed resting directly on the bed. R32 did not have derma saver boots on and was wearing gripper socks. R32 was also not wearing a left arm sling located in the room. On 6/29/23 at 8:15 AM, an interview was conducted with LPN A. LPN A was asked why R32 did not have feet elevated, derma saver boots on or the left arm sling. LPN A replied, I have to look at his care plan. LPN A reviewed R32's care plan and then stated, [R32] should be . and immediately went to see R32. An observation of R32's wound care, provided by LPN F on 6/29/23 at 12:25 PM, revealed an intact dressing located on his left posterior heel and left elbow. Upon entry to the room, R32 was up in his wheelchair wearing socks and shoes and his left arm sling was not in place. The left arm sling was observed located on top of a dresser in his room. Upon removal of R32's wound dressings, the following was observed: One round pressure ulcer, approximately 2 centimeter (cm) in diameter, over R32's left elbow. The wound was approximately 20 % covered with yellow colored slough (dead tissue) and the remaining wound bed was pink with scant (very small amount) serosanguinous (clear liquid mixed with blood) drainage. R32's left heel DTI was light purple/pink, blanchable and without drainage. A light skin colored small scab was noted forming over the center of the left heel area, measuring approximately 0.5 cm. A review of R32's electronic medical record (EMR) revealed wound care documentation of R32's left heel DTI and left elbow began on 6/7/23. Further review revealed the following: 06/07/2023, 09:50 AM, Treatment Note: . Left Elbow . Pressure . Unstageable, Wound Measurement . Length 2.7 cm (centimeters), Width 1.4 cm, Wound bed: Slough 90 % (percent), Appearance Red/Blanchable outward 1.5 cm, . Any Change in Wound?: Worsened new unstageable wound to elbow . 06/07/2023, 02:36 PM, Treatment Note: . Left Posterior Heel . Pressure . DTI, Wound Measurement . Length 0.8 cm, Width 1.1 cm, Wound bed: Appearance Red/Blanchable outward to the lateral 4 cm, outward to the medial, distal and proximal 1 cm each area, . Any Change in Wound?: Worsened new, Description of Change: new wound . A review of R32's care plan for the problem area, Resident is at risk for developing pressure injuries or other skin breakdown R/T [related to]: Diabetes, PVD, other displaced fracture of lower end left humerous (sic) . revealed the approach for the care plan, initiated on 6/2/23, was Derma Saver boots to be in place to BLE [bilateral lower extremities] at all times while resident is in bed . ; Elevate heels off mattress at all time while in bed using a pillow with a Derma Saver footpad over it, placing both under bilateral calves so heels are not in contact with mattress r/t aiding in pressure redistribution; Observations, monitors and treatment applications as per Physician's or nursing orders; Please refer to the standards of care. Resident #93 (R93) R93 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's, dementia, and contracture of muscle. Review of R93's quarterly MDS assessment, dated 5/26/23, revealed R93 required extensive, two-person physical assistance with bed mobility and was totally dependent on staff for transfers. Section C - Cognitive Patterns, revealed R93 was marked no as not being conducted related to resident being rarely/never understood under Brief Interview for Mental Status (BIMS). On 6/27/23 at 1:30 PM, an interview was attempted with R93 who did not respond to this Surveyor. R93 just stared with his mouth open. R93 was observed in his room lying in his bed wearing a hospital gown and a brief with a white bed sheet coving him, but his feet were visible. R93 had his legs crossed and was wearing gripper socks with his heels on his mattress. Upon exit a hand brace was observed hanging on a hook to the upper left of his sink a hand brace protector. On 6/27/23 at 2:30 PM, an observation was made of R93 in his room. R93 was lying in his bed, wearing a hospital gown, and had a white bed sheet over top of his torso. R93 was wearing a pair of gripper socks on his feet with his heels resting on his mattress. R93's hand brace remained on the hook near his sink in his room. On 6/28/23 at 7:40 AM, an observation was made of R93 in his room. R93 was lying in bed, with legs crossed, wearing gripper socks. R93's feet were not elevated on a pillow and he was not wearing derma saver boots. R93 was also observed rubbing his heels on the mattress. On 6/28/23 at 9:10 AM, an observation was made of R93 in his room. R93 was lying in bed with legs crossed, no pillow between them, feet not elevated with only gripper socks on, no derma saver boots on feet, and no hand brace on the left hand. On 6/29/23 at 7:45 AM, an observation was made of R93 in his room. R93 was lying in bed with bare feet, heels not elevated, legs crossed without a pillow in between them and no hand brace on the left hand. R93 was also observed rubbing his heels on the mattress. On 6/29/23 at 7:50 AM, an interview was conducted with Certified Nurse Aide (CNA) C. CNA C was asked if R93 should have protector boots on, his hand brace on and his heels elevated off his mattress. CNA C replied, He should have them on. CNA C immediately went into R93's room. CNA C then exited the room and called for CNA B to assist her with R93. CNA B was asked where R93's derma saver boots were and replied, They were in his closet. CNA B was asked if he was aware that R93 was to have his heels floated and replied, Yes, they are to be floated so they are not on his mattress. CNA B and CNA C both confirmed that care plan interventions for R93 were not being implemented. Review of R93's progress notes, dated 6/7/23 at 9:50 AM, revealed in part: Skin: MDS quarterly assessment completed for . end date of 5/26/23. [R93's] Braden scale score is 13, which is an indication that he is at a moderate risk for developing pressure injuries . is incontinent of bowel and bladder. He is an assist of 2 with transfers via a Hoyer lift, he is non-ambulatory and an assist of 1-2 for bed mobility . There are orders in place for Heel elevations . There is also a Dermasaver [sic] . The care plan has been reviewed. Review of R93's care plan for problem area, [R93] is at risk for developing pressure injuries or other skin breakdown R/T: Alzheimer's, dementia, pain, depression, functional urinary incontinence . Revealed the approach for the care plan, initiated on 4/18/2022, was Derma Saver boots to BIL [bilateral] feet at all times while in bed for pressure redistribution r/t [related to] blanching redness to heels; initiated date 1/10/2022 Elevate heels off mattress at all times while in bed using a pillow with a Derma Saver foot pad over it, placing both under bilateral calves so heels are not in contact with mattress r/t aiding in pressure redistribution. Review of R93's physician orders, dated 9/27/2022, revealed, Palm protector to left hand . During an interview on 6/29/23 at 11:00 AM, with the Director of Nursing (DON). The DON confirmed, per facility policy, a Braden scale skin assessment should have been completed on admission to the facility for R32. The DON also acknowledged a second Braden skin assessment should have been completed prior to the seventh day of R32's stay at the facility. The DON stated care plan interventions should have been followed for both R32 & R93. The DON stated the expectation was care plan interventions were to be in place. The DON confirmed anyone admitted to the facility with pressure ulcers would be considered a high risk for developing further pressure ulcers. The DON confirmed nursing should have been charting in the EMR daily on skin color, movement, and sensation with a medical device. Review of facility policy titled, Baseline Care Plan, last revised date 11/27/17, revealed the following in part: The facility will develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .

Based on interview and record review, the facility failed to ensure implementation of the written abuse policy including prohibition, prevention, and training to ensure appropriate abuse reporting and action for one Resident (#2) of three residents reviewed for abuse. This deficiency resulted in abuse policy implementation failure when staff and the facility failed to report, prevent, and protect Resident #2 from abuse according to their policies following an allegation of abuse. Findings include: This deficient practice was related to Facility Reported Intake #MI00132916. Review of the Investigative Summary revealed Certified Nurse Aide (CNA) A reported an allegation of abuse on 11/14/22, that occurred on 11/12/22, to Registered Nurse C. The allegation was immediately reported to the Director of Nursing (DON) on 11/14/22 at 2:03 a.m. Allegation details included the following, in part: [CNA A] and [CNA B] were performing incontinence checks and [Resident #2] had a bowel movement. [CNA A] stated that she was holding [Resident #2] over on her side facing the window when CNA B held a wipe with stool in front of [Resident #2's] face and said, 'Here [Resident #2]'. [CNA A] then said that after [CNA B] finished wiping her, he punched [Resident #2] in the butt cheek 3, 4, or 5 times with a closed fist and medium force . The local police authorities were called on 11/14/22 at 3:09 a.m., and CNA B was telephoned and told not to report for work until further notice and was suspended pending investigation. During an interview on 12/21/22 at 11:03 a.m., the Nursing Home Administrator (NHA), DON, and Assistant Director of Nursing (ADON) D were interviewed regarding actions taken by the facility following 11/12/22, the day of the alleged abuse. The NHA and DON agreed CNA A should have reported the allegation of abuse immediately to the NHA and DON, and confirmed it was approximately 48 hours before she reported the allegation. When asked if CNA B had worked following 11/12/22, ADON D, who had worked on the event investigation confirmed CNA B had worked on 11/13/22, prior to knowledge of the abuse allegation. CNA B worked 12-hour shifts in the facility. Review of the Abuse Prohibition/Abuse Investigation Policy, reviewed 11/14/22, revealed the following, in part: .D. Identification: 1. Any person (defined as staff, families, visitors, or other residents) who suspects or has reasonable cause to believe that a resident has been subject to abuse must immediately report the issue to: a. The Administrator [Telephone Number and Location] And b. The Director of Nursing [Telephone Numbers and Locations]. If the allegation of abuse is reported to the Nurse, Resident Care Coordinator, Nursing supervisor, or Staff Nurse, he/she must immediately report the issue to the Administrator and Director of Nursing so that appropriate action is assured . Assure that the resident has had an immediate and thorough nursing physical examination if applicable or medical attention as necessary . In a case involving an employee, at a minimum, the employee should be separated from further contact with the resident, which may include suspension with or without pay during the investigation . In response to allegations of abuse, neglect, exploitation or mistreatment, the facility will ensure that all alleged violations involving abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made . The facility immediately identified the deficiency in failure to implement their abuse policy related to CNA's failure to report in the specified timeframe to the facility, and failure to ensure the protection of residents related to allegations of abuse. The following Action Plan to address the deficiency was immediately implemented and included the following steps: 1. Resident was assessed multiple times with no noted injuries or psychosocial change. Employee (CNA A) was re-educated on abuse, abuse reporting, abuse policies, and the Elder Justice Act by the DON immediately. 2. All residents have the potential to be affected. Abuse audits were performed without any additional issues. (Audits conducted 11/14/22 through 11/22/22) 3. All staff were re-educated on abuse reporting. Facility Abuse policy and procedure reviewed (11/14/22 through 11/22/22) 4. Audits will be completed three times a week x 4 weeks, once a week x's 4 weeks with results to QAPI until determined substantial compliance. The Administrator is responsible for sustained compliance. While this deficiency did occur, the facility self-identified the issues involved, educated all staff, completed a thorough investigation, and performed resident and staff audits to ensure continued compliance, therefore Past Non-Compliance has been determined.

Based on interview and record review, the facility failed to provide adequate supervision to prevent falls and to develop and implement appropriate care plan interventions for one Resident (#32) of six residents reviewed for supervision. This deficient practice resulted in a fall with major injury. Findings include: Review of a facility incident report dated [DATE] and written by Licensed Practical Nurse (LPN) G revealed Resident #32 experienced an unwitnessed fall in his room at 4:30 p.m. on [DATE]. The Resident was observed on the floor laying on his back by the wall opposite of his bed with his head on the bottom of the overbed table. The report further revealed, .States he hit his head. Floor wet. Incontinent of urine. States he was trying to get to commode .Zero bumps or redness to back of head. [Resident with complaints of head pain] Unable to follow directions to grasp hands. All other neuros [within normal limits] immediate corrective action increased resident supervision. Remind to use call light and ask for assistance. The electronic medical record (EMR) Event Report dated [DATE] read, in part, found on floor (unwitnessed) .what was resident doing in the last hour prior to the fall: sitting in electric w/c . trying to transfer self to commode, mood or mental status - confusion .interventions: rest .increased supervision, reminded to use call light and ask for assistance . The Event Report revealed the physician was not notified until the next day on [DATE] at 2:04 p.m. A review of the Occupational Therapy Screening Form dated [DATE] read, in part, .reason for screen: wheelchair safety .patient exhibits the following problems: safety risk .staff noting [patient] increased safety risk [with] falling asleep in chair and running into objects .occupational therapy is not recommended .Staff education on encouragement to rest when tired for increased safety, as well as to [continue] safety checks as needed .Contacted the appropriate nursing home personnel for order. A review of the EMR revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including: chronic obstructive pulmonary disease, congestive heart failure, osteoarthritis, dependence on supplemental oxygen, history of falling, muscle weakness, and atrial fibrillation. The EMR also showed Resident #32 expired at the facility on [DATE] at 7:30 a.m. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact and required one staff supervision for transfers and toileting. A telephone interview was conducted with Certified Nurse Aide (CNA) J on [DATE] at 8:41 a.m. CNA J stated that she used to work with Resident #32 often and confirmed that he had a seatbelt for the use of his wheelchair. CNA J stated that he used to ride in his wheelchair often without his seatbelt fastened and became more compliant but would still not wear the seatbelt at times. CNA J stated that Resident #32 would often fall asleep in his wheelchair and would slump his body over the side or forward. When asked if staff were instructed to complete safety checks or more frequent monitoring, CNA J stated that CNAs on the floor were conscious of checking more because he was falling asleep in his chair but were never specifically told to document more frequent rounds on Resident #32. An interview was conducted with CNA I on [DATE] at 8:44 a.m. CNA I stated that Resident #32 fell asleep and ran into objects with his electric wheelchair. CNA I stated that Resident #32 had a seatbelt for his wheelchair but would not always wear it. CNA I confirmed Resident #32 did have 15-minute safety checks, but they were discontinued sometime prior and could not recall the exact date. On [DATE] at 9:16 a.m. a telephone interview was conducted with LPN G. LPN G stated that she was the nurse on schedule the afternoon of [DATE] and responded to Resident #32's fall. LPN G stated she was notified by CNA H that the Resident was found on the floor and stated he was trying to get to the commode. CNA H said he was last seen sitting in his electric wheelchair about 45 minutes prior. LPN G and staff transferred the Resident back to his wheelchair when he began to lose consciousness, turned grey, and stopped responding. LPN G stated that CNA H left the room to get help while she attempted to get the Residents oxygen back in place when the Residents eyes rolled to the back of his head. LPN G stated that staff transferred the Resident into bed for assessment. LPN G stated that the fall protocol for vital signs was every 15 minutes for one hour, then every hour for four hours, every four hours for four hours then once per shift. LPN G noted that the Resident's blood pressure was low (in the 70's) but stated that it did not concern her since she retook both blood pressures and found it to be 90 something over whatever. LPN G stated she did not know that the Resident had atrial fibrillation. When asked if LPN G notified the physician on [DATE] she stated, No. I guess I didn't realize I needed to. When asked if she had been notified that the Resident was to have increased supervision LPN G stated no. When asked if she was aware of incidents where the Resident was observed falling asleep in his wheelchair, LPN G stated, Yes. He was unsafe in operating of wheelchair. Two weeks before that he was driving his wheelchair and he had run into one of the lifts. LPN G said that she was checking in on the Resident more frequently on [DATE] but did not document every check-in and stated that the Resident was attempting to climb out of bed the night of [DATE] showing signs of increased confusion. Review of Resident #32's vital signs on [DATE] and [DATE] revealed the following: [DATE] 4:30 p.m. blood pressure (BP) ,d+[DATE], 103 beats per minute (BPM) [DATE] 4:45 p.m. BP ,d+[DATE], 118 BPM [DATE] 5:00 p.m. BP ,d+[DATE], 122 BPM [DATE] 5:15 p.m. BP ,d+[DATE], 120 BPM [DATE] 7:15 p.m. BP ,d+[DATE], 83 BPM [DATE] 8:15 p.m. BP ,d+[DATE], 109 BPM [DATE] 1:15 a.m. BP ,d+[DATE], 103 BPM [DATE] 5:15 a.m. BP ,d+[DATE], 108 BPM Review of progress notes dated [DATE] at 6:23 a.m. read, in part, Called to room by direct care staff, Resident pale in color with no respirations. No apical heart rate auscultated for greater than 60 seconds, no BP, pupils were fixed and dilated. Time of death was 0730. Wife was notified of death at 0737 . Review of a fax to Physician K dated [DATE] read, in part, (Resident #32) fall [DATE]. Stated he hit head. Resident did have an altered level of consciousness .Resident passed away [DATE] at 7:30 a.m. Review of Resident #32's care plans printed on [DATE] did not show any interventions of increasing safety checks for the resident or to monitor that the Resident's seatbelt was properly fastened while in his wheelchair. The care plan did reveal If resident is noted to be fatigued or falling asleep in wheelchair encourage him to lie down in bed. Review of the policy (Facility Name) Fall/Fall Risk Program dated [DATE] read, in part, .The Rehab Coordinator/designee will identify and initiate fall interventions with staff, resident and or family input which will be reflected in the plan of care .a physician's order will be generated for care planning purposes as needed. Interventions will be monitored for effectiveness and adjusted as necessary .The [physician] will be updated and review all falls .staff will observe for the effectiveness of the interventions and change or modify interventions as needed .The Nursing Staff will monitor for complications post fall for 48 hours. Late consequences of falls will be considered for all residents experiencing a change in function, mental status or level of consciousness for several weeks post fall . An interview was conducted with the Assistant Director of Nursing (ADON) on [DATE] at 9:38 a.m. The ADON confirmed that Resident #32's fall was not reported to the physician timely and that a root cause analysis of the fall was missed.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any or all the 112 residents in the facility. Findings include: On 3/23/22 at 7:45 AM observations were made of the point of service on the 600 hall morning meal. Two cups of poached eggs were observed sitting on the counter. The temperature was measured using a metal stem thermometer and found to be 91°F. An interview with Activity staff C, who was serving the food was conducted and asked if the egg temperature had been measured. Staff C stated No. It was taken when it was in the kitchen. Staff C pointed to a temperature log sheet lying on the counter. When reviewed. the log sheet did not have any entries documenting appropriate temperatures requirements. At the same time, a container of breakfast sausage was observed on the counter. The temperature of the sausage was measured to be 117°F. All the hot food being served was observed to be sitting on the counter without any heated device being used to maintain the food temperature. The FDA Food Code 2013 states: 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 §3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roast 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 54°C (130°F) or above; or (2) At 5ºC (41ºF) or less On 3/22/22 at 2:45 PM the refrigerator in the 600 unit's pantry/kitchen was observed to have two home canned containers of vegetables, including what appeared to be peppers, tomatoes, cucumbers, and other unidentified contents. A date on the lid read 2/21. Staff C stated he was not aware the containers were in the refrigerator and the resident identified on the jars was not on the unit anymore. An interview with Certified Nurse Aide B was conducted at this time. Staff B stated she did not know what the dates meant and was not aware the containers were in the refrigerator. The policy Use and Storage of Food Brought in by Family or Visitors (undated, unsigned) was provided and reviewed. Under the Heading Policy Explanation and Compliance Guidelines: was stated the following: 2. All food items that are already prepared by the family or visitor brought in must be labeled with contend and dated. a. The facility may refrigerate label and dated prepared items in the nourishment refrigerator. b. The prepared food must be consumed by the resident within 3 days. c. If not consumed within 3 days, food will be thrown away by facility staff. The FDA Food Code 2013 states: 3-101.11 Safe, Unadulterated, and Honestly Presented. FOOD shall be safe, unadulterated, and, as specified under § 3-601.12, honestly presented On 03/22/22 at 7:46 AM during the initial kitchen tour, four rolling bins labeled: flour, powdered sugar, oats, and wheat flour were observed to be dated as last cleaned on 2/27/21. The Certified Dietary Manager (Staff A) stated, The bins are supposed to be cleaned one time per month. It looks like we have not been doing that. During the same tour, the gas stove was observed to have copious amounts of furry dust around the control knobs and on the overhead nozzles of the fire suppression system. The stove crumb catcher pans had brown and amber dried cooked on debris with dehydrated food pieces. Staff A explained this was not from breakfast and should have been cleaned. The FDA Food Code 2013 states: 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. On 03/22/22 at 7:46 AM during the initial kitchen tour, the first reach-in refrigerated unit was observed to have juice cartons with label stickers. A fruit punch carton had a Use by date of 3/21, an apple juice carton had a Use by date of 3/13, and 4 other cartons of open juice had label stickers without any writing to indicate when opened or when outdated. The walk-in cooler had a rolling cart with items Staff A stated had come off the salad bar the previous day. These salad bar items including a pasta salad, mandarin oranges and cauliflower were not labeled or dated. The 2013 FDA Food Code states: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on observation, interview, and record review, the facility failed to adequately assess and monitor a wound to prevent worsening for one (Resident #62) of five residents reviewed for pressure ulcers. This deficient practice resulted in the worsening of an identified wound and the potential for pain and infection. Findings include: On 3/22/22 at 9:28 a.m., wound care was observed for Resident #62, performed by Registered Nurse (RN) E, and assisted by Licensed Practical Nurse (LPN) D. Resident #62 gave verbal permission for the observation. While setting up dressings and equipment, LPN D confirmed the Resident's sacral wound in January 2022 was simple shearing, but then changed to a stage 4 pressure ulcer. RN E removed the old dressing, which was saturated with red/brown serosanguineous drainage. The stage 4 pressure ulcer appeared to be about 3 centimeters (cm) roughly round, with significant tunneling at least one cm at about 12:00 and undermining around the entire wound. Connective tissues (muscle/ligaments) and adipose (fat) tissue were present and visible to the wound bed. The surrounding area was intact and clean. RN E cleansed to wound with pressurized sterile saline, then repacked and dressed the wound. The Minimum Data Set (MDS) assessment, dated 1/10/22, revealed Resident #62 was cognitively intact, required extensive assistance of one person for most activities of daily living (ADLs). The assessment also revealed the Resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/22/22 at 2:46 p.m., Resident #62 was asleep in bed positioned with pillows on her left side. Progress from admission on 6/24/21 revealed the following: 6/24/21 at 3:57 p.m. admission assessment: Buttocks crease and posterior peri area does have some redness and will be monitored daily during assessment of dressing placement . 6/24/21 at 4:10 p.m. admission charting: Resident stated buttocks was a little sore . [related to] 'sore on my butt .' From 6/27/21 to 7/6/21 notes reveal a reddened dressed area to the sacrum. 7/7/21 at 1:49 p.m. a progress note revealed an open area to the sacrum that measured 0.6 by 0.5 centimeters (cm). 7/7/21 at 2:01 p.m. a skin progress note called the area a shearing wound and noted improvement based on a smaller wound. But there were no prior measurements documented for comparison. From 7/8/21 to 8/11/21 notes revealed a superficial shearing area varying from 0.5 by 0.5 to 1.5 by 0.5 cm area. 8/11/21 at 1:00 p.m. a progress note revealed the area to be .scabbed . and measured 0.5 by 0.7 cm. On 8/12/21 a discharge note revealed a dressing in place to the scabbed area at the sacrum. On 9/10/21 an admission skin assessment noted a 4.3 cm scar to the sacral area, with no open areas. On 10/8/21 a skin assessment note revealed an open area that measured .9 by .9 cm to the left sacral area and a .4 by .5 cm open area to the right sacral area that was described as shearing. From 10/8/21 to 1/2/22 treatment progress notes revealed a shearing superficial area to the sacral region varying in size from 0.5 by 0.5 to 2.5 by 2.5 cm with no depth measurements, and no noted signs of infection or complication. On 1/3/22 a skin progress note revealed: . [treatment coordinator] in to assess left sacral region area of shearing this shift. On assessment, slight depth beginning to form .appears to be connective tissue at this time .adipose tissue present at this time .Wound area is changed to a [stage 4 pressure ulcer] at this time . During an interview on 3/23/22 at 10:01 a.m., LPN D and RN E were present. LPN D confirmed she was the treatment coordinator of a department staffing one other full time treatment nurse (RN E) and two part time nurses. LPN D said she did not visualize Resident #62's wound for some time as she was off for a period in December 2021. On 1/3/22, when she returned, LPN D confirmed she saw the Resident and assessed the wound to be a stage 4 pressure ulcer. LPN D confirmed the Resident's physician rounded monthly but did not observe the Resident's sacral wound more frequently during 2021. LPN D said a physician would be notified by herself or other treatment nurse if needed and that notification would be documented. Resident #62's progress notes were absent any physician notification regarding wounds in 2021. LPN D was asked about a wound policy and what it articulated. LPN D said she was unaware of any written policy outlining specific wound care. LPN D confirmed her wound care certification in 2015 through a recognized authority. LPN D was asked how a superficial shearing wound could deteriorate in 24 hours to a stage 4 pressure ulcer and confirmed that was unlikely. LPN D confirmed each time orders were changed for wound care, the treatment nurses changed the order, and the physician signed the order on rounds or remotely but did not necessarily observe each wound. Fax communications with the physician revealed the following: Sent on 10/14/21 notification of shearing areas to sacrum, noted by physician, with no new interventions ordered. Sent on 12/31/21 notification of shearing remains superficial with no new interventions ordered; signed by physician on 1/5/22. Sent on 1/5/22 notification of change to stage 4 pressure ulcer with no new interventions ordered; signed by physician on 1/6/22. Sent on 1/17/22 notification of a deteriorating wound with odor and slough formation, with new order for antibiotic administration; physician signed but not dated. Fax stamp showed return to facility on 1/18/22. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] 10/6/21 No skin issues noted, continue current treatment 11/3/21 a stage 2 pressure ulcer is noted on physical exam 12/1/21 noted on physical exam section: .I did not examine her wound today . no skin treatments noted 1/5/22 Stage 2 pressure ulcer noted to sacrum with no noted treatment changes. 2/2/22 Stage 4 pressure ulcer; continue current treatment 3/2/22 Stage 3 pressure ulcer During an interview on 3/23/22 at 10:29 a.m., the Assistant Director of Nursing (ADON) RN F said the Director on Nursing (DON) (who was not available during the survey) conducted a weekly skin meeting with the MDS nurse, dietary department, and treatment nurses, to discuss all wounds, as a result of a QA (quality assurance) project. Weekly skin meeting minutes revealed the following for Resident #62: 7/29/21: shearing resolved 11/4/21: shearing to left sacral area 11/11/21: shearing improved 11/18/21: shearing stable 12/1/21: shearing improves, then worsens 12/9/21: shearing stable no notes for week of 12/16/21 or 12/23/21 12/30/21: shearing stable 1/6/22: stage 4 to sacrum During a follow up interview on 3/23/22 at 11:30 a.m., LPN D again confirmed she was off much of the month of December 2021 and her first day back was 1/3/22, when she observed Resident #62's wound and staged it as a stage 4 pressure ulcer. When asked if she could tell when the wound deteriorated or over what time frame, LPN D said she didn't know and confirmed it was very unlikely the wound deteriorated over 24 hours to a stage 4 pressure wound. The policy Pressure Injury Prevention and Management, dated 3/27/19, revealed, .This facility is committed to reducing the risk of pressure injuries and the promotion of healing of existing pressure injuries .The facility shall establish and utilize a systematic approach for pressure injury risk reduction and management, starting with prompt assessment and treatment, including efforts to identify risk, stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate Monitoring .The attending physician will be notified of the presence, or lack of healing of any pressure injuries upon identification of the injuries .

Based on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards of practice for food service safety, as evidenced by: A) Failing to ensure proper dating procedures for potentially hazardous foods. B) Failing to ensure proper dating procedures for dry goods and canned foods. C) Failing to ensure potentially hazardous foods were held at proper holding temperature. These deficient practices resulted in the potential for food borne illness for all 109 facility residents. Findings include: During the initial tour of the kitchen on 10/27/20, beginning at 2:25 p.m. , the walk-in refrigerator in the facility main kitchen was observed with the Certified Dietary Manager, (CDM) M. The following items were noted: 1) A clear plastic container of diced green honeydew melon, with a handwritten use-by date of 10/19/20. 2) A 64 ounce blue cheese salad dressing, with a handwritten date of 7/07/20. 3) A 64-ounce Dijon mustard salad dressing, with a handwritten date of 6/30/20. CDM M immediately picked up these items and disposed of them, and stated, This (these items) should have been thrown out. During a subsequent tour of the dry goods food storage area on 10/27/20 at 2:55 p.m., in the facility main kitchen, the following items were noted without dates of receipt, or use by dates: 1) A large 105 ounce can of yellow cling peaches. 2) A large 105 ounce can of crushed pineapple. 3) A large 105 ounce can of diced peaches. 4) A large 105 ounce can of fruit cocktail. 5) A large 105 ounce can of pumpkin. 6) A large 6 pound can of cheddar (aged) cheese sauce. 7) A large bag of shredded coconut. 8) A large 112 ounce can of apple pie filling. 9) A large 126 ounce can of hot fudge syrup. CDM M removed these items from the shelves, and stated, It has been on my mind to date (mark a date on the items) when things (foods) come in (arrive at the facility from the vendor). CDM M denied any dietary process to regularly label, date, or review the dates of dry/canned foods. During an observation on 10/28/20 at approximately 1:00 p.m., CDM M accompanied Surveyor to the (number identifying hall) to temp (check the holding temperature) of the resident beverage cart. A ½ gallon milk container was observed on a metal cart, inside a grey plastic container, about five inches in depth. Ice was observed in part of the container, only covering a few inches of the milk container. CDM M poured a cup of milk from the ½ gallon plastic container of milk into a four ounce plastic cup, and measured the temperature of the milk using a digital (Vendor name) red thermometer with a metal stem. The thermometer read 48 ° Fahrenheit (F). CDM M discarded it immediately, and stated, It (the holding temperature) should be below 41 degrees (Fahrenheit). During an observation on 10/29/20 beginning at 8:00 a.m., CDM M accompanied Surveyor to the (same resident hall) to temp the resident beverage cart. A ½ gallon of milk and four ½ gallon juice containers were observed on a metal cart, inside a grey plastic container, about five inches in depth. Ice was observed in part of the container, beginning to melt. CDM M poured a cup of milk from the ½ gallon plastic milk container into a four ounce plastic cup, and measured the temperature of the food using a similar digital (Vendor name) red thermometer with a metal stem. The thermometer read 48 ° F. A second same type of thermometer was used with the same reading noted. Next, a ½ gallon container of white grape juice was temped (measured) by CDM M and observed at 49 ° F. CDM M stated, Clearly, we need to add more ice and get deeper bins (beverage holding containers). CDM M removed the milk and juice containers from the beverage cart, and discarded them. Review of the policy titled, (Facility name) Dietary Policy, dated 4/14/10, provided by the Director of Nursing (DON) on 10/29/20, revealed, .Dry storage: .Stock is rotated to prevent food from becoming outdated and spoiled. First-in, First-out is the rule. Items are arranged in an orderly fashion with labels toward the front .Label food with date it is opened or prepared and use by date: .cut melon: 3 days .salad dressings Use by date on container . Review of the policy titled, (Facility name) Dietary - Food Handling, dated 4/04/2010, provided by the DON on 10/29/20, revealed, .Items below must be maintained at the following temperatures: a. Cold food: stored at 40 ° F or below .All potentially hazardous food must be kept at 40 ° F or less .

Based on observation, interview, and record review, the facility failed to ensure two of four dish machines received verification of proper chemical sanitization during a focused COVID-19 Infection Control Survey. This deficient practice had the potential for transmission of infectious organisms which had the potential to affect all 27 residents who reside on the 500 and 600 Wings within the Memory Care Unit. Findings include: During an interview on 4/21/20 at 12:10 p.m., Plant Manager (Staff) B was asked what type of dish machines were used in the Memory Care Unit. Staff B reported cool temperature machines. When queried about sanitization testing, Staff B said staff should perform testing after the rinse cycle three times per day with breakfast, lunch, and dinner. On 4/21/20 at 12:20 p.m. during observations and interviews of the dish machines on the Memory Care Unit, in the presence of Staff B, Certified Nurse Aide (CNA) C, CNA D and CNA E all confirmed use of the dish machines and said no sanitization testing occurred by any of them. CNA C stated, Maintenance does this on night shift. Staff B then stated, Supposed to be done three times per day. CNA E then stated, We've never been shown that (how to perform sanitization testing). When asked to provide the dish machine sanitization logs, Staff B opened several cabinets and looked on shelves and stated, I didn't see any (logs). On 4/21/20 at 12:30 p.m., Certified Dietary Manager (CDM) F entered the 500 Unit in the Memory Care Unit. CDM F confirmed staff had not been performing dish machine sanitization testing. CDM F performed testing on the dish machine with guidance provided by Staff B. CDM F confirmed dish machine testing supplies had not been provided on either the 500 nor 600 Wings. A review of facility provided policy and procedure, Dishwater Temperature 5/7/2018, read in part, It is a policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions .Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded . A review of facility provided, LXe Series Dishwasher Instructions, March 2014, page 12, read, Follow the directions precisely that are on the litmus paper vial and test the water on the surface of the bottom of the glasses. Concentration should be 50 p.p.m. (parts per million) minimum to 100 p.p.m. maximum . Review of FDA (Food Drug Administration) 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that: (J) EMPLOYEES are properly SANITIZING cleaned multiuse EQUIPMENT and UTENSILS before they are reused, through routine monitoring of solution temperature and exposure time for hot water SANITIZING, and chemical concentration, pH, temperature, and exposure time for chemical SANITIZING Second: 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the SANITIZING solution shall be accurately determined by using a test kit or other device . During an interview on 4/21/20 at 12:45 p.m., when asked why dish machine sanitization had not occurred since installation on the Memory Care Unit, the Nursing Home Administrator stated in part, Not sure what happened with the communication there. During a telephone interview on 4/21/20 at 4:33 p.m., when asked if routine dish sanitization testing was necessary on the Memory Care Unit, the Director of Nursing responded, Absolutely.

Based on observation, interview, and record review, the facility failed to provide necessary supervision and assistive devices (door alarms) to prevent elopement from the facility for two Residents (#1 & #2) of three residents reviewed for safety/supervision. This deficient practice resulted in Resident #1 and Resident #2 exiting the facility unsupervised. Findings include: Resident #1 Review of Resident #1's Minimum Data Set (MDS) assessment, dated 5/21/19, revealed Resident #1 was admitted with [DIAGNOSES REDACTED]. Resident #1 scored 3 of 15 on the Brief Interview for Mental Status (BIMS), reflective of severely impaired cognition, and was rarely understood, and sometimes able to understand others. Resident #1 required supervision with setup help only for room and corridor ambulation, wandered in the facility, and wore a roam alert band daily to prevent elopement from the facility. Review of the facility Investigation Summary Report, regarding Resident #1's elopement on 6/27/19, revealed the following timeline based on video footage reviewed on camera #8 (new system) and camera #3, in part: 16:04 (4:04 p.m.) (Resident #1) walks into gathering room on 700 wing, walks towards side door and is looking out the glass. 16:06 (4:06 p.m.) Visitor walks to door, enters the code on the keypad, and proceeds to hold the door open for (Resident #1) . 16:08 (4:08 p.m.) (Certified Nurse Aide (CNA) I) is out on the walk-way walking towards (Resident #1) . On 8/12/19 at 11:49 a.m. the surveillance video of the 700 Hall gathering room exit door on 6/27/19 at approximately 3:15 p.m. showed a facility visitor entering the exit door code to permit the door to open without an alarm. The visitor then held the door open, allowing Resident #1 to walk out of the facility directly behind the visitor. No staff were present to prevent Resident #1 from leaving the building unsupervised, and a roam alert alarm was not present on the 700 Hall gathering room door to notify staff Resident #1 had left the building. On 8/12/19 at 8:35 a.m., when asked about Resident #1's elopement from the facility, the Nursing Home Administrator (NHA) stated, We purchased roam alert alarms, but we didn't activate them .We didn't anticipate someone would let a resident outside . Review of Resident #1's Potential for Unsafe Wandering Admission Assessment, dated 10/24/18, revealed Resident #1 had a Total Score of 16 and was noted as At risk, roam alert placed (on right ankle). A total score of 10 or more placed the resident At Risk for Unsafe Wandering. An Elopement Risk event (assessment), completed 5/30/19, revealed Resident #1 continued to be an elopement risk. Review of Resident #1's Potential for Unsafe Wandering care plan, revealed the following interventions at the time of elopement: Check placement of roam alert (band) every shift and PRN (as needed), 11/19/18 .Notify nurse of any increase in wandering, agitation, and attempts of elopement. Redirect away from exits; offer food, engage in conversation, walk with resident, etc. Observe whereabouts frequently, 10/24/18. On 8/12/19 at 8:50 a.m. all facility exit doors were observed with the Director of Nursing (DON), the NHA (until 9:10 a.m.) and Maintenance Director /Staff A (after 9:10 a.m.). Doors #13 (Dining Room exit door), #19 (500 Hall exit door), and #21 (600 Hall exit door) were found to have a keypad to disable the door alarm, and no backup alarm, or roam alert alarm to notify staff someone had opened or exited through those doors. Staff A said he would place a secondary alarm on each of those three doors. On 8/13/19 at 9:00 a.m., when asked about the 700 Hall door alarms, Staff A stated, The 700 gathering room door just had a 15 second delayed egress (exit). If they pushed on the door it would alarm the magnet and the staff pagers (held by nurses and Certified Nurse Aides (CNAs)) .Before (Resident #1) got out (of the facility), there was no roam alert alarm on that door .Residents like to go down there and sit, and we didn't want staff to have to run down there every 10 seconds . Staff A confirmed use of the keypad code disabled the egress alarm, allowing the door to open with no alarm sound. When asked about lack of a backup or roam alert alarm on the dining room exit door, Staff A stated, The dining room door is used a lot, and when we put up the new panel - you can't bypass this system. I guess it was an overthought. It should have been on the panel (to show location of the door alarm) . Resident #2 Review of Resident #2's Admission MDS, dated [DATE], revealed Resident #2 was admitted with [DIAGNOSES REDACTED]. Resident #2 was unable to complete the BIMS assessment and was documented with moderate cognitive impairment. Resident #2 was rarely understood, sometimes able to understand others, and required supervision for ambulation with no physical assistance from staff. Resident #2 wore a roam alert band daily to prevent elopement from the facility. Review of the facility Investigation Summary Report, regarding Resident #2's elopement on 7/29/19, revealed Resident #2 walked out the 400 Wing door (unseen and unsupervised) and it shut behind her at 15:24 (3:24 p.m.). The door alarm sounded. At the same time a visitor with a dog was at the 300 Wing exit door. Nursing staff, seeing the visitor and dog at the 300 wing exit door, turned off the alarm. Resident #2 walked into the 600 Wing courtyard, opened the gate, exited the courtyard and closed the gate. Resident #2 walked along the fence toward the SNU (skilled nursing unit) parking lot and into the main building parking lot. Resident #2 was returned to the facility by facility staff at 15:30 (3:30 p.m.). On 8/12/19 at 8:35 a.m., when asked about Resident #2's elopement, the NHA stated, If we looked at the alarm to see what door was opened, we would have checked the right door. It wasn't a seasoned nurse, who maybe didn't know to look at the (alarm) panel for the door before deactivating the alarms. Nobody opened the (exit) door and looked out (for a resident). On 8/12/19 at 11:49 a.m. observation of surveillance video of Resident #2's elopement on 7/29/19, with Nurse Risk Manager/Registered Nurse (RN) F, confirmed the above Investigation Summary details. Review of Resident #2's Potential for Unsafe Wandering Admission Assessment, dated 7/29/19, revealed Resident #2 had a Total Score of 18 with the following interventions marked for Resident #2: 1. Roam Alert Bracelet - placed on Right Ankle only. Check placement every shift. Check operation per facility policy. 2. Re-direct away from exits - offer food, engage in conversation, walk with resident, etc. On 8/12/19 at 3:15 p.m. CNA J said she heard the door alarm sounding on 7/29/19 when Resident #2 eloped but didn't know which alarm it was. CNA J stated, I looked out the 600 Wing doors - the doors between the 400 Hall and the 600 Hall and then I looked outside the window of the 400 exit door. Then the alarm shut off . I didn't go outside . I looked from inside but never went outside. If I knew it was on the 400 Hall, I would have been outside (looking for a resident) . On 8/13/19 at 1:20 p.m., Licensed Practical Nurse (LPN) O was interviewed by telephone. When asked about Resident #2's elopement on 7/29/19 LPN O said she was orientating to her position that day and was standing at the 300/400 nurses station talking with LPN K and the NHA when the door alarm sounded. LPN O stated, .There was a guy with his dog at the 300 Hall door. We all thought they (visitor and dog) had set off the alarm, so I turned around and shut it (door alarm) off .I totally forgot to check where the alarm was sounding before I turned off the alarm . LPN O confirmed the door alarm panel at the nurse's station would have indicated which door alarm was sounding, but she did not look at it. Review of the facility Potential for Unsafe Wandering policy, dated 7/5/19 revealed the following, in part: . RESPONSE TO ROAM ALERT/DOOR ALARMS: 1. When the roam alert/Door Alarm sounds, the nearest staff from any location must immediately respond. a. Immediately check the area around the alarmed door. On the interior and exterior of the building. b. Look inside and proceed out the door to the surrounding areas on all sides. c. Go around corners and be sure no resident exited the building. 2. If no one is in sight, thoroughly check the perimeter (when exiting the building staff are to turn to the right and walk around entire building checking surrounding parking areas and parking lots). 3. If no one is found around the alarmed door or outside, account for all residents on each nursing unit by performing a head count. Someone must physically see each and every resident and report whereabouts to the licensed nurse in charge. 4. Implement code Green policy and procedure if needed. 5. If a resident is found outside unsupervised, staff will immediately notify nursing personnel for assistance in returning resident to the building, notify RN Supervisor/charge nurse, and Administrator ASAP . 8. For safety purposes, staff will not give residents or visitors the code to exit out of the doors on the 700 wing . Signed by DON, dated 7/5/19.

Based on observation, interview, and record review, the facility to prevent the development of a Stage 3 pressure ulcer, and provide necessary treatment and services to promote wound healing, resulting in harm, for one Resident (#113) of four residents reviewed for pressure ulcer care. This deficient practice resulted in the worsening (increased size and depth) of the pressure ulcer, delayed nutritional supplementation, and the potential for infection and deterioration of condition. Findings include: According to the Minimum Data Set (MDS) quarterly assessment, dated [DATE], Resident #113 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #113's Brief Interview for Mental Status (BIMS) revealed a score of ,[DATE], designating the resident with moderate impairment. Resident #113 required total assistance for transfers and toileting, and extensive two-person assistance for bed mobility and dressing. The skin assessment showed no pressure ulcers present. Review of Resident #113's wound treatment progress notes revealed the following first entry for a new pressure ulcer(s): Entry date and time: [DATE] at 12:47 p.m. by Licensed Practical LPN E (wound treatment nurse): Writer called to (Resident #113's) room for a divit (sic) (small hole/opening) to her coccyx. Upon observation, there is the following noted: sDTI (suspected deep tissue injury) to the sacral region of 1 x 0.7 cm (centimeters) of non-blanching purple discoloration, with a superficial open area present of 0.8 x 0.3 cm and to the distal of this is MASD (Moisture Associated Skin Damage) area, with maceration tissue in the crease between the sacrum and coccyx with a small superficial slit of 0.7 x 0.4 cm. sDTI to the upper left gluteal cleft of 4.3 cm x 2.5 cm of non-blanching purple areas as the total area is not solid but a cluster of non-blanching purple. There is an open area to the more medial area of wound of 0.6 x 0.6 cm . Subsequent entries of wound treatment progress notes revealed the following: [DATE] at 11:22 a.m. .Small open area present to coccyx measuring 1.3 cm x 0.4 cm .small .scab present to left gluteal cleft measuring 0.3 cm x 0.3 cm . [DATE] at 10:42 a.m. .Open area to midline tissue between sacrum and coccyx is light purple in color and semi-blanching, measures 1.4 cm x 0.5 cm. Non-intact blister to left gluteal crease noted with skin flap no longer in place. Area measures 1.9 cm x 1.9 cm . [DATE] at 10:33 a.m. .Open area to sacrum/coccyx .measures 1.6 cm x 0.7 cm. Scant slough present to wound bed area .Non-intact blister to left gluteal crease measures 1.1 cm x 1.4 cm . [DATE] at 12:11 p.m. .Open area to sacrum measures 2.5 cm x 1.3 cm . [DATE] at 12:09 p.m. .Open area present to sacrum on observation, measures 2.7 cm x 1.8 cm with some depth observed. Depth unmeasurable at this time as there is a scant amount of slough present . [DATE] at 11:15 a.m. .Wound bed covered with yellow/tan slough .depth present that is unmeasurable at this time. [DATE] at 2:14 p.m. .Wound measuring 2.4 x 1.5 x 1.1 cm, with undermining from approximately ,[DATE] o'clock with the deepest being at 12 o'clock of 1.4 cm .there was a scant amount of slough noted . [DATE] at 1:33 p.m. .There is currently a stage 3 pressure injury to the sacrum . [DATE] at 1:57 p.m. .Open area to sacrum measures 3.1 cm x 1.7 cm, with depth not measurable at this time r/t slough present in the wound bed. Undermining preset to wound edges from 12 o'clock to 5 o'clock, with the deepest area measuring 2.9 cm at 2 o'clock . During an interview on [DATE] at 10:41 a.m., LPN E, was asked about the classification of the wound. LPN E said pressure injuries were staged based on the RAI (Resident Assessment of the Minimum Data Set-MDS) wound stage descriptions. The definitions included in the RAI User's Manual, Version 3.0, included the following, in part: - Stage 2 pressure ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. - Stage 3 pressure ulcer: Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Source: RAI User's Manual, Version 3.0. Defining Pressure Ulcers Under the MDS 3.0. MDS Insider. (MONTH) 22, 2010. HP Pro. [DATE] access. Httpp://www.hcpro.com/LTC-,[DATE]/Defining-Pressure-Ulcers-Under-the-MDS-30.html In the Nursing Manual,(NAME)Mauk, (2014), Gerontological Nursing: Competencies for Care.(NAME)and Barlett Learning, Pages ,[DATE], The National Pressure Ulcer Advisory Panel wound classifications are as follows: - Suspected Deep Tissue Pressure Injury (sDTI) -depth unknown: Purple or maroon localized area of discolored intact skin and blood-filled blister due to damage of the underlying soft tissue from pressure and/or shear .These types of wounds should be documented as suspected DTI, and documentation should indicate that the wound will likely develop into a stage III or stage IV pressure ulcer. Review of Resident #113's wound tracking logs revealed the following, in part: July, (YEAR): sacral sDTI and lglcl (left gluteal cleft) sDTI, first noted [DATE]. August, (YEAR): Sacrum, MASD/s/f (shearing/friction), first noted [DATE]. September, (YEAR): Sacrum, MASD/s/f, first noted [DATE]. October, (YEAR): Sacrum, MASD/s/f, first noted [DATE]. November, (YEAR): MASD/s/f (injury type) is crossed out and a handwritten, Unst (unstageable), with date next to abbreviation of [DATE], first noted [DATE]. December, (YEAR): MASD/s/f (injury type) is crossed out and a handwritten, Unst (unstageable), with date next to abbreviation of [DATE], first noted [DATE]. January, 2019: Sacrum, Stage 3 (with '3' handwritten and the number '4' crossed out), first noted [DATE]. A Stand-Up Meeting note (handwritten), dated [DATE], revealed, (Resident #113) sDTI x 2 Review of dietary notes and orders from July, (YEAR) through December, (YEAR) found no dietary consultation or nutritional supplementation (to promote wound healing) regarding the new pressure injury/ulcer. A nutritional supplement was discontinued on [DATE], per the dietary progress note. On [DATE] at 10:00 a.m., Registered Dietitian (RD) U confirmed the dietary notes and orders showed, no mention of a supplement, and no consultation regarding the new pressure injury to the sacrum/coccyx for Resident #113. The policy, 'Skin Integrity Program Policy', unsigned and dated ,[DATE], Item 7, stated, Dietician input will be requested for screening of nutritional deficiencies on any resident with a high risk of skin breakdown .Update dietician of any significant skin breakdown and treatment nurses will provide dietician with monthly ulcer report. Review of monthly physician visit notes from July, (YEAR) through December, (YEAR) did not reveal evidence of physician documentation addressing a sacrum/coccyx wound or pressure injury. During an interview on [DATE] at 12:50 p.m., LPN E was asked if Resident #113's open sacral wound, developed from a sDTI, would it be classified as a pressure injury. LPN E stated, Thinking back, I was thinking of that incorrectly. Once it (sDTI) opens I understand it is staged at the level it was prior .The entries designated as MASD and s/f entry on the logs should have been Unstageable .beginning in August, (YEAR) .I would have documented it (Resident #113's sacral wound) as an Unstageable pressure ulcer related to slough in August, (YEAR) . LPN E, after review of Resident #113's progress notes July, (YEAR) through December, (YEAR), confirmed there was no evidence of positioning resistance (to off-load pressure to the sacral wound) by Resident #113 before (MONTH) of 2019. Registered Nurse (RN)/Assistant Director of Nursing (ADON) A arrived during this interview, and reviewed the wound logs and progress notes for Resident #113 pertaining to the development of the pressure injury, specifically a wound progress note from [DATE]. Nurse A reviewed Resident #113's wound logs and progress notes and stated, I see that is an open area (on Resident #113's sacrum) .I totally see what you're saying (the pressure ulcer was not fully addressed), and added, I don't know how this happened in the first place. During an interview with ADON A on [DATE] at 1:00 p.m., ADON A reviewed the resident's entire medical record pertaining to the timing of the development and progression of the sacrum/coccyx pressure injury, beginning July, (YEAR), including progress notes, wound care reports/logs, physician notes, care plans, orders, and the treatment record. ADON A was asked how Resident #113's wound should have been addressed on the wound logs. ADON A responded, I would have documented this wound as an unstageable pressure ulcer. ADON A confirmed there was no nutritional supplementation from (MONTH) 13, (YEAR) through December, (YEAR), ADON A also acknowledged there were no care plan updates related to the pressure injury for impaired skin integrity and nutritional status until [DATE], when the wound was classified as a Stage 3 pressure ulcer.

Based on observation, interview, and record review, the facility failed to properly store food items in the kitchen. This deficient practice resulted in the potential for opened food products exposed to the environment to be used beyond what is safe and sanitary with the potential to cause food bourne illness. Findings include: On 03/11/19 at 07:15 PM during initial tour of the kitchen, the dry storage area was observed to have a storage bin and per Dietary Aide Q contained powdered thickener for food items. A scoop for the thickener remained in the container with the thickener product. On 03/11/19 at 07:23 PM, the walk in freezer was observed to have stuffed peppers in a storage bin covered with foil with no date. When asked if food items were supposed to be dated when stored outside of the original packaging, Dietary Aide Q stated Yes. On 03/11/19 at 07:25 PM, the walk in refrigerator was observed to have storage carts with multiple cartons of open juices with no written date on the cartons for when they had been opened. When asked if drink cartons should be dated when opened, Dietary Aide Q began dating them with a black marker during the observation and stated, Yeah they are supposed to be dated once they are opened. On 03/12/19 at 08:15 AM, the drink cart for breakfast for the 100/200 hallway was observed to have an apple juice container opened and undated. On 03/12/19 at 08:18 AM, the drink cart for 300/400 hallway had an orange juice drink container open with no cap present to cover the opening. There were also opened containers of cranberry juice, and apple juice that were undated. On 03/13/19 at 08:28 AM, a standing refrigerator on the end of the kitchen closest to the dish washing area was observed. Inside contained opened fruit punch and grape juice containers with no date opened observed. An opened bag of shredded lettuce with no date opened, and a serving of yogurt in a dish with a disposable lid undated were also observed. Two opened bags of frosting with frosting tips attached being stored in 'Ziploc' bags were also observed stored with no date. There was also a metal pan with two pies stored, and one of the pies having been over half served with no dates opened observed. On 03/13/19 at 08:38 AM a metal countertop was observed to have two containers of opened butter in storage bins with no dates observed anywhere on the containers. When asked if these items should be dated, the Dietary Manager (DM) Rstated, We don't because it's changed out every week . it's changed out every Friday. On 03/13/19 at 08:44 AM an interview follow-up interview with DM R after consulting policy stated Yes it should have been dated according to our policy, but I didn't really worry about that because it's changed out every week. On 03/13/19 at 08:55 AM during observation of seasoning storage areas, a container labeled 'Cream of Tartar' had a piece of tape affixed to the container with the hand written word salt on it. This container was observed sitting next to another container of 'Cream of Tartar' on the same shelf. There were also two opened partially used bottles of honey located in this area, and one of the bottles was dated, while the other one was not. There were also bottles of chocolate sauce and caramel sauce opened and undated in the same storage area. On 03/13/19 at 09:04 AM, a plastic container was observed on a metal counter with storage for dry powder items located below and next to the spice rack had an unknown food item stored inside which was undated and not labeled. The same metal counter had a shelf above it on the right side which had a container labeled granulated onion that was attempted to be scratched out with a pen tip and was relabeled as salt. On 03/13/19 at 09:11 AM, a stand up refrigerator located directly outside of the walk in refrigerator was observed to have a quart container of raw eggs, a bottle of real lemon juice, and a bag of oven roasted turkey breast lunch meat opened and undated. On 03/13/19 at 09:16 AM, a pink reusable personal water jug was observed located on a metal counter next to the coffee station. On 03/13/19 at 09:19 AM, a return trip to walk-in refrigerator revealed all opened juice cartons had been dated. On 03/13/19 at 09:22 AM a return trip to the walk-in freezer revealed two partial bags of cooked ground meat observed opened and undated. On 03/13/19 at 09:32 AM, a follow up interview with DM R revealed the following: When asked about dating opened honey, and chocolate/caramel sauces stated, Ok, I'll get that fixed. Yes, they should have been dated. When asked about items being kept in a container and labeled other than what the original label says, stated, No, that is not supposed to be that way. When asked about items being stored in a plastic bin, stated, It should be labeled (with what it is) and dated. When asked about the opened eggs and other items in the stand up fridge stated, They should be dated as well. When asked about the opened ground meat in the walk in freezer stated, Yes (supposed to be dated), I will take care of it. When asked about personal drink containers on food preparation surfaces, stated, No, that (Personal drink containers) is not supposed to be there. The pink personal water jug was gone at the time of the interview, however a Styrofoam cup with a person's name written on the lid was present at the time of the interview, which DM grabbed and discarded. On 03/13/19 at 11:59 AM, a container of orange juice and a tube of frosting was observed stored in the 500 unit refrigerator opened and undated. A container of cranberry juice was observed stored in the 600 unit refrigerator opened and undated. On 03/13/19 at 12:00 PM Interviews with Certified Nurse Aides (CNA) S and T revealed the following: When asked if the opened juice and frosting were supposed to be dated CNA S stated, Yes, when they get opened they are supposed to be dated. CNA T stated, I'm usually on the main floor and those (expensed juice containers) are dated. A review of the facility policy titled (Facility) Dietary Policy undated revealed the following: Labeling 1. All food items . in the refrigerator will be labeled with a use by day. 3. Label food with date it is opened or prepared and used by date: Food Item Use by date Raw meat, poultry seafood 3 days Any previously cooked items (leftovers) 3 days . . Juice 7 days after opened . . Deli Meat 7 days after opened** Cottage Cheese, ricotta cheese, whipped topping 7 days after opened ** If Manufacturer's use by day is less use manufacturer's date.

Based on observation, interview, and record review, the facility failed to maintain clean oxygen concentrator filters for four Residents (#6, #10, #63, and #113), of four residents reviewed for respiratory care. This deficient practice resulted in the potential for transmission of infectious organisms and exacerbation of respiratory condition. Findings include: Resident #10 Review of Resident #10's Face Sheet revealed the following Diagnoses: [REDACTED]. On 03/12/19 at 9:16 a.m. Licensed Practical Nurse (LPN) B removed the external filter from the back of Resident #10's oxygen concentrator, and dust billowed upward into the air. When asked about the condition of the external oxygen concentrator filter, LPN B stated, Poor. Resident #10, present during the observations, stated, Oh, look at that (dust). That is not good .You need to wash it out with soap and water and clean it. On 03/12/19 at 9:56 a.m. LPN B reported the external oxygen concentrator filters were changed by Central Supply Staff D once a month. When asked about cleanliness of Resident #10's external oxygen filter LPN B stated, I would not want that (dirty filter) on me. I would not want it on my mother's (oxygen concentrator). I would not want it on anyone's (oxygen concentrator). On 3/12/19 at 10:01 a.m. Staff D said the external oxygen concentrator filters were checked and usually changed the first week of the month. Staff D stated, They (external filters) have been really bad this month .I thought nursing was supposed to rinse those once a week . On 03/12/19 at 10:08 a.m. Staff D confirmed the internal filter to Resident #10's oxygen concentrator was dirty. That looks like it needs to be changed now. The internal oxygen concentrator filter contained no label/date to note date of last change. Staff D reported no documentation was available regarding the date the internal filter was last changed. Review of Resident #10's Physician Orders, included the following: Start Date: 9/28/18: Clean filter of portable oxygen concentrator Q (every) week with a toothbrush to wipe any debris or dust away . Start Date: 9/28/18: Oxygen @ (at) 1-4 Liters per NC (nasal canula) to keep sats (oxygen saturation) > (greater than) 88-92%. (MONTH) utilize the facilities portable concentrator . Resident #63 Review of Resident #63's Face Sheet revealed the following Diagnoses: [REDACTED]. Review of Resident #63's Physician order [REDACTED]. Use large oxygen concentrator while in bed . On 3/12/19 at 9:19 a.m. LPN B removed the back filter from Resident #63's oxygen concentrator and dust billowed into the air. LPN E, also present in Resident #63's room, stated, OOOOH!' to the puff of dust observed when LPN B removed the filter. When asked about the condition of the external oxygen concentrator filter, LPN E stated, Dusty. LPN B stated, That filter was in poor condition. It was very dusty. Yeah, it was as dirty as the other one (Resident #10's). During an interview on 3/13/19 at 8:59 a.m. the Assistant Director of Nursing (ADON) provided a printed copy of the (MONTH) 2019 maintenance sheet showing Resident #10 and Resident #63's oxygen concentrator filters were changed in (MONTH) of 2019. The ADON stated, If they (external oxygen concentrator filters) were that dirty, I would fail to believe that the (oxygen concentrator) filters were changed. The ADON confirmed LPN B had reported the filters were very dirty. After discussion related to this Surveyor's concern with the facility process for maintaining the cleanliness of oxygen concentrator filters, the ADON stated, I am sorry to say, that I totally agree. No policy or procedure was received by this Surveyor related to cleaning of the oxygen concentrator filters. During an interview on 3/13/19 at approximately 9:00 a.m. Staff D was asked for any additional filter maintenance/change logs for facility oxygen concentrators. Staff D stated, No, what I showed you yesterday is all that I have. Resident #113 Review of Resident #113's Face Sheet revealed the following diagnoses, in part: [MEDICAL CONDITION], and [MEDICAL CONDITION]. Review of Resident #113's physician orders [REDACTED].> 90% . Review of Oxygen Concentrator (#76) Service Record documentation for Resident #113's oxygen concentrator, revealed the following, in part: Date Received: 6/16/17 with filters changed on that date. Service on 10/22/18, 11/27/18, and 2/11/19 all showed completion of a concentration test, with NO filter changes performed. On 3/13/19 at 11:30 a.m. ADON A observed Resident #113's back, external oxygen concentrator filter with this Surveyor. ADON A confirmed dust had accumulated around the outside edges of the filter, in a thick layer. When ADON A removed the foam filter from its position on the concentrator, dust billowed into the air. Resident #6 Review of Resident #6's Face Sheet revealed the following diagnoses, in part: [MEDICAL CONDITION], and [MEDICAL CONDITION]. Review of Resident #6's Physician order [REDACTED]. Keep sats >88% . On 3/13/19 at 11:35 a.m. ADON A observed Resident #6's oxygen concentrator with this Surveyor. Upon inspection of the back, external filter the ADON A stated, This is in worse condition than the other one. Dust billowed from the filter as ADON A removed it from the concentrator. It's pretty dirty. When asked to review the Service Performed form for concentrator #70, ADON A stated, Yeah, it hasn't been cleaned. Review of the Oxygen Concentrator Service Record documentation revealed, Date Received as 10/4/2016. The form documented filter change on 4/5/17, 12/21/17, 5/31/18, and 1/4/19. During an interview on 03/14/19 at 9:29 a.m. ADON A confirmed Resident #6 and Resident #113 had oxygen concentrators supplied by Hospice. ADON A stated, The equipment (oxygen concentrator) is provided by a third party .Hospice arranges for everything - they (Hospice) are paying for it. When asked about cleaning of the external oxygen concentrator filters, ADON A stated, To be completely honest, that conversation has never happened between hospice and our self (facility). The best plan, moving forward, is for all of our oxygen concentrators, whether internally owned or third party supplied, is to have the nurse clean the back filter with the weekly tubing change. We will add that to our policy .

Based on observation, interview, and record review, the facility failed to provide dignity and respect during dining for five Residents (#20, #66, #85, #89, and #106), of five residents reviewed for dignified dining experience. This deficient practice resulted in the potential for resident embarrassment and decreased self-esteem. Findings include: Review of Resident #20's, #66's, #85's, #89's and #106's Minimum Data Set (MDS) assessments dated 12/14/18, 1/18/19, 1/31/19, 2/1/19, and 12/12/18, respectively, revealed all five residents had [DIAGNOSES REDACTED].#66, #85, and #89 also had a [DIAGNOSES REDACTED]. All five residents had severe cognitive impairment. Resident #66 needed cueing and supervision while dining, with Residents #85, #89, and #106 requiring one-person physical assistance with eating. On 3/12/19 at 8:31 a.m., this Surveyor asked Rehab Aide/ Staff L about residents who need assistance with eating, and if Resident #106 could eat independently or needed assistance. Staff L stated, There's feeders, and we go in and help them, and there's feeders in the big dining room that we help too. (Resident #106) has to be fed. On 3/13/19 at 12:13 p.m., Rehab Aide/ Staff N was seated at a round table in the main dining room, with Rehab Aides/ Staff P and O. All three staff members were assisting Residents #20, Resident #66, Resident #85 and Resident #89 with their meal. When asked if there were other residents that required assistance, Staff N stated, In the big dining area (solarium) we have more feeders in there. Resident #20, #66, #85, and #89 were all within audible range of Staff N when she referred to them as feeders. Review of Right of Residents in (Name of State) Nursing Facilities, dated 11/28/16 read, in part: Respect and Dignity: You have the right to be treated with respect and dignity, including: . The right to reside and receive services in the facility with reasonable accommodation of your needs . On 3/14/19 at 9:07 a.m., Registered Nurse (RN)/Assistant Director of Nursing (ADON) A was asked about the training dining assistants receive. ADON A stated, I use a .curriculum, it's an eight - hour training and I do it in two 4 - hour blocks. We also do an observation and a physical one with them (staff assisting residents). When told about the two Rehab Aides in the dining areas who used the term feeders, ADON A asked their position, and finding out they were Rehab Aides stated, They don't go through this same training as the paid dining assistants . they should have that (training) in their (CNA) classes . On 3/14/19 at approximately 10:15 a.m., Staff N stated, When I started in the therapy department, I followed somebody, and they showed me how to do it (assist residents during meals). When asked how a person would treat and speak to residents, Staff N stated, You treat them like everyday people. We treat them like they're family. When this Surveyor reminded Staff N of her use of the word feeders the previous day, Staff N stated, I knew when I said it (feeders) I shouldn't have.

Based on observation, interview, and record review, the facility failed to use a gait belt for safe transfer, resulting in harm to one Resident (#1), of three residents reviewed for falls. This deficient practice resulted in a fall with fracture, decreased range of motion, and the potential for delayed healing and increased duration of stay for Resident #1. Findings include: Review of Resident #1's admission Minimum Data Set (MDS) assessment, dated 1/9/2019, revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 scored 15/15 on the Brief Interview for Mental Status (BIMS), reflective of intact cognition, was 73 (inches) tall, weighed 256 pounds, and required extensive, one-person physical assist with transfers, and extensive, two-person physical assist with bed mobility and toileting. Balance during transitions was documented as Not steady, only able to stabilize with staff assistance for Moving from seated to standing position .Moving on and off toilet .and Surface-to-surface transfer (transfer between bed and chair or wheelchair) . Review of the Investigative Summary for Resident #1's fall on 2/14/19 revealed the following, in part: (Resident #1) was returning from the bathroom to his room (near Resident #1's bed) on 2/14/19 at approximately 0515 (5:15 a.m.) when he stood up from his wheelchair, attempted to grab (the) bed mobility device, and fell on his right side on the floor .(Resident #1) immediately complained of severe right hip pain and was transferred to the emergency room .was diagnosed with [REDACTED]. (Resident #1) had a right hip ORIF (open reduction and internal fixation) on 2/15/19 and (later) returned to the facility .(Certified Nurse Aide (CNA) G) .tried to reach over the wheelchair and grab onto (Resident #1) .she could not stop his fall .(CNA G) attempted to grab his gown when he was falling .she did not have time to apply a gait belt as everything happened to quickly and she wasn't anticipating the transfer .(CNA E) stated .they weren't ready for him to stand up, and she (CNA E) .did not have any time to reach (Resident #1) . Review of the acute care Hospital History and Physical, dated 2/14/19, revealed the following, in part: Imaging: And reviewed pelvic x-ray films, shows right intertrochanteric [MEDICAL CONDITION]. Review of the facility Lifting/Transfers of Resident policy, dated 1/3/19, received 3/4/19 at 12:40 p.m. from the DON, revealed the following, in part: 1. Transfers that involve physical contact with a resident require the use of a gait belt .3. Resident electronic health record (either care plan or profile) for each resident will be available for review. The proper lift/transfer will be followed according to the assessment criteria for safe resident lifting and transferring to help reduce the risk of resident and staff injury .8. A competent resident who refuses safety devices i.e. gait belt .will be explained the risk factors i.e. Injury, death. Licensed Staff will document refusal and explanation of risk factors in progress notes and care plan accordingly . On 3/4/19 at 11:50 a.m. Physical Therapist (PT) C was asked about use of a gait belt for Resident #1. PT C stated, Yeah, (Resident #1) .should have had a gait belt on with transfers .Order says gait belt and (physical) assist times one (staff person) . On 3/4/19 at 1:32 p.m. Certified Nurse Aide (CNA) E was interviewed by telephone. CNA E reported it was the first time she had provided care for Resident #1. CNA E stated, No, he did not have a gait belt on when he was on the toilet. I have to say no, I did not put one on (Resident #1) (with transfer off toilet and toward bed) and I have been reprimanded for that oversight .I had asked CNA D (who had placed Resident #1 onto the toilet) how (Resident #1) transfers. A gait belt was not mentioned .CNA G was standing between the bed and the wheelchair .the left side of the wheelchair .I was behind the wheelchair coming out of the bathroom .(Resident #1) was out of my reach .CNA G continued to stay to the left of the wheelchair toward the bed, and (Resident #1) went (fell ) forward toward the head of the bed . Review of CNA E's Documentation of Disciplinary Action, dated 2/21/19, detailed a written warning pertaining to 2/14/19 for Employee did not use a gait belt while transferring a resident from toilet . The document was signed by CNA E and RN A. On 3/4/19 at 5:28 p.m. CNA D, interviewed by telephone, confirmed he had transferred Resident #1 onto the toilet in the morning, on 2/14/19. CNA D stated, I put a gait belt around his waist .That is our (facility) rule, that is what we are supposed to do even if the person can stand up on their own .I pulled the belt off of him .and put it on the dresser (while Resident #1 was positioned on the toilet) .Rule is if you transfer anyone you are supposed to have a gait belt .You never know, he (Resident #1) could buckle or dip . On 3/5/19 at 2:15 a.m., CNA G, when interviewed by telephone, confirmed she had pulled Resident #1 out of the bathroom, backward in his wheelchair on 2/14/19. Resident #1 was not wearing a gait belt. CNA G was familiar with Resident #1's care, and reported Resident #1 was confused that morning. CNA G stated, (A) gait belt should be on at all times, when a transfer is going on .I was on his left side of the wheelchair as he was falling. I did get ahold of his gown, but without a gait belt the gown was not going to stop him from falling . On 3/5/19 at 2:36 a.m. Registered Nurse (RN) Supervisor H confirmed she was present following Resident #1's fall on 2/14/19. RN H stated, He was on his right side (on the floor) facing the bed .He was complaining of pain, and he tried to roll to his back, and his pain became excruciating .I did not see a gait belt . When asked about the possibility of Resident #1 refusing the gait belt that day, RN H stated, If he had refused the gait belt, they (CNAs) would have brought that up with the Wing nurse .(who) would have documented it (the refusal) in the progress notes .In this case .I know, I just reviewed the gait belt and there was nothing in the progress notes (about gait belt refusal by Resident #1). When asked about a policy on gait belts, RN H stated, It is in their (resident) care plan. Each resident is assessed according to their needs. I believe his care plan does say gait belt with assist of 1-2. Yes, staff should have put a gait belt on him that day (2/14/19) . Review of Resident #1's Resident Profile revealed the following CNA care instructions: 1/2/19: Transfer with A (assist) x (times) 1 (staff person), gait belt and walker. Ambulates short distances with Ax1-2, walker and gait belt . Review of Resident #1s Physician Orders, 1/14/19 - 2/14/19, revealed the following, in part: 1/2/19 - Open Ended, Transfers with Ax1 (Assist with one staff), gait belt and walker. Ambulates short distance with A1-2, walker and gait belt . On 3/5/19 at 2:58 a.m. RN I confirmed she was the Wing nurse on the 200 hall at the time of Resident #1's fall on 2/14/19. When asked if any staff had reported a refusal of the gait belt by Resident #1 on 2/14/19, RN I stated, At that time, no. Regarding a gait belt policy, RN I stated, If they are at least an assist of one (staff person) they are supposed to have a gait belt on .The purpose of the gait belt would be to guide him, to catch him .I don't know if they would have been able to catch him completely but maybe they would have been able to lower him to the floor . On 3/4/19 at 3:25 p.m. Resident #1 was observed lying in bed. During an interview at that same time, when asked about the fall with fracture on 2/14/19, Resident #1 confirmed a gait belt was not used when he was transferred from the toilet to the bed, and said he was not asked about, nor refused to use, a gait belt at that time. Resident #1 stated, Two girls were helping me, and one of them just disappeared .I fell and broke my hip .Did you see the x-rays? It is bad . On 3/5/19 at 11:19 a.m. Family Member (FM) K was interviewed by telephone. FM K reported Resident #1 was only supposed to be at the nursing home facility for knee rehab . Since he has been in there, he fell .He is supposed to have a waist (gait) belt on so they can help him get into bed. They (staff) didn't have a gait belt on him. He (fell and) broke his hip - went to the hospital .Now it could take up to six months to heal and possibly longer for him because he has so many health issues. He was told no weight bearing for one month. This is all a result of him falling . On 3/5/19 at 12:13 p.m. the Director of Nursing (DON) stated, The purpose of a gait belt is to assist the staff in the safe transfer of a resident. It is supposed to be used with contact with the resident .When he (Resident #1) was getting up (out of his wheelchair, moving toward the bed) it (gait belt) wasn't on . The DON agreed the staff should have used a gait belt for the transfer of Resident #1 on 2/14/19.

Based on observation, interview and record review, the facility failed to supervise and monitor the positioning of a fractured arm to prevent undue pain for one non-verbal (Resident #101) of three non-verbal residents reviewed for with pain from a facility population of 134 residents. This deficient practice resulted in harm to Resident #101 who had significant short-term pain as evidenced by grimacing, moaning and tears rolling down her cheeks, due to being left unsupervised in a physician's examination room with her broken arm dangling off the gurney. Findings include: According the the Minimum Data Set (MDS) assessment dated [DATE], Resident #101 was a [AGE] year old female and was admitted to the facility on [DATE] after a [MEDICAL CONDITION] left her in a persistent vegetative state. Resident #101 was bedbound and paralyzed on the right side of her body, but had some limited movement on the left side. Per Resident #101's "Activites for Daily Living (ADL) Plan of Care" updated 3/14/14, Resident #101 was repositioned throughout the day, but was only out of bed twice weekly for showering; at which time a mechanical lift was required to transfer her. According to Resident #101's "Communication Care Plan" updated 3/14/14, Resident #101 was non-verbal and non-communicative, except for some moaning and crying. All her needs must be anticipated by staff. Resident #101 was observed in her room on 6/3/14 at 10:05 a.m. Her eyes were shut. Resident #101 moved her left hand to her mouth and then stretched her hand out to the padded side rails and back again. Resident #101 made no response to verbal comments from this Surveyor. According to an interview with Registered Nurse (RN) "A" done on 6/3/14 at 11:15 a.m., no one was sure how much Resident #101 could hear, see, or understand. Resident #101's "Communication Care Plan" updated 3/14/14, directed staff to speak into Resident #101's left ear and to explain cares to her. During an interview on 6/3/14 at 1:15 p.m. with Physical Therapy aide "I", Resident #101 could be resistant to passive range of motion exercises and she cried and moaned at times, supposedly because of pain. A review of Resident #101's "Mood Care Plan" updated 3/14/14, revealed Resident #101 had a history of [REDACTED]. An intervention directed staff to "provide 1:1 post family visits to ensure comfort and to calm resident". This indicated the facility recognized Resident #101 might have some awareness of her surroundings. Resident #101's "Pain Care Plan" and "Mood Care Plan" indicated when Resident #101 showed signs of pain or discomfort such as "facial grimacing, crying, tearfulness, restlessness, moaning or guarding", the following interventions were to be used: "provide position change, hold her hand, talk to her and provide reassurance, and provide something soft to hold for comfort". The physician orders [REDACTED].#101 was to receive treatment for [REDACTED]. According to a facility "Incident-Accident" report, on 5/17/14 on the afternoon shift, a bruise on Resident #101's inner arm above the elbow was first noticed by Registered Nurse (RN) "G". An interview conducted on 6/3/14 at 1:00 p.m. with RN "G", revealed she discovered Resident #101 had a blood draw several days prior to 5/17/14. RN "G stated she completed the 5/17/14 "Incident-Accident" report, indicating she thought the blood draw was the source of the bruise. An interview with Certified Nurse Aide (CNA) "B" on 6/3/14 at 2:05 p.m., revealed at approximately 6:00 p.m. on 5/17/14, when Resident #101 was being showered, her bruise had increased to approximately 3 inches by 4 inches. By the time the midnight shift came on duty, Resident #101's right arm had swollen from the elbow to the shoulder, according to documentation in the nurses notes on 5/18/14 by Licensed Practical Nurse (LPN) "O". Treatment initiated was icing of the swollen, bruised arm. A second "Incident-Accident" report was completed by RN "O" listing the bruise as an injury of unknown origin. Subsequently, the next morning on 5/18/14, Resident #101 was taken to the emergency room at the hospital where x-ray revealed Resident #101 had a spiral fracture in her right upper arm (distal humerus), according to the emergency room report dated 5/18/14. Resident #101 was returned to the facility on [DATE], with her arm in a splint and a referral to an orthopedic surgeon for follow-up. Two days later on 5/20/14, the facility sent Resident #101 by ambulance to an orthopedic surgeon's office for the scheduled follow-up appointment. According to nurses notes dated 5/20/14, LPN "P" documented Resident #101 left the facility at 9:30 a.m. and returned from the orthopedic surgeon's office at 12:45 p.m., a time frame of three and one-quarters hours. Round trip transportation to the orthopedic surgeon's office is approximately one hour, meaning Resident #101 was at the orthopedic surgeon's office approximately two and one-quarters hours. According to an interview with RN "N" at 9:00 a.m. on 6/3/14, the ambulance personnel stated they would stay with Resident #101 during the appointment. Therefore no facility staff was sent to accompany Resident #101 to the orthopedic surgeon's office. However, while they were at the orthopedic surgeon's office, the ambulance service received another call and left Resident #101 unattended in an examination room, while they responded to the new call. According to the Clinical Manager "L" of the orthopedic surgeon's office, who was interviewed by phone on 5/30/14 at 1:35 p.m., the EMS (emergency medical services) personnel stayed with Resident #101 only 15-20 minutes before leaving her alone in an examination room for the remaining two hours. When the orthopedic surgeon entered the examination room where Resident #101 was waiting, he found her alone and showing signs of pain. Orthopedic Surgeon "M" was interviewed by phone on 6/3/14 at 12:35 p.m. Orthopedic Surgeon "M" stated, Resident #101's arm was "dangling" (off the gurney) and the resident was "grimacing, moaning, and tears were rolling down her checks" which he considered indicative of "severe pain". Orthopedic Surgeon "M" stated he was upset there was no one to attend to and comfort Resident #101, to put her arm back on the gurney, or to alert someone to the resident's level of pain. Since no staff from the facility had accompanied Resident #101, the orthopedic surgeon had no one to inform him how long the resident had been in that condition, and no one to tell him how the fracture had occurred. (This information was not included with the x-rays and other paperwork sent from the nursing home.) ( ) --

Based on interview and record review, the facility failed to implement their policy for reporting to the State agency multiple events of bruising and injuries of unknown origin which occurred over time, failed to fully develop procedures for adequately investigating allegations of neglect, abuse, mistreatment and injuries of unknown origin, and then failed to implement interventions for monitoring and corrective action to protect all residents and prevent reoccurrence for six (Residents #2, #6, #8, #10, #12 & #13) of 23 residents reviewed for abuse in the total sample of 24 residents out of a facility population of 139 residents. On 5/21/13, two staff members witnessed Certified Nurse Aide (CNA) "G" yank on the gait (safety) belt of Resident #13 in an inappropriate manner while ambulating causing Resident #13 to go off balance and stumble. Facility administration did not identify the incident as possible neglect or mistreatment with subsequent reporting to the State agency and did not adequately investigate the cause of CNA "G"'s unsafe practice. When CNA "G" returned to work, the facility provided no additional education or monitoring for CNA "G" to ensure residents were not mistreated or provided cares in an unsafe manner. Then on 10/29/13, Resident #12 reported CNA "G", "roughly" put her into bed. Further investigation during the survey revealed the facility had knowledge of multiple injuries of unknown origin involving Resident #2 on 6/16/13, Resident #6 on 10/15/13, Resident #8 on 11/10/13 and Resident #10 with three separate injuries on 7/16/13, 8/19/13 and 9/12/13. The facility's failure to develop and implement a comprehensive process for investigating these incidents and to take adequate corrective action resulted in immediate jeopardy to the health and safety of Residents #2, #6, #8, #10, #12 & #13. The Facility Administrator was notified of the Immediate Jeopardy on 11/14/13 at 5:30 p.m. which began on 5/21/13 when facility staff failed to provide care and services in a safe manner to Resident #13. The Immediate Jeopardy was removed on 11/18/13 at 12:30 p.m. when this surveyor verified that the facility had: 1) Written a new abuse investigation procedure and QA (quality assurance) form for abuse investigation. 2) Inserviced all department heads on the new policy and form on 11/18/13. 3) Completed skin assessments on Residents #2, #6, #8, #10, #12, & #13 (identified on the IJ) and investigated the root cause of any change in skin integrity found. 4) The 10/29/13 investigation of Resident #12's allegation was completed. As a result, CNA "G"'s employment with the facility will be terminated. 5) The facility's "Resident Incident Response" policy was updated to include a skin integrity investigation report on all cuts, bruises and other skin integrity issues. 6) The Inservice Coordinator, Registered Nurse supervisors, and Assistant Director of Nursing had been trained on the new forms and policies and are inservicing line staff on all shifts. 7) The facility's Abuse policy was revised to reflect the current changes. Although the immediate jeopardy was removed, the facility's deficient practice continues at a pattern level with the potential for more than minimal harm to the facility's most vulnerable residents until the facility has demonstrated that: 1) All residents have been assessed for any allegations of abuse, neglect, misappropriation of property, or injuries of unknown origin, and any allegations thoroughly investigated and reported if necessary. 2) All staff has been trained on the updated Resident Incident Response Policy and Skin Integrity Investigation Reports and revised Abuse policy. 3) Validation by the State agency of the facility's ability to maintain substantial compliance with ensuring all allegations of abuse, neglect, mistreatment, and misappropriations are identified, reported, thoroughly investigated and corrective action taken when necessary. ( ) Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #13 is an [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This MDS revealed Resident #13 had poor short term and long term memory deficits; needed extensive assistance with decision making; required limited to total assistance of 1-2 individuals for transfers, ambulation, dressing, eating and hygiene needs. On 11/12/13 at approximately 3:00 p.m., the facility Director of Nursing (DON) provided abuse & neglect investigations not previously reported to the State Survey Agency. The first file concerned the alleged mistreatment of [REDACTED]. The facility investigation dated 5/21/13 (1:10 p.m.), contained two written statements provided by Physical Therapy Staff "I" and "J." Physical Therapy Staff "I"'s written statement dated 5/21/13 at 1:10 p.m. read, "I was walking out of the therapy room towards the 300/400 wing to check on patients. (Physical Therapy Staff "J") was walking beside me. As we neared towards the 300/400 desk, I (Physical Therapy Staff "I") witnessed (Certified Nurse Aide (CNA) "G") walking (Resident #13) with her hand on the gait (safety) belt and forcefully pull (Resident #13) towards her (CNA "G"), yanking on the gait belt in an inappropriate manner. With this pull, she caused (Resident #13) to go off balance and side step towards the (L) {left}. (CNA "G") then looked over her shoulder and continued to walk (Resident #13) back towards the 300 wing. (Physical Therapy Staff "J") and I both looked at each other in shock! We had both witnessed something we felt was inappropriate. I reported this to (Rehabilitation Director) as well." A written statement by Physical Therapy Staff "J" dated 5/21/13 at 1:10 p.m. corroborated the statement given by Physical Therapy Staff "I". In an interview on 11/15/13 at 1:30 p.m., Physical Therapy Staff "J" confirmed her written statement and went on to say: "(CNA "G") was walking with (Resident #13) towards the 300 hallway desk... (Resident #13) was walking away from (CNA "G") towards the left and then (CNA "G") yanked on the gait (safety) belt and made (Resident #13) lose her balance." Physical Therapy Staff "J" stated, "She (CNA "G") pulled (Resident #13) back to her side because (Resident #13) was wandering away & she (CNA "G") didn't want her to. She (Resident #13) lost her balance, but didn't fall. I looked at (Physical Therapy Staff "I") and we both said, 'I can't believe what we just saw!' I've had family here and if that was my family member, I'd be extremely upset. We (Physical Therapy Staff "I" & "J") went directly to our supervisor." A facility "Documentation of Disciplinary Action" dated 5/21/13 showed CNA "G" had been disciplined for mistreatment of [REDACTED]." The action taken by the facility was a 3 day suspension. CNA "G" signed the Action notice on 5/24/13. On 11/13/13 at approximately 11:00 a.m., the DON was asked for any other documentation related to Resident #13's incident dated 5/21/13. The DON produced another written statement by the previous DON dated 5/24/13 which read, "Gave employee (CNA "G") discipline... informed her it was of concern to me that if she could not remember what occurred as it (incident) was described, then she (CNA "G") really isn't being aware of what she's doing with all the residents... She (CNA "G") stated this will be a wake-up call for further interactions with residents." The current DON could not produce an incident report, any evaluation of Resident #13 post the 5/21/13 incident or any indication/ evidence showing the facility had re-educated and/or monitored CNA "G"'s ability to provide appropriate care and services to all residents prior to and/or following her return to work. The second investigation not reported to the State survey agency involved Resident #12. This investigation revealed on 10/29/13, Resident #12 informed CNA "D" that CNA "G" roughly puts her into bed and leaves without making sure she was comfortable. The facility's investigation read, "She (CNA "G") would just stand there, while getting (Resident #12) off the toilet and did not make sure the resident's brief and pants were pulled up properly and comfortably. (CNA "G") would demand (Resident #12) open the door when leaving the bathroom... and (CNA "G") was rude while talking to her (Resident #12)." A written interview in the facility's abuse investigation with Social Worker (SW) "B" dated 11/1/13 read, "(Resident #12) described her (CNA "G") demeanor as '(like) a bull dog' and intimidating. (Resident #12) said (CNA "G") often 'moans and groans' about the amount of time it takes her to perform her tasks for (Resident #12's) care." The interview documented Resident #12 felt that CNA "G" does not help her enough at times (example: peri-care after toileting). SW "B" documented, "During a recent interaction, (Resident #12) stated that (CNA "G") waited with her hands on her hips and (Resident #12) felt rushed. (Resident #12) feels (CNA "G") is negative during their interactions together." On 11/14/13 at 10:00 a.m., SW "B" was asked if she interviewed any other residents or family members on this unit for care concerns related to (CNA "G") and she replied "No." According to the MDS assessment dated [DATE], Resident #12 is a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This MDS revealed Resident #12 was cognitively intact, didn't ambulate and needed extensive assist from one individual for transfers, dressing and bathing needs. Resident #12 needed set-up help and verbal cueing for placement of food items on her plate. An interview took place with Resident #12 in her room on 11/13/13 at 1:40 p.m. Resident #12 was asked about cares in general and then asked if she had problems with any particular caregiver. Resident #12 replied "Yes, on the day I clashed with her (CNA "G"), it was mid-morning ...I told her (CNA "G"), 'You look like a black cloud, you never smile'. She (CNA "G") grunted and stated, 'The reason I'm like this is because of you (Resident #12)!'" A third document dated 10/29/13 reflects a written account of an interview with CNA "G", the previous Director of Nursing (DON), a union representative and the current DON. CNA "G" was asked if she helped Resident #12 when she was finished in the bathroom with adjusting her clothes, and CNA "G" is quoted as saying "No." A facility document titled "Documentation of Disciplinary Action" dated 10/29/13 reflected CNA "G" was disciplined for failing to treat a resident under her care with dignity and respect. The action taken by the facility was a 10-day suspension for CNA "G". A review of CNA "G"'s personnel file revealed she was accused of 'rough with cares' in February of 2012 that was unsubstantiated by the facility. Following the alleged mistreatment of [REDACTED]." to ensure she was able to provide safe and appropriate resident care. At 9:30 a.m. on 11/14/13, during an interview with Personnel Coordinator "A", the facility could not find documentation of any further education provided to CNA "G" regarding resident care. An interview was held with the current Administrator and the recently retired Administrator (Administrative Consultant) on 11/13/13 at approximately 11:00 a.m. The facility was asked to provide any further documents, including witness statements, incident reports, or any other documentation related to the investigation for the events recorded on 5/21/13 and 10/29/13 involving CNA "G". The Administrative Consultant stated, "I was the Administrator of record for the event on 5/21/13, and I've provided you with all the documents we have related to the investigation of the May event." When the Administrative Consultant was asked why this event was not reported to the State Agency, she replied, "We (facility) felt it was more of a dignity & respect issue than an abuse and neglect... I do not know why (CNA "G") was not re-educated before she returned to work, I don't know what happened." The Administrator stated he was notified via telephone (but unable to confirm the time of notification) by the DON regarding the 10/29/13 incident, stating, "I didn't think it (incident) was anything more than a dignity and respect issue... I never thought it was mistreatment." ( ) A review of the admission face sheet for Resident #10 revealed this [AGE] year old male was admitted to the facility on [DATE]. A review of the physician's order sheets show Resident #10's current [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 as severely cognitively impaired with a staff assigned score of 3/15 on the assessment. A review of an "Incident Report" involving Resident #10, dated 9/12/13, provided the following information, "Resident noted to have dark purple bruise +(plus) [MEDICAL CONDITION] (swelling) to right eyelids. More so around inner corner of right eye." The incident report did not identify what had caused the bruising. In the category listed as "Witnesses", the document read NA (not available). The incident was reviewed by the interdisciplinary team and a section of the incident report titled "Corrective Measures to avoid repetition of the incident" read, "Assessed R (right) eye r/t (related to) bruising. 2.5 cm (centimeter) by 5 cm. Dark purple bruise noted to inner right eyelid and along inner eyelid. Slight swelling noted to area. Will monitor every day for 7 days." A review of nursing notes for this incident found in Resident #10's medical record dated 9/12/13 at 6:31 a.m., revealed the following statement, "Resident (#10) noted to have bruised right eyelids from unknown origin" and "Resident was combative and restless in bed last night. Possibly hit self while flailing arms". Another nursing note written 9/12/13 at 2:36 p.m. read, "Resident has remained without any complaints of pain. Resident asked and did state, 'Because I hit myself ' when asked what happened." An interview conducted with Registered Nurse (RN) "C" on 11/13/13 at approximately 2:30 p.m. revealed that Resident #10 was not a reliable informant. In addition, RN "C" revealed there was no record of additional follow-up or an investigation to determine the probable cause of the bruising to this resident's eye. There is no record that staff working prior to the event had been questioned and/or observed providing care in an effort to determine a cause of the bruising and, in doing so, identify potential interventions to prevent a similar event in the future. Resident #10 was involved in 2 other incidents within the last 6 months in which the cause of the incident/injury were not identified or investigated. A facility Incident Report, dated 8/19/13 at 3 p.m., read: "Found skin tear on left forearm unknown origin. Treatment nurse aware. Bruises on bilateral arms". Once again, "Corrective Measures to avoid repetition of incident" reflected only the nursing care provided at that time, and reflected no information as to the likely cause of the skin tears and the bruising or ways to prevent repetition of the bruising. A similar incident regarding Resident #10 was documented on 7/16/13 (time not identified). The incident read, "Resident noted to have skin tear on left finger. Triangular shaped". There was no information contained in the Incident Report as to the cause of the injury, and the Corrective Measures only identified the injury and the treatment provided, not the possible cause of the skin tear. During the interview on 11/13/13 at approximately 2:30 p.m., RN "C" was asked about both the incident on 8/19/13 and the injury to Resident #10 identified on 7/16/13, and could provide no documentation that these injuries had been investigated in an effort to determine a cause and possible solution to prevent reoccurrence. ( ) Review of Resident #6's medical file revealed, on her "Resident Admission Record," that she is an [AGE] year-old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her most recent Minimum Data Set (MDS) assessment dated [DATE], revealed she could not complete her Brief Interview for Mental Status (BIMS). A Staff Assessment for Mental Status was conducted and showed that Resident #6 had long and short-term memory problems, and was moderately impaired for daily decision making. A "Resident/Visitor Incident Report" dated 10/15/13, showed on that date at 2:00 p.m., Resident #6 was found to have a bruise to her left posterior hand, "of unknown origin." This form showed no investigation into the cause of Resident #6's bruise. On the back of the form, the section titled, "Interdisciplinary Team Review - corrective measures taken to avoid repetition of incident," was left blank. ( ) A review of Resident #8's Minimum Data Set (MDS) Assessment, dated 9/12/13, revealed the [AGE] year old male was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This MDS revealed Resident #8's cognition was severely impaired as he was listed in a "persistent vegetative state", needed total assistance with all cares and staff used a (mechanical) lift for transfers. A review of Resident #8's "Resident/Visitor Incident Report" form dated 11/10/13 revealed on 11/10/13, "(Resident #8's) family alerted writer (Nurse "E") to scratch on top of L (left) side of Resident head." Nursing assessment revealed vital signs were performed and Resident #8 had "a 0.6 centimeter (cm) scratch on top of head on L side." Immediate action was to cleanse the site with sterile water and monitor. The environmental assessment read: "? (mechanical) Lift." There was no corrective action written on the Incident Report or found in the clinical record. Resident #8's Nurses Note dated 11/11/13 revealed the scratch measured 0.5 cm by 0.2 cm. On 11/14/13 at 11:10 a.m., an interview was conducted with Registered Nurse (RN) "C" pertaining to the missing corrective action and the investigation of the 11/10/13 incident involving Resident #8. RN "C" said, "From the Incident Report Form, it looked like the scratch was from a (mechanical) Lift transfer." She agreed there was no written corrective action and there was no investigation performed. RN "C" stated, "(We) don't go any further with these (scratches or bruises)". RN "C" said the facility had an investigative process for falls but, as she shrugged her shoulders, said there "wasn't one" for bruises or scratches of unknown origin. ( ) According to the Minimum Data Set (MDS) assessment, dated 9/20/13, Resident #2 is an [AGE] year old woman with a primary [DIAGNOSES REDACTED].#2 had a bruise of unknown origin, along with a skin tear on the outer edge of her mid-forearm. The incident report noted that the injuries came from a medical alert bracelet on her wrist. However, the facility could produce no investigation interviews and could not explain how the alert bracelet would have caused the injuries. The incident report was left blank in the section of Corrective Action. In an interview with Registered Nurse (RN) "C" on 11/14/13 at 1:30 p.m., she stated the facility does not investigate the root cause of the injuries of unknown origin, but simply records the injuries on the Incident Report. A review of the facility policy and procedure titled "Abuse Investigation", dated 11/21/12, reads as follows: "....All alleged/possible incidents are reported to the facility administrator along with immediate telephone notification to the Complaint Hotline... Immediate completion and submission of the Facility Incident Report - 24 hours... to the State Agency is also required... B. The Director of Nursing or Administrator will report alleged violations of mistreatment, neglect, abuse or misappropriation of resident property, falls resulting in serious injuries or injuries of unknown source to the appropriate agency... 2. The investigation may consist of: a. A review of the complete Incident Report; b. An interview with person(s) reporting the incident; c. Interviews with any witnesses to the incident; d. An interview with the resident if possible; ...f. An interview with staff members having contact with the resident during the period/shift of the alleged incident; g. Interviews with the roommate, family members, and visitors; h. A review of all circumstances surrounding the incident; i. An immediate and thorough nursing physical examination if applicable or medical attention as necessary. A review of the facility's "Abuse Policy Program" (11/12) found the policy lacked specificity, especially in the areas of Abuse Investigation and Education for Prevention of Abuse. The investigation procedures were general, with no differentiation based on type of investigation, i.e. investigation of skin tears, bruises, neglect, misappropriation of property or abuse. The Education/Prevention section made no mention of supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, and ignoring residents. These omissions in the policy development increase the risk that mistreatment of [REDACTED]. An interview was held with the Administrator on 11/14/13 at 5:00 p.m. The Administrator confirmed that the facility Abuse Policy was not fully developed in all areas. ( ) --

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE ADEQUATE TRANSFER ASSISTANCE WAS PROVIDED AND FAILED TO ENSURE THE ENVIROMENT WAS FREE FROM TRIP HAZARDS TO PREVENT AN AVOIDABLE ACCIDENT IN ONE (RESIDENT #101) OF THREE RESIDENTS REVIEWED FOR FALL RISK FROM A FACILITY POPULATION OF 137 RESIDENTS. THIS DEFICIENT PRACTICE RESULTED IN RESIDENT #101 EXPERIENCING A FALL, SUSTAINING A RIGHT FEMORAL FRACTURE WHICH REQUIRED SURGICAL INTERVENTION TO REPAIR. FINDINGS INCLUDE: THE FACE SHEET FOUND IN RESIDENT #101'S MEDICAL RECORD REVEALED HE IS AN [AGE] year OLD MALE ORIGINALLY admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]., OSTEOPOROSIS AND DYSPHAGIA. IN THE MINIMUM DATA SET (MDS) assessment dated [DATE], THE BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) FOR RESIDENT #101 REVEALED A SCORE OF 3/15, INDICATING SEVERE COGNITIVE IMPAIRMENT. THIS MDS ALSO REFLECTS RESIDENT #101 REQUIRED SUPERVISION WITH ONE PERSON PHYSICAL ASSISTANCE TO TRANSFER. A REVIEW OF A FACILITY REPORTED INCIDENT 24 HOUR REPORT DATED 8/5/13, DOCUMENTS ON 8/3/13 AT 5:50 P.M.: "...CNA BROUGHT RESIDENT (#101) BACK FROM THE DINING ROOM TO THE 100 WING HALLWAY. SHE DID NOT REMOVE THE W/C (WHEELCHAIR) FOOT PEDALS AFTER TRANSPORT. THE RESIDENT (#101) THEN ATTEMPTED TO GET UP FROM HIS W/C TO 'SIT IN THE COMFY CHAIR'. HE TRIPPED OVER THE W/C FOOT PEDAL AND fell . ON 8/4/13, IT WAS NOTED HE HAD INCREASED PAIN THE RIGHT HIP/LEG AND WAS TRANSFERRED TO THE (LOCAL) HOSPITAL FOR EVALUATION. HE WAS admitted WITH A RIGHT HIP FRACTURE." RESIDENT #101 WAS UNABLE TO BE OBSERVED OR INTERVIEWED DURING THE INVESTIGATION DUE TO BEING TRANSFERRED FROM THE HOSPITAL TO ANOTHER FACILITY AFTER POST FALL HIP SURGERY ON 8/4/13. A REVIEW OF THE HOSPITAL X-RAY REPORT DATED 8/4/13 FOR RESIDENT #101 READS IN PART: "...THERE IS A SUGGESTION OF AN ACUTE FRACTURE OF THE RIGHT FEMORAL NECK WITH MILD VARUS ANGULATION." ANOTHER HOSPITAL X-RAY REPORT DATED 8/5/13 FOR RESIDENT #101 REFLECTS RESIDENT #101 RECEIVED surgery for [REDACTED]. THIS REPORT READS IN PART: "...TWO VIEWS OF THE RIGHT HIP OBTAINED... THERE ARE POST-OPERATIVE CHANGES FOR TOTAL RIGHT HIP ARTHROPLASTY..." A REVIEW OF RESIDENT #101'S CARE PLAN DATED 5/2/12, REVEALED THE FOLLOWING: RISK FOR FALLS R/T (RELATED TO) CHRONIC PAIN, SECONDARY TO THORACIC VERTEBRAE FRACTURE, PARKINSON'S DISEASE, DEMENTIA, OSTEOPOROSIS, ATHEROSCLEROTIC HEART DISEASE, [DIAGNOSES REDACTED], ISCHEMIC [DIAGNOSES REDACTED], DEPRESSION, LUMBAGO, AND A HISTORY OF FALLS. RESIDENT #101'S HISTORY OF FALLS WAS VERIFIED BY A REVIEW OF FACILITY INCIDENT REPORTS DATED 7/1/13, 7/23/13 AND 8/4/13. INTERVENTIONS LISTED ON THIS CARE PLAN INCLUDED; "...KEEP THE ENVIRONMENT FREE OF CLUTTER AND OBSTACLES..." A REVIEW OF RESIDENT #101'S ACTIVITIES OF DAILY LIVING (ADL) FLOW SHEET DATED 8/1/13-8/31/13, REVEALED THE FOLLOWING ORDER, "SBA (STAND BY ASSIST) FOR TRANSFERS". IN AN INTERVIEW AT THE FACILITY ON 8/7/13 AT 3:00 P.M. WITH CERTIFIED NURSE AIDE (CNA) "C", WHO WORKED ON RESIDENT #101'S HALL, SHE WAS ASKED ABOUT THE TRANSPORT OF RESIDENTS TO/FROM THE DINING ROOM. CNA "C" STATED, "WE KINDA SWITCH OFF... (CNA "E" ) HAD TO GO TO THE DINING ROOM. I FOUND OUT LATER THAT (RESIDENT #101) fell ... NO CONVERSATION TOOK PLACE (REGARDING RESIDENT #101 BEING BACK FROM THE DINING ROOM)." WHEN ASKED ABOUT RESIDENT #101'S FOOT PEDALS, SHE STATED, "(CNA "E") SHOULD HAVE REMOVED THEM." IN AN INTERVIEW ON 8/7/13 AT 3:41 P.M., CNA "D", WHO WAS WORKING ON THE DAY OF RESIDENT #101'S FALL, STATED, "... HIS BACK (RESIDENT #101) WAS FACING ME... I COULDN'T SEE IF HIS (FOOT) PEDALS WERE ON OR NOT... HE ATTEMPTED TO STAND, HE DOES IT ALL THE TIME... HE GOT UP AND SIDE-STEPPED AND fell ... WHEN HE WAS ON THE GROUND, I NOTICED HIS FOOT PEDALS ON (THE WHEELCHAIR)." A REVIEW OF THE FACILITY'S INVESTIGATIVE SUMMARY DATED 8/8/13, REFLECTS LACK OF SUPERVISION WAS PROVIDED FOR RESIDENT #101 WHEN HE ATTEMPTED TO SELF TRANSFER FROM HIS WHEELCHAIR INTO A CHAIR: "THE EMPLOYEE WITNESSED THE FALL FROM BEHIND THE RESIDENT AND WAS UNABLE TO SEE IF HE ACTUALLY TRIPPED OVER THE FOOT PEDALS OR NOT. SHE ATTEMPTED TO REACH THE RESIDENT TO PREVENT THE FALL FROM OCCURRING BUT WAS UNABLE TO DO SO AS IT HAPPENED SO QUICKLY." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADEQUATELY SUPERVISE AND PREVENT THE ELOPEMENT FOR ONE SEVERELY COGNITIVELY IMPAIRED RESIDENT (#101) OF FIVE SAMPLED RESIDENTS REVIEWED FOR ELOPEMENT RISKS OUT OF THE TOTAL FACILITY POPULATION OF 120 RESIDENTS RESULTING IN IMMEDIATE JEOPARDY TO THE HEALTH AND SAFETY OF RESIDENT #101. THE IMMEDIATE JEOPARDY BEGAN ON 2/13/13 AT APPROXIMATELY 8:09 P.M., WHEN RESIDENT #101 LEFT THE FACILITY UNSUPERVISED OUT THE FRONT DOOR IN A WHEELCHAIR. THE FACILITY'S WANDERGUARD ALARM SYSTEM FOR THE FRONT DOOR FAILED TO FUNCTION AND ALERT FACILITY STAFF THAT A VULNERABLE RESIDENT WAS LEAVING THE FACILITY IN THE COLD WINTER WEATHER. RESIDENT #101 WAS FOUND ON THE EDGE OF THE SIDEWALK ATTEMPTING TO SELF-PROPEL HER WHEELCHAIR INTO THE PARKING LOT, WITHOUT SUITABLE OUTDOOR WINTER ATTIRE. PER THE VIDEO CAMERA, RESIDENT #101 WAS WEARING A SHIRT, SWEATER, LONG PANTS, SHOES AND SOCKS. ACCORDING TO THE WEBSITE, WWW.WUNDERGROUND.COM, ON 2/13/13 AT APPROXIMATELY 8:00 P.M., THE AIR TEMPERATURE WAS 26 DEGREES FAHRENHEIT WITH A WINDCHILL OF 22 DEGREES FAHRENHEIT. ON 2/15/13 AT 11:00 A.M., THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT WAS IDENTIFIED ON 2/15/13 AND BEGAN ON 2/13/13, WHEN THE FACILITY'S AUDIBLE ALARM SYSTEM FAILED TO NOTIFY STAFF THAT RESIDENT #101 HAD EXITED THE FACILITY WITHOUT APPROPRIATE WINTER WEATHER PROTECTION OR ADEQUATE SUPERVISION. RESIDENT #101 WAS ASSISTED BACK INTO THE FACILITY AT APPROXIMATELY 8:11 P.M. BY VISITORS. DURING THE EXTENDED SURVEY PROCESS ON 2/15/13, THE IMMEDIATE JEOPARDY WAS REMOVED BY THE FOLLOWING ACTIONS: - IMMEDIATELY UPON RESIDENT #101'S RETURN TO THE FACILITY, THE FACILITY'S ELOPEMENT PROCEDURE WAS ACTIVATED. A RESIDENT HEAD COUNT WAS CONDUCTED TO ENSURE ALL RESIDENTS WERE ACCOUNTED FOR AND THE WANDERGUARDS FOR ALL OTHER ELOPEMENT RISK RESIDENTS WERE CHECKED, AND FOUND TO BE IN WORKING ORDER. - AS PART OF THE ELOPEMENT PROCEDURE AND DURING THE EXIT DOOR CHECKS IMMEDIATELY AFTER THE INCIDENT, THE FRONT DOOR ALARM WAS THE ONLY DOOR FOUND TO MALFUNCTION. IT DID NOT ALARM WHEN THE RESIDENT WANDERGUARD DEVICE CAME NEAR THE DOOR. THE ADDITIONAL 12 EXIT DOOR ALARMS AUTOMATICALLY ACTIVATED IF THEY WERE OPENED. - IMMEDIATELY UPON RESIDENT #101'S RETURN TO THE FACILITY, STAFF DISCOVERED THE FRONT DOOR PUSH BUTTON MECHANISM USED TO ALLOW TRANSPORTERS TO DISENGAGE THE WANDERGUARD DOOR ALARM SYSTEM, WAS NOT RE-ENGAGING. THEREFORE, FROM 8:30 P.M. ON 2/13/13 UNTIL 10 A.M. ON 2/14/13, THE FRONT DOOR WAS EITHER MANNED BY STAFF OR THE FACILITY'S ENTRANCE/EXIT DOOR ALARM SYSTEM WAS ACTIVATED TO ENSURE STAFF WERE ALERTED IF ANYONE EXITED OR ENTERED THE BUILDING. - THE MAINTENANCE DEPARTMENT WITH OVERSIGHT FROM MAINTENANCE DIRECTOR "B", BEGAN MORNING AND AFTERNOON OPERATIONAL CHECKS OF A NEW "PUSH BUTTON RELEASE SYSTEM" INSTALLED ON 2/14/13, TO ENSURE THE PUSH BUTTON ALARM RELEASE CONTINUED TO FUNCTION APPROPRIATELY. - THE TRANSPORTERS WERE TRAINED TO MAKE SURE THE NEW "PUSH BUTTON ALARM SYSTEM" ENGAGED/DISENGAGED PROPERLY AFTER THEIR EXIT OR ENTRANCE INTO/OUT OF THE FACILITY. - RESIDENT #101'S WHEELCHAIR MOUNTED WANDERGUARD WAS CHECKED AND FOUND TO BE WORKING BUT FOR SAFETY MEASURES, ANOTHER WANDERGUARD WAS PLACED ON RESIDENT #101'S ANKLE. RESIDENT #101 WAS PLACED ON FIFTEEN MINUTE CHECKS WITH NO DATE FOR REMOVAL. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT AN ISOLATED LEVEL OF POTENTIAL FOR MORE THAN MINIMAL HARM, DUE TO: - THE CONTINUATION OF THE FACILITY'S QUALITY ASSURANCE (QA) PROCESS TO HAVE THE MAINTENANCE DEPARTMENT WITH OVERSIGHT FROM MAINTENANCE DIRECTOR "B", CONTINUE THE MORNING AND AFTERNOON OPERATIONAL CHECKS OF THE NEW "PUSH BUTTON RELEASE SYSTEM", TO ENSURE THE PUSH BUTTON ALARM RELEASE CONTINUES TO FUNCTION APPROPRIATELY. - THE FACILITY'S ASSESSED NEED TO INSTALL A NEW "KEY PAD TYPE ENTRANCE SYSTEM" FOR RESIDENT TRANSPORTERS TO USE. TRANSPORTERS WILL PUNCH A CODE INTO THE PAD WHICH WILL DISENGAGE, FOR A SHORT PERIOD OF TIME, THE DOOR WANDERGUARD ALARM SYSTEM. THE TRANSPORTERS WILL ENSURE THE SYSTEM IS RE-ENGAGED PRIOR TO THEM LEAVING THE FRONT DOOR AREA. - THE NEED TO TRAIN ALL TRANSPORTERS IN A NEW "KEY PAD FRONT DOOR SYSTEM". - THE FACILITY'S NEED TO ALERT ALL STAFF OF THE ELOPEMENT INCIDENT, REVIEW THE ELOPEMENT PROCEDURE WITH THEM AND TRAIN THEM ON THE USE OF THE NEW KEY PAD ALARM SYSTEM THAT WILL BE USED AT THE FRONT DOOR. - VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH PROVIDING ADEQUATE SUPERVISION IN ORDER TO PREVENT AN UNSAFE ELOPEMENT. FINDINGS INCLUDE: A REVIEW OF RESIDENT #101'S MINIMUM DATA SET (MDS) assessment dated [DATE], SHOWED SHE HAD RESIDED AT THE FACILITY SINCE 11/22/11 AND IS [AGE] years OLD. THE MDS DOCUMENTED HER [DIAGNOSES REDACTED]. RESIDENT #101'S CARE PLAN DATED 1/2013, SHOWED HER COGNITION WAS SEVERELY IMPAIRED, SHE USUALLY COULD UNDERSTAND WHAT WAS SAID TO HER AND USUALLY WAS UNDERSTOOD WHEN SHE SPOKE, AND HAD BOTH SHORT AND LONG TERM MEMORY PROBLEMS. THE CARE PLAN SHOWED RESIDENT #101 COULD SELF PROPEL HER WHEELCHAIR THROUGHOUT THE FACILITY AND HAD BEEN ASSESSED TO BE AN ELOPEMENT RISK. A FACILITY'S INVESTIGATION REPORT DATED 2/14/13, SHOWED ON 2/13/13 PER THE FACILITY INTERNAL VIDEO CAMERA, AT APPROXIMATELY 8:09 P.M., RESIDENT #101 SELF PROPELLED HERSELF OUT THE FRONT DOOR OF THE FACILITY AND WAS FOUND BY INCOMING VISITORS AT 8:11 P.M. AND RETURNED TO THE FACILITY. A REVIEW OF A NURSES NOTE DATED 2/13/13 FOUND IN RESIDENT #101'S MEDICAL RECORD, REVEALED RESIDENT #101 WAS RETURNED TO THE FACILITY AND ASSESSED TO HAVE NO INJURIES. THE FOLLOWING WAS LEARNED DURING AN INTERVIEW WITH REGISTERED NURSE (RN) "A" ON 2/15/13 AT 8:30 A.M.: RESIDENT #101 WAS AT THE NURSES STATION AROUND 8:00 P.M. TALKING WITH RN "A". RN "A" STATED RESIDENT #101 MADE NO INDICATION SHE WAS GOING TO LEAVE THE FACILITY. WHEN ASKED IF RESIDENT #101 HAD TRIED TO LEAVE BEFORE, RN "A" EXPLAINED RESIDENT #101 WOULD SAY SHE WANTED TO GO HOME OR WANTED TO GO HOME WITH RN "A". RN "A" SAID AFTER RESIDENT #101 WOULD TALK ABOUT WANTING TO LEAVE, RESIDENT #101 COULD BE EASILY REDIRECTED TO ANOTHER ACTIVITY. SHE EXPLAINED, "...ALL I CAN FIGURE OUT IS AFTER OUR DISCUSSION AT THE NURSES STATION AND I WENT TO ASSIST ANOTHER RESIDENT, (RESIDENT #101) MADE A BEE LINE FOR THE FRONT DOOR..." DURING AN INTERVIEW WITH MAINTENANCE DIRECTOR "B" ON 2/15/13 AT 9:30 A.M., MAINTENANCE DIRECTOR "B" STATED THE FACILITY REPORT WAS CORRECT. HE EXPLAINED THE PUSH BUTTON ALLOWING THE TRANSPORTERS TO DISENGAGE THE WANDERGUARD ALARM SYSTEM HAD BEEN CHECKED THE MORNING OF 2/13/13 AND HAD BEEN WORKING "FINE". A REVIEW OF THE FORM TITLED "DAILY DOOR LOCK LOG" (NO PRINT DATE) VERIFIED THE FRONT DOOR LOCK SYSTEM HAD BEEN CHECKED ON 2/12/13 AND 2/13/13. MAINTENANCE DIRECTOR "B" SAID WHEN THE PUSH BUTTON WAS CHECKED AFTER THE INCIDENT, IT WAS FOUND STUCK AND "PUSHED IN" DISENGAGING THE WANDERGUARD ALARM SYSTEM. HE STATED THE DOOR WAS MANNED, BECAUSE THE PUSH BUTTON SYSTEM COULD NOT BE IMMEDIATELY REPAIRED. THE ADMINISTRATOR AND DIRECTOR OF NURSING WERE INTERVIEWED ON 2/15/13 AT 11:30 A.M. BOTH STAFF CONFIRMED RESIDENT #101, A VULNERABLE RESIDENT IDENTIFIED AS AN ELOPEMENT RISK, HAD LEFT THE FACILITY WITHOUT STAFF KNOWLEDGE WHEN THE FACILITY'S FRONT DOOR WANDERGUARD ALARM SYSTEM HAD FAILED. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION FOR ONE (#1) COGNITIVELY IMPAIRED AMBULATORY RESIDENT IDENTIFIED AS AN ELOPEMENT RISK OF FOUR SAMPLED RESIDENTS REVIEWED FOR ELOPEMENT IN THE FACILITY'S 137 TOTAL RESIDENT POPULATION, RESULTING IN RESIDENT #1 ELOPING FROM THE COMMUNITY SENIOR CENTER (CENTER) DURING A FACILITY ACTIVITY OUTING AND FOUND AT HER FAMILY HOME, WHICH IS MORE THAN 2 BLOCKS AWAY AND REQUIRED RESIDENT #1 TO CROSS TWO STREETS, PLACING RESIDENT #1 IN IMMEDIATE JEOPARDY TO HER HEALTH AND SAFETY. THE IMMEDIATE JEOPARDY BEGAN ON 11/16/12 AT APPROXIMATELY 3:15 P.M., WHEN ACTIVITY AIDE "A" LEFT RESIDENT #1 ALONE IN THE CENTER AND RESIDENT #1 EXITED OUT THE CENTER'S BACK DOOR AND IN COLD WEATHER, WALKED WITHOUT STAFF ASSISTANCE TO HER FAMILY HOME. THE IMMEDIATE JEOPARDY CONTINUED UNTIL 11/16/12 AT APPROXIMATELY 3:25 P.M., WHEN ACTIVITY AIDE "A" FOUND RESIDENT #1 UNHARMED AT RESIDENT #1'S FAMILY HOME AND THEN WAS ESCORTED BACK TO THE FACILITY. BASED ON THE FACILITY'S ACTIONS TO PREVENT REOCCURRENCE OF AN ELOPEMENT DURING AN ACTIVITY OUTING, THESE FINDING ARE DETERMINED TO CONSTITUTE PAST NON COMPLIANCE. THE IMMEDIATE JEOPARDY WAS REMOVED ON 11/16/12 WHEN RESIDENT #1 RETURNED TO THE FACILITY AND WAS IMMEDIATELY PLACED ON 15 MINUTE SUPERVISORY CHECKS AND THE FACILITY ADMINISTRATOR HALTED ALL FURTHER ACTIVITY OUTINGS UNTIL THE ACTIVITY POLICY WAS REVISED AND ALL ACTIVITY STAFF HAD BEEN TRAINED. FINDINGS INCLUDE: THE REVIEW OF RESIDENT #1'S 10/12/12 MINIMUM DATA SET (MDS) ASSESSMENT SHOWED SHE WAS admitted to the facility on [DATE] AND WAS [AGE] years OLD. THE MDS ASSESSMENT DOCUMENTED HER [DIAGNOSES REDACTED]. THE MDS AND 11/12 CARE PLAN IDENTIFIED RESIDENT #1'S COGNITION AS SEVERELY IMPAIRED, BUT SHE USUALLY UNDERSTOOD WHAT WAS SAID TO HER AND COULD USUALLY BE UNDERSTOOD WHEN SHE SPOKE. THE CARE PLAN SHOWED RESIDENT #1 WAS "PLEASANTLY CONFUSED" AND WAS INDEPENDENT WITH TRANSFERS AND AMBULATION. THE CARE PLAN SHOWED RESIDENT #1 WAS AN ELOPEMENT RISK AND WORE A CODE ALERT ANKLE BRACELET AT ALL TIMES. THE FACILITY'S 11/26/12 INVESTIGATION REPORT SHOWED ON 11/16/12, RESIDENT #1 WAS ATTENDING AN OUTING WITH FOUR OTHER RESIDENTS, ACTIVITY AIDE "A" AND ACTIVITY AIDE "C" AT THE CENTER, WHICH WAS LOCATED APPROXIMATELY 5 MILES FROM THE FACILITY. THE INVESTIGATION REPORT DOCUMENTED AT APPROXIMATELY 3:15 P.M., ACTIVITY AIDE "A" LEFT RESIDENT #1 ALONE IN THE CENTER WHILE SHE ASSISTED OTHER RESIDENTS INTO THE FACILITY BUS, WHERE ACTIVITY AIDE "C" WAS SUPERVISING THE OTHER RESIDENTS. THE REPORT SHOWED ACTIVITY AIDE "A" HAD SAID RESIDENT #1 WAS ANGRY ABOUT THE COAT SHE WAS TOLD TO WEAR, SO ACTIVITY AIDE "A" LEFT RESIDENT #1 IN THE CENTER TO "CALM DOWN". THE REPORT DOCUMENTED RESIDENT #1 HAD LEFT OUT THE BACK DOOR OF THE CENTER SOMETIME AFTER 3:15 P.M. AS PART OF ACTIVITY AIDE "A"'S SEARCH FOR RESIDENT #1, PER THE REPORT, AN UNIDENTIFIED "MAN" SAID THEY SAW RESIDENT #1 WALKING, AROUND THE CORNER FROM THE CENTER AND DOWN THE STREET. AS DOCUMENTED IN THE REPORT, ACTIVITY AIDE "A" SAW RESIDENT #1 ON THE SIDEWALK APPROXIMATELY 2 BLOCKS FROM THE CENTER AND BEFORE ACTIVITY AIDE "A" COULD REACH RESIDENT #1, RESIDENT #1 HAD ENTERED HER FAMILY HOME WHERE FAMILY MEMBER "T" WAS RESIDING. AT APPROXIMATELY 3:30 P.M., FAMILY MEMBER "T" TRANSPORTED RESIDENT #1 AND ACTIVITY AIDE "A" BACK TO THE CENTER WHERE RESIDENT #1 WAS ASSISTED INTO THE FACILITY BUS WITHOUT INCIDENT OR IDENTIFIED INJURY, PER THE REPORT. AN INTERVIEW WAS CONDUCTED WITH THE ADMINISTRATOR AND DIRECTOR OF NURSING (DON) ON 11/27/12 AT 2:20 P.M. BOTH STAFF STATED THE FACILITY'S INVESTIGATION REPORT WAS CORRECT. THE DON STATED THAT WHEN RESIDENT #1 ARRIVED BACK AT THE FACILITY, SHE WAS CONFUSED AND DID NOT UNDERSTAND WHY SHE WAS AT THE FACILITY. THE DON EXPLAINED SOCIAL WORKER (SW) "D" SPOKE WITH RESIDENT #1 UPON HER RETURN FROM THE CENTER AND LICENSED PRACTICAL NURSE (LPN) "E" FOUND NO INJURIES UPON ASSESSMENT OF RESIDENT #1. DURING AN INTERVIEW ON 11/27/12 AT 2:20 P.M. WITH THE ADMINISTRATOR AND DON, THE ADMINISTRATOR PROVIDED A DOCUMENT FROM "...ACCUWEATHER.COM..." SHOWING THE LOCAL AREA WEATHER AS "38" DEGREES AND NO PRECIPITATION ON 11/16/12. SHE ALSO PRESENTED A "...MAPQUEST.COM..." DOCUMENT DATED 11/27/12 WHICH MAPPED OUT THE DISTANCE FROM THE CENTER TO RESIDENT #1'S FAMILY HOME AS 0.23 MILES OR APPROXIMATELY A QUARTER MILE. THE DOCUMENT SHOWED RESIDENT #1 HAD CROSSED 2 STREETS TO REACH THE HOUSE. THE SURVEYOR DROVE THE "MAPQUEST" IDENTIFIED ROUTE ON 11/28/12 AT 7:00 A.M. THE ROADS CONTAINED SIDEWALKS AND THREE CARS WERE SEEN TO BE TRAVELING AT SLOW SPEEDS ON THE STREETS WHICH SEEMED TO BE LOCATED ON THE EDGE OF THE TOWN. THE ACTIVITY DEPARTMENT DOCUMENT TITLED "MONTHLY ACTIVITY DEPARTMENT MEETING" DATED 10/3/12 READS UNDER DURING ACTIVITIES, #3: "ALL RES. (RESIDENTS) IN VIEW AT ALL TIMES..." THE MEETING SIGN IN SHEET DOCUMENTED ACTIVITY AIDE "A" AND ACTIVITY AIDE "C" HAD ATTENDED THE MEETING. ACTIVITY DIRECTOR "F" AND ACTIVITY AIDE "C" WERE INTERVIEWED ON 11/27/12 AT 3:00 P.M. AND AT 3:30 P.M. RESPECTIVELY. A TELEPHONE INTERVIEW WAS CONDUCTED WITH ACTIVITY AIDE "A" ON 11/28/12 AT 11:00 A.M. THE THREE STAFF SAID THE REPORT WAS CORRECT. WHEN ASKED WHAT THE FACILITY PRACTICE WAS REGARDING RESIDENT SUPERVISION WHILE ON AN OUTING, ALL THREE STAFF SAID THERE IS NO SITUATION WHEN A RESIDENT IS NOT WITHIN STAFF SIGHT WHILE ON AN OUTING. ACTIVITY AIDE "A" SAID, "...I HAVE NO EXCUSE FOR WHAT I DID... I KNOW NOT TO LEAVE A RESIDENT OUT OF MY SIGHT..." SHE EXPLAINED, "...YES, WHEN I TURNED THE CORNER ONTO THE ROAD TO (RESIDENT #1'S) HOUSE, I COULD SEE HER WALKING QUITE A WAYS AHEAD OF ME... SHE WAS ON THE SIDEWALK AND WEARING HER COAT... (RESIDENT #1) WAS ALREADY IN THE HOUSE TALKING TO (FAMILY MEMBER "C")..." ACTIVITY AIDE "A" CONFIRMED SHE HAD BEEN PLACED ON SUSPENSION IMMEDIATELY AFTER THE INCIDENT AND IS STILL SUSPENDED. A TELEPHONE INTERVIEW WAS CONDUCTED WITH LICENSED PRACTICAL NURSE (LPN) "E" ON 11/28/12 AT 1:10 P.M. SOCIAL WORKER (SW) "D" WAS INTERVIEWED ON 11/28/12 AT 10:05 A.M. SW "D" SAID RESIDENT #1 WAS "VERY CONFUSED AND ANXIOUS" WHEN SHE RETURNED FROM THE CENTER AROUND 4:00 P.M. SW "D" EXPLAINED SHE ESCORTED RESIDENT #1 TO HER ROOM WHERE RESIDENT #1 SAT IN HER RECLINER. SW "D" SAID SHE STAYED WITH RESIDENT #1 FOR ABOUT 15 MINUTES UNTIL RESIDENT #1 "SEEMED RELAXED" IN HER CHAIR. SW "D" SAID RESIDENT #1 WAS PUT IMMEDIATELY ON 15 MINUTE CHECKS WHEN SHE RETURNED FROM THE CENTER. LPN "E" STATED RESIDENT #1 WAS FOUND TO HAVE NO INJURIES AND "WAS BACK TO HER OLD, PLEASANTLY CONFUSED SELF" BY THE TIME SHE WAS ESCORTED TO THE DINING ROOM FOR DINNER "JUST BEFORE 5 P.M." AN INTERVIEW WAS CONDUCTED WITH RESIDENT #1 ON 11/28/12 AT 1:35 P.M. SHE WAS OBSERVED SITTING IN HER RECLINER WITH A CODE ALERT ANKLE BRACELET AROUND HER RIGHT ANKLE. RESIDENT #1 SMILED AND LOOKED AT THE SURVEYOR WHEN SHE SPOKE. SHE STATED EVERYONE AT THE FACILITY WAS "NICE AND HELPFUL" AND SHE HAD "NO COMPLAINTS". RESIDENT #1 WAS NOT QUESTIONED ABOUT THE INCIDENT DUE TO THE TOPIC POSSIBLY TRIGGERING NEGATIVE BEHAVIORS REGARDING RESIDENT #1'S PERCEPTIONS OF HER PREVIOUS HOME AND WANTING TO RETURN. BASED ON THE REVIEW OF THE FACILITY DOCUMENT TITLED "FACILITY REQUEST FOR PAST NON-COMPLIANCE" DATED 11/28/12, THE SURVEYOR VERIFIED THROUGH DOCUMENT REVIEWS AND STAFF INTERVIEWS, THAT THE IMMEDIATE INTERVENTIONS IMPLEMENTED BY THE FACILITY ON 11/16/12 THROUGH 11/27/12 TO PREVENT REOCCURRENCE OF ELOPEMENT INCIDENTS, INCLUDED THE FOLLOWING: 1. RESIDENT #1 WAS PLACED ON 15 MINUTE CHECKS UPON HER RETURN FROM THE OUTING ON 11/16/12 AND THE 15 MINUTE CHECKS CONTINUE IN PLACE. HER CARE PLAN WAS UPDATED TO SHOW RESIDENT #1 NEEDED 1:1 SUPERVISION WHEN ATTENDING ACTIVITY OUTINGS. 2. ACTIVITY AIDE "A" AND ACTIVITY AIDE "C" WERE SUSPENDED IMMEDIATELY FOLLOWING THE INCIDENT AND RECEIVED DISCIPLINARY ACTION. ACTIVITY AIDE "A" REMAINS ON SUSPENSION. 3. A NEW ACTIVITY OUTING POLICY/PROCEDURE WAS IMPLEMENTED ON 11/20/12 AND INCLUDED: A. DETERMINE THE NUMBER OF STAFF REQUIRED BASED ON THE RESIDENT'S COGNITION AND ELOPEMENT RISK. B. ENSURE RESIDENT IS SAFE FOR OUTING BY COMPLETING THE RESIDENT SAFETY LIST FOR ACTIVITY OUTINGS CHECKLIST. C. DETERMINE THE NUMBER OF STAFF REQUIRED FOR OUTING WITH SAFE STAFF ACTIVITY OUTING CHECKLIST. A MINIMUM OF THREE STAFF MUST BE SCHEDULED FOR THE OUTING. D. INITIATE AND COMPLETE THE FACILITY OUTING PLAN AND RECEIVE APPROVAL BY THE DIRECTOR OF NURSING AND THE ADMINISTRATOR PRIOR TO THE OUTING. 4. ON 11/16/12, NO FURTHER ACTIVITY OUTINGS WERE SCHEDULED UNTIL ALL ACTIVITY STAFF HAD BEEN INSERVICED ON THE NEW POLICY/PROCEDURE. 5. ALL ACTIVITY STAFF WERE INSERVICED ON 11/19/12 ON RESIDENT SAFETY DURING ACTIVITY OUTINGS AND THE NEW ACTIVITY OUTING POLICY/PROCEDURE. 6. ALL STAFF WERE INSERVICED BETWEEN 11/20/12 AND 11/27/12 BY 2 P.M., ON THE FACILITY'S RESIDENT SUPERVISION POLICY, CODE GREEN AND ACTIVITY OUTINGS POLICY/PROCEDURE. 7. THE ACTIVITY DIRECTOR WILL ATTEND ALL OUTINGS FOR ONE MONTH AND MONTHLY THEREAFTER. THE ACTIVITY DIRECTOR WILL COMPLETE THE QUALITY ASSURANCE (QA) AUDIT "ACTIVITY OUTING AUDIT SHEET" AND FORWARD IT TO THE ADMINISTRATOR FOR REVIEW. THE ACTIVITY DIRECTOR WILL ATTEND THE FIRST OUTING THAT A NEW ACTIVITY AIDE IS ASSIGNED TO AND ENSURE THEY ARE PROPERLY TRAINED REGARDING RESIDENT SAFETY. 8. THE FIRST ACTIVITY OUTING OCCURRED ON 11/27/12 BETWEEN 10:30 A.M. AND 1:30 P.M. THE AUDIT TOOL INDICATED 100 PERCENT COMPLIANCE WITH THE NEW ACTIVITY OUTING POLICY/PROCEDURE. THE AUDIT TOOLS WILL BE PRESENTED AT THE NEXT QA MEETING SCHEDULED FOR 12/12/12. NO CONTINUING NON-COMPLIANCE WITH THE REGULATORY REQUIREMENT WAS IDENTIFIED DURING THE ABBREVIATED SURVEY THAT BEGAN 11/27/12 AT 2:00 P.M. AND WAS COMPLETED BY 2:15 P.M. ON 11/28/12. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE PRESCRIBED LONG TERM OXYGEN THERAPY FOR ONE (#1) RESIDENT WHO WAS OXYGEN DEPENDENT OF EIGHT RESIDENTS REVIEWED WITH PHYSICIAN ORDERS [REDACTED]. THIS FACILITY DEFICIENT PRACTICE PLACED RESIDENT #1 IN IMMEDIATE JEOPARDY TO HER HEALTH AND SAFETY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON [DATE] AT 3:00 P.M. THE IMMEDIATE JEOPARDY BEGAN ON [DATE] AT APPROXIMATELY 10:30 P.M. WHEN RESIDENT #1 WAS RETURNED TO THE FACILITY FROM THE HOSPITAL WITH PHYSICIAN ORDERS [REDACTED].M. (OVER AN HOUR, AFTER RESIDENT #1 HAD BEEN RETURNED TO THE FACILITY) AND WAS FOUND WITH NO BLOOD PRESSURE, PULSE OR RESPIRATION AND REGISTERED NURSE "B" PRONOUNCED RESIDENT #1 "...HAD EXPIRED." THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON [DATE] AT 4:30 P.M. AND A WRITTEN PLAN FOR REMOVAL OF THE IMMEDIATE JEOPARDY WAS REQUESTED. ON [DATE] AT 5:30 P.M., THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THE FACILITY PRODUCED THE FOLLOWING: - THE ADDITIONAL SEVEN RESIDENTS USING OXYGEN WERE ASSESSED BY EITHER NURSING SUPERVISOR RN "D" OR RN "F" TO ENSURE THE SEVEN RESIDENTS' OXYGEN FLOWMETERS WERE ON AND THE OXYGEN WAS BEING DELIVERED AT THE PRESCRIBED RATE. ON [DATE] BETWEEN 9:00 A.M. AND 11:00 A.M., RESIDENTS #2, #3, #4, #5, #6, #7 AND #8'S NASAL CANNULAS AND FLOW METERS WERE OBSERVED TO BE IN WORKING ORDER. - MAINTENANCE DIRECTOR "G" VERIFIED "ALL WALL OXYGEN UNITS/FLOW METERS WERE PROPERLY WORKING INCLUDING THE FLOW METER USED FOR (RESIDENT #1)..." - LICENSED PRACTICAL NURSE "C", THE NURSE THAT ASSESSED RESIDENT #1 AFTER HER RETURN TO THE FACILITY AND FAILED TO TURN THE OXYGEN FLOW METER ON AND CHECK RESIDENT #1'S OXYGEN SATURATION LEVELS, WAS SUSPENDED AND THEN TERMINATED ON [DATE] AND DID NOT HAVE THE OPPORTUNITY TO SERVICE FACILITY RESIDENTS AFTER THE INCIDENT. - THE POLICY, "OXYGEN THERAPY-MASK AND NASAL CANNULA", (REVISED ,[DATE]) WAS UPDATED TO INCLUDE "...#2. THE LICENSED NURSE WILL CHECK TO ENSURE OXYGEN IS BEING DELIVERED AT THE CORRECT ORDERED RATE WHEN RESIDENT RETURNS TO FACILITY FOLLOWING A LOA (LEAVE OF ABSENCE), EMERGENCY TRANSFER OR ADMISSION/RE-ADMISSION TO FACILITY..." - THE POLICY TITLED, "EMERGENCY TRANSFER" (REVISED, [DATE]) WAS UPDATED TO INCLUDE, "...12. UTILIZE THE RESIDENT RETURN "CHECK OFF LIST" TO PREPARE FOR RESIDENT'S RETURN...14. THE LICENSED NURSE WILL ASSIST EMS (EMERGENCY MEDICAL SERVICES) PERSONNEL UPON (RESIDENT) RETURN TO THE FACILITY TO ENSURE THAT ALL REQUIRED INFORMATION AND MEDICAL EQUIPMENT (I.E. OXYGEN, IV'S) NEEDS ARE MET..." THE UPDATED DOCUMENTS WERE REVIEWED. - THE POLICY TITLED, "O2 (OXYGEN) SATURATIONS WITH PULSE OXIMETER...STANDARD: TO ENSURE THAT A SYSTEM IS IN PLACE THAT PROVIDES FOR THE MEASUREMENT, RECORDING, AND REPORTING OF OXYGEN SATURATION...(DATE [DATE])..." DOCUMENTED "...SPO2 (PULSE SATURATION) LEVELS..." WILL BE PERFORMED AT A MINIMUM, EVERY SHIFT BY THE LICENSED NURSE UNLESS OTHERWISE ORDERED BY THE PHYSICIAN AND/OR THE RESIDENT EXHIBITS "RESPIRATORY DISTRESS..." THE SURVEYOR INTERVIEWED RN "D" AND LPN "A" ON [DATE] AT 11:10 A.M. AND 11:59 A.M. RESPECTIVELY. THE STAFF INTERVIEWED STATED THE RESIDENTS RECEIVING OXYGEN WERE BEING CHECKED PER THE "OXYGEN CHECKLIST." A REVIEW OF THE O2 CHECKLISTS FROM [DATE] THROUGH [DATE] WERE CHECKED AND SHOWED DOCUMENTATION FOR EACH SHIFT FOR THE 7 RESIDENTS OXYGEN USE. - INSERVICE TRAINING TITLED "OXYGEN THERAPY P&P (POLICIES & PROCEDURES)" WERE COMPLETED BY [DATE] FOR ALL NURSING STAFF NOT ON A LEAVE OF ABSENCE. THE TRAINING SIGN IN SHEETS AND TRAINING AGENDAS WERE REVIEWED BY THE SURVEYOR. DURING [DATE] 10:45 A.M. 11:59 A.M. AND 1:50 P.M. RESPECTIVE INTERVIEWS WITH LPN "H", LPN "A" AND RN "E", THEY STATED RECEIVING THE TRAINING'S. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT AN ISOLATED LEVEL WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM. THE DEFICIENT PRACTICE WILL CONTINUE PENDING VERIFICATION BY THE STATE AGENCY OF THE FOLLOWING ACTIONS NEEDED TO BE MADE BY THE FACILITY: - MANAGEMENT WILL CONTINUE TO MONITOR NURSE PERFORMANCE REGARDING THE RESIDENT VITALS CHECKS INCLUDING THE DIRECTOR OF NURSING'S (DON) REVIEW OF THE O2 CHECK LISTS RECORDED ON EACH SHIFT. THIS WILL CONTINUE UNTIL THE FACILITY'S QUALITY ASSURANCE (QA) COMMITTEE DETERMINES, THE CORRECTION(S) PUT IN PLACE HAVE SATISFIED THE FACILITY'S QA PROCESS. - MANAGEMENT REVIEW AND DOCUMENTATION THAT ANY RESIDENT LEAVING OR RETURNING TO THE FACILITY HAVE RECEIVED AN ASSESSMENT OF NEED AND HAVE RECEIVED ANY TREATMENTS NEEDED. THE MANAGEMENT REVIEW WILL CONTINUE UNTIL THE FACILITY'S QA COMMITTEE DETERMINES THE CORRECTION(S) PUT IN PLACE HAVE SATISFIED THE FACILITY'S QA PROCESS. FINDINGS INCLUDE: THE FACILITY'S [DATE] INVESTIGATION REPORT SHOWED ON [DATE] AT 10:30 P.M., RESIDENT #1 WAS RETURNED TO THE FACILITY FROM THE emergency room BY EMS (EMERGENCY MEDICAL SERVICES) PERSONNEL AND WAS "ACTIVELY DYING..." PER THE REPORT, "..(RESIDENT #1) RETURNED ON OXYGEN..." THE REPORT DOCUMENTED LPN "C" DID NOT ASSESS RESIDENT #1 UNTIL APPROXIMATELY 10:45 P.M. THE REPORT SHOWED LPN "C", "...DID NOT CHECK THE OXYGEN FLOW METER TO ENSURE THAT IT WAS ON." AT 11:40 P.M., LPN "A" WENT TO ASSESS RESIDENT #1 "...IN HER ROOM AND FOUND HER DEAD..." THE REPORT DOCUMENTED "...WHEN LPN "A" WENT TO TURN THE OXYGEN OFF, SHE FOUND THAT THE OXYGEN WAS NOT ON..." THE FACILITY'S [DATE] INVESTIGATION REPORT FURTHER DOCUMENTED: - "THE NURSE (LPN "C") DID NOT ASSIST EMS PERSONNEL WHEN THE RESIDENT (#1) ARRIVED AT THE FACILITY TO ENSURE THAT ALL MEDICAL AND EQUIPMENT NEEDS WERE MET." AND, - "THE NURSE (LPN "C") DID NOT INCLUDE CHECKING THE OXYGEN FLOW METER WHEN SHE ASSESSED THE RESIDENT UPON RETURN TO THE FACILITY. SHE (LPN "C") ASSUMED EMS HAD TURNED THE OXYGEN ON SINCE THE NASAL CANNULA WAS IN HER NOSE..." RESIDENT #1'S CLINICAL CHART FACE SHEET SHOWED SHE admitted to the facility on [DATE] AND WAS [AGE] years OLD. THE FACE SHEET DOCUMENTED HER [DIAGNOSES REDACTED]. RESIDENT #1'S [DATE] MINIMUM DATA SET (MDS) ASSESSMENT AND ,[DATE] CARE PLAN SHOWED SHE USUALLY UNDERSTOOD WHAT WAS SAID AND WAS USUALLY UNDERSTOOD WHEN SHE SPOKE. THE MDS ASSESSMENT DOCUMENTED RESIDENT #1'S COGNITION WAS IMPAIRED, SHE HAD SOME CONFUSION AND NEEDED ASSISTANCE WITH HER ACTIVITIES OF DAILY LIVING. THE [DATE] PHYSICIAN NOTE DOCUMENTED "...HAVING WORSENING [MEDICAL CONDITION]" THE [DATE] PHYSICIAN NOTE SHOWED "...(RESIDENT #1) IS OXYGEN DEPENDENT..." THE [DATE] AT 2:30 P.M. NURSES NOTE SIGNED BY LPN "C" SHOWED "...VS (VITAL SIGNS) 96, 104 - 24, ,[DATE] O2 SAT (SATURATION) 97% - 2L (LITERS O2)..." THE [DATE] AT 10:45 P.M. NURSES NOTE SIGNED BY LPN "C" DOCUMENTED, RESIDENT #1 RETURNED FROM THE HOSPITAL "...(RESIDENT #1) LOOKS PALE AND UNRESPONSIVE. VS ,[DATE], 104 24, 98.7... RESIDENT CURRENTLY IN BED. WILL CONTINUE TO MONITOR..." AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSING (DON) ON [DATE] AT 1:40 P.M. SHE SAID THE FACILITY'S INVESTIGATION REPORT WAS CORRECT. THE DON EXPLAINED, LPN "C" SHOULD HAVE GONE INTO RESIDENT #1'S ROOM WITH THE EMS PERSONNEL AND COMPLETED THE ASSESSMENT OF RESIDENT #1'S VITAL SIGNS WHICH, "SHOULD'VE INCLUDED O2 SATURATION LEVELS WHICH WOULD'VE ALERTED (LPN "C") TO THE OXYGEN FLOW METER ISSUE...VITAL SIGN ASSESSMENTS ALWAYS INCLUDE RESPIRATORY/OXYGEN CHECKS, ESPECIALLY WITH A RESIDENT WITH [MEDICAL CONDITION] LIKE (RESIDENT #1)... A NURSE KNOWS THAT, I EXPECT A NURSE TO KNOW THAT..." TELEPHONE INTERVIEWS WERE CONDUCTED WITH LPN "A" AND LPN "C" ON [DATE] AT 3:00 P.M. AND 3:55 P.M. RESPECTIVELY. BOTH STAFF SAID THE REPORT WAS CORRECT. LPN "C" SAID, "I KNEW I WAS SUPPOSED TO CHECK HER OXYGEN WHEN I DID HER OTHER VITALS WHEN SHE CAME BACK (FROM THE HOSPITAL)... I DID IT (CHECKED O2 SATURATION LEVEL) EARLIER IN THE DAY... I MISSED IT THIS TIME... I KNEW I WAS SUPPOSE TO DO IT (CHECK THE OXYGEN) AND I DIDN'T..." DURING THE INTERVIEW WITH LPN "A", SHE EXPLAINED, "WHEN (RESIDENT #1) WAS PRONOUNCED DEAD I WENT TO TURN OFF THE FLOW METER... IT WAS ALREADY OFF..." LPN "A" SAID, "THE OXYGEN FLOW METER SHOULD'VE BEEN CHECKED DURING VITAL CHECKS... OXYGEN SATURATION LEVELS ARE ALWAYS CHECKED DURING VITAL CHECKS..." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE SUPERVISION BY NOT UTILIZING AN ASSISTIVE DEVICE (FOOT PEDALS ON WHEELCHAIRS) DURING TRANSPORT OF TWO (#100 AND #104) OF FIVE RESIDENTS REVIEWED WITH ASSISTIVE DEVICES, FROM A TOTAL POPULATION OF 137 RESIDENTS IN THE FACILITY. THIS FAILURE RESULTED IN RESIDENT #100 FALLING OUT OF THE WHEELCHAIR SUSTAINING MULTIPLE NASAL FRACTURES, MULTIPLE LACERATIONS WITH SUTURES AND SIGNIFICANT SWELLING OF THE LEFT EYE AND PLACED RESIDENT #104 AT RISK FOR A FALL FROM A WHEELCHAIR RELATED TO STAFF TRANSPORTING THE RESIDENT WITHOUT FOOTPEDALS. FINDINGS INCLUDE: RESIDENT #100'S CLINICAL RECORD WAS REVIEWED. THE FACE SHEET REVEALED RESIDENT #100 IS A [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) assessment dated [DATE], REVEALED RESIDENT #100 HAS SEVERE COGNITIVE IMPAIRMENT, WITH RANGE OF MOTION DEFICITS OF THE UPPER AND LOWER EXTREMITIES OF HER RIGHT SIDE. THIS MDS assessment dated [DATE], SHOWED RESIDENT #100 NEEDED AN ASSISTIVE DEVICE (WHEELCHAIR) FOR LOCOMOTION WITH EXTENSIVE ASSISTANCE OF ONE, ON AND OFF THE UNIT. IN ADDITION, RESIDENT #100 had a history of [REDACTED].#100 HAS A DESIGNATED RESPONSIBLE PARTY TO MAKE HER HEALTHCARE DECISIONS FOR HER. A FACILITY REPORTED INCIDENT (FRI) DATED 11/4/11, REVEALED RESIDENT #100 HAD A FALL OUT OF A WHEELCHAIR ON 10/25/11 AT 1:15 P.M., WHILE ON AN OUTING WITH STAFF FROM THE FACILITY, RESULTING IN "MULTIPLE FRACTURES". THE "EMERGENCY DEPARTMENT" REPORT DATED 10/25/11, REVEALED RESIDENT #100 HAD "MULTIPLE SM (SMALL) LACS (LACERATIONS) ABOUT THE NOSE WITH NOSE BLEED (WHICH WERE CLOSED WITH SUTURES)...BILATERAL NASAL BONE FRACTURES AND NASAL SPINE FRACTURE, AND SEPTAL FRACTURE WITH MILD DEVIATION TO (THE) RIGHT, BLOOD IN MAXILLARY SINUS WITH NO ASSOCIATED FRACTURE." THE "NURSING PROGRESS NOTES" DATED 10/25/11 AT 1650 (4:30 P.M.), READ "RES (RESIDENT #100) HAS NASAL SPINE FX (FRACTURE), SEPTAL FX, BILATERAL NASAL FX AND NOSE IS DEVIATED TO THE RIGHT. VSS (VITAL SIGNS STABLE) MULTIPLE SUTURES ON EXTERIOR OF NOSE, NOSE ALSO EVACUATED OF BLOOD CLOTS AND RHINOROCKET (NASAL PACKING) APPLIED/INSERTED INTO EACH NARE AND IS TO STAY IN PLACE X2 DAYS. RES (RESIDENT #100) ALSO HAS SWOLLEN (LEFT) EYE." ON THE RESIDENT'S RETURN TO THE FACILITY, A NURSE PROGRESS NOTE DATED 10/25/11 AT 2355 (11:55 P.M.), READ "RES (RESIDENT #100) WITH MULTIPLE CONTUSIONS AND ABRASIONS TO FACE, EYES AND (RIGHT) KNEE. RIGHT KNEE CLEANSED (WITH) NS (NORMAL SALINE) AND BANDAGE APPLIED... UNABLE TO ASSESS (LEFT) EYE R/T (RELATED TO) SWOLLEN SHUT." THE FACILITY'S "INVESTIGATION" DATED 10/25/11, REVEALED INTERVIEWS WITH FACILITY STAFF PRESENT ON THE OUTING. THE STATEMENT MADE BY ACTIVITY AIDE "E" 'TAKEN ON 10/26/11 (NO TIME SPECIFIED) READ, " ...NO, I WASN'T PRESENT WHEN IT HAPPENED...(WHEN ASKED ABOUT FOOT PEDALS) AROUND THE FACILITY..., SHE DOESN'T... BUT YEAH, SHE'S SUPPOSED TO HAVE FOOT PEDALS ON WHILE ON OUTINGS. I KNOW THEY NEVER DO THAT, THE STAFF WHEN THEY BRING HER ... THEY ALWAYS BRING HER UP THERE, BUT THEY DON'T BRING THE FOOT PEDALS WITH HER. ACTIVITIES HAS TO RUN TO HER ROOM TO GET THE PEDALS. THEY DIDN'T THIS TIME. SHE DIDN'T HAVE HER FOOT PEDALS WITH HER." THE FACILITY'S "INVESTIGATION" REPORT (DATED 10/25/11) RECORDED AN INTERVIEW WITH ACTIVITY CERTIFIED NURSE AIDE (CNA) "F" ON 10/26/11 AT 10:15 A.M., WHICH READ, "I DIDN'T REALIZE SHE HAD ANY FOOT PEDALS. WHEN I CAME BACK, THEY FOUND THEM UNDERNEATH A WHOLE BUNCH OF CLOTHING IN THE CLOSET." DURING AN INTERVIEW ON 12/6/11 AT 12:35 P.M. WITH ACTIVITY CNA "G", SHE STATED SHE WAS THE STAFF PERSON PUSHING RESIDENT #100 DURING THE INCIDENT. CNA "G" STATED, "SHE (RESIDENT #100) DID NOT HAVE FOOT PEDALS ON... NO, SHE (RESIDENT #100) DID NOT HAVE THE FOOT PEDALS IN THE POUCH... NO, I NEVER EVEN OFFERED TO PUT ON THE FOOT PEDALS.... NO ONE DID... NO, WE HAVE NEVER EXPLAINED TO HER (RESIDENT #100) THE RISK OF NOT USING THE FOOT PEDALS... WE MUST JUST TAKE THE FEW EXTRA MINUTES TO PUT ON THE FOOT PEDALS.... YEAH, I GUESS THE FOOT PEDALS NOT BEING ON COULD HAVE CAUSED THE FALL OUT OF HER WHEELCHAIR BECAUSE SHE DROPPED HER FEET. YES, WE SHOULD HAVE HAD HER FOOT PEDALS ON." DURING AN INTERVIEW ON 12/6/11 AT 1:43 P.M., WITH THE DPOA "H", SHE STATED, "NO, I NEVER HAD THAT CONVERSATION WITH THE FACILITY (DISCUSSING THE RISK OF NOT USING FOOT PEDALS WHEN STAFF TRANSPORT RESIDENT #100). I WOULD HAVE TOLD HER (RESIDENT #100) SHE NEEDED TO USE THE FOOT PEDALS WHEN STAFF ARE PUSHING HER OR WHEN SHE WAS ON OUTINGS... ABSOLUTELY!" DURING AN INTERVIEW ON 12/6/11 AT 10:45 A.M. WITH RESIDENT #100, SHE STATED, (WHEN ASKED ABOUT THE FALL FROM THE WHEELCHAIR) " FALL? ...YES ...I DID." WHEN ASKED IF SHE DID NOT WANT HER FOOT PEDALS ON HER WHEELCHAIR SHE STATED, "NO ...I DON'T REMEMBER." RESIDENT #100 WAS ASKED IF SHE COULD HOLD HER LEGS UP AND SHE RESPONDED, "A LITTLE BIT." WHEN ASKED IF SHE WAS HURT FROM THE FALL SHE STATED, "YEAH, I THINK SO." AN INTERVIEW TOOK PLACE ON 12/6/11 AT 10:50 A.M. WITH PHYSICAL THERAPIST (PT) "D" WHO STATED, " ...YES, SHE (CNA "G") SHOULD HAVE PUT FOOT PEDALS ON. ANYONE WITH WEAKNESS LIKE HERS (RESIDENT #100).... WHEN TAKING RESIDENTS OUTSIDE THE FACILITY STAFF USUALLY ALWAYS USE FOOT PEDALS. I DON'T KNOW WHY SHE (RESIDENT #100) DIDN'T HAVE WHEELCHAIR PEDALS ON HER WHEN SHE WAS OUT... BEING PUSHED BY STAFF. EVEN PEOPLE WITH NORMAL STRENGTH... WHEN OUTSIDE THEY NORMALLY PUT PEDALS ON THEM SO THEY CAN PUSH THEM SAFELY." THE FACILITY POLICY TITLED, "SAFE VEHICLE TRANSPORT POLICY" DATED 1/22/10, DID NOT ADDRESS WHEELCHAIR FOOT PEDALS DURING OUTINGS. THE POLICY WAS REVISED 10/27/11 AND READ, "PROCEDURE: 7. DRIVER/TRANSPORTER WILL SECURE ALL WHEELCHAIRS TO VEHICLE USING APPROPRIATE DEVICES, LOCK THE WHEELCHAIR BREAKS, AND ENSURE WHEELCHAIR FOOT PEDALS ARE ATTACHED TO THE WHEELCHAIR FOR SAFETY." IN AN INTERVIEW ON 12/6/11 AT 3:00 P.M. WITH THE DON, SHE STATED THE FACILITY DOES NOT HAVE A GENERAL SAFETY POLICY ON TRANSPORTING RESIDENTS IN WHEELCHAIRS. DURING THE INITIAL TOUR ON 12/6/11 AT 10:11 A.M., AN OBSERVATION WAS MADE OF RESIDENT #104 BEING PUSHED BY LICENSED PRACTICAL NURSE (LPN) "A" IN HER WHEELCHAIR UP HALLWAY 200, TOWARD THE NURSING STATION (TO THAT HALL). THIS SURVEYOR STOPPED LPN "A" AND ASKED WHY SHE WAS TRANSPORTING RESIDENT #104 WITHOUT APPLYING HER FOOT PEDALS, WHICH WERE OBSERVED IN THE POUCH IN THE BACK OF THE WHEELCHAIR. RESIDENT #104 RESPONDED BY SAYING "BECAUSE I CAN HOLD MY FEET UP." LPN "A" AGREED WITH RESIDENT #104. WHEN RESIDENT #104 WAS ASKED BY THIS SURVEYOR IF SHE WOULD USE HER FOOT PEDALS FOR SAFETY, SHE STATED, "I GUESS FOR SAFETY IT WOULD BE OKAY." LPN "A" THEN APPLIED THE FOOT PEDALS TO THE WHEELCHAIR. THE FACE SHEET REVEALED RESIDENT #104 IS A [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. THE MDS dated [DATE], REVEALED RESIDENT #104 HAD SEVERE COGNITIVE IMPAIRMENT AND REQUIRED EXTENSIVE ASSIST OF ONE WITH TRANSFERS AND LOCOMOTION ON THE UNIT. IN ADDITION, THE MDS (9/27/11) SHOWED SHE NEEDED AN ASSISTIVE DEVICE (WHEELCHAIR) FOR MOBILITY. AN INTERVIEW TOOK PLACE ON 12/6/11 AT 10:50 A.M. WITH PHYSICAL THERAPIST (PT) "D." SHE STATED, " ...BECAUSE YOU COULDN'T BE 100% SURE THEY (RESIDENTS) WOULDN'T JUST DROP THEIR FEET...THAT IS WHY RESIDENTS IN WHEELCHAIRS SHOULD USE THEIR FOOT PEDALS WHEN BEING TRANSFERRED BY STAFF." ( )