Every finding on record at Maryville

Based on interview and record review it was determined the facility failed to ensure the care plan related to dining was followed for 1 of 7 sampled residents (#151) reviewed for accidents. This placed residents at risk for choking. Findings include:The facility's 1/10/25 Definition of Level of Assist at Meal Times policy stated if a resident was not in the dining room and required one to one supervision during meals, staff needed to be with the resident in her/his room. Resident 151 was admitted to the facility in 11/25 with diagnoses including dementia and dysphagia.A review of the 11/13/25 Care Plan revealed Resident 151 required one to one supervision with meals.The 11/19/2025 admission MDS revealed Resident 151 had a BIMS score of 11, which indicated the resident had a moderate cognitive impairment. A 11/24/25 Facility Reported Incident revealed during dinner service on 11/20/25 Resident 151 was observed coughing and required staff assistance to clear her/his airway after Staff 7 (Former CNA) was reported to have left the resident to eat unsupervised in her/his room. On 7/21/26 at 1:08 PM Staff 7 stated she was late and stressed out when she delivered meal trays to residents during dinner service on 11/20/25. Staff 7 stated Resident 151 was assigned to her on 11/20/25 and that was the first time she worked with the resident. Staff 7 stated she delivered a meal tray to Resident 151 and left the resident to eat alone in her/his room to assist a different resident. On 7/21/26 at 2:51 PM Staff 5 (LPN) stated during her shift on 11/20/25 she found Resident 151 alone in her/his room with a partially eaten meal tray. Staff 5 stated she observed Resident 151 coughing and place her/his hands on her/his neck to indicate she/he was choking. Staff 5 stated Resident 151 was able to clear her/his airway with staff assistance. Staff 5 stated Staff 7 did not ask her if Resident 151 required supervision with meals. On 7/22/26 at 12:12 PM Staff 6 (SLP) stated she completed an initial evaluation of Resident 151 on 11/21/25, which revealed the resident had limited alertness and required verbal cues to take small bites during meals. Staff 6 stated Resident 151 was at risk of aspiration in the facility and the supervision requirements indicated in the resident's care plan were appropriate on 11/20/25. On 7/22/26 at 2:57 PM Staff 4 (RNCM) stated she investigated the incident on 11/20/25 and determined Staff 7 did not follow Resident 151's Care Plan when she left the resident to eat unsupervised in her/his room. On 7/23/26 at 3:16 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Compliance Officer) confirmed the incident occurred on 11/20/25 between Resident 151 and Staff 7 and did not provide any additional information. The deficient practice was identified as Past Noncompliance based on the following: On 12/1/25, the deficient practice was corrected when the facility implemented a plan of correction. The Plan of Correction included the following: 1. A chest x-ray, SLP follow-up, and increased monitoring were completed for Resident 151 to determine if the resident's care plan addressed her/his risk of aspiration 2. Staff were educated on reviewing care plans at the beginning of each shift, levels of dining assistance and aspiration precautions for residents in the facility.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled resident (#6) reviewed for medication administration. This placed residents at risk for adverse medication consequences. Findings include:Resident 6 was admitted to the facility in 2025 with diagnosis including orthostatic hypotension and implantation of a prosthetic heart value. Resident 6's 5/21/25 Care Plan indicated Resident 6 had impaired cardiovascular function and altered cardiovascular function due to the presence of a pacemaker. Resident 6's MDS identified the resident with a BIMS score of 12 out 15 indicating mild to moderate cognitive impairment. A 6/5/25 Facility Risk Management Report identified Staff 16 (LPN) wrongly administered a combination of the following medications to Resident 6: Levothyroxine 50mcg, Tylenol 500mg, Gabapentin 300mg, Bactrim 800-160, Amidarone 200mg, Baclofen 5mg, Calcium Citrate 315mg-5mcg, Vit D3 125 mcg, Clopidogrel 75mg, CoQ10 75 mg, Entresto 300mg, Finasteride 5mg, Multivitamin 1 tab, Torsemide 100mg and Ezetimibe 10mg. Staff 16 was noted to have immediately discover the medication error and reported the incident to facility administration. Per Staff 16, she asked Resident 16 if she/he was the identified resident and resident responded yes and took the medication. Staff 16 confirmed during the report that she did not check to see if the medications administered were for the correct resident. Upon discovery of the medication error, Resident 6 was monitored and upon experiencing a change of condition including a low blood pressure of 99/49 was sent to the emergency room for evaluation. Resident 16 later returned to the facility after the hospital administered IV fluids to the resident to flush the medications from her/his system. Resident 16 was noted to have experienced no long-term effects from the medication administration error. A 6/5/25 Nursing Progress Note revealed Resident 6's systolic pressure dropped below 100 reaching a total blood pressure range of 99/49 as a result of the medication administration error. Resident 6 was sent to the emergency room for evaluation. On 4/23/26 at 1:10 PM, Staff 4 (RCM) stated Resident 6 was sent to the hospital after Resident 6's blood pressure dropped to 99/49. Staff 4 stated Resident 6 safely returned to the facility after being administered IV fluids to flush the medications from her/his system. On 4/23/26 at 1:21 PM, Staff 16 (LPN) confirmed she committed the medication error and confirmed Resident 6 was sent to the hospital after experiencing a change of condition from the medication error. Staff 16 stated the failure was due to an unstructured medication system and failing to confirm the identity of the resident before administration. Staff 16 reported during the incident, Staff 16 was assigned to administer medications managing three different treatment carts during her shift. Staff 16 indicated that upon preparing Resident 6's medications, she failed to confirm if the medication she prepped and administered was for Resident 6. On 4/23/26 at 3:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the findings and indicated Staff 16 failed to administer the correct medication to Resident 6.

1. Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene was completed during meals for 1 of 6 halls reviewed for dining. This placed residents at risk for cross contamination. Findings include: The 8/2019 Handwashing/Hand Hygiene Policy indicated hand hygiene was the primary means to prevent the spread of infections. The policy indicated: 7. Use of an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. before and after direct contact with residents; l. after contact with objects in the immediate vicinity of the resident; o. before and after eating or handling food; p. before and after assisting a resident with meals; On 4/7/25 during the lunch meal in the west hall and dining room the following observations were made: -12:05 PM Staff 10 (NA) removed three dirty breakfast trays from a two-tier serving cart and loaded the cart with three lunch trays. Staff 10 did not sanitize the cart prior to loading the cart with the lunch trays. - 12:07 PM Staff 10 delivered lunch trays to three residents in the dining room, donned clothing protectors and set-up each tray for the three residents. Staff 10 did not sanitize her hands between each resident or after leaving the dining room. -12:10 PM Staff 10 loaded the two-tier cart with three lunch trays and delivered the lunch tray to room [ROOM NUMBER] and exited the room without sanitizing her hands. Staff 10 delivered a lunch tray to room [ROOM NUMBER].1, assisted the resident with repositioning, adjusted the head of the bed and moved the bedside table. Staff 10 delivered a lunch tray to room [ROOM NUMBER].2, assisted the resident with repositioning in the bed, cleared and adjusted the bedside table. On 4/7/25 at 12:14 PM Staff 10 acknowledged she did not sanitize her hands in between delivering the lunch trays and touching each resident in the dining room and in the rooms. Staff 10 stated she should have sanitized the cart after removing the dirty breakfast trays and before using it for the lunch trays. On 4/7/25 at 12:20 PM Staff 2 (DNS) stated she expected all staff to complete hand hygiene after they passed out each resident tray and went in and out of resident rooms. Staff 2 stated she expected staff to sanitize the meal cart before each use. 48830 2. Based on interview and record review it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens and illness. This placed all residents at risk for exposure to water-borne pathogens. Findings include: The Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality/Safety and Oversight Group letter 17-30, revised on 7/6/18, on Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease stated, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. A review of the facility's 9/2022 Legionella Water Management Policy revealed the following: -The water management program is reviewed annually by the facility water management team. -The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. -The water management program includes a detailed description and diagram of the water system in the facility and areas identified in the water system that could encourage the growth and spread of Legionella or other water-borne bacteria. A review of the 2/2025 Facility Assessment revealed no evidence a risk assessment was completed to prevent the growth and spread of water-borne pathogens in the facility's main water system. On 4/11/25 at 10:05 AM Staff 1 (Administrator) stated the facility did not have a water management program and did not have a prevention plan or system in place for the prevention of the spread of water-borne pathogens, such as Legionella, in the facility's main water system.

Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 3 sampled residents (#36) reviewed for ADLs. This placed residents at risk for lack of personal hygiene. Findings include: Resident 36 was admitted to the facility in 8/2024 with diagnoses including cerebral atherosclerosis (hardening of arteries in the brain) and dementia. Resident 36's Significant Change MDS dated [DATE] indicated the resident was dependent on staff for personal hygiene and grooming. Resident 36 was observed on 4/8/25 at 10:24 AM, and on 4/9/25 at 8:24 AM with a significant amount of chin hair visible. On 4/8/25 at 10:24 AM, Resident 36 stated she/he did not want to have facial hair and would like for staff to take care of it for her/him. Resident 36 stated she/he relied on staff to shave unwanted facial hair. On 4/9/25 at 2:13 PM, Staff 6 (CNA) stated she obtained information to care for Resident 36 from the Kardex (bedside care plan) and acknowledged Resident 36 had long chin hairs. On 4/9/25 at 2:18 PM, Staff 2 (DNS) observed and acknowledged Resident 36's facial hair and stated the resident was in need of a shave.

Based on observation, interview and record review, it was determined the facility failed to follow care plan interventions related to aspiration risks for 1 of 3 sampled residents (#3) reviewed for accidents. Resident 3 admitted to the facility in 2024 with diagnoses including traumatic subdural hemorrhage (severe head injury) and dysphagia (difficulty with swallowing). Resident 3's 9/3/24 Care Plan indicated the resident required one on one eating assistance due to dysphagia. The care plan stated staff were not to deliver until staff was ready to assist the resident. The 9/2024 Admission MDS identified Resident 3 was cognitively intact. A 9/4/24 choking/aspiration investigation revealed Staff 5 (CNA) delivered Resident 3's lunch tray to the resident and informed Resident 3 that she would return to assist Resident 3 after delivering the last lunch tray. Resident 3 was noted to have begun eating without assistance and began to choke due to placing too much food in her/his mouth. Staff 4 (OT) was in the room at the time assisting Resident 3's roommate. Staff 4 was alerted by the resident's roommate that something was wrong with Resident 3. Staff 4 noted Resident 3 was choking and began to turn reddish purple. Staff 4 performed the Heimlich maneuver and was able to dislodge Resident 3's food from her/his throat. The facility's choking and aspiration investigation concluded Staff 5 did not follow Resident 3's care plan and residents who required one on one eating assistance were not to be left alone with a meal tray until staff were ready to immediately assist residents with eating. Observations conducted from 12/31/24 to 1/3/25 from, 9:30 AM to 3:40 PM, identified no additional issues or risks related to choking or aspiration for residents. On 12/31/24 at 10:00 AM, Staff 5 (CNA) could not be reached for interview. On 12/31/24 at 11:10 AM, Staff 4 confirmed Staff 5 had left Resident 3 with her/his meal tray before leaving the room and had conducted the Heimlich maneuver due to Resident 3 choking after she/he began to self-feed herself/himself. On 12/31/24 at 11:49 AM, Staff 6 (RNCM) indicated that staff were not to leave trays for residents who required meal assistance due to the risk of choking and aspiration occurring. On 1/3/25 at 11:52 AM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 3 choked as a result of Staff 5 not following the resident's care plan by leaving the resident's tray alone in her/his room.

Based on interview and record review it was determined the facility failed to ensure the plan of care was followed to provide care-planned assistance to prevent a fall for 1 of 3 sampled residents (#3) reviewed for falls. This resulted in Resident 3's hospitalization with leg fracture and surgical repair. Findings include: Resident 3 admitted to the facility in 2023 with diagnoses including a history of falls. The 11/16/23 Care Plan indicated Resident 3 was at risk for falls related to impaired mobility. Interventions included providing a safe environment, including personal items within reach. The Care Plan also indicated Resident 3 required one-person assistance with bathing. The 11/23/23 Admission MDS indicated Resident 3 was cognitively intact. A 12/30/23 fall investigation indicated Staff 3 (CNA) called Staff 4 (LPN) and Staff 5 (LPN) into Resident 3's room as the resident suffered a fall while in the shower. Upon entering the room, the resident was found lying on her/his right side. Resident 3 initially did not want to go to the hospital for evaluation. Resident 3 waited until family arrived and after speaking with staff, the resident agreed to go to the hospital. Resident 3 was found to have a right leg fracture requiring surgical repair. Witness statements indicated the following: - Resident 3 stated she/he was in the shower and was not able to recall what she/he was doing. Resident 3 thought she/he may have reached for water or the shampoo and then fell on her/his side. - Staff 3 stated she was providing Resident 3 with a shower in the resident's room. Staff 3 stated she transferred the resident to the shower chair and gave the resident a washcloth and shampoo. Staff 3 stated Resident 3 asked her to give her/him some time to wash her/his hair. Staff 3 stated she left the door open and closed the shower curtain halfway but was able to still see the resident. Staff 3 stated she went to make the resident's bed. Staff 3 stated Resident 3 fell out of the shower chair and onto the floor. Staff 3 stated she quicky called for the nurse. Staff 3 stated she read the Kardex (CNA Care Plan) and Resident 3 was to receive one-person assistance with bathing. Staff 3 stated she did not physically assist the resident with bathing before she left to make the resident's bed. Staff 3 stated she, honestly didn't think anything would happen. I'm sorry. - Staff 4 stated Staff 3 called her and Staff 4 into Resident 3's room. Resident 3 was found laying on her/his right side with the shower chair tipped over. Resident 3 denied pain to the right thigh and indicated pain only when putting her/his leg down. Resident 3 was assisted to a wheelchair. - Staff 5 stated she assisted Staff 4 after Resident 3 fell . Staff 5 stated the resident was found wet on the floor inside the shower on her/his right side. Staff 5 stated Resident 3 indicated she/he may have been reaching for the shampoo or trying to get to the water, but could not recall for sure. The resident indicated she/he slipped and fell on her/his right side. Resident 3 was unable to extend her/his right leg completely out and an ice pack was applied to the right thigh. The resident was assisted to the wheelchair. The fall investigation concluded Staff 3 read Resident 3's Care Plan prior to the shower and if Staff 3 remained with Resident 3, and completed the shower, the fall could have been avoided. The Care Plan Indicated Resident 3 required one-person assistance with bathing and Staff 3 was not physically close to the resident at the time of the incident. On 3/15/24 at 9:58 AM Staff 5 (LPN) stated Resident 3 fell while in the shower. Staff 5 stated she recalled the resident was reaching for something when she/he fell . Staff 5 stated Resident 3 was able to move after the fall but was later sent out to the hospital. Staff 5 stated she believed Staff 3 was in the room with the resident but was unable to recall if Staff 3 was standing next to the resident or in the room doing other things when the fall occurred. On 3/15/24 at 2:43 PM Staff 4 (LPN) stated she assisted Resident 3 after the fall. Staff 4 stated Staff 3 came out of the room and indicated Resident 3 fell . Staff 4 stated she and Staff 5 went to assist and found the shower chair was tipped over and the resident was on her/his right side. Staff 4 stated Resident 3 did not complain of any pain and was able to transfer to the wheelchair. Staff 4 stated Resident 3 did not want to go to the hospital at first, but later complained of increased pain and was sent out. Staff 4 stated Staff 3 indicated she was making Resident 3's bed while the resident was in the shower. On 3/18/24 at 9:24 AM Staff 3 stated Resident 3's shower was connected to her/his room. Staff 3 stated she provided Resident 3 a shower on 12/30/23. Staff 3 stated she set up Resident 3 for the shower and the resident indicated she/he needed a minute to wash her/his hair. Staff 3 stated Resident 3 wanted to wash her/his own hair. Staff 3 stated she could see the resident in the shower from where she was standing at the bed. Staff 3 stated she didn't believe she was leaving the resident alone in the bathroom. Staff 3 stated she was next to the bed when she heard Resident 3 fall. Staff 3 stated the resident did not call out for help, and she was not sure how the resident fell as the resident was previously sitting on the shower chair. Staff 3 stated at the time of the incident, Resident 3's Care Plan indicated she/he required one-person assistance with bathing. Staff 3 stated she read Resident 3's Care Plan prior to the fall. On 3/15/24 at 11:53 AM Staff 6 (RNCM) stated Staff 3 was providing a shower to Resident 3 at the time of the fall on 12/30/23. Staff 6 stated Resident 3 required one-person assistance with bathing at the time. Staff 6 stated Resident 3 asked for privacy and Staff 3 stepped out of the shower and went to make the resident's bed while keeping an eye on the resident. Staff 6 stated she believed the resident reached out for something and fell . Staff 6 stated Staff 3 was supposed to be within reach of Resident 3 during the shower. Staff 6 stated Staff 3 was able to see the resident in the shower, but was not close enough reach the resident to prevent the fall. Staff 6 stated Staff 3 was aware that Resident 3 required one-person assistance with bathing and acknowledged Staff 3 did not provide assistance per the resident's Care Plan, which resulted in a fall with a leg fracture. On 3/18/24 at 12:39 PM Staff 17 (DNS) acknowledged Resident 3 suffered a fall with fracture due to Staff 3 not providing assistance per the resident's Care Plan for bathing. Staff 17 stated she asked Staff 3 to not return to the facility after the incident. On 3/20/24 at 6:59 PM the facility provided additional information to indicate education and an inservice was provided to nursing staff related to the identifed incident. The deficient practice was determined to be past non-compliance, corrected on 1/3/24.

Based on observation, interview and record review it was determined the facility failed to assess elopement risk and provide services to prevent elopement for 1 of 3 sampled residents (#272) reviewed for elopment. This failure resulted in an immediate jeopardy situation when the facility failed to implement services to prevent elopement which resulted in Resident 272's elopment from the facility. Findings include: Resident 272 admitted on [DATE] with diagnoses including severe vascular dementia. Hospital records dated 11/29/23 revealed Resident 272 had severe cognitive impairment, a history of wandering and was recommended for a Memory Care Unit (MCU) (secure locked unit attached to a skilled nursing facility). On 11/30/23 a provider progress note indicated Resident 272 was a high elopement risk. A 12/3/23 facility investigation revealed the following: - On 12/3/23 at approximately 2:00 AM staff determined Resident 272 was not in her/his room. Facility staff began searching the facility as well as notifying local authorities. - On 12/3/23 staff last made visual contact with Resident 272 at approximately 1:00 AM. - On 12/3/23 Resident 272 was located at approximately 3:30 AM, a half mile from the facility, at a local convenience store. - On 12/3/23 the facility staff determined Resident 272 removed the window screen, opened the window, and eloped from her/his room. - On 12/5/23 Staff 23 (RN) stated she was aware an elopement assessment was needed but failed to inform the next shift of the incomplete assessments. Observations during the survey revealed the facility was located on a busy four lane road and weather conditions at the time were low 40 degrees Fahrenheit and potential drizzle. Further review of Resident 272's record revealed no elopement assessment was completed upon admission, and no care plan for elopement was in place prior to Resident 272's elopement. On 12/14/23 at 4:32 PM Staff 49 (Activities Aide) stated Resident 272 exhibited exit-seeking behaviors. Staff 49 stated regularly around 4:00 PM Resident 272's behavior was to ask to leave the facility and Resident 272 stated staff couldn't hold her/him here. Staff 49 stated she witnessed Resident 272 go into other residents' rooms and opened a window; she/he tried to exit from the doors and walked up and down the halls. Staff 49 stated there was no redirecting her/him when she/he was like that. On 12/14/23 at 4:40 PM Staff 50 (CNA) stated she was not familiar with Resident 272, but staff expressed concern regarding the position of her/his room [it faced a main road] because of Resident 272's history. On 12/14/23 at 4:43 PM Staff 51 (CNA) stated Resident 272 was confused why she/he was in the MCU. Staff 51 stated the resident thought she/he was in jail. Staff 51 stated she had her/him the day prior to the incident and she/he wanted to call the police because of feeling trapped in the facility. On 12/14/23 at 4:45 PM Staff 52 (CNA) stated he helped Resident 272 a few days prior to the incident, and the resident thought she/he was in jail and talked about being trapped. On 12/14/23 at 10:09 AM Staff 53 (CNA) stated Resident 272 was far more active in the evenings. Staff 53 stated Resident 272 did not cause any problems in the morning, but she knew that was not the case on evening or night shift. Staff 53 stated she only knew if residents were an elopement risk if they had a wander guard on or if the resident asked her about getting out. On 12/14/23 at 10:49 AM Staff 55 (CNA) stated she did not know Resident 272 was an elopement risk. Staff 55 stated the only thing staff were told was Resident 272 was found by police breaking into houses. Staff 55 stated he was told Resident 272 was going to be very active. On 12/14/23 at 11:11 AM Staff 56 (LPN) stated when Resident 272 was admitted she was given report that Resident 272 was confused and paranoid, and Resident 272 stated she/he didn't need to be here for too long and she/he didn't want to be here. On 12/14/23 at 4:30 PM Staff 57 (LPN) stated Resident 272 walked the entire unit every evening shift before the elopement. Staff 57 stated she spoke to staff on night shift to figure out Resident 272's care needs and night shift staff didn't have any information either. Staff 57 stated she tried to redirect her/him and educate her/him about the risks [of elopement], but Resident 272 didn't care. Staff 57 stated Resident 272 was lucky she/he wore a jacket, and it wasn't too cold that night. Staff 57 stated an elopement assessment was supposed to be done on the first day. If the nurse didn't finish the assessments on the shift the resident admitted , then the next shift was supposed to continue working on it and finish the assessment. On 12/14/23 at 4:59 PM Staff 23 (RN) stated staff were not aware Resident 272 was an elopement risk when the resident admitted . Staff 23 stated she was not aware of a process to complete an elopement assessment upon admission. On 12/14/23 at 5:30 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 12/14/23 at 8:17 PM The facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: 1. a. Resident 272 had an elopement risk assessment and elopement care plan initiated on 12/3/23. One on one monitoring and 15-minute checks were initiated immediately on return to secure unit. Her/his room and the adjacent room window alarms were installed on 12/4/23. A room change occurred when a room was available that did not have street access via window on 12/6/23. Physician adjusted residents' medication for behavior management and resident was placed on alert for medication changes and behavior monitoring. Resident will remain on every 15-minute checks until 12/26/23 when resident will be re-evaluated for medication effectiveness, continued elopement risk, determine if 15 minute checks are to continue or check time adjusted and elopement risk assessment re-evaluation will be completed. b. The facility will audit every 15 minutes visual checks every shift by Charge Nurse and continue to monitor visual checks ongoing per determined schedule based on elopement assessment. Elopement assessment will be re-evaluated every two weeks times 90 days, then quarterly or more often as needed. 2. Resident 85, Residents 101, and Resident 105 will have their elopement risk assessment re-evaluated and updated as applicable and care plan interventions for elopement risk will be updated as applicable by 12/15/23. 3. On admission to the facility secured memory care unit, an elopement risk assessment will be completed on the day of admission to determine risk and safety needs and an elopement care plan will be initiated on the day of admission. 4. The elopement admission criteria policy and procedure will be updated to reflect elopement assessment process change by 12/15/23. 5. All staff assigned to memory care unit and facility IDT will be in serviced on updated policy and procedure regarding elopement assessment, risk and care plan interventions for safety by 12/15/23 end of day and ongoing. 6. The administrator, DNS, Quality Assurance nurse will audit all new admissions to memory care unit for elopement assessment and care plan completion. 7. Environmental Service Department will monitor window alarm devices placement daily. The immediacy was removed on 12/15/23 based on onsite verification of the removal plan.

Based on interview and record review it was determined the facility failed to prevent the development of moisture associated skin damage (MASD) and follow physician orders for 2 of 3 sampled residents (#s 322 and 372) reviewed for skin conditions and pain management. This failure resulted in Resident 372 developing MASD and placed residents at risk for increased pain. Findings include: 1. Resident 372 was admitted to the facility in 2018 with diagnoses including heart failure. On 3/1/23 a diagnosis of dementia with agitation was added. Resident 372's 4/21/23 physician order indicated to apply barrier cream and cover with a foam dressing to the coccyx area two times a day for skin care protection. The 8/2023 TAR indicated Resident 372 received dressing changes twice daily from 8/13/23 through 8/17/23. The 8/18/23 Skin Incident Report indicated on 8/17/23 during a preventative dressing treatment it was noted Resident 372 had a partial-thickness skin loss that measured 4.78 cm in length x 3.2 cm wide moisture associated dermatitis to the coccyx. Resident 372 did not know how she/he got the skin injury. The 8/17/23 progress note by Staff 3 (LPN) indicated Resident 372 had an order to apply barrier cream and cover with foam dressing to the coccyx area BID for skin protection. The last time the dressing was changed was by Staff 3 on 8/13/23. On 8/13/23 her/his skin was not effected and the dressing was for ulcer prevention. On 8/17/23 when Staff 3 came to work Resident 372 had a bed bath completed by Staff 4 (CNA). Staff 4 reported the dressing had a date of 8/13/23 that was signed by Staff 3. The skin check was completed and pressure was noted on the coccyx area and her/his skin came off. The area measured 4.8 cm x 3.2 cm. The skin was cleaned, barrier cream and dressing were applied. On 12/13/23 at 2:31 PM Staff 3 stated on 8/17/23 Staff 4 reported Resident 372's current dressing on the coccyx was dated 8/13/23 and signed by Staff 3. Staff 3 stated he observed the dressing with Staff 4 and it was very wet. Staff 3 stated when he applied the dressing on 8/13/23 the skin was intact and when he removed the wet dressing on 8/17/23 the resident had a Stage 2 (partial thickness skin loss) pressure ulcer. On 12/13/23 at 2:47 PM Staff 4 stated on 8/17/23 she observed Resident 372's dressing to the coccyx dated 8/13/23 and signed by Staff 3. Staff 4 stated she reported the observation to Staff 3. On 12/15/23 at 12:23 PM Staff 5 (RNCM) acknowledged Resident 372 did not receive BID dressing changes as ordered from 8/14/23 through 8/17/23. Staff 5 further acknowledged Resident 372 did not have skin issues prior to the removal of the dressing on 8/17/23. Staff 5 acknowledged the skin assessment indicated it measured 3.11 cm x 2.03 cm on 8/18/23 and stated her/his open skin area was a combination of moisture related issues and a pressure ulcer. 36494 2. Resident 322 was admitted in 11/2023 with diagnoses including right leg fracture and stroke. Physician's orders dated 11/25/23 directed facility staff to place one lidocaine patch externally every 12 hours and to remove for 12 hours. Review of the 11/2023 and 12/2023 MAR revealed Resident 322 refused her/his lidocaine patch on the following days: -11/25/23, 11/26/23 and 11/27/23. -12/4/23, 12/5/23, 12/6/23, 12/7/23, 12/8/23, 12/9/23, 12/10/23 and 12/11/23. There was no documented evidence the resident's physician was notified of Resident 322's refusals. On 12/13/23 at 7:57 PM Staff 44 (LPN) stated the resident struggled with chronic pain but was not aware Resident 322 had an order for a lidocaine patch. On 12/14/23 at 6:57 PM Staff 36 (CMA) stated she was aware Resident 322 refused her/his lidocaine patch and documented as a refusal but did not notify the physician. On 12/18/23 at 10:30 AM Staff 2 (DNS) and Staff 29 (LPN-Resident Care Manager) confirmed, based on information on Resident 322's MARs, staff should have contacted the physician regarding her/his refusals.

Based on observation, interview and record review it was determined the facility failed to follow physician orders for oxygen therapy and to ensure respiratory equipment was maintained for 1 of 1 sampled resident (#89) reviewed for respiratory care. This placed residents at risk for adverse respiratory complications and outcomes. Findings include: Resident 89 was admitted to the facility in 6/2022 with diagnosis including COPD (chronic obstructive pulmonary disease). a. Resident 89's Physician Order Summary Report as of 12/13/23 revealed the resident was to wear oxygen at one to three liters to keep her/his oxygen saturation between 88 to 92 percent. Staff were directed to document the saturation levels three times a day. Resident 89's oxygen saturation levels from 11/12/23 through 12/12/23 indicated the resident wore oxygen at night and while oxygen was in use the resident's oxygen saturation levels ranged from 93 to 96 percent. The amount of oxygen the resident used at night was not documented. On 12/13/23 at 1:21 PM Staff 22 (RN) stated the resident wore oxygen at night for COPD with parameters to keep the resident's oxygen saturation levels between 88 to 92 percent. Staff 22 stated they kept Resident 89's oxygen on all night per the resident's preference even when her/his oxygen saturation level exceeded 92 percent. Staff 22 verified Resident 89's oxygen saturation levels were above 92 percent when she/he was administered oxygen. On 12/18/23 at 11:40 AM Staff 2 (DNS) confirmed Resident 89's oxygen saturation levels were at levels that exceeded the physician ordered parameter for oxygen administration. Staff 2 stated her expectation was for staff to follow the physician's orders. b. Observations on 12/11/23 and 12/13/23 revealed Resident 89's oxygen tubing did not indicate when it was last changed. Resident 89's 12/2023 Physician Orders and 12/2023 TAR revealed no order for oxygen tubing changes. On 12/13/23 at 1:21 PM Staff 22 stated Resident 89's oxygen tubing was to be changed weekly, and labeled with a date and initials of staff to indicate when they were last changed. Staff 22 confirmed Resident 89's oxygen tubing was not labeled and there was no physician order for oxygen tubing changes. On 12/18/23 at 11:40 AM Staff 2 stated her expectation was for residents receiving oxygen therapy to have a physician's order for oxygen tubing changes to be completed weekly.

Based on observation, interview, and record review it was determined the facility failed to ensure 2 of 9 medication carts were properly secured during random observation. This placed residents at risk for reduced efficacy of medication and unauthorized access to medications. Findings include: 1. On 12/12/23 observations were made from 9:56 AM to 10:12 AM of a medication cart left unlocked and unattended near rooms [ROOM NUMBERS]. On 12/12/23 at 10:12 AM Staff 24 (CMA) acknowledged the cart was unlocked and was to be locked at all times when not in use. On 12/18/23 at 9:09 AM Staff 2 (DNS) stated she expected the medication carts to be locked when the CMA and nurse were not at the cart. 2. On 12/13/23 observations were made from 12:47 PM to 1:02 PM of a medication cart left unlocked and unattended near the Center Hall dining room. On 12/13/23 at 1:02 PM Staff 6 (RN) acknowledged the cart was unattended and unlocked. On 12/18/23 at 9:09 AM Staff 2 (DNS) stated she expected the medication carts to be locked when the CMA and nurse were not at the cart.

Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 2 of 7 sampled residents (#s 17 and 57) reviewed for medication administration. The facility's medication error rate was 10.71%. This placed residents at risk for adverse medication consequences. Findings include: 1. Resident 17 was admitted to the facility in 12/2017 with diagnoses including diabetes. Resident 17's 12/14/23 physician's orders included Humalog insulin 8 units to be administered to the resident subcutaneously (under the skin) two times a day. The Humalog manufacturer instructions indicated a priming dose of two units prior to each dose with the Humalog insulin pen was required to remove air and ensure an accurate dose. On 12/13/23 at 8:09 AM Staff 8 (LPN) was observed to dial 8 units on the Humalog insulin pen without first performing the two unit priming dose. On 12/13/23 at 8:09 AM the surveyor stopped Staff 8 and asked about the priming dose. Staff 8 stated she did not routinely use a priming dose. On 12/13/23 at 8:32 AM Staff 5 (RNCM) stated a priming dose for the Humalog insulin pen was completed when the pen was first accessed and not with every dose. On 12/18/23 at 11:26 AM Staff 2 (DNS) stated she expected each dose of an insulin pen to be primed first with 2 units and medications were administered according to manufacturer instructions. 2. Resident 57 was admitted to the facility in 8/2018 with diagnoses including gastroenteritis and colitis (inflammation of the stomach and colon). Resident 57's Physician Order Summary Report as of 12/12/23 indicated the following scheduled medication orders: - polyethylene glycol (laxative) daily. Hold for loose stools. - senna-docusate sodium (laxative) twice daily. Hold for loose stools. Resident 57's bowel movement (BM) records indicated on 12/12/23 the resident had two soft/loose BMs and one large diarrhea BM. On 12/13/23 at 9:00 AM Staff 8 (LPN) was observed to administer Resident 57 the scheduled polyethylene glycol and senna-docusate sodium medications. On 12/13/23 at 11:39 AM Staff 8 stated her process was to check resident's bowel records prior to the administration of scheduled bowel medications. Staff 8 stated she was not aware of Resident 57's loose stools and acknowledged the resident's bowel medications should have been held for loose stools as the physician ordered. On 12/18/23 at 11:26 AM Staff 2 (DNS) confirmed Resident 57 had loose/diarrhea stools on 12/12/23 and the resident's scheduled bowel medications were not held as the physician ordered. Staff 2 stated she expected medications to be administered as ordered.

Based on observation, interview and record review it was determined the facility failed to ensure a resident was treated in a dignified manner for 1 of 1 sampled resident (#324) reviewed for activities. This placed residents at risk for being treated in a dishonorable manner. Findings include: Resident 324 was admitted to the facility in 11/2023 with diagnoses including stroke and dysphagia (difficulty swallowing). A 11/28/23 care plan revealed Resident 324 required one staff person assistance with personal hygiene, dressing and needed one to one assistance with eating. On 12/13/23 at 8:30 AM Resident 324 was observed in bed asleep and two CNAs moved the resident up in bed and adjusted her/his pillows, the resident's eyes remained closed, and staff did not speak to the resident. Staff 32 (CNA) turned on the overhead light and said, it's time to wake up. Staff 32 used the bed control to raise the head of the bed to approximately 90 degrees (in an upright position) and Resident 324's head slumped towards her/his left shoulder. Staff 32 placed a clothing protector on the resident's chest but did not speak to the resident and her/his eyes remained closed and Staff 32 left the room. At 8:34 AM Staff 32 came back to the room with a washcloth in her hand, wet the washcloth and wiped the resident's face without speaking to the resident. Resident 324 lifted both of her/his arms up in the air in attempt to stop Staff 32, who said it's time to wake up. Resident 324 kept her/his eyes closed and Staff 32 stopped wiping the resident's face. Staff 32 proceeded to the right side of the resident's bed next to the bedside table that had Resident 324's breakfast. Staff 32 stood by the bed, took a spoon and scooped some thick liquid out of a cup and tried to feed the resident. Resident 324 did not open her/his mouth or eyes. Staff 32 removed the clothing protector from the resident and left the room. On 12/13/23 at 8:40 AM Staff 32 stated Resident 324 was difficult to wake up in the mornings. Staff 32 admitted she should have talked more to the resident in attempt to wake her/him before raising the head of the bed in an upright position. Staff 32 stated the resident required one staff to help her/him with eating because she/he was a feeder. Staff 32 indicated she should have talked to the resident prior to washing her/his face and before placing the clothing protector on Resident 324. On 12/13/23 at 9:28 AM Staff 31 (Speech Language Pathologist) stated she worked with Resident 324 regularly due to her/his dysphagia. Staff 31 indicated the resident was hard to wake up in the mornings and staff should talk to her/him and not rush the resident when providing assistance. On 12/18/23 at 11:06 AM Staff 2 (DNS) and Staff 29 (LPN-Resident Care Manager) stated staff were expected to wake up Resident 324 gently and not rush her/his care. Staff 2 stated she expected staff to talk to Resident 324 the whole time or try to stimulate her/him by rubbing the resident's shoulder or feet and tell the resident what care they were going to give. Staff 2 stated staff were expected to ask permission before putting a clothing protector on for meals and to sit down when feeding any residents that needed help with eating.

Based on interview and record review it was determined the facility failed to notify a resident's responsible party of a change in condition for 1 of 1 sampled resident (#372) reviewed for change of condition. This placed residents at risk for having uninformed responsible parties. Findings include: Resident 372 was admitted to the facility in 2018 with diagnoses including heart failure. On 3/1/23 a diagnosis of dementia with agitation was added. Resident 372's clinical record indicated Witness 2 (Family Member) was her/his responsible party, POA (Power of Attorney) for care, and Emergency Contact #1. On 12/11/23 at 9:55 AM Witness 2 stated Resident 372 passed away in 8/2023 and when she went to the facility the day after to collect the resident's belongings, Staff 5 (RNCM) told her the resident had pressure ulcers. Witness 2 stated it was the first time she was notified of Resident 372's skin issues. The 8/18/23 Skin Investigation by Staff 3 (LPN) indicated on 8/17/23 Resident 372 had a partial thickness skin loss which measured 4.78 cm x 3.2 cm to the coccyx. The investigation indicated it was moisture associated dermatitis. The investigation further indicated Witness 2 was not notified of the skin issue until 8/21/23 at 12:49 PM (four days after the skin issue was discovered). On 12/13/23 at 2:31 PM Staff 3 stated he identified Resident 372's skin issue on 8/17/23 and acknowledged Witness 2 was not notified. On 12/15/23 at 1:03 PM Staff 2 (DNS) acknowledged Witness 2 was not notified of Resident 372's skin issue until 8/21/23 and the expectation was for staff to inform the responsible party within 24 hours.

Based on interview and record review it was determined the facility failed to provide written notification to 2 of 3 sampled residents (#s 373 and 374) reviewed for Notice of Medicare of Non-Coverage (NOMNC). This placed residents at risk for unknown financial liabilities. Findings include: 1. Resident 373 was admitted to the facility on [DATE] and discharged from the facility on 6/27/23. The 6/27/23 Discharge MDS indicated Resident 373 had a planned discharge with a Medicare covered stay at the facility. A review of the resident's medical record revealed no indication a NOMNC was provided. On 12/14/23 at 10:17 AM Staff 16 (Assistant Administrator) acknowledged a NOMNC was not provided to Resident 373. 2. Resident 374 was admitted to the facility on [DATE] and discharged from the facility on 7/14/23. The 7/14/23 Discharge MDS indicated Resident 374 had a planned discharge with a Medicare covered stay at the facility. A review of the resident's medical record revealed no indication a NOMNC was provided. On 12/14/23 at 10:17 AM Staff 16 (Assistant Administrator) acknowledged a NOMNC was not provided to Resident 374.

Based on interview and record review it was determined the facility failed to provide adequate bowel and bladder care for 2 of 3 sampled residents (#s 48 and 118) reviewed for bowel and bladder. This placed residents at risk for skin breakdown. Findings include: 1. Resident 48 was admitted to the facility in 11/2023 with diagnoses including left leg/hip fracture and right foot drop (difficulty lifting the front part of the foot). A 11/2/23 care plan revealed Resident 48 required one staff person assistance with toileting and personal hygiene needs. A review of a FRI dated 11/6/23 revealed Resident 48 was placed on a bedpan by Staff 41 (CNA). The resident was left on the bedpan for 30 minutes before Staff 43 (CNA) entered the room and removed the bedpan from under Resident 48. The resident was assessed by Staff 42 (RN) directly after the incident and was noted to have an indentation from the bedpan, she/he was not painful, not upset, or angry. Staff 2 (DNS) interviewed all parties involved and concluded Staff 41 did not abuse Resident 48 but could not rule out neglect. On 12/12/23 at 11:46 AM Resident 48 indicated she/he was left on a bedpan for about 30 minutes. Resident 48 stated she/he was a little uncomfortable but did not have skin breakdown from the incident. Resident 48 indicated it was a one time occurrence and was dealt with appropriately. On 12/13/23 at 12:28 PM Staff 43 indicated she arrived for her shift on 11/6/23 and was informed by Staff 42 that Resident 48 needed to be taken off a bedpan because she/he had been on the bedpan for roughly 40 minutes. Staff 43 stated when she entered the resident's room the resident did not appear upset but asked for the bedpan to be removed. Staff 43 indicated she removed the bedpan and could see marks on her/his buttocks from the bedpan. On 12/13/23 at 6:41 PM Staff 42 stated he worked on 11/6/23 when Resident 48 was placed on a bedpan and Staff 41 forgot to remove the bedpan prior to leaving his shift. Staff 42 stated Resident 48 used her/his call light and Staff 43 removed the bedpan from underneath the resident. Staff 42 indicated the resident was assessed, was not angry or painful but indicated she/he was left on the bedpan too long. On 12/18/23 at 9:27 AM Staff 41 (CNA) stated he cared for Resident 48 on 11/6/23 and acknowledged he placed the resident on the bedpan and forgot to remove the bedpan before he left his shift. Staff 41 indicated he was educated and in-serviced regarding the incident and that it was not a purposeful act and apologized to Resident 48. On 12/18/23 at 11:14 AM Staff 2 (DNS) confirmed and acknowledged the incident occurred regarding Resident 48 on 11/6/23. 2. Resident 118 was admitted to the facility in 11/2023 with diagnoses including right arm fracture and a history of a hip fracture. A 11/16/23 care plan revealed Resident 118 required two staff person assistance with toileting and required one staff person for personal hygiene needs. A review of Resident 118's Urinary Incontinence and Indwelling Catheter CAA, dated 11/28/23 revealed the resident was frequently incontinent of bladder. Staff were to anticipate her/his needs, offer toileting frequently throughout the shift and provide incontinence care as needed. On 12/12/23 at 10:48 AM and 12/13/23 at 1:02 PM Resident 118 and Witness 6 (Family Member) stated on two different occasions, staff neglected her/his call light and left her/him in a soaked brief and saturated bed for an extended period. Resident 118 indicated on one occasion staff failed to change her/him after dinner and she/he was not provided assistance until evening shift. On 12/13/23 at 12:28 PM Staff 43 (CNA) stated Resident 118 required assistance with incontinence care because of bladder incontinence and she/he was a heavy wetter. Staff 43 indicated the resident was upset about sitting in a wet brief and bed several times. Staff 43 stated she provided incontinence care, changed the resident's bedding, and reported her concerns to the charge nurse. On 12/13/23 at 6:51 PM Staff 42 (RN) stated Resident 118 had bladder incontinence and had sat in wet brief and bed. On 10/18/23 at 10:52 AM Staff 2 (DNS) and Staff 40 (RNCM) denied knowing that Resident 118 received inadequate incontinence care and sat in a wet brief and bed. Staff 2 stated staff were expected to round every two hours and check on residents' dryness before the end of their shift.

Based on interview and record review it was determined the facility failed to follow resident care plans related to transfers for 3 of 7 sampled residents (#s 1, 2 and 24) reviewed for safety and transfers. This resulted in orthopedic fractures and placed all residents at risk for physical injury. Findings include: Resident 1 was admitted to the facility in 2022 with diagnoses including hypertension, lymphedema, and reduced mobility. The Admission MDS dated [DATE] indicated Resident 1 required two-person extensive physical assistance for transfers. Resident 1's Care Plan dated 8/30/22 identified Resident 1 to be at risk for falls due to decreased mobility and weakness. Interventions on the care plan included two person mechanical lift assistance for transfers. A Facility Investigation Report dated 6/15/22 at 3:10 PM indicated Resident 1 fell to the floor from the commode and sustained an oblique fracture of the right distal femur. According to the investigation, Staff 18 (CNA) assisted Resident 1 from the commode back to bed when Resident 1 slid from the commode to floor. This caused Resident 1's right leg to point inwards while her/his left leg remained straight. Staff 18 grabbed Resident 1 by the upper body and called for help. Staff 19 (CNA) assisted Staff 18 to lower Resident 1 to the floor. The investigation revealed Resident 1 sustained a right distal femur fracture as a result of the fall. Staff 18 indicated she did not follow Resident 1's care plan that required 2-person extensive assistance for transfers. On 8/8/23 at 10:30 AM the surveyor attempted to contact Staff 18 but was unable to reach her. On 8/8/23 at 1:08 PM Staff 19 stated Staff 18 called for help during the 6/15/22 incident and witnessed Resident 1 with both legs twisted while she/he began to slide to the floor. Staff 19 confirmed Resident 1 was a two-person transfer and Resident 1 sustained an injury as a result of the fall. On 8/8/23 at 1:37 PM Staff 20 (RN) stated Staff 18 reported the incident. Staff 20 further stated Resident 1 complained of pain and an x-ray was conducted at the facility which confirmed Resident 1 sustained a fracture and was transferred to the hospital. Staff 20 confirmed Staff 18 did not follow the care plan. On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 9 (Regional RN) and Staff 2 (Quality Assurance RN) acknowledged Staff 18 did not follow Resident 1's Care Plan which resulted in a right femur fracture. 2. Resident 2 was admitted to the facility in 2018 with diagnoses including stroke and paralysis. The Admission MDS dated [DATE] indicated Resident 2 required two-person extensive physical assistance for transfers. Resident 2's Care Plan dated 7/10/23, revised on 4/17/23 identified Resident 2 to be at high risk for falls related to paralysis. According to Nursing Notes dated 6/21/22 at 7:59 AM and 10:30 AM, Staff 3 (LPN) indicated Resident 2 experienced pain near her/his left breast. The note revealed Staff 19 strapped Resident 2 too tightly then transferred her/him into a shower chair which caused significant pain and resulted in a 15 cm x 14 cm bruise near the left breast. Resident 2 was identified as a two-person assistance for transfers. A Facility Investigation Report dated 6/25/22 revealed Staff 19 confirmed the strap used to transfer Resident 2 was tightened too tightly. Staff 19 further indicated when he attempted to transfer Resident 2 the strap became unsecured which caused Resident 2 significant pain. Staff 19 removed the strap and reported the incident. The facility revealed Resident 2 sustained a significant bruise on her/his left breast. On 8/7/23 at 11:47 AM Resident 2 stated she/he was being transferred using a sit to stand device. Resident 2 indicated Staff 19 strapped her/him too tightly which caused significant discomfort. Resident 2 stated she/he had to communicate several times to the CNA to stop the transfer due to the pain before the CNA stopped. Resident 2 stated once the strap was removed a large bruise had formed near her/his left breast. Resident 2 confirmed to the surveyor that she/he required two-person assistance for transfers. On 8/7/23 at 2:43 PM Staff 19 (CNA) confirmed he did not follow the care plan when transferring Resident 2 which led to the bruise. On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 2 (Quality Assurance RN) and Staff 9 (Regional RN) confirmed the findings above and no additional information was provided. 3. Resident 24 was admitted to the facility in 2023 with diagnosis including atrial fibrillation and heart failure. The Admission MDS dated [DATE] indicated Resident 24 required two-person extensive physical assistance for transfers. Resident 24's Care Plan dated 4/5/23 indicated Resident 24 was a two-person transfer and required non-skid footwear and use of a transfer pole for all transfers. Resident 24 was identified as a fall risk due to gait, balance, vision, and hearing problems. A Facility Investigation Report dated 5/10/23 at 11:40 AM indicated Staff 4 (LPN) was alerted by Staff 21 (PT Assistant/PTA) that Resident 24 reported significant pain in her/his great right toe during physical therapy. Resident 24 indicated her/his foot slipped and hit a wall during a shower performed by Staff 22 (CNA). An x-ray was ordered which revealed Resident 24 sustained a fracture in her/his great right toe. Staff 22 (CNA) reported that despite knowing Resident 24 was a two-person transfer with a transfer pole and required non-skid socks, he did not believe it to be necessary. The Facility Investigation revealed Staff 22 failed to follow Resident 24's Care Plan related to transfers. On 8/11/23 at 11:22 AM Staff 22 confirmed he did not follow Resident 24's care plan, Staff 22 indicated he believed Resident 24 was not injured after she/he hit her/his foot based on his assessment and therefore did not report the incident to the Charge Nurse. Staff 22 confirmed Resident 24 sustained a fracture on the right great toe as a result of the incident. On 8/11/23 at 11:28 AM Staff 4 stated the incident was reported to her the day after by the PTA. Staff 4 stated she requested an order for an x-ray to be conducted on Resident 24's right big toe. Staff 4 confirmed a fracture of Resident 24's right big toe was sustained as a result of Staff 22 not following Resident 24's care plan. On 8/11/23 at 11:45 AM Staff 21 confirmed she was alerted by Resident 24 regarding the residents reported toe pain. Staff 21 confirmed Resident 24 sustained a fracture. On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 2 (Quality Assurance RN) and Staff 9 (Regional RN) confirmed the above findings and no additional information was provided.

Based on observation, interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for delayed and unmet care needs. Findings include: Resident 15 admitted to the facility in 8/2022 with diagnoses including congestive heart failure and chronic kidney disease. Resident 15's most recent Quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Resident 15 was assessed to be an extensive assist with bed mobility, transfers and toileting, was continent of bowel and bladder and used a bedpan. The facility submitted a report to the state agency on 10/3/22 which revealed Resident 15 told a staff member she/he was left on the bedpan for one and a half hours on 9/30/22. She/he stated the call light was activated around 6:00 PM and she/he waited a long time for a CNA to respond. The facility's investigation concluded the agency CNA who initially assisted Resident 15 on the bedpan left for her meal break and assumed the other CNA would assist the resident off the bedpan. The other CNA was unable to assist the resident and she/he was not assisted for approximately two hours. Resident 15 reported discomfort on her/his back and coccyx while on the bedpan but sustained no injuries. Resident 15 was not interviewed due to discharging from the facility. Resident 19 admitted to the facility in 4/2022 with diagnoses including stroke and heart disease. Resident 19's Quarterly MDS dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. Resident 19 was assessed to be an extensive assist with bed mobility, transfers and toileting. She/he was incontinent of bowel and bladder and wore incontinent briefs. On 8/16/23 at 1:22 PM, Witness 1 (Family Member) stated she frequently visited Resident 19 from 4/2022 through 11/2022, recalled the resident had on a wet or soiled brief, and it took staff half an hour to an hour to respond. Witness 1 stated she had to find staff due to nobody answering the call light and upon responding staff told her they were short-staffed. Witness 1 recalled a few occasions when Staff 15 (CNA) was the only CNA on the hall and could not reposition or provide cares to Resident 19 alone. On 8/8/23 at 10:49 AM and 8/14/23 at 2:20 PM, Staff 13 (CNA) stated last fall and winter was really bad related to staffing levels and day shift was the least staffed. She/he recalled CNA's had up to 12 residents assigned to them on a shift, there were long call light response wait times, delayed care for residents, and it was chaotic. Staff 13 stated the current resident assignent for CNA's was six to seven residents but there were times when showers were not given due to time constraints. On 8/14/23 at 12:12 PM Staff 15 recalled the facility was short-staffed 11/2022 and 12/2022 and the resident assignments were higher than usual. Staff 15 recalled she/he finished resident cares but was unsure if other staff were able to finish the care timely. On 8/14/23 at 2:41 PM, Staff 14 (CNA) stated the facility was short-staffed in the fall of 2022 and cares were provided late which included taking vital signs, bringing water and snacks to residents and completing incontinence care timely. Staff 14 recalled she/he was assigned up to 11 residents and the average ratio for evening shift was nine residents per CNA. Review of the Direct Care Staff Daily Reports from 9/1/22 through 9/30/22, 10/1/22 through 10/31/22, 11/1/22 through 11/30/22 and 12/1/22 through 12/31/22 revealed the facility did not meet state staffing requirements for CNAs for 16 out of 30 days in 9/2022, 14 out of 31 days in 10/2022, 21 out of 30 days in 11/2022 and 19 out of 31 days in 12/2022. The majority of the staffing shortages were for day shift. On 8/14/23 at 2:21 PM, Staff 11 (Staffing Coordinator) confirmed the facility was short staffed from 9/2022 through 12/2022 and it was challenging to find staff willing to work day shifts.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 2 of 11 sampled residents (#s 18 and 25) reviewed for abuse. This placed residents at risk for verbal and physical abuse and psychosocial harm. Findings include: 1. Resident 3 admitted to the facility in 2020 with diagnoses including dementia. Resident 25 admitted to the facility in 2020 with diagnoses including dementia and stroke. Resident 3's 6/6/23 Progress Note indicated Resident 3 had a physical altercation with Resident 25. Resident 3 scratched Resident 25's face when Resident 25 accidentally bumped Resident 3's wheelchair. Resident 25 sustained a skin tear to the forehead which measured 0.4 cm x 0.3 cm. The 6/6/23 Facility Investigation revealed Resident 3 scratched Resident 25 on the forehead when Resident 25 accidentally bumped her/his wheelchair into Resident 3's wheelchair, which resulted in a 0.4 cm x 0.3 cm skin tear. On 8/9/23 at 12:20 PM Staff 2 (Quality Assurance RN) and Staff 3 (LPN Resident Care Manager) confirmed Resident 2 physically abused Resident 25 on 6/6/23 when Resident 3 scratched Resident 25's forehead. 46054 2. Resident 18 was admitted to the facility in 2016 with diagnoses including dementia, hypertension, and hyperlipidemia. Resident 18's 7/20/23 Admission MDS included Resident 18 had a BIMS score of 2 out of 15 indicating significant cognitive impairment. Resident 18's Care Plan dated 11/27/19, and revised on 10/24/22, revealed Resident 18 had a history of behaviors related to verbal and physical altercations related to verbal abuse. A Facility Incident Report dated 10/19/22 revealed Staff 24 (CNA) stated to Resident 19 you think you are special; you are not better than everyone else. The facility conducted interviews with Staff 24 and identified Staff 24 admitted to the altercation. On 8/8/23 at 11:50 AM Staff 24 could not be reached for comment. On 8/8/23 at 12:02 PM Staff 3 (LPN) confirmed the incident of verbal abuse as well as the words that were spoken from Staff 24 on the day of incident. On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 2 (Quality Assurance RN) and Staff 9 (Regional RN) the verbal abuse findings were confirmed with all parties and no additional information was provided.

Based on interview and record review it was determined the facility failed to provide timely ADL assistance for 1 of 4 sampled resident (#13) reviewed for ADL Assistance. This placed residents at risk for untimely and unmet care needs. Findings include: Resident 13 was admitted to the facility in 2022 with diagnosis including Gullain-Barre Syndrome (a condition that causes rapid muscle weakness). Resident 13's Care Plan dated 8/3/22 identified Resident 13 required assistance with toileting. A Facility Investigation Report dated 9/27/22 stated Resident 13 reported she/he was left on the commode for nearly an hour by Staff 23 (CNA). Resident 13 indicated no staff came to assist her/him off the commode until they were notified by family. The investigation revealed Staff 23 witnessed Resident 13's call light activation but continued to complete his daily duties as he assumed other staff were going to answer the call light. On 8/11/23 at 3:10 PM Staff 23 confirmed he walked past the resident's activated call light, but did not respond and assist Resident 13. On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 2 (Quality Assurance RN) and Staff 9 (Regional RN) confirmed Resident 13 did not receive timely ADL assistance. No additional information was provided.

Based on interview and record review it was determined the facility failed to respond timely to a change of condition for 1 of 3 sampled residents (#26) reviewed for change of condition. This placed residents at risk for a delay in treatment. Findings include: 1. Resident 26 admitted to the facility on [DATE] with diagnoses including left femur fracture with left artificial joint. The 6/16/23 Pain Care Plan instructed staff to monitor, record and report to the nurse any signs or symptoms of non-verbal pain or complaints of pain. The 6/26/23 at 10:50 AM Progress Note revealed Resident 26 had increased pain to the left hip, was unable to work with therapy and the left leg appeared to be turned in. The physician was notified. The 6/26/23 Physician Encounter note revealed the resident had significant pain and a deformity was noted upon exam. An urgent x-ray was ordered and a left leg dislocation was suspected. The 6/26/23 Facility Investigation revealed Staff 5 (CNA) noted the resident had pain both times incontinent care was performed during the night shift, but did not report the pain to the nurse. Staff 6 (CNA) assisted the resident to transfer to the commode on day shift, had to utilize the sit-to-stand machine and noted the resident had pain. Staff 6 did not report the deviation from Resident 26's baseline related to transferring or the complaints of pain to the nurse. Staff 4 (LPN) observed the resident in her/his wheelchair sitting awkwardly. Staff 4 assisted Resident 26 back to bed and noted the resident was weak, in pain and not helping much to stand. The nurse provided the resident with a narcotic pain medication and ice, but did not assess the resident for the change of condition. Staff 10 (PT Assistant) assessed the resident and notified Staff 4 (at 10:00 am) the left leg was turned inward. Staff 4 then notified the physician. The 6/27/23 Physician Encounter Note revealed Resident 26 was transferred to the Emergency Department on 6/26/23 due to worsening pain in the left leg with notable internal rotation. Resident 26 was diagnosed with a prosthetic dislocation, she/he underwent a closed reduction in the Emergency department and was transferred back to the facility the same day. Staff 5 and Staff 6 were unavailable for interview. On 8/14/23 at 11:14 AM Staff 4 verified she assisted Resident 26 back to bed, noted she/he was painful and weak and confirmed Staff 10 was the staff member who assessed Resident 26's change of condition. On 8/14/23 at 11:30 AM Staff 8 (RNCM) confirmed both Staff 5 and Staff 6 did not report Resident 26's pain or change of condition to the nurse and Staff 4 did not assess Resident 26's change of condition. 46054

Based on interview and record review it was determined the facility failed to provide adequate foot care for 1 of 3 sampled residents (#6) reviewed for diabetic foot care. This caused Resident 6 to develop a full thickness diabetic foot ulcer. This placed other residents at risk for increased foot problems. Findings include: Resident 6 was admitted to the facility in 2017 with diagnoses including diabetes with neurological complication. Review of Resident 6's clinical record revealed the following: A care plan intervention initiated 7/2017 revealed Resident 6 was to always wear her/his custom diabetic shoes when up and or mobilizing. According to the resident's record she/he was provided new diabetic shoes on an annual basis from 2019 through 2021. On 5/2/22 secure communication with the physician noted the top of all the toes on Resident 6's left foot were pink, possibly from the resident's shoes. Resident 6's clinical record indicated she/he was not reassessed, the care plan was not updated to address potential issues with the shoes not fitting, and monitoring of the resident's toes was not initiated. There was no documentation in Resident 6's clinical record indicating her/his toes were being monitored daily by a licensed nurse. According to the resident's record, in June of 2022 the resident did not receive new diabetic shoes due to a physician refusing to sign the authorization request. Progress notes dated 10/1/22 indicated Resident 6 had a full thickness wound to the top of her/his left great toe. A United Wound Healing (UWH) progress note dated 10/20/22 indicated not to use the diabetic shoes due to the shoes causing increased irritation to the left foot. A UWH progress note dated 10/25/22 indicated despite wound nurse recommendations, Resident 6 still wore her/his old diabetic shoe over the full thickness ulcer on her/his left great toe. Additionally, a blister to the same toe as the full thickness ulcer was noted to have formed since 10/20/22. On 3/29/23 at 3:37 PM Staff 9 (CNA) stated in the last six months Resident 6 stated she/he did not like her/his shoes, they made her/his feet hurt. Staff 9 also stated there were times when Resident 6 had non-skid socks and her/his shoes on and that caused a lot of pain to the resident as well. There was no documented evidence in Resident 6's clinical record this information was reported, and no changes were made to the resident's care as a result. On 4/5/23 at 12:13 PM Staff 7 (Care Manager) stated Resident 6's foot wound could have been caused by her/his old diabetic shoes not fitting properly. On 4/7/23 at 3:38 PM Witness 3 (Wound RN) indicated Resident 6 had a claw toe which raised the knuckle up; it put her/him at risk because the toe rubbed on any type of surface not designed to take that into consideration. She advised the facility to stop use of the resident's old shoe, however it was noted still on the left foot five days after she advised the shoe to no longer be used. Witness 3 indicated given the information available, Resident 6's shoes were the cause of irritation that led to the diabetic foot ulcer.

Based on interview and record review it was determined the facility failed to ensure a resident received sufficient fluid intake for 1 of 3 sampled residents (#6) reviewed for hydration. This failure resulted in Resident 6 being hospitalized due to dehydration. This placed residents at risk for dehydration. Findings include: Resident 6 was admitted to the facility in 2022 with diagnoses including Alzheimer's disease and difficulty swallowing. A 3/28/19 aspiration care plan indicated Resident 6 had a diet order of General/Puree/honey thick liquids; no straws, liquids via 2 handled cup. Resident 6 was to be close 1:1 supervision with full 1:1 cueing and 1:1 assistance as indicated for eating and drinking. The care plan provided no info on how resident 6 was to get drinks between meals, or how the resident was being monitored specifically for dehydration. A 6/29/21 and 4/19/22 medical nutritional therapy assessment indicated Resident 6 required an estimated 1700 milliliters of fluids per day. A review of Resident 6's meal and fluid intake record for 4/2022 revealed the following intakes: 4/1 - 940 mL 4/2 - 833 mL 4/3 - 640 mL 4/4 - 1000 mL 4/5 - 980 mL 4/6 - 400 mL 4/7 - 680 mL 4/8 - 720 mL 4/9 - 640 mL 4/10 - 720 mL 4/11 - 870 mL 4/12 - 710 mL 4/13 - 240 mL 4/14 - RNA 4/15 - RNA 4/16 - --- 4/17 - 240 mL 4/18 - 1030 mL 4/19 - 660 mL 4/20 - 820 mL 4/21 - 360 mL 4/22 - 720 mL 4/23 - 1000 mL 4/24 - 400 mL A progress note dated 4/24/22 indicated resident 6 was sent out to the emergency room for evaluation due to low blood pressure and increased respirations. A progress note dated 4/27/22 indicated Resident 6 was readmitted from the hospital with diagnoses including dehydration and lethargy. Hospital Records dated 4/27/22 indicated Resident 6 was treated in the hospital for free water deficit and received three liters of fluids. On 4/7/23 at 10:58 AM Staff 11 (RN) indicated new interventions were put in place to monitor Resident 6's fluid status after returning from the hospital due to dehydration.

Based on interview and record review it was determined the facility failed to complete admission and annual MDSes, for 4 of 9 sampled residents (#s 1, 2, 3 and 9) reviewed for MDS. There were an additional 26 non-sampled residents with incomplete admission or annual MDSes. This failure was determined to be an immediate jeopardy situation because it put residents at risk for unmanaged medications, side effects from medications, skin conditions, and unknown needs that were never identified or addressed, which could have led to permanent injury, severe infection, and unknown potential harm due to the lack of comprehensive assessment. Findings include: 1. Resident 1 admitted in 2022 with diagnoses including dementia, depression, and neurocognitive disorder with Lewy body dementia (uncontrolled body movements and hallucinations). Review of Resident 1's record indicated the following was missing: - 11/7/2022 Admission MDS was incomplete. - Comprehensive care plan was incomplete. - Monitoring of symptoms and side effects for clonazepam (antianxiety medications). - Monitoring of symptoms and side effects for Olanzapine (antipsychotic medications). - Monitoring of symptoms and side effects for Paroxetine (antidepressant medications). Failure to assess for the appropriate use of these medications and failure to monitor for symptoms and side effects of these medications can lead to seizures, internal bleeding, difficulty breathing, uncontrolled body movements, loss of self-control, swelling, and thoughts of suicide. The incomplete admission assessment also resulted in a failure to assess the resident's functional capacity and needs, and an appropriate plan of care for, but not limited to, the following: -Infections, psychotropic medications, behavioral health, permanent side effects from medications, vision and dental needs, trauma informed care, appropriate activity and socialization, cultural and religious needs as well as other unassessed needs. This failure put Resident 1 at risk for unmonitored medications, behavioral health issues, psychotropic medication reactions, and any number of unknown treatable conditions due to a lack of assessment. This deficiency was likely to result in permanent injury, severe infection, mental anguish, and/or exposed other residents in the facility to potential behaviors. On 1/18/23 at 11:14 Staff 4 (RN) stated she believed all MDSes she was responsible for were completed and was unaware Resident 1's MDS was not completed. On 1/24/23 at 7:00 PM - Staff 3 (RN Consultant) confirmed the comprehensive care plans and monitoring of medications were not in place due to the Admission MDS not being completed. 2. Resident 3 admitted in 2022 with diagnoses including Parkinson's disease, depression, and osteoporosis. Review of Resident 3's record indicated the following was missing: - 8/29/22 Admission MDS. - Comprehensive care plan. - Assessment of and monitoring for symptoms and side effects for Paroxetine (antidepressant medications). - Assessment of and monitoring for symptoms and side effects for Carbidopa-Levodopa (Parkinson's medications). - A care plan for antipsychotic medications. Failure to monitor for symptoms and side effects of these medications can lead to internal bleeding, swelling of face, throat, thoughts of death, uncontrolled movement, seizures, and difficulty breathing. The incomplete admission assessment also resulted in failure to assess the resident's functional capacity and needs, and lack of an appropriate provide a plan of care for, but not limited to, the following: - Infections, psychotropic medications, behavioral health, permanent side effects from medications, pain, vision and dental needs, trauma informed care, cultural and religious needs, weight and fluid management and other unassessed needs. These failures put Resident 3 at risk for unmanaged medications and side effects, unmonitored behaviors, potential vision impairment, dental pain, and any number of unknown treatable conditions due to a lack of assessment. This deficiency was likely to result in permanent injury, severe infection, mental anguish, and/or potentially exposed other residents in the facility to behaviors. On 1/25/22 at 12:42 Staff 5 (RN) confirmed the monitoring, care plans, and MDS were missing or incomplete. 3. Resident 2 admitted in 2022 with diagnoses including mental and behavioral disorders, chronic obstructive pulmonary disorder, presence of cardiac pacemaker, and heart failure. Review of Resident 2's record indicated the following was missing: - 10/17/22 Admission MDS was incomplete. - Comprehensive care plan was incomplete. The incomplete admission assessment resulted in a failure to assess the resident's functional capacity and needs, and lack of an appropriate plan of care for, but not limited to, the following: -Infections, behavioral health, pain, vision and dental needs, trauma informed care, appropriate activity and socialization, respiratory problems, cultural and religious needs as well as other unassessed needs. This failure put Resident 2 at risk for behavioral health issues, vision issues, dental problems, pain, medication reactions, breathing issues, and any number of unknown treatable conditions due to a lack of assessment. This deficiency was likely to result in permanent injury, severe infection, mental anguish, and could have exposed other residents in the facility to behaviors. On 1/24/23 at 7:00 PM Staff 3 (RN Consultant) confirmed the comprehensive care plans were not in place due to the Admission MDS not being completed. 4. Resident 9 admitted in 2022 with diagnoses including gout, skin cancer, kidney disease, and atrial flutter. Review of Resident 9's record indicated the following was missing: - 9/3/22 Admission MDS - Comprehensive care plan. The incomplete admission assessment resulted in a failure to assess the resident's functional capacity and needs, and lack of an appropriate plan of care for, but not limited to, the following: - Psychotropic medications, behavioral health, permanent side effects from medications, safety, pain, vision and dental needs, trauma informed care, appropriate activity and socialization, cultural and religious needs, end of life care, other unassessed needs. This failure put Resident 9 at risk for unmanaged medications, unmanaged pain, incomplete knowledge of skin issues, potential heart problems, bleeding risk, and any number of unknown treatable conditions due to a lack of assessment. This failure was likely to result in permanent injury, significant physical pain, mental anguish, inadequate end of life services and potentially an early death. On 1/26/23 Staff 6 (RN) confirmed the admission MDS and care plans were missing or incomplete. 5. The 1/13/23 MDS [NAME] report (computer generated list of residents with missing MDS information) was compared to current medical records on 1/19/23 which revealed an additional 19 missing Admission MDSes, as well as seven Annual MDSes. On 1/24/23 at 7:00 PM staff 3 (RN consultant) confirmed the comprehensive care plans were not in place due to the admission MDS not being completed. On 1/24/23 at 6:20 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 1/24/23 at 7:53 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: - The facility will complete any Admission and/ or Annual assessments that are incomplete for Residents 1 and 3 and update the care plan and other appropriate monitoring and documentation as applicable by 1/27/2023 - The facility has audited all current in-house residents for MDS completion as of 1/24/23. Any current admission and annual missing assessments will be completed by 1/27/23 which includes care planning and other appropriate monitoring and documentation as applicable. - The facility will immediately begin reviewing all new admissions for timely completion of MDSes including care planning and other appropriate documentation as applicable within the 24-hour report process 1/25/2023 - The medical records coordinator will monitor all admission and annual assessment due dates and report all due dates to the interdisciplinary team members and daily stand up and report immediately to the director of nursing services and administrator any Admission and Annual MDSe that are out of compliance. The director of nurses will meet with the interdisciplinary team for an action plan of timely completion. - The facility has a skilled MDS Coordinator who will be utilized to assist with other facility units to maintain timely admission and annual MDS assessments. The facility will continue to retain outside MDS completion support as needed with a contracted RCM (Resident Care Manager) and Nurse Consultant. - The Quality Assurance nurse, administrator and director of nursing services will review weekly for ongoing compliance. On 1/30/23 at 1:45 PM record review was completed which verified the immediacy removal plan was fully implemented on 1/26/23.

1. Based on observation, interview and record review it was determined the facility failed to ensure care planned safety interventions and supervision were in place and followed to protect residents from unsafe elopement from the facility for 1 of 2 sampled residents (# 3) reviewed for elopement. This resulted in an immediate jeopardy situation which placed residents at risk for potentially avoidable accidents. Resident 3 sustained a fractured wrist after eloping from the facility. Findings include: Resident 3 was admitted to the Memory Care Unit (MCC) of the facility in 1/2019 with [DIAGNOSES REDACTED]. On 1/3/19 the facility placed a Code Green Document (elopement risk) of Resident 3 at the front desk. The document included a picture of the resident, noted the resident's non-English primary language and the resident would try to follow family out of the MCC after their visits. The resident had paranoia and hallucinations which could trigger the resident to attempt to leave the facility. Successful interventions included to re-direct the resident away from the exit doors. The resident wore a wanderguard on her/his right ankle and the resident required to be visually supervised when approaching exit doors. The resident also wandered toward the exit doors when family were not present and may accidentally follow staff or visitors out of the door. The resident had a history of [REDACTED]. Resident 3's 1/31/19 Elopement Risk Assessment revealed the resident was new to the facility and eloped seven times from her/his home setting in the past six months. The resident was cognitively impaired with short and long term memory, confusion, impaired decision making and was disoriented. The resident displayed exit seeking behaviors, wandering, restlessness and verbalized seeking things such as people. The overall risk of elopement was left blank. The 1/3/19 care plan revealed the resident was on [MEDICAL CONDITION] medications for behavior management, the resident spoke only in her/his native language, the resident had a history of [REDACTED]. Staff were to monitor and record occurrences of target behavior symptoms (pacing and wandering) and document per the facility protocol. Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and a book. Staff were to monitor the resident's location every 15 minutes and document on the behavioral log. The resident wore a wander alert device on her/his right ankle and staff were to check the device and supervise the resident, even from a distance. The facility did not transfer the triggers that indicated elopement trends from the 1/3/19 Code Green Documentation Tool to the 1/3/19 care plan. These triggers included: -Will try to follow family out after visits. -Heads to the exit doors when family were not present and accidentally follow staff or visitors out of the door. -had a history of [REDACTED]. The 1/3/19 care plan indicated staff were to monitor the resident's location every 15 minutes and were to document the wandering behaviors and attempted diversions. On 2/10/19 (the day the resident eloped) there was no documentation for the 15-minute checks. Resident 3's progress notes from 1/3/19 to 2/9/19 revealed the resident wandered around the unit and had exit seeking behaviors. On 2/10/19 around 2:30 PM, Staff 9 (RN) tried to say goodbye to Resident 3 as she always did after her shift, but was unable to locate the resident. The resident was last seen pacing around the unit at 2:00 PM. A thorough search of the MCC for the resident was not successful. Staff reported the resident was missing to the front desk and the weekend manager. A thorough search of the entire building and the outside vicinity was initiated and was unsuccessful. The police and family were notified. The police found the resident two miles away from the facility around 4:00 PM on the ground in 37- degree weather. The resident had a coat on, appeared hurt and was taken to the emergency room . The 2/10/19 Emergency Department Encounter document revealed the following: The resident was found wandering outside approximately 2-3 miles away from the facility, unknown history how she/he got out and presented with an abrasion, ecchymosis (a discoloration of the skin resulting from bleeding underneath) and [MEDICAL CONDITION] to the left eye socket. The resident also had the following injuries: -Prominent left eye socket bruising with dried blood on her/his lips and teeth. -Visible bruising on the palm aspect of the right hand with tenderness. -Right hand x-ray revealed the resident had a fourth metacarpal (hand bone) and fifth proximal phalanx fracture (finger fracture). -Traumatic injury of the head, initial encounter. The 2/2019 TAR revealed the facility performed the following treatments for the resident's injuries starting 2/11/19: -Check the right hand for severe pain and elevate the hand for one to two hours if symptoms persisted, resolved on 3/6/19. -Monitor the abrasion to the bridge of the nose 2 x 0.1 cm and apply triple antibiotic ointment, resolved on 2/19/19. -Monitor the abrasion to the left chin 1.5 x 1.5 cm, resolved on 2/19/19. -Monitor the left abrasion to the left cheek 2 x 2 cm apply triple antibiotic ointment, resolved on 2/19/19. -Monitor the bruise and swelling to the left cheek and under the eye 5 x 3 cm, resolved on 2/26/19. -Monitor the bruise to the left jaw 3 x 2, resolved on 3/12/19. -Right hand cast care, resolved on 3/6/19. The resident's facial abrasions and bruises resolved over the following month after the resident eloped and fell . The resident wore a cast on her/his right hand from 2/13/19 to 3/6/19. The facility completed a thorough incident report which indicated the resident may have followed a visitor out the exit door because the resident always wore a coat and appeared to look like a visitor. The facility determined that the resident's wanderguard alarmed the exit door on the west unit and Staff 6 (LPN) silenced the alarm after checking for residents and she was unable to locate any resident. The police arrived and the facility provided a picture of the resident and they found the resident around 4:00 PM and transported the resident to the emergency room where she/he was diagnosed to have a fractured right wrist and facial abrasions. The facility investigation included interviews with staff and visitors from 2/10/19 through 2/15/19 to determine how the resident exited the MCC. Signs were placed on the exit doors in Resident 3's native language to indicate the doors were not exit doors. The wanderguard was checked and was in working order and the doors were checked and were latched properly. On 2/15/19 the facility Quality Assurance team met and discussed the solutions for enhanced security. The maintenance department was to evaluate the MCC door functions and removing the egress through the doors to the adjacent MCC and others which were low visibility doors. A new and improved procedure would be put into place for nurses on what to do when the alarm sounded. The facility did not place the elopement triggers noted on the 1/3/19 Code Green Documentation Tool to the 1/3/19 care plan. The facility failed to adequately supervise Resident 3 and document 15-minute checks of the resident per the care plan, monitor and re-direct the resident from the exit doors, and keep the resident from exiting the secured MCC. Staff interviewed by this surveyor regarding the incident on 2/10/19 indicated: On 5/23/19 at 11:27 AM Staff 9 (RN) indicated after her shift she always said goodbye to Resident 3. She attempted to find the resident on 2/10/19 after 2:30 PM and was unable to locate the resident on the MCC unit. On 5/23/19 at 11:35 AM Staff 3 (RNCM) indicated the day the resident got out was a Sunday and she was not working. She indicated she thought Resident 3 followed someone out the exit door because the resident did not look like a resident because she/he dressed in street clothes and was fast. On 5/23/19 at 1:17 PM Staff 6 (LPN) indicated she heard the alarm sound on the west wing and opened the door to look for a resident but was unable to find a resident outside the building and turned off the alarm. On 5/23/19 at 1:33 PM Staff 20 (CNA) indicated the last time she saw the resident was around 1:30 - 2:00 PM when she walked into the resident's room. The resident was wearing a puffy coat. On 5/23/19 at 2:06 PM Staff 11 (CNA) indicated she worked the day shift and the resident was trying to get out of the MCC most of the day and she/he was redirected. She did her last checks around 2-2:30 PM and the resident was still in the MCC. On 5/29/19 at 3:20 PM Staff 1 (Administrator) was notified the incident on 2/10/19 was an immediate jeopardy situation. As the facility had identified the deficient practice, instituted corrections and maintained the corrections. This was determined to qualify for designation as past non-compliance. Survey determined that the facility instituted the following interventions: -15 minute checks on the resident. -The resident was placed on a RA program for walking. -Large signs were placed on the exit doors to ensure staff and visitors did not let residents out of the MCC. One of the signs was written in the resident's native language to alert the resident the doors were not exit doors. -Maintenance evaluated the door function. -The doors outside the MCC in adjacent areas to the front parking lot and a door facing a different street were equipped with additional alarms. -The procedure for nurses on what to do in the event of an elopement was reviewed and improved upon. -The facility completed one on one training with the MCC staff after the elopement. The immediate jeopardy was determined to be removed on 2/15/19. Observations of the resident on 5/23/19 and 5/29/19 revealed the resident was restless and wandered the halls towards the exit doors. Staff supervised and redirected the resident away from the exit doors and were very attentive to the resident. The resident was fast in her/his movements and did not like to sit still. There was also a sign on the door near the piano room which indicated the door was closed for repairs and a sign on both MCC doors to alert staff and visitors to watch for residents following them out of the MCC doors. 2. Based on observations, interviews and record review it was determined the facility failed to care plan for the risks of an unsafe environment for 1 of 2 sampled residents (# 19) reviewed for resident to resident altercation. This placed the residents at risk for an unsafe environment. Findings include: Resident 19 was admitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. The 4/11/19 Behavior/Psychoactive Meeting revealed the resident exhibited behaviors including yelling and sometimes tossing her/his front wheel walker, but did not hit staff. The resident became upset when she/he felt her/his attends were wet. Staff were to redirect, provide reassurance and frequent checks. The resident's 5/19/19 annual MDS revealed the resident had a BIMS (brief interview for mental status) score of 8 (mildly cognitively impaired). The 5/22/19 Behavior and Cognition CAA revealed the resident refused care and was forgetful about visits from family. The resident had loud vocalizations and escalation of behaviors due to dementia and the inability to handle frustrations. The resident also had sleep disturbances. The 5/11/18 care plan revealed the resident had impaired cognition and thought processes due to [MEDICAL CONDITION], had a history of [REDACTED]. The progress notes revealed the following incidents: On 4/27/19 the resident refused incontinent care and grabbed her/his walker and slammed it on the floor and began yelling at the care givers, then threw her/his walker toward a CN[NAME] On 5/2/19 the resident was seen by the physician and noted if the behaviors persisted to discuss the use of medication with the family. On 5/23/19 the resident was on alert for aggressive behaviors. The resident threw her/his walker in the shower room and began kicking and aggressively yelling at staff. The resident began thrashing and ripping at shirt while yelling. Later that day the resident began thrashing the walker around and yelling during toileting. On 5/26/19 the resident refused to be changed and she/he yelled at the CNA and Resident 19 shook her/his walker and stomped her/his feet. On 5/28/19 the progress note revealed the resident was seen to have a resident to resident altercation on 5/27/19 around noon. The resident yelled at Resident 20 and pushed her/his walker into Resident 20's walker. Resident 20 was not using her/his walker at the time but had several drinks on the seat of the walker which all spilled and some of the beverage spilled on Resident 20. The drinks were not hot so Resident 20 was not hurt. Staff separated the two residents. Resident 19 did not recall the incident. Staff completed an incident report and reported it to the State Survey Unit. The resident was in the dining room and was moving toward the place she/he normally sat and Resident 20 was sitting in that place with her/his walker next to him/her. Resident 19 yelled at Resident 20 asking her/him to get out. Resident 19 then began to shove her/his walker into Resident 20's walker which had beverages on the seat of the walker and they all spilled. Some of the beverages spilled on Resident 20 but they were not hot. Once Resident 19 moved Resident 20's walker she/he sat in her/his place. Resident 20 was removed from the dining room. The facility was aware of the resident's behavior since 4/11/19 of throwing her/his walker and yelling. The facility failed to care plan Resident 19's aggressive behaviors with her/his walker. The resident was involved in a resident to resident altercation involving her/his walker with Resident 20 rendering the environment unsafe for Resident 20 and other residents. On 6/3/19 at 10:53 AM Staff 22 (Dietary Aide) indicated she was in the dining area and heard Resident 19 yell at Resident 20 asking her/him what she/he was doing there and to get out and Resident 20 appeared confused. Resident 19 then shoved her/his walker into Resident 20's walker and all the beverages that were sitting on Resident 20's walker seat spilled. Resident 20 was removed from the scene. On 6/3/19 at 2:53 PM Staff 39 (RN) assisted with language translation with Resident 20 and Resident 20 was unable to recall the incident. On 6/3/19 at 10:43 AM Staff 5 (Interim RNCM) indicated Resident 19 was moved to a private room on a different unit and indicated on 5/30/19 they started Resident 19 on a low dose of [MEDICATION NAME] (manic episodes related to bi-polar) to see if the resident could get a good night's sleep and decrease the behaviors. On 6/10/19 At 1:45 Staff 2 (DNS) indicated there were approaches on the care plan but were not specific towards other residents. Resident 20's behaviors became baseline and the staff were all aware of what to do for the resident when she/he exhibited behaviors. The interventions were not placed on the care plan until after the 5/27/19 incident.

Based on interview and record review it was determined the facility failed to implement fall precautions for 1 of 2 sampled residents (#7) who was reviewed for accidents. The resident obtained a fracture after a fall. Findings include: Resident 7 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The comprehensive care plan dated 7/15/17 revealed Resident 7 was a high risk for falls. Interventions initiated on 7/17/17 included Resident 7 used chair and bed electronic alarms. Staff were to ensure the devices is in place and in working order with each encounter. An Incident report dated 7/31/17 revealed Resident 7 was found on the floor. Staff 37 (Social Services) stated she was walking with the the resident and Staff 18 (RA) and went back to the room together with Resident 7. Staff 37 asked Staff 18 to turn on the bed alarm. Staff 18 responded to Staff 37 the alarm was pressure sensitive and turned on automatically. The (NAME)ville Nursing Home Discharge Summary dated 8/14/17 revealed on 7/31/17 Resident 7 was found on the floor in her/his room and complained of right hip pain. After being sent to the hospital an x-ray revealed a right pelvic fracture. On 8/24/17 the Kardex (care instructions for nursing assistants) was reviewed and stated Resident 7 used electronic alarms on the chair and the bed. Staff was directed to ensure the device was in place and working with each encounter. On 8/25/17 at 10:05 am Staff 18 confirmed she did not check the alarm on the bed after Resident 7 was brought back to her/his room on 7/31/17 before the fall to see if it was functioning. On 8/29/17 at 2:42 pm Staff 12 (RNCM) confirmed the care plan stated to check bed alarm during each encounter and Staff 18 failed to check the bed alarm to ensure it was functioning. Staff 12 reported Resident 7 was not as mobile as she/he was before the fall.

Based on interview and record review it was determined the facility failed to treat on-going diarrhea, and screen for and treat [MEDICAL CONDITION] (a bacterial infection that causes diarrhea) in a timely manner for 2 of 3 sampled residents (#s 1 & 2) reviewed for changes in condition. Resident 1 was hospitalized and died from [MEDICAL CONDITION] as a consequence of [MEDICAL CONDITION] and pneumonia. Resident 2 was at risk for complications from untreated diarrhea and potential [MEDICAL CONDITION]. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Admission Physician order [REDACTED]. The [DATE] ADL Functional/Rehabilitation CAA described Resident 1 as alert and oriented. On [DATE] the physician ordered [MEDICATION NAME] (an antibiotic with side effects including gastrointestinal symptoms, diarrhea, and [MEDICAL CONDITION]) ,[DATE] mg for 10 days. The ,[DATE] MAR documented the [MEDICATION NAME] was given as ordered. On [DATE] the physician ordered [MEDICATION NAME] (a medication to treat nausea and vomiting) 25 mg every six hours PRN. The [DATE] Emar Notes, OT (Occupational Therapy) Note, and the ,[DATE] BM (Bowel Movement) Report disclosed the resident reported being nauseous, having an upset stomach, and had two episodes of loose stool/diarrhea. The [DATE] Emar Notes, the 11:10 pm Progress Note and the ,[DATE] BM report documented the resident received [MEDICATION NAME] twice and had two episodes of loose stool/diarrhea. The Progress Note inaccurately documented the resident continued on [MEDICATION NAME] with no adverse reactions noted. The [DATE] at 12:49 pm Progress Note and the ,[DATE] BM Report disclosed Resident 1 had an episode of loose stool/diarrhea. The resident had a large, mucus-like BM, complained of nausea/upset stomach, and received a PRN [MEDICATION NAME]. A new order to send out a STAT stool sample to rule out [MEDICAL CONDITION] was obtained and a hat was placed in the resident's commode for obtaining the sample. The [DATE] OT Note revealed Resident 1 developed signs and symptoms of nausea and upset stomach with diarrhea that decreased the resident's level of participation. Nursing staff was to obtain a stool sample to rule out [MEDICAL CONDITION]. The ,[DATE] BM Report, the [DATE] at 6:01 pm and 7:55 pm Progress Notes and the 9:00 pm Emar Note disclosed Resident 1 had an episode of loose stool/diarrhea documented at 3:34 pm and at 6:01 pm it was documented the resident had a small BM collected for the [MEDICAL CONDITION] screening. The lab rejected the stool specimen because it was formed and the stool for [MEDICAL CONDITION] screening should be loose. Staff documented at 9:00 pm the resident received [MEDICATION NAME] for nausea and stomach cramps. The [DATE] at 12:30 pm physician progress notes [REDACTED]. The physician inaccurately documented the resident had no diarrhea. The physician ordered Pepto-Bismol PRN. On [DATE] at 12:08 pm the ,[DATE] BM Report documented Resident 1 had loose stool/diarrhea. There was no documented evidence the stool sample was sent in for [MEDICAL CONDITION] screening. The [DATE] at 1:23 pm Progress Note documented the order for the stool sample was discontinued as the resident had no further episodes of diarrhea or mucous-like stools since Sunday ([DATE]). Per the ,[DATE] BM Report the progress note was inaccurate regarding the lack of diarrhea. The [DATE] Emar Note, [DATE] Emar Note, [DATE] Emar Note, and ,[DATE] BM Report revealed the following: *The resident was treated with [MEDICATION NAME] on [DATE] and Pepto-Bismol on [DATE] for an upset stomach and with Tylenol for abdominal cramps on [DATE]. *The resident had an episode of loose stool/diarrhea on [DATE] and [DATE]. The ,[DATE] BM Report noted on [DATE] Resident 1 had two episodes of loose stool/diarrhea. The physician ordered Immodium 2 mg every hour PRN for diarrhea. The [DATE] at 7:02 am and 10:15 am Emar Notes documented Resident 1 received Pepto-Bismol and [MEDICATION NAME], both documented as ineffective. The [DATE] at 10:02 am and 5:03 pm Emar Notes, the ,[DATE] MAR and the ,[DATE] BM Report disclosed Resident 1 received Pepto-Bismol and [MEDICATION NAME] for stomach upset/nausea. Resident 1 had two episodes of loose stool/diarrhea. The MAR lacked documented evidence the Immodium was administered as ordered. The [DATE] at 3:54 pm Progress Note and lab reports disclosed Resident 1 had abnormal labs including an elevated white blood count and a critically low calcium. The physician was informed, who directed staff to monitor the resident and encourage fluids. The [DATE] at 10:45 pm and 10:57 pm Emar Notes, ,[DATE] MAR and ,[DATE] BM Report disclosed Resident 1 received five doses of Immodium. Per the Emar notes the resident received the Immodium and [MEDICATION NAME] for loose stool, abdominal cramps and nausea. Resident 1 had three episodes of loose stool/nausea. There was no documented evidence [MEDICAL CONDITION] was ruled out with the initial [DATE] ordered lab nor when the resident's symptoms continued in ,[DATE] through [DATE]. The ,[DATE] meal monitor noted from [DATE] at 12:42 pm through [DATE] the resident had a decline in intake. The resident either refused meals or only consumed ,[DATE]% of the meal. The [DATE] Physician Assistant Progress Note disclosed Resident 1 reported a one week history of feeling crummy. The resident reported intermittent nausea, abdominal cramping, loose to watery stool, and decreased appetite, which was present for approximately one week. The physician assistant noted the resident received Immodium for watery stools on [DATE] and a stool sample for [MEDICAL CONDITION] was pending. The [DATE] lab report and [DATE] at 1:48 pm Progress Note revealed the stool sample was positive for [MEDICAL CONDITION] and the physician ordered [MEDICATION NAME] (an antibiotic). Per the ,[DATE] MAR Resident 1 received two doses of the [MEDICATION NAME] on [DATE]. The [DATE] at 7:46 am Progress Note disclosed Resident 1 was very pale and weak. The resident's vitals included a blood pressure of ,[DATE], a pulse of 105 and temperature of 97.4 and an elevated INR (a measurement of how long it takes the blood to form a clot). An attempt was made to call the PCP with no answer. After discussing with the resident how she/he felt, the resident's extreme nauseated feeling for several days, weakness, faint feeling and the elevated INR the resident wanted to go to the hospital for an evaluation. Medical transportation was called and the resident was sent to the hospital. The [DATE] hospital records noted the resident reported nausea, abdominal cramping and frequent, watery diarrhea that started 6 days prior. The resident had marked leukocytosis (elevated white blood cells) and the Emergency Department [DIAGNOSES REDACTED]. The History and Physical noted the resident reported constant abdominal pain, for the prior three days she/he had significant nausea to the point of almost vomiting and has not been able to eat or drink hardly anything. The resident reported being very weak for the past nine days, especially over the past three. On the resident's 5th day in the hospital she/he began treatment for [REDACTED].component of septic given c.diff [MEDICAL CONDITION] and likely superimposed pneumonia . The resident passed away on [DATE]. The [DATE] Resident Death Summary noted the primary cause of death was [MEDICAL CONDITION] with circulatory shock as a consequence of [MEDICAL CONDITION] and pneumonia complicated by acute [MEDICAL CONDITION]. In interview on [DATE] at 9:35 am Witness 1 (Complainant) stated while at the facility in ,[DATE] the resident was treated with [MEDICATION NAME] which placed the resident at high risk for [MEDICAL CONDITION]. On around [DATE] the resident complained of nausea, upset stomach and had diarrhea which continued until [DATE]. The resident was positive for [MEDICAL CONDITION] but it was too late. The resident was hospitalized , declined, her/his kidneys shut down from dehydration, and the resident died [MEDICAL CONDITION] and [MEDICAL CONDITION]. In interview on [DATE] at 9:48 am Staff 16 (RN) stated Resident 1 had diarrhea for several days (could not recall the dates). The inaccurate documentation in the resident's clinical record regarding the resident's bowel status and possible ADR to the [MEDICATION NAME] was discussed with Staff 2 (DNS) on [DATE] at 12:03 pm. Staff 2 acknowledged the inaccurate documentation. Staff 2 stated when obtaining a stool sample for [MEDICAL CONDITION] the stool needed to be loose. Staff 2 was asked what staff were expected to do when the initial specimen was rejected and the resident had additional gastrointestinal complaints and diarrhea. Per Staff 2 the facility protocol was for staff to pursue obtaining a definitive test for [MEDICAL CONDITION] since the diarrhea kept returning. 2. Resident 2 was admitted to the hospital in ,[DATE] with [DIAGNOSES REDACTED]. The [DATE] at 3:56 pm Progress Note disclosed the resident was readmitted to the facility from the hospital for an unrelated concern. The ,[DATE] and ,[DATE] BM Reports documented Resident 2 had loose stools/diarrhea daily from [DATE] to [DATE]. Examples included: *Four episodes on [DATE] and [DATE] *Three episodes on [DATE], [DATE] and [DATE]. There was no documented evidence the physician was contacted for treatment orders for the loose stool/diarrhea nor was a stool specimen obtained to rule out possible [MEDICAL CONDITION]. The [DATE] Nurse Practitioner Progress Note documented the resident presented with [MEDICAL CONDITION] and lethargy. The resident was minimally responsive to physical or verbal stimulation. The [DATE] at 12:32 pm Progress Note disclosed the resident was sent to the hospital. The [DATE] hospital records noted on [DATE] the resident was diagnosed with [REDACTED]. In interview on [DATE] at 9:08 am Staff 23 (RN) stated Resident 2 had multiple loose stools before discharging to the hospital on [DATE]. The resident returned from the hospitalization with a [DIAGNOSES REDACTED]. In interview on [DATE] at 9:24 am Staff 8 (LPN) stated there was a time the resident had loose stools or diarrhea. Staff 8 stated she did not know if the diarrhea was treated. In interview on [DATE] at 10:22 am Staff 4 (RNCM) stated she did not recall getting reports the resident had diarrhea from [DATE] to [DATE]. Staff 4 stated nurses should have reviewed the resident's BM report to see what was happening. When asked for the expectations for treatment of [REDACTED]. The resident was on a lot of antibiotics and the standard of practice was if a resident had two consecutive loose stools staff were to obtain a stool sample. Staff 4 stated had she known about the resident's diarrhea she would have counseled staff to obtain a stool sample and was surprised CNAs did not report the diarrhea to her and that nurses were not charting on it. In interview on [DATE] at 10:54 am Staff 19 (LPN) stated during [DATE] to [DATE] staff did not report the resident had loose stools/diarrhea. Staff 19 stated she reviewed residents' BM records at the start of shift and CNAs should report the diarrhea to the nurse. When asked about treatment and screening for [MEDICAL CONDITION] for repeated episodes of loose stools/diarrhea Staff 19 stated she would have treated the resident with Immodium. Depending on the situation, if the resident had multiple episodes, the interventions did not work and there was an odor she would obtain a [MEDICAL CONDITION] screen. In interview on [DATE] at 5:06 am Staff 14 (CNA) stated the resident had loose BMs for a long time. Staff 14 stated she charted the resident's BMs and told some nurses. Per Staff 14 everyone knew the resident had loose BMs including the nurses as they had to check the BM records. In interview on [DATE] at 8:36 am Staff 30 (RN) stated she did not receive reports about the resident having diarrhea. Staff 30 stated she reviewed residents' BM reports during her shift for bowel status including if a resident had loose BMs. If the resident had multiple episodes of diarrhea she would check the resident's record for treatment orders. In interview on [DATE] at 8:54 am Staff 25 (CNA) stated Resident 2 often had diarrhea which she documented and reported to nurses. Almost everybody knows which included other CNAs who also reported the diarrhea to nurses.

Based on interview and record review it was determined the facility failed to ensure care plan interventions were in place for 1 of 3 residents (#1) who were reviewed for accidents. Resident 1 fell and suffered lacerations which required sutures. Findings include: Resident 1 was admitted to the facility 1/27/17 with [DIAGNOSES REDACTED]. On 1/27/17 Resident 1's care plan identified the resident had a potential for injury from seizure activity. The interventions included place fall mats on both sides of the bed. A 2/3/17 incident fall report indicated on 2/3/17 at 4:30 pm Resident 1 was found sitting on her/his bedroom floor by staff with lacerations to the forehead and below the right eye. A large amount of bleeding was noted and controlled by pressure. The resident stated she/he went to the window and on the way back to the bed tripped over the floor mats which were stacked next to (her/his) bed fell and hit her/his head. The resident was assessed, the wound was cleansed and a dressing was applied. Resident 1 was sent to the emergency department for an evaluation of the lacerations. Staff 4 (RCM) noted the seizure careplan was not followed due to the mats were stacked together rather than on each side of the bed as the seizure careplan indicated. In a 2/3/17 witness statement Staff 3 (CNA) who was the resident's CNA at the time of Resident 1's fall, stated Resident 1 had toileted her/himself 15 minutes prior to the fall. Staff 3 stated she responded to the resident's alarm, helped the resident back to bed and reminded Resident 1 to use the call light. She observed both fall mats stacked on top of each other in the back side of the bed between the bed and the window at that time. Staff 3 stated the mats remained that way from the day shift. The 2/3/17 emergency department documentation which included a CT scan indicated a laceration which involved the glabella and frontal scalp region was found. The wound was sutured and Resident 1 returned to the facility on [DATE]. At the time of this survey, the resident no longer resided at the facility. In interviews on 2/23/17 at 10:29 am and 2/27/17 at 3:00 pm Staff 2 (Quality Assurance/Infection Control) stated prior to the fall Resident 1 used the toilet, walked to the window to see if it snowed then caught her/his toe on the two fall mats piled on top of each other. The two mats on top of each other was a tripping hazard. In interview on 2/24/17 at 10:00 am Staff 3 (CNA) stated she was Resident 1's CNA at the time of the fall. She stated when she started her shift, she did not see that the mats were on top of each other on the window side of the bed. Staff 3 stated per the care plan, the mats were supposed to be on the left side and the right side of the bed. In interview on 2/28/17 at 11:40 am Staff 5 (LPN) stated she was called to Resident 1's room by Staff 3 (CNA). The resident was sitting on her/his floor and pressure was applied by staff to the facial lacerations. The lacerations were assessed, cleansed and a dressing was applied. Staff 5 stated she asked Resident 1 what happened and the resident stated she/he went to the bathroom and headed to the window. The resident stated she tripped over the mat, fell and hit her/his head on the head board. The resident was sent to the emergency department for an evaluation. Staff 5 stated when she assisted Resident 1 after the fall, she saw the two mats on top of each other by the window side of the bed. The mats were supposed to be on each side of the bed per the careplan.

Based on interview and record review it was determined the facility neglected to provide appropriate measures to prevent heat injuries and to evaluate each resident for possible complications from heat exposure for 12 of 12 sampled residents (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 & 12) after being transported in a vehicle, without a working cooling system and during a period of extreme heat. Resident 1 sustained a heat stroke [MEDICAL CONDITION] the lower extremities. Other residents were at risk of complications from exposure to extreme heat. This failure resulted in an immediate jeopardy and was determined to be substandard quality of care. Findings include: 1. The 8/18/16 Shared Vehicle Agreement with a transportation service provider noted as part of emergency planning, if the shared vehicle broke down, the facility was directed to notify the service provider's Transportation Coordinator. .A driver and vehicle are dispatched to pick up passengers and deliver them to their destination. The Shared Vehicle Agreement included contact information for the Transportation Coordinator and additional contacts for the service provider. The Shared Vehicle Agreement included a Pre Trip Inspection completed on each day the vehicle was in use. If the inspection revealed an issue the facility would not operate the vehicle and report it to the service provider immediately. The 8/25/16 Daily Pre-Trip Inspection Report noted Staff 2 (Activities Director) checked off completing the inspection, including Check heater/air conditioner. Staff 2 noted on the inspection report (service provider staff) walked me thru how to do air . The 8/26/16 National Climatic Data Center Climatological Report noted at 3:31 pm the temperature for the region was 97 degrees. Per documentation provided by Staff 1 (Administrator) on 9/9/16, Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, & 12 participated in an 8/26/16 facility outing to a park, approximately 27 miles from the facility. Resident 1 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The 8/19/16 Wound And Skin Assessment noted Resident 1's weekly skin audit was completed with no skin issues noted at that time. The 8/26/16 Wound and Skin Assessment noted the resident had a rash to the abdominal folds. No additional skin breakdown was noted. Staff 4 (LPN) documented in the 8/26/16 at 9:58 pm Progress Note Resident 1 was on an outing. Upon return to the facility staff reported the resident was unresponsive and was sent to the emergency room . There was no documented nursing assessment of the resident at the time of her/his return to the facility from the outing. The 8/30/16 at 7:59 am Incident Note disclosed on 8/26/16 Resident 1 participated in a facility sponsored trip. The group left the facility at approximately 10:00 am and arrived at a park at approximately 11:00 am. From there the residents and staff moved to a different park where lunch was served at approximately 12:30 pm. Staff noted Resident 1 was alert and oriented, she/he ate well and had an unknown intake of fluids. The group arrived back at the facility at approximately 4:20 pm. Soon after arrival the resident was noted to be asleep, staff tried to wake her/him up and get the resident off the bus, but they were unable to wake the resident up. Wet towels were applied to the resident's head, armpits and legs. .Staff were still unable to arouse resident . Paramedics at the facility to transport a different resident were called over to assist Resident 1. In addition to being unresponsive the resident was found to have severe burns on the lower extremities. The resident was transported to the hospital where she/he was admitted to the ICU (Intensive Care Unit). The weather was very hot that day, the air conditioning on the vehicle did not work properly and there was a heater under the seat in front of Resident 1 that blew hot air towards the resident. Reports from other people on the bus indicate that it was uncomfortably warm. The local EMS (Emergency Medical Services) 8/26/16 Emergency Medical Services Patient Care Report and Supplemental Event Report noted on 8/26/16 EMS personnel were at the facility for another call. EMS personnel documented responding to an incident related to Resident 1 at 5:01 pm (approximately 40 minutes after the residents returned to the facility). When EMS personnel walked past the facility's receptionist desk, a staff member asked if they had an extra stretcher. Facility staff reported there was a resident at the back of the vehicle they could not wake up, which they attempted for a while with no success. .The staff and shuttle driver (Staff 2) did not appear to be concerned that patient had been asleep for possibly sometime or that there was an issue . Staff 2 reported Resident 1 was conscious and ambulatory while on an outing. Per EMS documentation, the outside air temperature was .currently approx 95 degrees with National Weather Service red flag warning in effect . EMS staff obtained their medical kits and went to the vehicle to evaluate the resident. Resident 1 was in the last seat of the vehicle. .It was extremely hot in back of bus . EMS staff found the resident unresponsive and slumped in the back seat. Hot air blew directly on the resident, who wore a dress with no shoes on. The resident only responded to painful stimulus with groans and breathed with difficulty. The resident's skin was extraordinarily hot to touch and was completely dry. The temporal thermometer scan read high and the resident had huge blisters on both feet that were broken and .sloughing off like sheets of rice paper with copious secretions . The blisters .appeared to be [MEDICAL CONDITION]. The resident's oxygen level was at 84% on room air and paramedics could not obtain a pulse or blood pressure due to the resident's obesity. The resident was diagnosed with [REDACTED]. EMS staff implemented cooling measures while in route to the nearest emergency room . The 8/26/16 emergency room Report noted facility staff reported Resident 1 was in her/his usual state of health and was not ill recently. The resident was noted to be unconscious on arrival to the facility. The resident was mumbling, not opening her/his eyes or was verbal. The physical examination revealed the resident had a temperature of 106.2, blood pressure of 85/48, dry mucous membranes, was notably bradycardic (a slower than normal heartbeat), with redness to both lower extremities below the knees with multiple bullae (similar to blisters) and degloving (a pulling or tearing away) of the skin on the top of the right foot. Resident 1 .may also be septic with a component of heat exhaustion . and antibiotics were given. [DIAGNOSES REDACTED]. Per hospital records dated 9/4/16 to 9/12/16, on 9/4/16 Resident 1 was transferred to a second hospital for treatment of [REDACTED]. During the initial hospitalization the resident was treated for [REDACTED]. The resident eventually stabilized and was transferred to the second hospital for wound management. The resident was admitted to the second hospital with full [MEDICAL CONDITION] the bilateral lower extremities. The right great toe was necrotic and the second toe was partially necrotic at the tip. There was a small burn on the right groin area. .Will need surgery, would need right great toe amputation. The 9/10/16 to 9/12/16 physician progress notes [REDACTED]. The facility's correlating investigation noted training was provided to activity personnel concerning vehicle operations, including console knobs controlling air conditioning and heat at the time of the inspection on 8/25/16. There were two vehicles used for transporting residents to the park outing on 8/26/16. 12 residents including Resident 1 were transported in the vehicle obtained through the shared vehicle program. Two staff members (Staff 2 (Activities Director) and Staff 3 (Activities Assistant)) were also in the vehicle, with no empty seats available. The air conditioning worked during the drive to the park. After lunch the residents left the park at approximately 3:00 pm and returned to the facility at approximately 4:20 pm. On the trip back the vehicle was hot and the air conditioning appeared to not work in the back of the vehicle. The residents complained the vehicle was too hot. Resident 1 complained hot air came out from under the seat. A box was found under the seat that blew hot air. Staff 2 attempted to turn knobs for the air conditioning, however, hot air continued to flow out of the box. Resident 1 was provided water, however, there was no additional water available for the other 11 residents in the vehicle. During the drive back to the facility the vehicle was stopped to reposition a different resident and vehicle windows were opened. The facility's investigation noted both Resident 1 was responsive upon initial return to the facility and .upon arrival to (facility), activity personnel found (Resident 1) to be semi responsive. While unloading other residents, activity personnel were concerned Resident 1 did not look good and called for assistance from a facility nurse and paramedics that happened to be at the facility for another resident. Staff 4 (LPN) unaware of the emergency situation on the bus . sent a CNA to assist the activity staff. Staff 4 was assisting a different resident in the building for transport to the hospital. Upon hearing a second call for assistance for Resident 1, Staff 4 went to the vehicle to assist with an evaluation of the resident. Staff were using cool cloths in an attempt to assist the resident. Staff 4 asked Staff 5 (RN) to assist as paramedics had arrived for the resident in the building. The EMTs (emergency responders) who arrived were consulted and Resident 1 was sent to the hospital [MEDICAL CONDITION] possible heat stroke. The facility's conclusion noted We are unclear if the air conditioning was faulty . and activity staff thought it was better to return the residents to the facility. Per documentation provided by Staff 1 (Administrator) on 9/15/16 at 1:27 pm, six additional LNs worked the evening shift when the residents returned to the facility on [DATE] at approximately 4:20 pm. There was no documentation those LNs were informed of the situation or if they were requested to assist. The 8/31/16 automotive repair invoice noted the vehicle service provider requested the rear heater under a seat be checked for anything that was missing, faulty or out of place as a passenger burned their leg. The rear heater was inspected and all areas worked as designed. No problems were found. In interview on 9/13/16 at 11:31 am Resident 2 stated on the 8/26/16 return trip to the facility, about a mile down the road from the park Staff 2 (Activities Director) knew the air conditioning did not work and a box on the floor put heat out directly onto Resident 1's legs. Everyone complained of being hot and then about half way home everyone got quiet and Resident 1 looked bad. The other vehicle used for the trip had the leftover fluids from the picnic but there was no water available on her/his vehicle. When they stopped to help a different resident staff were able to open the windows half way. I was cooking, I know what heat stroke feels like and wanted to pour water on the others to cool them off. A couple of miles before returning to the facility, Resident 1 was slumped over. In interview on 9/13/16 at 12:10 pm Resident 11 stated on the 8/26/16 return trip to the facility, she/he sat by Resident 1. Just prior to returning to the facility, Resident 1 started shaking and her/his head kept going forward and bumping on the seat back in front of her/him. In interview on 9/13/16 at 4:08 pm Resident 8 stated during the 8/26/16 return trip back to the facility, the air conditioning did not work at all. Staff on the vehicle informed Staff 2 there was a resident who reported her/his legs were burning. Everyone complained about it being hot, It was a nightmare. In interviews on 9/9/16 at 12:29 pm and 2:22 pm, 9/13/16 at 4:57 pm, and 9/14/16 at 1:28 pm Staff 1 (Administrator) stated Staff 2 (Activities Director) reported to Staff 1 she did not check the heater operations during the pre-trip inspection due to it being summer and did not realize the box in front of Resident 1 was a floor heater. Staff 2 drove the vehicle from the shared vehicle program and Staff 3 (Activities Assistant) rode in the back of the vehicle. Staff 1 stated Staff 2 and Staff 3 had no documented first aide training. CNA staff drove in a second vehicle for the outing. Regarding the return trip to the facility, Staff 2 believed Resident 1 was capable of making it back to the facility. Staff 1 stated when Staff 4 (LPN) visualized the resident, tapping on her/him, it was a form of assessing the resident. Staff 1 stated the 8/26/16 incident was an accident and not foreseeable and things would be done differently in the future. In interviews on 9/9/16 at 12:41 pm and 1:57 pm and 9/14/16 at 8:26 am Staff 2 (Activities Director) stated on 8/25/16 she reviewed the vehicle operations with two of the transportation service provider staff. One of their staff pointed to a dial with a snowflake on it and said it was for the air conditioning. The other staff member told Staff 2 that control was for the heater, however, Staff 2 was not sure where that staff member was pointing at. Staff 2 stated it was not explained to her there were two air conditioning/heating systems in the front and back of the vehicle, but assumed there were two systems because the vehicle was similar to one previously used by the facility. After the incident Staff 2 learned the dial with a snowflake was for the back air conditioning system. On 8/26/16 there were no concerns on the drive to the park. They left the park to return to the facility at approximately 3:00 pm. Around 10 - 20 minutes into the return drive, Staff 3 (Activities Assistant) reported there was no air conditioning in the back of the vehicle. Staff 2 stated she adjusted the dials, however, Staff 3 kept saying it was so hot in here. Resident 1 reported her/his feet were hot. Staff 3 got on her knees and reported there was a box with hot air coming out of it underneath the seat in front of Resident 1. During the drive they stopped to help adjust another resident's positioning. At that time Resident 1 was alert and talking. All I kept thinking was I want to get my people home. If the resident had said something or screamed, she would have called 911. When asked if she contacted the service provider or the facility regarding the problems with the heat in the vehicle and Resident 1's legs, Staff 2 stated she did not. There were fluids available in the second vehicle used for the trip, however, Staff 2 did not contact staff in the second vehicle to request fluids for the residents. Upon return to the facility and after a few residents were transferred off the vehicle, Resident 1 did not look good. Staff 2 tapped Resident 1's leg and asked the resident to wake up. The resident did not respond, her/his eyes were fluttering and Staff 2 had a CNA get the nurse. A CNA came to assist instead and staff placed cool towels on the resident because of her/his complaints of being hot on the way home. The resident still did not respond. Staff 2 told staff she wanted the nurse and Staff 4 (LPN) came out, kneeled on the seat in front of the resident, saw there were towels on the resident and said he had to go deal with a different resident related to paramedics that were onsite. Staff 2 stated she asked paramedic staff for help due to the resident not responding. In interviews on 9/9/16 at 1:10 pm and 9/13/16 at 2:19 pm Staff 3 (Activities Assistant) stated on 8/26/16 there were no concerns on the drive to the park. Resident 1 sat in the last seat of the vehicle. When driving in the park's parking lot for the return trip to the facility Resident 1 reached down in front of herself/himself and said hot. Staff 3 put her hand down in front of Resident 1 and felt blowing heat. Staff 3 discovered there was a black box under the seat in front of Resident 1 and told Staff 2 (Activities Director) it was hot in the vehicle and there was blowing hot air. Staff 2 pushed different buttons, however, Staff 3 could still feel blowing heat by Resident 1's knees. Staff 2 directed her to place a blanket over the box, however, she placed it on the resident's legs as she felt it was too hot to place a blanket on the box itself. Staff 3 stated she did not think there was room for Resident 1 to move her/his legs due to the resident's physical size. Staff 3 periodically turned around and checked on Resident 1, who responded with shaking her/his head and sighing. There were fluids available in the second vehicle, however, she did not contact staff in the second vehicle to obtain those fluids for the residents. Upon return to the facility, emergency staff were at the facility for another resident. When paramedics were asked for assistance, they requested the air in the vehicle be turned off due to the blowing hot air. In interview on 9/9/16 at 2:43 pm Staff 4 (LPN) stated on 8/26/16 there was a resident in the facility that was a new admission with a change in condition and was being sent back to the hospital. When Resident 1 returned to the facility, a CNA said they needed help with Resident 1. Staff 4 sent another CNA to help with transfers and he returned to the newly admitted resident to complete paperwork for paramedics. When he heard Resident 1 was not waking up, he rushed to see what was happening. As he arrived staff were trying to wake the resident up. He went to Resident 1, tapped her/his sternum, the resident made a moaning sound, opened her/his eyes and took a little sip of fluids. Staff 4 reported to staff he could not stay with Resident 1 because of the need to finish up the other resident's paperwork. He returned to the building and told Staff 5 (RN) Resident 1 was unconscious. When asked how the resident appeared at the time and if he assessed Resident 1, Staff 4 stated the resident looked like she/he was asleep and there was hot air coming from underneath the resident. He asked staff about the hot air and was told the air conditioning broke. Staff 4 stated he did not have time to assess Resident 1, only saw her/his face, the resident was waking up when tapped on the sternum and staff brought cold washcloths. In interview on 9/9/16 at 2:37 pm Staff 5 (RN) stated as she was getting ready to go home for the day when Staff 4 (LPN) told her Resident 1 was not waking up. She went out to check on the resident, however, by the time she got there paramedics were already with the resident. Staff 5 stated she did not assess Resident 1 due to the paramedics already working with the resident and left to get the resident's paperwork for transport. Witness 3 (Lt. Paramedic), Witness 4 (Fire Department Engineer) and Witness 5 (Fire Department Chief) were interviewed on 9/13/16 at 1:51 pm. Witness 3 stated on 8/26/16 they were on another call at the facility. When they were cleared from that call facility staff asked them to help move a resident from the vehicle to her/his bed as staff stated they could not wake the resident up for a while, but there was no sense of urgency. Realizing it was more of a medical call the crew grabbed their kits and got on the vehicle. Resident 1 was not conscious, kind of opened her/his eyes, groaned and vomited. The resident was hot to the touch and the thermometer read high. Per the thermometer's manual, body temperatures above 107.6 read as high. The resident never verbally responded other than groaning. The resident's lower legs looked [MEDICAL CONDITION], had blisters on her/his ankles and the skin degloved. It was 95 degrees outside at the time. The front of the vehicle had air conditioning, however the back of the vehicle was roasting hot .felt like you were in an oven. There was hot air coming from under and above the resident's seat. The resident had heat stroke and was transported to the emergency room . Witness 6 (Executive Director), Witness 7 (Asset and Contract Director) and Witness 8 (Mobility Director) for the transportation service provider were interviewed on 9/13/16 at 3:02 pm. They stated there were no issues with the vehicle in the two weeks prior to the facility using the vehicle and none since. The service provider's Transportation Coordinator gave instruction on how to use the vehicle and facility staff signed off on the pre-trip form. The vehicle had two air conditioning/heating systems, one in the front of the vehicle that operated the driver's area and the first three rows of the vehicle and one in the back for the rear of the vehicle. There was a switch to activate the rear heater which had a light that illuminated when it was on and the rear air conditioning was activated with a dial with a snowflake on it. The black box under the seat was a heater. The windows only opened at the very top of the window. Witness 6 stated it was in the shared vehicle agreement to report serious incidents immediately, however, the facility did not report the incident for over 24 hours. The vehicle was sent in for inspection, with no concerns identified related to the HVAC system. In interview on 9/13/16 at 3:29 pm Staff 11 (RNCM for Resident 1) stated on 8/26/16 there was a breakdown in communication and staff did not recognize the urgency of the situation. Regarding the lack of assessment, Staff 11 stated perhaps it was better if Staff 4 (LPN) stayed with Resident 1 and completed an assessment and sent someone to communicate with nurses in the facility. In interview on 9/13/16 at 3:43 pm Staff 8 (CNA) stated on 8/26/16 a CNA asked Staff 4 (LPN) for assistance checking on Resident 1 and for help getting the resident off the vehicle. Staff 4 stated he was busy and sent Staff 8 to assist with the resident. Staff 8 stated Resident 1 was in the back of the vehicle, who went between being conscious and unconscious and he had to shake the resident to wake her/him up. The resident only opened her/his eyes a little and drank two or three sips of water. It was hot outside, the inside of the vehicle was hotter and Staff 8 realized hot air blew on the resident from underneath. The resident's skin was hot, she/he was not sweating and he told someone to get more wet towels for the resident. Fire department personnel arrived and he left when he saw the resident getting help from them. In interview on 9/14/16 at 8:39 am Staff 12 (CNA) stated on 8/26/16 she was not in the vehicle with Resident 1. When asked why both CNAs on the trip were in a separate vehicle, Staff 12 stated Staff 2 (Activities Director) decided which staff rode in each vehicle. While at the park the resident was alert, talking and at her/his baseline. Upon return to the facility, she assisted with transferring residents off Resident 1's vehicle. It was very hot in the vehicle, everyone's faces were red and it was reported the air conditioning went out. Staff 12 was told by Staff 3 (Activities Assistant) there was a black box under the seat in front of Resident 1 that blew hot air on the resident's legs. Resident 1 was sitting in the back of the vehicle and staff unloaded the other residents first. When Staff 12 attempted to wake up Resident 1 there was very hot air blowing directly onto the resident's legs. Staff 12 informed Staff 2 (Activities Director) she could not wake the resident up and they needed a nurse. Staff 12 asked another staff member to get cold towels for the resident, Staff 2 sat with the resident and Staff 12 went into the building and told Staff 4 (LPN) she could not wake the resident up and she needed him to come out to the vehicle. Staff 4 initially sent Staff 8 (CNA) out, then followed a few minutes later. Staff 4 looked at the resident, the fire department arrived at the facility and Staff 4 went back into the building. Staff 12 asked Staff 2 if they could have the fire department help transfer the resident as they could not do it. Fire department personnel took the resident's temperature and found it was off the scale and thought the resident had a heat stroke. In interview on 9/14/16 at 8:55 am Staff 6 (CNA) stated on 8/26/16 she helped transfer residents off of Resident 1's vehicle. The vehicle felt very hot and when they first started unloading residents, she thought Resident 1 was sleeping. Resident 1 was the last person assisted out of the vehicle and she worked with Staff 12 (CNA) to help wake the resident up. The resident did not respond. Someone obtained cold towels to see if the resident would wake up, however, that was unsuccessful. 2. There was no documented evidence Resident #s 2, 3, 4, 5, 6, 7, 9, 10, 11 and 12 were assessed timely for possible complications related to extreme heat exposure. Resident 7 was not assessed until 9/1/16 (six days after the 8/26/16 facility outing) and Resident #s 2, 3, 4, 5, 6, 9, 10, 11 and 12 were not assessed until 9/2/16 (seven days after the 8/26/16 facility outing). For example: a. Resident 2 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The 9/2/16 at 12:09 pm Progress Note indicated the resident went on the 8/26/16 facility outing and reported not feeling well and was hot. The note documented on 8/31/16 the resident reported upon return from the outing she/he ran cold water over her/his head and did not feel well all weekend. In interview on 9/13/16 at 11:31 am Resident 2 stated on 8/26/16 the air conditioner in the vehicle did not work right and a box on the floor put out heat. I was cooking, I know what heat stroke feels like. Upon return to the facility, the resident's face and chest were red, staff did not check on her/him and she/he poured water on her/his head to cool off. b. Resident 3 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. The 9/2/16 at 12:00 pm Progress Note disclosed Resident 3 was on the 8/26/16 facility outing. The resident was noted with no signs or symptoms of dehydration at that time. In interview on 9/14/16 at 9:20 am Resident 3 stated on the 8/26/16 return trip, it was a hot day and there was a heater underneath her/his seat in the vehicle. The heater started acting up directly after they left the park for the drive home. Resident 3 was hot, including her/his face and legs. Per Resident 3 the compression stockings on her/his legs protected the legs. c. Resident 4 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The 9/2/16 at 6:36 pm Progress Note disclosed Resident 4 was alert and oriented to her/his baseline. The resident's skin turgor was consistent with normal aging and her/his mucous membranes were moist. In interview on 9/13/16 at 11:57 am Resident 4 stated on the 8/26/16 return trip to the facility, the air conditioning in the vehicle did not work. Generally during outings there was singing and talking in the vehicle but most residents were quiet because it was so hot in the vehicle, they were trying to keep it all together. At one point staff opened the little windows, which helped some but not much. In interview on 9/13/16 at 4:57 pm Staff 1 (Administrator) stated when they learned Resident 1 suffered a heat stroke on the Monday (8/29/16) after the 8/26/16 outing, they assessed all the residents involved in the outing. Staff 1 stated Resident 2 was able to accurately report times when not feeling well. In interview on 9/16/16 at 11:55 am Staff 7 (RN) stated on 8/26/16 no staff reported concerns regarding the 8/26/16 outing. Resident 2 reported it was too hot but assumed the resident was talking about the weather. Staff 7 stated she did not assess residents in her unit (Residents 2, 3, 5, 6 and 7) for exposure to extreme heat when they returned to the facility. In interview on 9/16/16 at 2:49 pm Staff 10 (LPN) stated on 8/26/16 no staff reported concerns regarding the 8/26/16 outing. Another resident reported the vehicle temperature was uncomfortable. When asked if he assessed Resident 9, Staff 10 stated the resident reported no complaints and she/he was okay. Resident #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12 were neglected when the facility did not intervene timely when there were known issues with extreme heat in the vehicle, including hot air blowing directing on Resident 1's legs, did not ensure first aide trained staff were available during extended transportation, did not ensure fluids were available for all residents for an extended drive in extreme heat, did not thoroughly assess Resident 1 during a medical crisis and did not assess residents timely after extreme heat exposure. Refer to F225, F309, F323

Based on interview and record review it was determined the facility failed to ensure safe transportation for 12 of 12 sampled residents (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 & 12) in a vehicle, without a working cooling system and during a period of extreme heat. Resident 1 sustained a heat stroke and burns to the lower extremities. Other residents were at risk of complications from exposure to extreme heat. This failure resulted in an immediate jeopardy and was determined to be substandard quality of care. Findings include: On 8/25/16 the facility obtained a shared vehicle from a transportation service provider. Staff 2 (Driver, Activities Director) was instructed on how to operate the vehicle, including the cooling system. On 8/26/16, Resident #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 & 12 participated in an outing to a park, approximately 27 miles away from the facility. Two vehicles were used for transporting residents. Resident 1, along with 11 other residents and two staff (Staff 2, Activities Director and Staff 3, Activities Assistant) were in the shared vehicle. Staff 6 (CNA) and Staff 12 (CNA) were in a second vehicle. Prior to the 8/26/16 outing, Resident 1's skin assessments revealed no skin issues other than a rash to the abdominal folds. The documented outdoor temperature on 8/26/16 at 3:31 pm was 97 degrees. There were no concerns regarding the operation of the vehicle's cooling system during the trip to the park. While at the park no concerns were identified and Resident 1 was at baseline. At approximately 3:00 pm the residents and staff left the park to return to the facility. While the vehicle was still in the parking lot at the park, Resident 1 reached down in front of herself/himself and said hot. Staff confirmed there was a floor heater under the seat in front of Resident 1 that blew hot air directly onto Resident 1's legs. Additionally, the air conditioning did not operate in the back of the vehicle. Other residents complained of extreme heat in the vehicle. Staff 2 (Activities Director) attempted to push different buttons, however, it did not resolve the situation. Staff 2 did not attempt to contact the facility, the transportation service provider, nor the CNA staff in the second vehicle to obtain assistance. Resident 1 was given fluids, however, there was none available for the other residents in the vehicle. There were leftover fluids from the outing in the second vehicle, however, there was no attempt to contact staff in that vehicle to request those fluids for the residents. Resident 1's vehicle returned to the facility at approximately 4:20 pm. Per staff interview the resident appeared to be asleep upon return and due to her/his placement in the vehicle the other residents were assisted off the vehicle first. When staff attempted to transfer Resident 1, CNA staff could not wake the resident up, they obtained cool cloths for the resident and requested assistance from Staff 4 (LPN). Staff 4 documented upon return from the outing staff reported Resident 1 was unresponsive. After the residents and staff returned to the facility, Local EMS (Emergency Medical Services) personnel were at the facility for a different resident. Per EMS documentation and interview, facility staff asked for assistance with transferring Resident 1 from the vehicle to her/his room. Staff reported they could not wake Resident 1 up for a while. EMS staff documented initiating a response for Resident 1 at 5:01 pm (approximately 40 minutes after the residents returned to the facility). The outside air temperature was 95 degrees with National Weather Service red flag warning in effect. When EMS staff assessed Resident 1 they noted it was extremely hot in the back of the vehicle and Resident 1 was slumped over and unresponsive. The resident only responded to painful stimulus, breathed with difficulty, had an oxygen saturation of 84% on room air, her/his skin was extraordinarily hot to touch and was completely dry and the resident had a body temperature exceeding 107.6 degrees. There were huge blisters on both feet that appeared to be from burns, with skin sloughing off. EMS staff rapidly transported Resident 1 to the hospital. The resident was diagnosed with [REDACTED]. Once medically stable, the burns would require surgical intervention, including the amputation of the right great toe due to necrosis. Residents who rode in the shared vehicle stated Staff 2 was aware the air conditioning did not work in the vehicle and the floor heater put heat directly on Resident 1's legs. Residents complained of extreme heat in the vehicle and everyone was quiet, which was not the norm for outings. Fluids were not available and Resident 1 exhibited signs and symptoms of changes prior to arriving at the facility. Staff and residents reported residents in the shared vehicle had red faces and chests and one resident reported feeling ill after the outing. The facility's correlating investigation noted both Resident 1 was responsive upon initial return to the facility and .upon arrival to (facility), activity personnel found (Resident 1) to be semi responsive. While unloading other residents, activity personnel were concerned Resident 1 did not look good. The facility's conclusion noted We are unclear if the air conditioning was faulty . and activity staff thought it was better to return the residents to the facility. In interview Staff 1 (Administrator) stated the 8/26/16 incident was an accident and not foreseeable and things would be done differently in the future. Resident 1 suffered a heat stroke and severe burns while being transported during a facility outdoor outing and Residents 2 through 12 were at risk for significant injury when the facility did not intervene timely when there were known issues with extreme heat in the vehicle, including hot air blowing directing on Resident 1's legs, did not ensure first aide trained staff were available during extended transportation and did not ensure fluids were available for all residents for an extended drive in extreme heat. Refer to F224, F225, F309

Based on interview and record review it was determined the facility failed to evaluate each resident for possible complications from heat exposure for 11 of 12 sampled residents (#s 1, 2, 3, 4, 5, 6, 7, 9, 10, 11 & 12) after being transported in a vehicle, without a working cooling system and during a period of extreme heat. Resident 1 sustained a heat stroke [MEDICAL CONDITION] the lower extremities. Other residents were at risk of complications from exposure to extreme heat. This failure resulted in an immediate jeopardy and was determined to be substandard quality of care. Findings include: On 8/25/16 the facility obtained a shared vehicle from a transportation service provider. On 8/26/16, Resident #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 & 12 participated in an outing to a park, approximately 27 miles away from the facility. Two vehicles were used for transporting residents. Resident 1, along with 11 other residents and two staff (Staff 2, Activities Director and Staff 3, Activities Assistant) were in the shared vehicle. Staff 6 (CNA) and Staff 12 (CNA) were in the second vehicle. Prior to the 8/26/16 outing, Resident 1's skin assessments revealed no skin issues other than a rash to the abdominal folds. The documented outdoor temperature on 8/26/16 at 3:31 pm was 97 degrees. There were no concerns regarding the operation of the vehicle's cooling system during the trip to the park. While at the park no concerns were identified and Resident 1 was at baseline. At approximately 3:00 pm the residents and staff left the park to return to the facility. While the vehicle was still in the parking lot at the park, Resident 1 reached down in front of herself/himself and said hot. Staff confirmed there was a floor heater under the seat in front of Resident 1 that blew hot air directly onto Resident 1's legs. Additionally, the air conditioning did not operate in the back of the vehicle. Other residents complained of extreme heat in the vehicle. Staff 2 (Activities Director) attempted to push different buttons, however, it did not resolve the situation. Resident 1 was given fluids, however, there was none available for the other residents in the vehicle. Resident 1's vehicle returned to the facility at approximately 4:20 pm. Per staff interview the resident appeared to be asleep upon return and due to her/his placement in the vehicle the other residents were assisted off the vehicle first. When staff attempted to transfer Resident 1, CNA staff could not wake the resident up, they obtained cool cloths for the resident and requested assistance from Staff 4 (LPN). Staff 4 documented upon return from the outing staff reported the resident was unresponsive. In interview Staff 4 stated Resident 1 looked like she/he was asleep and there was hot air coming from underneath the resident. Staff 4 stated he did not have the time to assess Resident 1 and went back inside the facility and reported the resident was unconscious to Staff 5 (RN). There was no documented nursing assessment of the resident at the time of her/his return to the facility from the outing. At the time the residents returned to the facility there were six additional LNs working the evening shift. There was no documentation those LNs were informed of the situation or if they were requested to assist. After the residents and staff returned to the facility, Local EMS (Emergency Medical Services) personnel were at the facility for a different resident. Per EMS documentation and interview, facility staff asked for assistance with transferring Resident 1 from the vehicle to her/his room. Staff reported they could not wake Resident 1 up for a while. EMS staff documented initiating a response for Resident 1 at 5:01 pm (approximately 40 minutes after the residents returned to the facility). The outside air temperature was 95 degrees with National Weather Service red flag warning in effect. When EMS staff assessed Resident 1 they noted it was extremely hot in the back of the vehicle and Resident 1 was slumped over and unresponsive. The resident only responded to painful stimulus, breathed with difficulty, had an oxygen saturation of 84% on room air, her/his skin was extraordinarily hot to touch and was completely dry and the resident had a body temperature exceeding 107.6 degrees. There were huge blisters on both feet that appeared to be from burns, with skin sloughing off. EMS staff rapidly transported Resident 1 to the hospital. The resident was diagnosed with [REDACTED]. Once medically stable, [MEDICAL CONDITION] require surgical intervention, including the amputation of the right great toe due to necrosis. Residents who rode in the shared vehicle stated Staff 2 was aware the air conditioning did not work in the vehicle and the floor heater put heat directly on Resident 1's legs. Residents complained of extreme heat in the vehicle and everyone was quiet, which was not the norm for outings. Fluids were not available and Resident 1 exhibited signs and symptoms of changes prior to arriving at the facility. There was no documented evidence Residents 2, 3, 4, 5, 6, 7, 9, 10, 11 and 12 were assessed timely for possible complications related to extreme heat exposure. Resident 7 was not assessed until 9/1/16 (six days after the 8/26/16 facility outing) and Residents 2, 3, 4, 5, 6, 9, 10, 11 and 12 were not assessed until 9/2/16 (seven days after the 8/26/16 facility outing). Staff and residents reported residents in the shared vehicle had red faces and chests and one resident reported feeling ill after the outing. LNs who had residents that were transported in the extreme heat stated the concern was not reported to them, nor did they assess their residents upon return from the outing. The facility's correlating investigation noted both Resident 1 was responsive upon initial return to the facility and .upon arrival to (facility), activity personnel found (Resident 1) to be semi responsive. While unloading other residents, activity personnel were concerned Resident 1 did not look good. In interview Staff 1 (Administrator) stated when they learned Resident 1 suffered a heat stroke on the Monday after the 8/26/16 outing (8/29/16), they assessed all the residents involved in the outing. In interview on 9/13/16 at 3:29 pm Staff 11 (RNCM for Resident 1) stated on 8/26/16 there was a breakdown in communication and they did not recognize the urgency of the situation. Regarding the lack of assessment, Staff 11 stated perhaps it was better if Staff 4 (LPN) stayed with Resident 1 and completed an assessment and sent someone to communicate with nurses in the facility. Refer to F224, F225, F323

Based on interview and record review it was determined the facility failed to provide care and adequate supervision to ensure resident safety for 1 of 3 sampled residents (#1) reviewed for accidents. The failure to provide adequate supervision resulted in Resident 1 falling and sustaining a fracture. Findings include: Resident 1 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The ADL Care Plan dated 5/17/13 indicated Resident 1 was a two person assist with repositioning and turning in bed. The 10/14/15 quarterly MDS indicated Resident 1 needed extensive two person physical assist with her/his bed mobility. A 10/9/15 Incident Note revealed Staff 5 (LPN) entered Resident 1's room at 9:15 pm and found Resident 1 lying face down on the floor with a 5 cm chin laceration, limited hand grip and movement due to generalized weakness and had complaints of forehead and left knee pain. Resident 1's scheduled oxycodone (narcotic pain medication) was administered previously at 9:00 pm. Resident 1 was sent to the emergency room (ER) for evaluation at 10:15 pm. A 10/9/15 Incident Note revealed Resident 1 returned from the ER the following day around 7:25 am with a left elbow fracture and sutures noted under the chin. A skin assessment was completed and found bruising to the chest, left elbow and both knees. Resident 1 stated she/he had knee pain at a 8/10 pain level. The 10/9/15 hospital notes revealed a chin laceration, soft tissue swelling over the right knee and soft tissue swelling to left elbow with nondisplaced radial head fracture. The 10/27/15 Incident Report for the 10/9/15 fall revealed the following information: * Resident 1 had a fall from her/his bed which resulted in a 9 cm x 7 cm left knee bruise, a 7 cm x 8 cm right knee bruise, a facial (chin) laceration and a left elbow fracture. * Predisposing factors: The firmness of the air mattress was not increased to full prior to staff providing care. * Staff 3 (CNA) and Staff 4 (CNA) did not slide Resident 1 to the left so she/he was not centered in the mattress when rolled to her/his right side. * Staff 3 removed her hands off of Resident 1 who had significant lack of muscle tone and control which resulted in removal of support and stability and enabled Resident 1 to roll off of the bed. * A 10/9/15 written statement by Staff 3 indicated when Staff 4 left the room .I stood by the left side of the bed, tried to grab something from the floor and (the) resident fell down on the other side of the bed. * A 10/9/15 written statement by Staff 2 (RNCM) based on a phone interview with Staff 4 revealed Resident 1's air mattress firmness was not adjusted prior to giving care, the bed was raised to staff level, the resident was rolled onto her/his right side and was not shifted to the left to ensure she/he was centered in the bed. After providing care Staff 4 left the room to get Staff 5 (LPN). Staff 4 noted she heard Staff 3 call for help. Staff 4 re-entered the room and found Resident 1 on the floor. * A 10/12/15 Staff 2 written statement based on a 1:1 interview with Staff 3 revealed Staff 3 and Staff 4 went into the resident's room to provide care. Staff 3 stated they removed the pillows from around and under Resident 1, utilized a draw sheet to shift her/his hips into alignment and rolled the resident onto her/his right side. Staff 3 stated they did not adjust the firmness of the air mattress prior to giving care. Staff 3 stated Staff 4 exited the room to get Staff 5 and Resident 1 remained on her/his right side. Staff 3 stated she kept her right hand on Resident 1's hip and then packed trash into the garbage can with her left hand with her body slightly bent over. Resident 1 fell away from her right hand and fell face down onto the floor. Staff 3 called for assistance. * A 10/13/15 (summary) note revealed, After interviews and collection of data, known cause of incident (was) staff member (who) became distracted when needing to keep resident safe. Air mattress was not utilized properly via not placed to max firm (maximum firmness) when giving care. On 11/10/15 at 11:21 am Staff 2 (RNCM) verified the 10/13/15 Incident Report (summary) note was correct. Staff 2 verified Resident 1 required two person staff assistance with repositioning and turning in bed and when Resident 1 fell off the bed she/he was not centered in bed, the air mattress was not adjusted, Staff 4 had left the room and Staff 3 was pushing trash into the garbage can with one hand while the resident's weight took her/him over the side of the bed. Staff 2 stated Staff 3's hand was not supporting the resident's weight and both staff should have placed Resident 1 on her/his back prior to Staff 4 exiting the room. Staff 2 stated Staff 3 was no longer employed at the facility. On 11/10/15 at 12:35 pm Staff 1 (DNS) verified the Incident Report findings were correct and Staff 3 was no longer employed by the facility. On 11/12/15 at 10:56 am Staff 4 verified her written statement in the Incident Report was correct and she had no further information to add. Staff 3 was unavailable to be interviewed.