Every finding on record at Meadowbrook Healthcare and Rehabilitation Center

Based on observation, interview, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 1 (Resident #9) of 25 residents reviewed for EBP. Findings included: A facility policy titled, Transmission Based Precautions, revised 01/01/2025, indicated, It is our policy to take appropriate precautions to prevent transmission of infectious agents. 'Enhanced barrier precautions' (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Initiation of Enhanced Barrier Precautions: 2. An order for enhanced barrier precautions shall be obtained for residents with any of the following: i. Wounds (e.g. [exempli gratia, for example], chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO [multidrug-resistant organism]. ii. Infection or colonization with a CDC [Centers for Disease Control and Prevention]-targeted MDRO when Contact Precautions do not otherwise apply. Implementation of Enhanced Barrier Precautions: 1. Make gowns and gloves available which may include near or outside of the outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e. [id est, that is], wound irrigation, tracheostomy care). 2. PPE [personal protective equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. An admission Record revealed the facility admitted Resident #9 on 01/13/2026. According to the admission Record, the resident had a medical history that included a diagnosis of gastrostomy status. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2026, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate impairment in cognition. The MDS revealed the resident had a feeding tube and one Stage 2 pressure ulcer. Resident #9's Order Summary Report, with active orders as of 02/19/2026, revealed an order dated 02/18/2026 for EBP. The indications listed were wounds and percutaneous endoscopic gastrostomy (PEG) tube. On 02/18/2026 at 9:50 AM, two staff members were observed going into Resident #9's room. The staff were observed entering the room with clean bedding and supplies to give the resident a bed bath. During an observation on 02/18/2026 at 10:00 AM, two staff members were observed finishing up with a bed bath for Resident #9. The staff members were observed pulling the covers up over the resident and positioning the resident up in bed. One staff member was observed leaning and reaching over the resident, allowing her clothing to touch the bedding. The staff member placed a pillow under the resident's head. The two staff members who were providing close contact care were observed wearing gloves. The two staff members did not have a gown on. There was an EBP sign in the middle of the resident's door indicating staff should wear gowns and gloves during close contact care. On 02/18/2026 at 10:01 AM, Certified Nursing Assistant (CNA) #9 stated she provided care for Resident #9 and provided the bed bath. She stated the PPE used to give Resident #9 a bath was gloves. CNA #9 observed the door and stated the resident was on EBP, and she should have worn a gown. She stated that the resident had a wound. On 02/18/2026 at 10:31 AM, CNA #10 stated she provided the bed bath for Resident #9. She stated she was wearing gloves to provide the bed bath. She stated she should have also been wearing a gown. She stated the resident was on EBP, and the directions were on the door. She stated that if she had close contact with the resident, a gown and gloves should have been worn. She stated she just realized she had not worn the proper PPE. She stated she should have been wearing a gown due to the resident being on EBP. On 02/19/2026 at 9:19 AM, the Assistant Director of Nursing (ADON), who is also the Infection Preventionist (IP), stated residents requiring EBP have signs on their door and in their room. He stated that EBP should be initiated for residents with wounds that required dressing changes and catheters. He stated he would expect staff to wear a gown and gloves when providing a bed bath to a resident with a PEG tube and a wound. On 02/19/2026 at 10:01 AM, the Director of Nursing (DON) stated that for a resident requiring EBP, staff should wear gloves and a gown with any close contact. She stated she would expect the staff to wear gloves and a gown while providing a bed bath. She stated Resident #9 required EBP, and she expected staff to wear a gown and gloves. On 02/19/2026 at 2:09 PM, the Administrator stated she expected a gown and gloves to be worn if that was what the EBP guidelines required.

Based on observation, interview, record review, and facility policy review, the facility failed to complete an assessment for self-administration of medications for 1 (Resident #38) of 5 residents reviewed for medication administration. Findings included: A facility policy titled, Self-Administration of Medication, revised 01/01/2025, indicated, If the resident indicates a desire to self-administer medication, he/she shall be assessed utilizing the Self-Administration of medication assessment found under the assessment tab in the EHR [electronic health record]. A Face Sheet revealed the facility admitted Resident #38 on 07/07/2022. According to the Face Sheet, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, urticaria (hives), dementia, and allergic rhinitis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/2025, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS revealed Resident #38 was able to make themself understood and able to understand others. Resident #38's Care Plan Report, revealed a focus area revised on 03/22/2025, that indicated the resident had the potential for impaired cognitive function or impaired thought processes related to dementia. Interventions initiated 03/22/2025 included administering medications as ordered, discussing concern about confusion and disease process with family, and giving step-by-step instructions one at a time as needed to support cognitive function. An observation on 02/17/2026 at 10:41 AM in Resident #38's room revealed a tube of Aspercreme pain relief cream, Orajel cream, Afrin nasal spray, and hydrocortisone cream on the resident's overbed table. An observation on 02/18/2026 at 9:10 AM revealed hydrocortisone cream was on Resident #38's overbed table. During a concurrent interview, Resident #38 stated that staff had put the other medications in their dresser drawer. An observation revealed the Aspercreme, Orajel cream, and Afrin nasal spray in the top drawer of the resident's dresser. Resident #38 stated that staff had told them they were not allowed to keep the medications on their overbed table and the medication needed to be kept in the dresser drawer. Resident #38 stated they took the Afrin nasal spray every night. During an interview on 02/18/2026 at 9:17 AM, Licensed Practical Nurse (LPN) #1 stated all resident medications, including over-the-counter medications, were kept on the medication cart. LPN #1 stated that to her knowledge, residents in long-term care facilities were not allowed to keep medications, including over-the-counter medications, in their rooms. When LPN #1 was shown the medications in Resident #38's room, she stated the medications should not be in the room, and she had removed the medications from Resident #38's room in the past. LPN #1 removed the medication from the room. During a concurrent interview, Resident #38 stated they did not know why they could not keep their stuff. Resident #38's Order Summary Report, with active orders as of 02/18/2026, revealed no active orders for Aspercreme, Orajel, Afrin nasal spray, or hydrocortisone cream. The Order Summary Report also revealed no active orders for the resident to self-administer medication. A review of Resident #38's EHR revealed no assessment for self-administration of medication. During an interview on 02/19/2026 at 11:45 AM, the Director of Nursing (DON) stated the facility had no residents who self-administered medications. The DON stated if a resident wanted to self-administer medications, they would complete an assessment, provide a lock box to store the medications, and get an order from the physician. The DON denied prior knowledge of Resident #38 requesting to self-administer medications, but acknowledged she was now aware that the resident had been self-administering medications. The DON stated that Resident #38 had never had an assessment to self-administer medications. During an interview on 02/19/2026 at 12:05 PM, the Administrator (ADM) stated that as far as she was aware, the facility had no residents who self-administered their medications. The ADM stated she was unaware Resident #38 requested to self-administer medications or requested to keep medications in their room. The ADM stated there should be no medications in Resident #38's room if they had not gone through the proper procedures for self-administration.

Based on facility policy, record review, and interview the facility failed to maintain a qualified Infection Preventionist with specialized training and failed to report an outbreak of COVID to the local health department during July of 2023 for 5 of 6 (Resident #1, 2, 3, 4, and 5) sampled residents, which had the potential to affect all residents in the facility. Census of 62. The finding include: Review of the facility policy titled, Infection Prevention and Control Program, with revision date 10/24/2022 revealed, .It is a policy of this facility to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .The designated Infection Preventionist (IP) serves as a consultant to our staff on infectious diseases, resident room placement, implementing of isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases .The IP serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings .The Infection Preventionist or designee shall coordinate screening procedures in case of widespread exposure of staff to any infectious disease . Review of the facility policy titled, COVID-19 Prevention, Response, and Reporting, with revision date of 5/12/2023 revealed, .Purpose: To provide guidance and prevent the spread of COVID-19 .This facility shall ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and respond promptly upon suspicion of illness associated with SARS-CoV-2 infection in efforts to identify, treat, and prevent the spread of the virus .The Infection Preventionist shall assess facility risk associated with COVID-19 through surveillance activities of emerging diseases in the community and illnesses present in the facility .Notify the state/local health department promptly about any of the following per state reportable disease list: [greater than or equal to] 1 residents or healthcare personnel (HCP) with suspected or confirmed SARS-CoV-2 infection . Review of the facility policy titled, Covid-19 Visitation Policy, with revision date of 5/12/2023 revealed, .Purpose: To provide guidance on COVID-19 visitation procedures to comply with state, federal, and local guidelines .Procedure .The Infection Preventionist shall monitor the status of the COVID-19 situation through the CDC website and local/state health department and shall keep facility leadership informed of current directives or recommendations and the need for restricting visitation if indicated . Review of the medical record revealed Resident #1 admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic Heart Failure, Type 2 Diabetes Mellitus, and Chronic Kidney Disease. Review of the Clinical Notes Report for Resident #1 revealed .7/8/2023 .Resident positive for Covid isolation precautions placed into affect . Review of the medical record revealed Resident #2 admitted to the facility on [DATE] with diagnoses which included Personal History of Traumatic Brain Injury, Essential Primary Hypertension, and Epilepsy. Review of the Clinical Notes Report for Resident #2 revealed .7/17/2023 .Resident has tested positive for Covid this shift .Covid isolation precautions in place . Review of the medical record revealed Resident #3 admitted to the facility on [DATE] with diagnoses which included Cerebral Vascular Disease, Pneumonia, and Chronic Atrial Fibrillation. Resident #3 was discharged to hospital on 7/10/2023 with an admitting diagnosis of Hypertension. Review of the Clinical Notes Report for Resident #3 revealed .7/10/2023 .Resident on isolation for recent positive Covid test .[Resident #3 was in isolation at the facility prior to being sent to the hospital] . Review of the medical record revealed Resident #4 admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy, Dementia, and Pressure Ulcer of Right Buttock. Review of the Clinical Notes Report for Resident #4 revealed .7/13/2023 .Covid isolation continues with no complications. Continues to remain asymptomatic . Review of the medical record revealed Resident #5 admitted to the facility on [DATE] with diagnoses which included Hemiplegia following Cerebral Infarct, Hypertensive Heart Disease, and Cardiomyopathy. Review of the Clinical Notes Report for Resident #5 revealed .7/10/2023 .Resident on isolation for recent positive Covid test . During an entrance conference on 7/17/2023 at 1:21 PM, the Administrator stated, We do have COVID in the facility. During an interview on 7/17/2023 at 3:00 PM, Assistant Director of Nursing (ADON) (Named Infection Control Preventionist) revealed the facility currently had 5 resident rooms under droplet precautions due to positive COVID status. On 7/17/2023, the ADON was asked to provide this surveyor her certification or specialized training for Infection Preventionist. The ADON was unable to provide her certification or specialized training for the qualification of an Infection Preventionist. During an interview on 7/18/2023 at 12:03 PM, the Administrator stated, The ADON is having trouble finding her training on infection Control. She has emailed someone to find it, but she has been unable to provide it yet. If the ADON had given me a copy, I would have placed it in her employee file. During an interview on 7/18/2023 at 1:45 PM, the ADON stated, The COVID outbreak started on 7/1/2023 when 9 residents tested positive .outbreak testing started for staff 2 times per week on Monday and Thursday .July 5th 5 more residents were positive majority was on the 100 hall with 2 residents on the 200 hall .14 cases .then 1 more case 2 days later a roommate of a positive resident .we had 22 cases .7/13/2023 1 resident positive with 2 staff testing positive .7/17/2023 no positive staff with one positive resident . During a telephone interview on 7/18/2023 at 2:27 PM, Registered Nurse Supervisor with Local Health Department confirmed the facility had not notified the local health department of the COVID outbreak. During an interview on 7/18/2023 at 2:35 PM, the Administrator was asked if the facility notified the local health department related to the recent COVID outbreak. The Administrator stated, We don't have to notify the Health Department any longer, just do the NHSN report weekly. During an interview on 7/18/2023 at 3:20 PM, the Administrator reviewed the facility COVID-19 Prevention, Response, and Reporting, policy and confirmed the policy of the facility was to notify the local Health Department during an outbreak. During an interview on 7/18/2023 at 4:00 PM, the Administrator stated, We were unable to find the Infection Preventionist certification but we have the ADON's transcript, but we were unable to find a passing score for the training. Review of the Transcript for the ADON revealed .Nursing Home Infection Preventionist Training Course .Score 62 .Completion date 5/18/2022 .Status Failed .

Based on facility policy review, medical record review, and interview, the facility failed to report a change in condition for a resident to the resident's representative for 1 of 6 (Resident #4) sampled residents. The findings include: Review of the facility policy titled, Infection Prevention and Control Program, with revision date 10/24/2022 revealed, .A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents .visitors .The RNs [Registered Nurse] and LPNs [Licensed Practical Nurse] participate in surveillance through assessment of residents and reporting changes in condition .Residents, family members, and visitors are provided information relative to the rationale for the isolation, behaviors required of them in observing these precautions . Review of the facility policy titled, Notification of Change, with revision date 3/28/2023 revealed, .The purpose of this policy is to ensure the facility promptly informs the resident, consult the resident's physician, and notifies the resident's representative .when there is a change requiring notification .Definitions .Significant alteration of treatment: Examples-A need that occurs due to an adverse consequence of the need to begin a new course of treatment, procedure or therapy .Circumstances that require a need to alter treatment . Review of the facility policy titled, Covid-19 Visitation Policy, with revision dated of 5/12/2023 revealed, .Purpose: To provide guidance on COVID-19 visitation procedures to comply with state, federal, and local guidelines .Procedure .The Infection Preventionist shall monitor the status of the COVID-19 situation through the CDC [Centers for Disease Control and Prevention] website and local/state health department and shall keep facility leadership informed of current directives or recommendations and the need for restricting visitation if indicated . Review of the medical record revealed Resident #4 admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy, Dementia, and Pressure Ulcer of Right Buttock. Review of a Significant Change in Status Minimum Data Set, dated dated dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status score of 2 which indicated severe cognitive impairment. Review of the July 2023 Physician Order Sheet revealed, .Order Isolation Precautions .order date 7/13/2023 .Continuous for Eleven Days . Review of the Clinical Notes Report for Resident #4 dated 7/13/2023 revealed .Covid isolation continues with no complications. Continues to remain asymptomatic . During an entrance conference on 7/17/2023 at 1:21 PM, the Administrator stated, We do have COVID positive residents in the facility. During a telephone interview on 7/18/2023 at 1:36 PM, Family Member #4 (Resident #4's responsible party) stated, The facility called me last week, I asked them if my sister had it and they said No. Does she have COVID? [Family Member #4 confirmed no knowledge that Resident #4 had COVID] During an interview on 7/18/2023 at 1:40 PM, the Director of Nursing reviewed Resident #4's progress notes and confirmed no documentation that Resident #4's responsible party was notified of residents positive COVID status. During an interview on 7/18/2023 at 1:55 PM, the Administrator confirmed the facility should call the family or responsible party if their resident tests positive for COVID.

Based on facility policy review, medical record review, and interview the facility failed to implement a baseline care plan for [CONDITION(S)] medications (antidepressant and antianxiety) for 1 of 19 residents (Resident #185) receiving [CONDITION(S)] drugs. The findings include: Review of the undated facility policy, Baseline Care Plan, revised 11/2020, showed .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .the baseline care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #185 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Baseline Care Plan dated 5/26/2021, showed Resident #185 was not care planned regarding the use of psychoactive medications and monitoring for behaviors and side effects. During an interview on 6/8/2021 at 3:03 PM, after reviewing Resident #185's baseline care plan, the Director of Nursing confirmed, It (the use of psychoactive medications) should have been on the baseline care plans because it's part of the admission process. I'm not seeing it. There is not a category for psychoactive med use and there should be.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe environment that provided adequate supervision to prevent elopement for 1 of 4 (Resident #2) sampled residents with wandering behaviors and assessed as an elopement risk, which resulted in Immediate Jeopardy (IJ) when Resident #2 exited the facility and was found at the hospital, 0.2 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility identified 6 cognitively impaired residents with wandering behaviors who were independently mobile via ambulation or wheelchair. The facility reported a total census of 47 residents. The Administrator and the Regional Director of Operations were notified of the Immediate Jeopardy (IJ) on 8/9/19 at 3:33 PM in the Conference Room. F-689 was cited at a scope and severity of J and is Substandard Quality of Care. A partial extended survey was conducted on 8/9/19. The IJ was effective from 7/31/19 through 8/1/19. The IJ was removed on 8/2/19 when the facility implemented a corrective action plan. Corrective actions were validated by the surveyor on 8/8/19 - 8/9/19. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction. The findings include: The facility's Elopements and Wandering Patients policy undated documented, .This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment, and had poor decision making skills. Resident #2 required cues and supervision and wandering occurred 4-6 days of the assessment period. Resident #2 had an unsteady gait, did not use assistive devices, and was able to stabilize without human assistance. The Care Plan revised 6/18/19 documented, .Assess potential physical causes for wandering (need for toilet, water, food, pain relief) .Redirect (Resident #2's name) behavior/activity when wandering is observed .Problem date 10/24/18 .Wandering Behaviors .PROBLEM Date: 7/31/19 Pt (patient) had an incident of elopement. Visitor opened door for pt (patient) to go out .Ensure the door alarms/locks are armed to reduce risk of (Resident #2's name) leaving secure area An Elopement Risk assessment dated [DATE], 11/28/18, 3/13/19, 6/18/19, and 8/1/19 documented, .cognitive impairment and/or poor decision making skills . The assessments revealed Resident #2 was at risk for elopement. The physician's orders [REDACTED].(3/29/19 start date) Wander Guard .Notes: Wander guard in place .Monitor .Notes: placement of wanderguard . Review of the (Named Hospital) history and physical dated 7/31/19 documented, .pt (patient) (Resident #2) found by hospital security walking around the woods behind the hospital (in the hospital upper parking lot), pt confused, states 'a friend dropped me off and didn't come back' pt denies complaint, follow commands .verbal response: Confused .Patient (Resident #2) is disoriented .ED (Emergency Department) Course: 20:26 (8:26 PM) Patient (Resident #2) arrived in ED .(8:50 PM) (Named Resident #2's contact person) called from contact info (information) regarding pt (Resident #2), (Resident #2's contact person) informed (this caller) that pt (Resident #2) was a resident of (Named Nursing Home) .history of Alzheimer's, [MEDICAL CONDITION], hallucinations, and possible [MEDICAL CONDITION] .CONFUSION DON'T KNOW WHERE SHE (is) .Skin: lesion(s) (none documented) . Review of the Clinical Note dated 7/31/19 at 11:55 PM documented, .pt returned via stretcher with EMS (Emergency Medical Services) .pt's demeanor is calm, cooperative, and joking/playful. Alarm for wanderguard activated as pt entered facility, reset alarm. pt continues to wear wanderguard bracelet to right ankle and is functioning properly. pt ambulating in room/hall with steady gait. when asked why she left, pt states 'I don't know what you're talking about. I went on a picnic and got 2 good looking men . Observations in the common areas of the facility on 8/6/19 at 9:45 AM, 10:40 AM, 12:10 PM and 1:26 PM, 8/7/19 at 9:36 AM, 8/8/19 at 6:58 PM and 7:53 PM, and 8/9/19 at 11:10 AM and 12:26 PM, revealed Resident #2 was ambulating in the halls with her blue bag on her arm, a wanderguard on her right ankle, and she was confused. Resident #2 walked to the front door multiple times but stopped at the front door mat and would look around. Resident #2 never touched the door or activated the alarm. Observations of the area beside the facility on 8/8/19 at 7:47 PM, revealed a slightly sloped embankment with low cut grass. There was a physician's parking lot with street lights and flood lights directed at the parking area. There was a 6 inch curb from the grassy area to the pavement. The hospital parking lot on the lower level had a 6 inch step-up to the curbs and the walkway. The upper parking lot to the hospital (where Resident #2 was located after her elopement from the facility) had a wooded area that was approximately 20 to 30 feet from where Resident #2 was located. Interview with the Administrator on 8/6/19 at 9:30 AM in the Conference Room, the Administrator was asked about Resident #2's elopement and she stated, A visitor (Visitor #1) was taking (Visitor #1's) mother out on the front porch and when another visitor and (Named Resident #2) went through the door. (Visitor #1) deactivated the alarm . Interview with the Maintenance Supervisor on 8/6/19 at 9:40 AM in the Conference Room, the Maintenance Supervisor was asked about Resident #2's elopement incident on 7/31/19. The Maintenance Supervisor stated, .I checked all the doors before and after it (elopement) happened .they were working properly .I checked her wanderguard and it was functioning properly .I checked all the residents with wanderguards and they were working properly . The Maintenance Director stated he checked the doors weekly for wanderguard activation. Interview with Certified Nursing Assistant (CNA) #1 (Resident #2's CNA on the night of the elopement, 7/31/19) on 8/8/19 at 6:59 PM in the Conference Room, CNA #1 was asked when Resident #2 was last seen on 7/31/19. CNA #1 stated, .I seen her walk down to the 200 Hall at 7:30 PM .I received a call at 8:30 PM from the hospital and went to get the charge nurse . Interview with Registered Nurse (RN) #1 (the Charge Nurse on the night of the elopement, 7/31/19) on 8/8/19 at 7:01 PM at Nurse's Station #1, RN #1 was asked when Resident #2 was last seen on 7/31/19. RN #1 stated, .(Resident #2's name) was ambulating in the hall at 7:00 PM . Interview with Visitor #1 on 8/8/19 at 7:10 PM on the Front Porch, Visitor #1 was asked when she last saw Resident #2 on 7/31/19. Visitor #1 stated, .we (Visitor #1 and her mother) were sitting on the front porch when (Resident #2) came out the door with another visitor. It set the alarm off and I went in and cut the alarm off .we sat on the porch awhile and when we started in (Resident #2) stopped and said she (Resident #2) would go this way .I didn't think anything about it because they (residents) use the other door too .I didn't know (Resident #2) didn't go in .it was about 20 till 8:00 (7:40 PM) .she went toward the other door .I hate I had cut the alarm off. I won't ever do that again . Interview with the Hospital Security Officer (that located Resident #2) on 8/8/19 at 7:55 PM outside the (Named Hospital) emergency room (ER) Waiting Room, the Security Officer was asked when he first saw Resident #2 on 7/31/19. The Security Officer stated, .I just happened to get a glimpse of her in the upper parking lot .she wasn't in the woods, she was standing in the middle of the parking lot .she was confused .first saw (Resident #2) at 8:00 (PM) . Interview with the Hospital ER Registered Nurse (RN) (the RN that notified the facility of Resident #2's elopement) on 8/8/19 at 8:04 PM in the ER, the RN was asked how long Resident #2 was in the hospital before the facility was notified. The RN stated, .About 20 minutes . The RN was asked about Resident #2's assessment in the ER. The RN stated, .she wasn't hurt .she was clean .she had a UTI (urinary tract infection) . Telephone interview with the Medical Director on 8/9/19 at 1:10 PM, the Medical Director was asked if he was involved in the Quality Assurance (QA) meeting, and he stated, Yes . The Medical Director was asked if the plan put into place after the elopement was effective, and he stated, Yes . The Medical Director was asked if the visitor had not disarmed the alarm, would Resident #2 have been able to exit the facility. The Medical Director stated, No, I do not think so . The facility failed to ensure a safe environment for Resident #2 when the staff had no knowledge of her location for approximately 1 hour. Resident #2 had been assessed and documented as cognitively impaired with a risk for elopement. Resident #2 eloped from the facility on 7/31/19 and was found approximately 1 hour later on 7/31/19 in the middle of the upper hospital parking lot. The facility's corrective action plan included the following: On 8/1/19 the facility did the following: A. Staff confirmed Resident #2's whereabouts every 15 minutes for 3 days. B. The Maintenance Supervisor checked the functionality of all 5 exit doors with a wanderguard tester, door code boxes and the alarm systems of the doors. C. The Maintenance Supervisor checked the functionality of all wanderguards. D. Signs were posted at the front and back of the front door entrance. The sign on the key pad beside the doors documented, ATTENTION VISITORS!! Please do not let residents outside without notifying the charge nurse. Our residents' safety is our priority. If you see someone outside unsupervised, please notify someone immediately. Please do not take any resident outside other than your family member without permission from the charge nurse. Thank you for helping keep (Named Nursing Home) a safe place to call home. E. The security codes to all 5 entrance/exit doors were changed by the Maintenance Director. F. The facility conducted in-service education on wandering residents, elopement, and systemic changes that were implemented to promote resident safety with 100% of the staff. Staff were required to have the in-service education prior to working their next shift. 1. If staff observed changes in a resident's behavior that included wandering and/or exit seeking behavior, the nurse completed an elopement risk assessment. After completing the risk assessment, if the resident was determined to be at risk of elopement, the resident was to be added to alert charting to be completed by nursing. 2. The CNA is to communicate to nurses any observed changes in a resident's behavior that involved wandering and/or exit seeking. 3. If any entrance/exit door alarm sounds, a staff member is to go to the door and check outside and never assume it was a visitor. 4. Never give anyone the code to the doors. G. The Elopement Prevention Tips were placed at each nurses' station. H. Letters were mailed to all families that only staff are allowed to deactivate the alarm system. All visitors are to have a visitors pass when taking a resident out of the building and return it to the charge nurse when reentering the facility. These letters were included in all new admission packets also. I. A visitor's pass was implemented that requires all visitors to obtain a pass from the charge nurse before going out of the facility with a resident and the pass is to be returned to the charge nurse upon reentering the facility. This pass contains the resident's room number and the location of the resident and the visitor. J. The Director of Nursing (DON) and designee conducted in-services with the all nursing staff on the procedure for elopement risk. If a resident is observed with elopement behaviors the following must be done: 1. Ensure safety of resident/residents 2. Complete Elopement risk assessment 3. Notify the Medical Doctor (MD) and family 4. Notify the DON and Administrator The charge nurse and unit manager will monitor the implementation of interventions, response to interventions, and document accordingly. K. The Nursing Home Administrator, DON, Assistant Director of Nursing (ADON), Director of Social Services, Maintenance Director, and Medical Director conducted a Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. The surveyor verified the facility's corrective action plan on 8/9/19 as follows: A. Review of the Quality Assurance Performance Improvement (QAPI) meeting documented the attendance at the meeting. The agenda sheets and minutes were reviewed and the QAPI team began the monthly review on 8/6/19 to ensure sustainability of the plan of correction. B. Medical record review revealed 100% of residents with wanderguards were assessed on 8/1/19 for proper functioning of their wander guards with 100% found to be functioning properly. C. Review of the Resident Monitoring System log and interview with the Maintenance Supervisor on 8/6/19 at 9:40 AM in the Front Door Area, the Maintenance Supervisor confirmed the 5 exit door alarms were checked weekly for functioning alarm sounding, and had been checked on 7/30/19, 8/1/19, and 8/6/19. Continued interview confirmed the security code was changed immediately after the elopement. D. On 8/9/19 at 2:23 PM the surveyor attempted to exit through the doorway located at the end of the 200 hall by pushing on the door which activated the alarm. The facility staff responded immediately. E. Review of the in-service records on facility policy and systemic changes and the sign in forms beginning 8/1/19 validated the attendance of all staff at the in-services conducted. Interview on 8/9/19 at 10:13 AM in the Conference Room with the DON, the DON confirmed all staff had received the education. The DON confirmed the facility will continue to do elopement risk assessments weekly times 4 weeks, monthly times 3 months and quarterly thereafter. After the assessments are completed they will be submitted to the Administrator and presented at the Quality Assurance Performance Improvement (QAPI) meetings. F. Multiple observations and interviews were conducted with residents, visitors, and employees on both shifts throughout the complaint survey conducted on 8/6/19 - 8/9/19, which confirmed full implementation of the systemic changes to provide supervision and safety for residents with elopement/wandering behaviors. G. Review of the facility's self-reported incidents to the State Agency and review of the Concern/Comment Log revealed the facility had no other incidents or allegations of neglect and/or elopement since the implementation of the corrective action plan.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by dirty floor with debris, improper food storage, opened and undated food stored in the reach in freezer, ice buildup on the chest freezer, and refrigerator temperatures were not documented daily. The facility had a census of 62 residents, with 60 of those residents receiving a tray from the kitchen. The findings include: 1. The facility's .Food Storage . policy revised 11/2017 documented, .Leftover foods are stored in appropriate container so that the interior temperature of the food chills quickly .They are covered, labeled and dated . The Dietary Services Training Manual documented, .Freezer will be clean .Floors .should be swept and mopped after each meal . Observations in the kitchen on 6/17/19 beginning at 5:37 AM, revealed a dirty kitchen floor with scattered pieces of paper lying on the floor and a metal pan in the oven with food inside. Interview with the Certified Dietary Manager (CDM) on 6/17/19 at 6:17 AM, in the Kitchen, the CDM was shown the pan in the oven and was asked what kind of food was inside. The CDM stated, .left over from lunch .beef macaroni . The CDM was asked if food should be stored in the oven. The CDM stated, Should have been thrown out . Observations in the kitchen on 6/17/19 beginning at 9:25 AM, revealed the following: a. 1 bag of carrots in the freezer opened and undated b. 1 bag of hamburger patties in the freezer opened and undated c. 2 bags of French toast in the freezer unlabeled and dated d. 1 bag of egg rolls in the freezer unlabeled and dated e. chest freezer with thick ice buildup around the sides and the bottom of the freezer Interview with the CDM on 6/17/19 at 9:27 AM, the Kitchen, the CDM was asked if there should be an open date on opened foods in the freezer. The CDM stated, Yes, ma'am . The CDM was asked should there be ice build up in the freezer. The CDM stated, No . Observations in the kitchen on 6/18/19 beginning at 11:15 AM, revealed the following: a. a small plastic lid lying on the floor b. pieces of paper scattered on the floor c. a metal lid touching the floor d. a wet oven mitt lying on the floor e. a long metal spoon lying on the floor f. a plastic scraper lying on the floor Observations in the Kitchen on 6/19/19 at 9:32 AM, revealed a metal lid touching the floor. Interview with the CDM on 6/19/19 at 9:35 AM, in the Kitchen, the CDM was asked should the metal lid be touching the floor. The CDM stated, .shouldn't be . Review of the Refrigerator Temperature Log for 100 Hall refrigerator revealed incomplete daily refrigerator temperature documentation on 23 of 31 days on the (MONTH) 2019 log, 10 of 28 days on the (MONTH) 2019 log, 11 of 31 days on the (MONTH) log, 13 of 30 days of the (MONTH) 2019 log, and 7 of 31 days of the (MONTH) 2019 log. Interview with the Director of Nursing (DON) on 6/19/19 at 11:20 AM, in the Administrator office the DON was asked how often should the refrigerator temperatures to be done. The DON stated, .night shift is supposed to do it .it didn't get documented .

Based on medical record review and interview, the facility failed to ensure psychiatric services were provided for 1 of 6 (Resident #44) sampled residents reviewed for behavioral health issues. The findings include: Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] reviewed a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognition impairment, a mood severity score of 5, no behaviors, walking did not occur, required extensive staff assistance with all activities of daily living, and received antianxiety and antidepressant medications daily for the past 7 days. The physician's PROGRESS NOTE dated 4/2/19 documented, .Patient has been depressed, sad, withdrawn .Will set up transfer to the psych (Psychiatric) due to the severity of the depression . The hospital Admission History and Physical dated 4/3/19 documented, .woman with major [MEDICAL CONDITION] and anxiety disorder who was admitted .for worsening depressive symptoms . The hospital PATIENT DISCHARGE SUMMARY REPORT dated 4/12/19 documented, .DISCHARGE INSTRUCTIONS .Discharge to SNF (Skilled Nursing Facility) .Psych and PCP (Primary Care Physician) follow up at facility . Interview with the Director of Nursing (DON) on 6/19/19 at 10:06 AM, in the Conference Room, the DON was asked if the discharge instructions to follow up with psychiatric services had been followed. The DON stated, I'll have to look into it. The facility was unable to provide documentation that psychiatric services had been provided after Resident #44 was readmitted to the facility on [DATE].

Based on medical record review, observation, and interview, the facility failed to ensure 1 of 16 (Resident #263) beds were in working order. The findings include: Medical record review revealed Resident #263 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #263's room on 6/17/19 at 8:10 AM, revealed the Speech Language Pathologist (SLP) delivered Resident #263's meal tray, and attempted to raise the head of his bed. The head of the bed would not raise. Observations on 6/17/19 at 8:29 AM, on the 100 Hall, revealed Certified Nursing Assistant (CNA) #1 stated to the Maintenance Director, Resident #263's bed won't raise or lower . Interview with the Maintenance Director on 6/18/19 at 7:53 AM, on the 200 Hall, the Maintenance Director was asked if he was aware Resident #263's bed was not working properly. The Maintenance Director stated, .It needs a new .remote. It was in (named another room number), and I took it out. They moved it right down to another room and put a resident in it . Interview with the Maintenance Director on 6/18/19 at 8:37 AM, in Resident #263's room, the Maintenance Director stated, The pins are wore out on the plug . The Maintenance Director pushed the button on the remote to raise the head of the bed, but it did not raise. The Maintenance Director was asked if he knew why the bed had not been replaced out. The Maintenance Director stated, .I can't say exactly what happened. Interview with CNA #2 on 6/18/19 at 8:41 AM, on the 100 Hall, CNA #2 was asked if Resident #263's bed was working properly. CNA #2 stated, .it wouldn't raise . CNA #2 was asked if she had reported that to anyone. CNA #2 stated, .they already knew about it.

Based on observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by 1 Dietary Aide working in the Dietary Department without a covering for his facial hair. The findings included: Observation on 9/12/17 at 7:31 AM in the Dietary Department revealed Dietary Aide #1 working at the chemical sanitation sink without a covering for his facial hair. Interview with the Registered Dietician (RD) on 9/12/17 at 7:35 AM in the Dietary Department revealed the facility expected dietary staff to cover their hair. When asked if Dietary Aide #1 should have his beard covered the RD replied yes. The RD confirmed the facility failed to maintain infection control practices in the dietary department.

Based on review of the facility's Dietary Training Manual, review of the grievance log, observation, and interview, the facility failed to ensure hot food was held at temperatures to prevent food borne illness for 5 of 5 residents eating a regular mid day meal in the dining room and 8 of 8 residents eating a pureed diet midday meal. The findings included: Review of facility, Dietary Training Manual, dated October 2014 revealed .Hot food 135 degrees Fahrenheit or above .Food will be placed on the steam table to maintain acceptable temperatures during meal service .To maintain 135 degrees throughout meal service, it is recommended that all hot food items reach the highest acceptable temperature before placing on steam table .Food temperatures will be obtained and recorded prior to meal service, and any inappropriate temperatures will be corrected to ensure proper serving temperature .Test tray monitoring will be completed .The cook will be responsible for monitoring adequate heating time .for the steam table line system so that temperatures can be maintained during the serving process . Review of the grievance log revealed a grievance dated 9/9/16 the .food is cold . and a grievance dated 4/14/17 .their food is cold when it gets to them . Observation on 9/11/17 at 11:57 AM in the dining room steam table revealed Cook #1 obtained the following temperatures: mashed potatoes 107 degrees Fahrenheit, fish 94 degrees Fahrenheit, and peas 94 degrees Fahrenheit. Continued observation revealed residents had been served food from the dining room steam table. Observation on 9/11/17 at 12:02 PM at the steam table in the Dietary Department revealed Cook #2 obtained the following temperatures: pureed fish 127 degrees Fahrenheit and pureed cabbage 108 degrees Fahrenheit. Continued observation revealed residents had been served pureed food from the Dietary Department steam table. Interview with the Dietary Supervisor and the Registered Dietician on 9/11/17 at 12:12 PM in the Dietary Department revealed the cooks were expected to check the temperatures on the steam tables. Continued interview revealed the temperatures were not obtained for food on the steam table in the dining room. Observation on 9/13/17 at 12:00 PM on the 200 hall revealed the Dietary Supervisor obtained a temperature of 123 degrees Fahrenheit for the pureed meat on the 200 hall test tray. The Dietary Supervisor confirmed the facility failed to hold food at temperatures at or above 135 degrees Fahrenheit.

Based on record review, review of nurses orientation checklist, and interview, the facility failed to provide services according to accepted standards of clinical practice for a resident whose suprapubic catheter was removed without a physician's order and failed to monitor following removal of the catheter for for 1 of 29 (Resident #89) sampled residents. The findings included: Resident #89 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/25/15 Nursing Skilled Note recorded, .S/P (suprapubic) catheter intact. The admission care plan dated 7/25/15 recorded the resident was incontinent of bladder and lacked any information about the resident's urinary catheter. The resident was admitted with a suprapubic catheter. The Admission/Re-Admission note dated 7/26/15 recorded, .Patient S/P (suprapubic) catheter intact . The admission Minimum Data Set ((MDS) dated [DATE] recorded the Brief Interview for Mental Status (BIMS) score of 3 indicating the resident was severely cognitively impairment. The MDS recorded the resident had a urinary catheter. The Nursing Skilled Note dated 7/27/15 recorded, .Foley (catheter) patent and draining yellow urine . On 7/27/15, nursing recorded the resident had a Foley catheter, (a flexible tube that is passed through the urethra in the area of the genitalia, and into the bladder). Review of the 8/2/15 1:45 PM Nursing Skilled Note recorded, Patient sent to ER (emergency room ) for evaluation and reinsertion of suprapubic catheter. review of the resident's medical record revealed [REDACTED]. There was no documentation that the resident's suprapubic catheter was removed, how the resident tolerated the procedure, or any follow-up monitoring of the resident post procedure; the suprapubic catheter had been surgically inserted and removed by facility staff. Review of LN #1's Orientation Checklist RN (Registered Nurse) /LPN (Licensed Practical Nurse) dated 3/10/14 (hire date) recorded the nurse was signed off for Physician Orders - Written, Standing Orders-Proper Use and (&) Documentation and Transcribing & Following Physician's Orders. The Orientation Checklist stated that the signature indicated that the nurse had been in-serviced, observed and participated independently in each item on the list. During interview on 8/12/15 at 3:46 PM, the Director of Nursing (DON) stated the resident was admitted on Saturday, 7/25/15. On the following Monday, 7/27/15 the DON inquired to Licensed Nurse (LN) #1 why the resident had a Foley catheter, instructed LN #1 to check orders for the catheter, and none were found for an indwelling (Foley) catheter. The DON stated at that point he/she instructed LN #1 to pull the resident's catheter, assuming it was a Foley catheter. The following Sunday, 8/2/15, it was discovered the resident had a suprapubic catheter, not a Foley catheter, and the suprapubic catheter was removed. The DON stated LN #1 worked at the facility for a year, and had completed his/her orientation check-off for physician orders and catheter care. The DON stated that LN #1 no longer worked at the facility. The DON stated there were no annual competency standards/education for the nurses. The DON stated, I never imagined any nurse pulling a suprapubic catheter without a doctor's order. The DON agreed it was outside the nurse's scope of practice to remove the catheter. During interview on 8/12/15 at 4:40 PM, the Staff Educator stated he/she did not have the Educator position when LN #1 was hired, but the signed off Orientation Checklist meant LN #1 was inserviced, observed or participated in the listed items. The Educator stated there were no annual competency standards at the facility. On 8/13/15 at 2:48 P.M., the Educator stated he/she re-educated all the Licensed Nurses in the facility after the incident with the catheter, but admitted 5 Licensed Nurses still had not received the education. The facility failed to train all of the nurses. The facility lacked requested policies including 1) following physician orders, 2) removal of catheters, 3) removal of suprapubic catheters, and 4) nurse competency. The facility failed to provide care according to professional standards for this dependent resident.

Based on record review, observation and staff interview, the facility failed to promptly assess wounds for 2 of 29 (Residents #53 and #56) sampled residents. The findings included: 1. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with a Reference date (ARD) date of 5/19/15 recorded the resident's Brief Interview for Mental Status (BIMS), score of 12 which indicated intact cognition. The resident required extensive assistance by two (2) staff members for transferring, dressing, toileting, incontinent care, bed mobility, bathing and supervision by one (1) staff member for eating. The resident was coded as not having any pressure ulcers. The Care Area Assessment (CAA) dated 5/12/15 recorded the resident had risk factors of activities of daily living (ADL) function, visual function, falls, nutritional status, psychosocial well being, [MEDICAL CONDITION] use, cognitive loss and urinary incontinence. The resident was identified at risk for pressure ulcers. Review of the weekly pressure ulcer report revealed the following documentation of the resident's pressure ulcer on the coccyx: a. 6/19/15 - 4.50 centimeters (cm) by (x) 0.75 cm. b. 6/24/15 - 4.50 cm x 0.75 cm. c. 7/1/15 - 4.0 cm x 2.0 cm. d. 7/9/15 - 2.0 cm x 1.0 cm. e. 7/15/15 - 1.75 cm x 1.0 cm. f. 7/22/15 - 1.75 cm x 0.75 cm. g. 7/30/15 - 1.75 cm x 0.75 cm. A review of the care plan dated 6/19/15 revealed the resident had an unstageable wound to the coccyx and the interventions included the following: a. Assist with turning and repositioning every two (2) hours and as needed. b. Offer toileting and provide incontinence care every two (2) hours and as needed. c. Resolution of coccyx within ninety (90) days. d. Refer to medical doctor (MD) for current orders. e. Weekly wound progress notes for current interventions. Observation of Resident #53's wound care on 8/12/15 at 10:40 AM, revealed a new red area to the resident's sacrum measuring 2.0 cm x 1.5 cm. Interview with the Wound Care Nurse (WCN) on 8/12/15 at 10:40 AM, the WCN confirmed Resident #53 had a new wound on her sacrum. The WCN revealed the resident's wound was a stage one and that she/he failed to document the resident's new wound prior to wound care on 8/12/15 at 10:40 AM. Interview with the Director of Nursing (DON), on 8/12/15 at 9:10 AM, the DON revealed the skin audits (assessments) are expected to be held weekly by the night shift staff nurses. The DON revealed that it is an expectation for the staff to assess the residents' skin weekly and during daily care. The DON revealed staff are expected to report any new skin issues to the Wound Care Nurse immediately. The DON further revealed the Corporate Office sent a Wound Care Nurse from American Medical Technology (AMT) to the facility on [DATE] to help with assessments due to staff not completing the assessments as required. 2. Record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) with an assessment Reference Date (ARD) date of 4/23/15 recorded the resident had a Brief Interview for Mental Status (BIMS) score of 00 which indicated the resident was not cognitively intact. The resident required extensive assistance of two (2) staff members for transfer, dressing, bed mobility, toilet use, bathing, eating, and hygiene. The resident was coded with two (2) pressure ulcers on admission. The pressure ulcer Care Area Assessment (CAA) date 4/23/2015 recorded the resident had a pressure ulcer, had risk factors of immobility, urinary incontinence, loss of cognition / dementia, behavior symptoms, falls, communication deficit and nutritional status issues. The urinary incontinence CAA dated 4/23/15 recorded the resident as being incontinent of urine and required incontinent care by staff. The care plan objective was for the resident to be kept clean, dry and repositioned every two hours and as needed. The care plan objective dated 7/26/15 was for the resident to have any area of skin breakdown observed and report (x) ninety (90) days and to assist the resident with turning and repositioning every two (2) hours and as needed and to provide incontinent care every two (2) hours and as needed. Review of the weekly pressure ulcer report revealed the following documentation of the resident's pressure ulcer on his/her coccyx: a. 7/26/15 - coccyx area as 4.50 cm x 3.0 cm. x UTD (Unable To Determine). b. 7/30/14 - coccyx area as 4.25 cm x 3.0 cm x 0.25 cm. c. 8/5/15 - coccyx area as 4.50 cm x 3.0 cm x UTD. Review of the weekly pressure ulcer report revealed the following documentation of the resident's pressure ulcer on his/her acronym process/shoulder: a. 7/31/15 - left acronym process area 2.0 cm x 1.0 cm. b. 8/5/15 - left acronym process/shoulder area 1.0 cm x 1.0 cm x 0.10 cm. Observations of wound care for Resident #56 8/12/15 at 1:40 PM, with the Wound Care Nurse revealed Resident #56 had three new stage one pressure ulcers as followed: a. One (1) to the resident's lower right sacrum area measuring 2.5 cm x .5 cm. b. Two (2) new wounds to the residents right foot one (1) measuring 1.5 cm x 1.5 cm and the other measuring .5 cm x 1.0. cm. Interview with the WCN on 8/12/15 at 1:50 PM, during the wound care revealed wound care was provided to Resident #56 earlier on 8/12/15. The WCN confirmed she/he did not notice the new wounds on Resident #56 during the morning wound care. The WCN stated the wound to the lower right sacrum would be classified as a stage one wound, and the two wounds to the right foot would be classified as suspected deep tissue injury. The WCN stated she failed to document the wounds prior to wound care on 8/12/15 at 1:40 PM. 3. The facility failed to promptly assess and document stage one pressure sores for Resident #53 and 56 with a history of pressure ulcers development.

Based on record review, interview, and policy review, the facility failed to immediately inform the resident's legal representative about a significant change in the resident's condition which had the potential for requiring physician intervention for 1 of 29 (Resident #89) sampled residents. The findings included: Resident #89 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/25/15 Nursing Skilled Note recorded, .S/P (suprapubic) catheter intact. The admission care plan dated 7/25/15 recorded the resident was incontinent of bladder and lacked any information about the resident's urinary catheter. The Admission/Re-Admission note dated 7/26/15 recorded, .Patient S/P (suprapubic) catheter intact . The admission Minimum Data Set ((MDS) dated [DATE] recorded the Brief Interview for Mental Status (BIMS) score of 3 indicating the resident was severely cognitively impairment. The MDS recorded the resident had a urinary catheter. The Nursing Skilled Note dated 7/27/15 recorded, .Foley (catheter) patent and draining yellow urine . On 7/27/15, nursing recorded the resident had a Foley catheter, (a flexible tube that is passed through the urethra in the area of the genitalia, and into the bladder). Review of the 8/2/15 1:45 PM Nursing Skilled Note recorded, Patient sent to ER (emergency room ) for evaluation and reinsertion of suprapubic catheter. review of the resident's medical record revealed [REDACTED]. There was no documentation that the resident's suprapubic catheter was removed, how the resident tolerated the procedure, or any follow-up monitoring of the resident post procedure; the suprapubic catheter had been surgically inserted and removed by facility staff. Review of the Nursing Notes lacked any documentation that the family/legal representatives were notified that the resident was sent out to the ER. The resident was severely cognitively impaired and required a legal Power of Attorney for health care decisions. Interview on 8/13/15 at 3:13 PM with the resident's family member/legal representative revealed the facility did not inform the family that the resident was sent to the emergency room until about 2 to 3 hours after the resident was sent. The family member stated the facility sent out the resident alone to the ER and the resident was very confused; It was the family's job to consent to the ER visit, and the family's job to accompany (the resident). The facility provided the policy titled, Requirements for Transfer, dated 5/14 which directed, Notify family member/responsible party. During interview on 8/12/15 at 3:46 PM, the Director of Nursing (DON) stated the resident was admitted on Saturday, 7/25/15. On the following Monday, 7/27/15 the DON inquired to Licensed Nurse (LN) #1 why the resident had a Foley catheter, instructed LN #1 to check orders for the catheter, and none were found for an indwelling (Foley) catheter. The DON stated at that point he/she instructed LN #1 to pull the resident's catheter, assuming it was a Foley catheter. The following Sunday, 8/2/15, it was discovered the resident had a suprapubic catheter, not a Foley catheter, and the suprapubic catheter was removed. The DON stated LN #1 worked at the facility for a year, and had completed his/her orientation check-off for physician orders and catheter care. The DON stated that LN #1 no longer worked at the facility. The DON stated there were no annual competency standards/education for the nurses. The DON stated, I never imagined any nurse pulling a suprapubic catheter without a doctor's order. The DON agreed it was outside the nurse's scope of practice to remove the catheter. During interview on 8/13/15 at 4:38 PM, the DON stated there should have been a note about notification to the family before the resident was sent out to ER, and acknowledged there was no note in the medical record. The facility failed to notify the family/legal representatives in a timely manner about this dependent resident's change of condition and transfer to ER.

Based on record review, observation and staff interview, the facility failed to promptly assess wounds for 2 of 29 (Residents #53 and #56) sampled residents. The findings included: 1. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with a Reference date (ARD) date of 5/19/15 recorded the resident's Brief Interview for Mental Status (BIMS), score of 12 which indicated intact cognition. The resident required extensive assistance by two (2) staff members for transferring, dressing, toileting, incontinent care, bed mobility, bathing and supervision by one (1) staff member for eating. The resident was coded as not having any pressure ulcers. The Care Area Assessment (CAA) dated 5/12/15 recorded the resident had risk factors of activities of daily living (ADL) function, visual function, falls, nutritional status, psychosocial well being, [MEDICAL CONDITION] use, cognitive loss and urinary incontinence. The resident was identified at risk for pressure ulcers. Review of the weekly pressure ulcer report revealed the following documentation of the resident's pressure ulcer on the coccyx: a. 6/19/15 - 4.50 centimeters (cm) by (x) 0.75 cm. b. 6/24/15 - 4.50 cm x 0.75 cm. c. 7/1/15 - 4.0 cm x 2.0 cm. d. 7/9/15 - 2.0 cm x 1.0 cm. e. 7/15/15 - 1.75 cm x 1.0 cm. f. 7/22/15 - 1.75 cm x 0.75 cm. g. 7/30/15 - 1.75 cm x 0.75 cm. A review of the care plan dated 6/19/15 revealed the resident had an unstageable wound to the coccyx and the interventions included the following: a. Assist with turning and repositioning every two (2) hours and as needed. b. Offer toileting and provide incontinence care every two (2) hours and as needed. c. Resolution of coccyx within ninety (90) days. d. Refer to medical doctor (MD) for current orders. e. Weekly wound progress notes for current interventions. Observation of Resident #53's wound care on 8/12/15 at 10:40 AM, revealed a new red area to the resident's sacrum measuring 2.0 cm x 1.5 cm. Interview with the Wound Care Nurse (WCN) on 8/12/15 at 10:40 AM, the WCN confirmed Resident #53 had a new wound on her sacrum. The WCN revealed the resident's wound was a stage one and that she/he failed to document the resident's new wound prior to wound care on 8/12/15 at 10:40 AM. Interview with the Director of Nursing (DON), on 8/12/15 at 9:10 AM, the DON revealed the skin audits (assessments) are expected to be held weekly by the night shift staff nurses. The DON revealed that it is an expectation for the staff to assess the residents' skin weekly and during daily care. The DON revealed staff are expected to report any new skin issues to the Wound Care Nurse immediately. The DON further revealed the Corporate Office sent a Wound Care Nurse from American Medical Technology (AMT) to the facility on [DATE] to help with assessments due to staff not completing the assessments as required. 2. Record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) with an assessment Reference Date (ARD) date of 4/23/15 recorded the resident had a Brief Interview for Mental Status (BIMS) score of 00 which indicated the resident was not cognitively intact. The resident required extensive assistance of two (2) staff members for transfer, dressing, bed mobility, toilet use, bathing, eating, and hygiene. The resident was coded with two (2) pressure ulcers on admission. The pressure ulcer Care Area Assessment (CAA) date 4/23/15 recorded the resident had a pressure ulcer, had risk factors of immobility, urinary incontinence, loss of cognition / dementia, behavior symptoms, falls, communication deficit and nutritional status issues. The urinary incontinence CAA dated 4/23/15 recorded the resident as being incontinent of urine and required incontinent care by staff. The care plan objective was for the resident to be kept clean, dry and repositioned every two hours and as needed. The care plan objective dated 7/26/15 was for the resident to have any area of skin breakdown observed and report (x) ninety (90) days and to assist the resident with turning and repositioning every two (2) hours and as needed and to provide incontinent care every two (2) hours and as needed. Review of the weekly pressure ulcer report revealed the following documentation of the resident's pressure ulcer on his/her coccyx: a. 7/26/15 - coccyx area as 4.50 cm x 3.0 cm. x UTD (Unable To Determine). b. 7/30/14 - coccyx area as 4.25 cm x 3.0 cm x 0.25 cm. c. 8/5/15 - coccyx area as 4.50 cm x 3.0 cm x UTD. Review of the weekly pressure ulcer report revealed the following documentation of the resident's pressure ulcer on his/her acronym process/shoulder: a. 7/31/15 - left acronym process area 2.0 cm x 1.0 cm. b. 8/5/15 - left acronym process/shoulder area 1.0 cm x 1.0 cm x 0.10 cm. Observations of wound care for Resident #56 on 8/12/15 at 1:40 PM, with the Wound Care Nurse revealed Resident #56 had three new stage one pressure ulcers as followed: a. One (1) to the resident's lower right sacrum area measuring 2.5 cm x .5 cm. b. Two (2) new wounds to the residents right foot one (1) measuring 1.5 cm x 1.5 cm and the other measuring .5 cm x 1.0. cm. Interview with the WCN on 8/12/15 at 1:50 PM, during the wound care revealed wound care was provided to Resident #56 earlier on 8/12/15. The WCN confirmed she/he did not notice the new wounds on Resident #56 during the morning wound care. The WCN stated the wound to the lower right sacrum would be classified as a stage one wound, and the two wounds to the right foot would be classified as suspected deep tissue injury. The WCN stated she failed to document the wounds prior to wound care on 8/12/15 at 1:40 PM. 3. The facility failed to promptly assess and document stage one pressure sores for Resident #53 and 56 with a history of pressure ulcers development.

Based on policy review, medical record review and interview the facility failed to follow facility policy for "Leave of Absence (LOA), Patient" by not documenting required specific information for 5 (#7, 8, 9, 10 and 11) of 5 residents sampled. Record Review (RR) of the facility Leave of Absence (LOA), Patient policy, dated June 2014, documented, "...Patients...leave...facility...visit friends...family...day or overnight. The physician...must approve the leave...order...leave with meds...in the patient's medical record. If LOA...exceed forty-eight (48) hours, medication...obtained...from the Pharmacy. Nurses...give patient a 48-hour supply from the Med Cart. The Release of Liability for Personal Outing (LOA) form...signed...dated...family member...friend...patient is leaving with...hour of return noted...Clinical notes...leaving facility...returning. Clinical notes...include...patient left with, destination, physical condition of patient...leaving...upon return, meds taken...instructions for use given to person leaving with patient, emotional and mental status of patient...leaving and return, dietary department..." Medical Record Review (MRR) of Resident #7 documented admission to the facility on [DATE] with [DIAGNOSES REDACTED]. MRR of the Minimum Data Set ((MDS) dated [DATE] documented Resident #7's Brief Interview of Mental Status (BIMS) a 15, which indicates the resident is cognitively intact. MRR of Resident #7 Clinical Notes Report dated 11/26/2014 at 7:00 PM documented "LOA with family" Continued MRR revealed no documentation of Resident #7's destination, physical condition of Resident #7 when leaving, medications taken and instruction for use given to person leaving with resident, emotional and mental status of resident upon leaving and dietary department notification note found in the Clinical Notes Report or Medication Administration Record (MAR). MRR of Resident #7 Clinical Notes Report dated 11/29/2014 at 7:56 PM documented "returned to facility..." MRR of Resident #7 Clinical Notes Report dated 12/25/2014 at 5:22 PM documented "LOA with granddaughter overnight" Continued MRR revealed no documentation of Resident #7's destination, physical condition of Resident #7 when leaving, medications taken and instruction for use given to person leaving with resident, emotional and mental status of resident upon leaving and dietary department notification note found in the Clinical Notes Report or MAR. MRR of Resident #7 Clinical Notes Report dated 1/2/2015 at 10:18 PM documented "return from LOA with family...supervisor aware of...return..." Interview with Nurse #5 on 1/28/2015 at 12:42 PM in 100 hall nurses' station confirmed that Resident #7 did not leave with meds on 12/25/14 due to family loading her into car without informing nurse. LOA was to be a one-night (overnight) stay. MRR of Resident #8 documented admission to the facility on [DATE] with [DIAGNOSES REDACTED]. MRR of the MDS dated [DATE] documented Resident #8 BIMS a 9, which indicates the resident is moderately cognitively impaired. MRR of Resident #8 Clinical Notes Report dated 7/7/2014 at 4:26 PM documented "Went LOA with sister for a overnight visit. Meds sent with pt." Continued MRR revealed no documentation of Resident #8's destination, physical condition of Resident #8 when leaving, medications taken and instruction for use given to person leaving with resident, emotional and mental status of resident upon leaving and dietary department notification note as per facility LOA policy found in the Clinical Notes Report or MAR. MRR of Resident #8 Clinical Notes Report dated 7/8/2014 at 1:37 PM documented "returned from loa". Continued MRR of the Clinical Notes Report revealed no documentation of the resident's physical condition or emotional and mental status upon return to the facility as per facility LOA policy found in the Clinical Notes Report or MAR. MRR of Resident #8 Clinical Notes Report dated 12/24/2014 at 10:32 AM documented "LOA with family for the night." Continued MRR revealed no documentation of Resident #8's destination, physical condition of Resident #8 when leaving, medications taken and instruction for use given to person leaving with resident, emotional and mental status of resident upon leaving and dietary department notification note as per facility LOA policy found in the Clinical Notes Report or MAR. MRR of Resident #8 Clinical Notes Report dated 12/25/2014 at 2:17 PM documented "Returned from LOA". Continued MRR of the Clinical Notes Report revealed no documentation of resident's physical condition or emotional and mental status upon return to the facility as per facility LOA policy found in the Clinical Notes Report or MAR. MRR of Resident #9 documented admission to the facility on [DATE] with [DIAGNOSES REDACTED]. MRR of the MDS dated [DATE] documented Resident #9's BIMS a 15, which indicates the resident is cognitively intact. MRR of Resident #9 Clinical Notes Report dated 11/27/2014 at 1:02 PM documented "LOA with family". Continued MRR revealed no documentation of Resident #9's destination, physical condition of Resident #9 when leaving, medications taken and instruction for use given to person leaving with resident, emotional and mental status of resident upon leaving and dietary department notification note as per facility LOA policy found in the Clinical Notes Report or MAR. MRR of Resident #9 Clinical Notes Report dated 11/28/2014 at 10:25 PM documented "pt. returned from loa". Continued MRR of the Clinical Notes Report revealed no documentation of the resident's physical condition or emotional and mental status upon return to the facility as per facility LOA policy found in the Clinical Notes Report or MAR. MRR of Resident #9 Clinical Notes Report dated 12/26/2014 at 9:05 AM documented "Pt LOA with brother." Continued MRR revealed no documentation of Resident #9's destination, physical condition of Resident #9 when leaving, medications taken and instruction for use given to person leaving with resident, emotional and mental status of resident upon leaving and dietary department notification note as per facility LOA policy found in the Clinical Notes Report or MAR. MRR of Resident #9 Clinical Notes Report dated 12/29/2014 at 1:15 PM documented "Pt return from LOA status." Continued MRR of Resident #9 Clinical Notes Report revealed no documentation of the resident's physical condition or emotional and mental status upon return to the facility as per facility LOA policy found in the Clinical Notes Report or MAR. MRR of Resident #10 documented admission to the facility on [DATE] with [DIAGNOSES REDACTED]. MRR of the MDS dated [DATE] documented Resident # 10's BIMS a 15, which indicates the resident is cognitively intact. RR of Resident #10 Clinical Notes Report on 11/28/2014 at 5:32 PM documented "Pt. LOA with...". Continued MRR revealed no documentation of Resident #10's destination, physical condition of Resident #10 when leaving, and emotional and mental status of resident upon leaving as per facility LOA policy found in the Clinical Notes Report or MAR. RR of Resident #10 Clinical Notes Report on 11/28/2014 at 10:22 PM documented "pt. returned from loa". Continued MRR of the Clinical Notes Report revealed no documentation of the resident's physical condition or emotional and mental status upon return to the facility as per facility LOA policy found in the Clinical Notes Report or MAR. MRR of Resident #11 documented admission to the facility on [DATE] with [DIAGNOSES REDACTED]. MRR of the MDS dated [DATE] documented Resident #11's BIMS a 11, which indicates the resident is moderately cognitively impaired. RR of Resident #11 Clinical Notes Report on 12/25/2014 at 11:01 AM documented "Pt. LOA w/ (with) family for Christmas." Continued MRR revealed no documentation of Resident #11's destination, physical condition of Resident #11 when leaving, medications taken and instruction for use given to person leaving with resident, emotional and mental status of resident upon leaving and dietary department notification note as per facility LOA policy found in the Clinical Notes Report or MAR. RR of Resident #11 Clinical Notes Report on 12/25/2014 at 7:49 PM documented "Resident return from loa with great granddaughter..." Interview with the DON on 1/28/2015 at 1:20 PM in the DON's office confirmed "LOA documentation would be in the Clinical Notes Report or on the MAR and if not found in either of those places then it would not have been documented." The DON confirmed that the LOA policy was not being followed and additionally, there is not an LOA notebook to keep the "Release of Liability for Personal Outing (LOA)" forms in as dictated by policy. The DON confirmed the facility has failed to document resident LOA's as specified in the LOA policy.

Based on policy review, observation and interview, it was determined 5 of 10 (Certified Nursing Assistants (CNA) #3, 4, 5, 6 and 7) failed to promote residents' dignity as evidenced by CNAs stood over residents to feed them, referred to residents as "feeders" and failed to deliver meal trays within 30 minutes after leaving the kitchen. The findings included: 1. Review of facility's "A COMMITMENT TO CARING WELCOME BOOKLET" documented, "...The right to dignity. Patient's of nursing homes are honored guests and have the right to be so treated..." Review of the facility's "Director of Nursing Training Manual Dining Room Meals" documented, "...7. No one is allowed to stand while assisting the patients to eat... Room Service... 2. Meals must be delivered to the patient in a timely fashion (within 30 minutes after they exit the dietary department)..." 2. Observations in room [ROOM NUMBER] on 6/23/14 at 8:21 AM, revealed CNA #3 stood at Resident #78's bedside while assisting with dining. Resident #78's eyes were at CNA #3's waist level. During an interview in front of room [ROOM NUMBER] on 6/23/14 at 5:49 PM, CNA #3 was asked if she was going to give the resident in room [ROOM NUMBER]A her dinner tray. CNA #3 stated, "She's a feeder. We have several feeders on this hall." 3. Observations in the 100 hall on 6/23/14 at 5:15 PM, revealed the tray cart was delivered. At 6:45 PM, CNA #4 delivered a meal tray from this cart to Resident #78's room (1 hour and 30 minutes after the tray cart was delivered to the floor). CNA #4 stood while assisting Resident #78 with dining. Resident #78's eye level was at CNA #4's waist level. 4. Observations in room [ROOM NUMBER] on 6/22/14 at 12:15 PM, revealed CNA #5 stood over a resident while feeding. During an interview outside room [ROOM NUMBER] on 6/22/14 at 12:26 PM, CNA #5 was asked about the delayed tray service. CNA #5 stated, "She's a feeder and I'll have to come back to feed her." 5. Observations in room [ROOM NUMBER] on 6/22/14 at 12:45 PM, revealed CNA #6 delivered the resident's dinner tray and started to move a chair to sit down but stated, "No, I'll just stand up." and stood over the resident while feeding. Observations in room [ROOM NUMBER] on 6/23/14 at 6:15 PM, revealed CNA #6 stood over a resident while feeding. During an interview in front of room [ROOM NUMBER] on 6/23/14 at 5:50 PM, CNA #6 was asked if there were any trays left on the food cart. CNA #6 stated, "There are some more feeders." 6. Observations in the 100 hall on 6/23/14 at 6:27 PM, CNA #7 asked CNA #6, "Are there anymore feeders on the cart." 7. During an interview in the Director of Nursing's (DON) office on 6/24/14 at 3:25 PM, the DON was asked what she expected the staff to call residents that require feeding assistance. The DON stated, "We teach them to call residents assisted diners." The DON was then asked how long should it take to get the meal trays passed out on a hall. The DON stated, "I would hope the trays would be passed out within 15 minutes." The DON was asked how did she expect the trays to be passed when you have a resident that needs assistance with the meal and an independent resident in the same room. The DON answered, "They (CNAs) should serve both patients (residents) at the same time. Ideally they (CNAs) should arrange their schedule so that the independent tray was served at the same time the assisted diner was fed." The DON was then asked if the dining room policies apply to the residents who eat in the rooms. The DON stated, "Yes." The DON was asked what posture she expected her staff to have during assisting residents with their meals. The DON answered, "I expect them (staff) to sit at eye level while feeding the patient (resident)."

Based on observation and interview, it was determined the facility failed to provide effective housekeeping and maintenance services to maintain a sanitary, orderly and comfortable environment as evidenced by odors in 1 of 3 (100 hall) halls; and odors, stained commodes and bathroom floors, a hole in a wood covering and dirt around baseboards in 8 of 37 (Rooms 103, 112, 113, 116, 117, 119, 120 and 121) resident rooms. The findings included: 1. Observations in the 100 hall on 6/22/14 at 11:00 AM, on 6/23/14 at 8:00 AM and on 6/24/14 at 8:45 AM, revealed strong urine odors that got stronger as the surveyor progressed down the hallway. During an interview in the 100 hall on 6/24/14 at 12:05 PM, the housekeeping supervisor (HS) was asked what was the odor. The HS stated, "Urine." During an interview in the 100 hall on 6/24/14 at 4:45 PM, the Director of Nursing (DON) was asked what was the odor. The DON stated, "Urine." 2. Observations in room 103 on 6/22/14 at 4:05 PM, on 6/23/14 at 7:47 AM, 2:45 PM, 5:45 PM and 6:45 PM and on 6/24/14 at 8:50 AM and 9:15 AM, revealed the room had a foul odor. During an interview in room 103 on 6/24/14 at 11:25 AM, the HS was asked about the odor in the room. The HS stated, "Yes, I smell it." The HS was asked about deep cleaning the room. The HS stated, "It has been several months." During an interview in room 103 on 6/24/15 at 11:40 AM, Housekeeper #1 and Housekeeper #2 verified they smelled the odor and they had smelled it before in room 103. 3. Observations on 6/22/14 at 11:05 AM and on 6/23/14 at 8:05 AM revealed the following: a. Room 112 - stale urine odors in the bathroom and a yellowish stain around the base of the toilet. b. Room 113 - stale urine odors in the bathroom and a yellowish substance around the base of the toilet. c. Room 116 - stale urine odors in the bathroom, a yellowish substance around the base of the toilet and a hole in the wood covering of pipes at base of floor. d. Room 117 - stale urine odors in the bathroom and a yellowish substance around the base of the toilet and dirt around the baseboards in the resident's room. e. Room 119 - yellowish substance around the base of the toilet and behind the sink. f. Room 120 - stale urine odors in the bathroom and a yellowish substance around the base of the toilet. g. Room 121 - stale urine odors in the bathroom and a yellowish substance around the base of the toilet. 4. During an interview in room 121's bathroom on 6/24/14 at 12:10 PM, the HS was asked what the odors were in the bathrooms of rooms 112, 113, 116, 117, 120, and 121. The HS stated, "Urine." The HS was asked what the yellowish substance was around the base of the toilets bowl in rooms 112, 113, 116, 117, 119, 120 and 121. The HS stated, "Urine, we have started renovating the bathrooms. The urine smell is coming from under the linoleum. We need to be more consistent and thorough when cleaning the bathrooms." During an interview in room 121's bathroom on 6/24/14 at 4:45 PM, the DON was asked what the odors were in the bathrooms of rooms 112, 113, 116, 117, 120 and 121. The DON stated, "Urine." The DON was asked what the yellow substance was around the base of the toilets in rooms 112, 113, 116, 117, 119, 120 and 121. The DON stated, "Urine" and shook her head.

Based on review of the "MEDICATION GUIDE for the Long-Term Care Nurse," policy review, medical record review, observation and interview, it was determined the facility failed to ensure 2 of 3 (Nurses #1 and 2) nurses checked placement of a Percutaneous Endoscopy Gastrostomy (PEG) tube prior to administering medications to 2 of 2 (Residents #47 and 59) sampled residents observed with a PEG tube. The findings included: 1. Review of the "MEDICATION GUIDE for the Long-Term Care Nurse sixth Edition", page 71 documented, "...Administration of Medication Via (through) Feeding Tube... Check for correct placement of feeding tube prior to administration of medication..." Review of the facility's medication administration policy documented, "...Medication administered via feeding tube (Nasogastric or Gastrostomy)... Check placement of tube by performing aspiration and auscultation techniques..." 2. Medical record review for Resident #47 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Observations in Resident #47's room on 6/23/14 at 3:14 PM, revealed Nurse #1 administered medication to Resident #47 per PEG tube. Nurse #1 did not check placement of the PEG tube prior to administering medications. During an interview in the 200 hall on 6/23/14 at 5:21 PM, Nurse #1 stated, "I know what I did wrong when I was doing that PEG medication. I failed to check placement." 3. Medical record review for Resident #59 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Observations in Resident #59's room on 6/23/14 at 2:32 PM, Nurse #2 administered medication to Resident #59 per the PEG tube. Nurse #2 did not check placement of the PEG tube prior to administering the medication. 4. During an interview in the Director of Nursing's (DON) office on 6/24/14 at 2:30 PM, The DON was asked what she would expect of nurses when administering medications through a PEG tube. The DON stated, "Check placement by auscultating, drawing back residual fluid and flush PEG."

Based on policy review, observation and interview, it was determined 2 of 3 (Nurses #2 and 3) medication nurses failed to practice sanitary hand hygiene during medication administration. The findings included: 1. Review of the facility's "Hand Hygiene" policy documented, "Hand hygiene is the simplest, most effective means of infection control... Hand hygiene must be performed at a minimum... Before and after each patient contact... Before donning gloves and after removing gloves..." 2. Observations on the 100 hall on 6/23/14 at 2:32 PM, revealed Nurse #2 put gloves in his pocket, went into room [ROOM NUMBER]B after donning gloves, pulled the privacy curtain and turned on the light, and closed the window curtain. Nurse #2 didn't wash hands or change gloves prior to starting to administer medications through a Percutaneous Endoscopy Gastrostomy (PEG) tube. During an interview in the Director of Nursing's (DON) office on 6/24/14 at 2:30 PM, the DON was asked when would you expect a nurse to change their gloves after touching objects before actually starting to administer medications to a resident. The DON stated, "Take off old gloves, wash hands and put new gloves on." Observations on the 100 hall on 6/23/14 at 9:00 AM, revealed Nurse #2 put gloves in his pocket, entered room [ROOM NUMBER]B to apply a medicated patch to Resident #2, donned gloves, and applied the patch. Nurse #2 did not cleanse the skin after removing the old patch or applying the new patch. During an interview in the Assistant Director of Nursing's (ADON) office on 6/24/14 at 4:45 PM, the DON was asked did she expected staff to put gloves in their pocket. The DON stated, "No, (staff) should not put them (gloves) in their pockets." The DON was asked what she expected when nurses are changing a medicated patch. The DON stated, "Wash hands and remove old patch and wash hands and apply new patch." The DON was asked about care of the site where the old patch was removed. The DON stated, "Cleanse with saline or soap and water where they remove old patch." 3. Observations on the 100 hall on 6/24/14 at 9:10 AM, revealed Nurse #3 cleansed a pulse oximeter with gloves on, entered room [ROOM NUMBER]A, checked a resident's pulse, went back to the medication cart, cleansed a pulse oximeter and removed gloves. Nurse #3 didn't wash hands or use hand sanitizer before giving medication and after removing the gloves During an interview in the ADON's office on 6/24/14 at 4:45 PM, the DON was asked what is expected of staff when using gloves and when gloves are removed. The DON stated, "Wash hands."

Based on medical record review, observations, and interviews, it was determined the facility failed to implement professional standards for training staff, notifying physicians of changes in residents' conditions, and carrying out physicians' orders, which caused actual harm to 1 of 20 (Resident #2) sampled residents. The findings included: Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #2's restorative care plan documented passive range of motion (PROM) 3 times per week. Review of the physician's standing orders dated 12/10/10 documented, "...Tylenol 325 mg (milligrams) -- (to) 650 mg, po (by mouth) or per PEG (Percutaneous Endoscopy Gastrostomy) tube or suppository p.r. (per rectum) every 4 hours PRN (as needed) for headache, pain..." Review of the medication administration records had no documentation that Resident #2 had received Tylenol for pain. Observations in Resident #2's room on 3/23/11 at 9:30 AM, Nurse #1 began PROM on Resident #2's left forearm. With the elbow on the bed, Nurse #1 attempted to pull the left forearm forward. Resident #2 started to twitch and jerked her arm. Nurse #1 continued to attempt to extend the left arm, and Resident #2 twitched and attempted to pull away. Observations in Resident #2's room on 3/23/11 at 3:00 PM, Certified Nursing Assistant (CNA) #1 performed PROM on Resident #2's left hand. Resident #2 twitched and moaned during manipulation of the left hand. During an interview in Resident #2's room on 3/23/11 at 9:35 AM, Nurse #1 was asked if she thought Resident #2 was in pain. Nurse #1 stated, "No." Nurse #1 was asked what nonverbal signs of pain did she observe for. Nurse #1 stated, "We were taught to watch the facial expressions for frowning or grimacing." During an interview in Resident #2's room on 3/23/11 at 3:00 PM, CNA #1 was asked what she considered nonverbal signs of pain. CNA #1 stated, "Grimacing and moaning." CNA #1 was asked how often PROM was performed on Resident #2. CNA #1 stated, "Every 2 hours." During an interview in the conference room on 3/23/11 at 3:25 PM, the Speech Therapist (ST) was asked who the restorative coordinator was for the facility. The ST stated, "Me." The ST stated, "...I work with all the patients... perform therapeutic screenings and make recommendations ..." The ST was asked about restorative care. The ST stated, "...I write a restorative consult and give instructions to the direct care staff..." The ST was asked when was the last inservice with the staff on how to perform ROM. The ST stated, "In the fall." The ST brought a sign-in sheet from an inservice dated 6/10. There was no documentation of training provided at that time related to ROM. During a telephone interview on 3/23/11 at 4:50 PM, Physician #1 was asked if he was aware of any problems with Resident #2. Physician #1 stated, "No." Physician #1 was asked if he was notified by the staff that Resident #2 exhibited symptoms of pain during PROM. Physician #1 stated "No." Physician #1 was asked if he had been notified on 3/23/11 of any pain issues involving Resident #2. Physician #1 stated, "No, not to my knowledge..." The facility staff failed to meet professional standards for providing PROM resulted in actual harm to Resident #2, who displayed non-verbal signs of pain that were not identified and treated by the staff.

Based on medical record review, observations, and interviews, it was determined the facility failed to ensure the staff notified the physician of pain during passive range of motion (PROM) or of elevated blood sugars for 2 of 20 (Residents #2 and 8) sampled residents. The failure to notify the physician of Resident #2's signs and symptoms of pain during PROM resulted in actual harm to Resident #2. The findings included: 1. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's standing orders dated 12/10/10 documented, "...Tylenol 325 mg (milligrams) -- (to) 650 mg, po (by mouth) or per PEG (Percutaneous Endoscopy Gastrostomy) tube or suppository p.r. (per rectum) every 4 hours PRN (as needed) for headache, pain..." Review of the medication administration records documented the resident had not received Tylenol for pain. Observations in Resident #2's room on 3/23/11 at 9:30 AM, Nurse #1 began PROM on Resident #2's left forearm. With the elbow on the bed, Nurse #1 attempted to pull the left forearm forward. Resident #2 started to twitch and jerked her arm. Nurse #1 continued to attempt to extend the left arm, and Resident #2 twitched and attempted to pull away. During an interview in Resident #2's room on 3/23/11 at 9:35 AM, Nurse #1 was asked if she thought Resident #2 was in pain. Nurse #1 stated, "No." Nurse #1 was asked what nonverbal signs of pain did she observe for. Nurse #1 stated, "We were taught to watch the facial expressions for frowning or grimacing." Observations in Resident #2's room on 3/23/11 at 3:00 PM, Certified Nursing Assistant (CNA) #1 performed PROM on Resident #2's left hand. Resident #2 twitched and moaned during manipulation of the left hand. During an interview in Resident #2's room on 3/23/11 at 3:00 PM, CNA #1 was asked what she considered nonverbal signs of pain. CNA #1 stated, "Grimacing and moaning." CNA #1 was asked how often PROM was performed on Resident #2. CNA #1 stated, "Every 2 hours." During a telephone interview on 3/23/11 at 4:50 PM, Physician #1 was asked if he was aware of any problems with Resident #2. Physician #1 stated, "No." Physician #1 was asked if he was notified by the staff that Resident #2 exhibited symptoms of pain during PROM. Physician #1 stated "No." Physician #1 was asked if he had been notified on 3/23/11 of any pain issues involving Resident #2. Physician #1 stated, "No, not to my knowledge..." 2. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].< (less than) 80 or > (greater than) 300..." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the January 2011 MAR documented, the blood sugar for 1/17/11 was 312. There was no documentation in the medical record that the physician was notified of Resident #8's elevated blood sugars on 12/27/10 and 1/17/11. During an interview at the 100 hall nurse's station on 3/23/11 at 7:15 AM, Nurse #2 was asked if the physician had been notified of the elevated blood sugars on 12/27/10 and 1/17/11. Nurse #2 stated, "...it should be in the nurses notes or an order written [REDACTED]. 3. During an interview in the business office on 3/23/11 at 3:00 PM, the Administrator was asked if the facility had a policy for notifying the physician of changes in the residents' conditions. The Administrator stated, "...no we do not..."

Based on medical record review, observations, and interviews, it was determined the facility failed to implement measures to prevent a resident with contractures from experiencing pain during passive range of motion (PROM) exercises, or obtaining weekly weights as ordered by the physician for 2 of 20 (Residents #2 and 17) sampled residents. The failure to implement measures to prevent pain during PROM resulted in actual harm when Resident #2 exhibited signs and symptoms of pain during PROM. The findings included: 1. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #2's restorative care plan documented passive range of motion (PROM) 3 times per week. Review of the physician's standing orders dated 12/10/10 documented, "...Tylenol 325 mg (milligrams) -- (to) 650 mg, po (by mouth) or per PEG (Percutaneous Endoscopy Gastrostomy) tube or suppository p.r. (per rectum) every 4 hours PRN (as needed) for headache, pain..." Review of the medication administration records had no documentation that Resident #2 had received Tylenol for pain. Observations in Resident #2's room on 3/23/11 at 9:30 AM, Nurse #1 began PROM on Resident #2's left forearm. With the elbow on the bed, Nurse #1 attempted to pull the left forearm forward. Resident #2 started to twitch and jerked her arm. Nurse #1 continued to attempt to extend the left arm, and Resident #2 twitched and attempted to pull away. Observations in Resident #2's room on 3/23/11 at 3:00 PM, Certified Nursing Assistant (CNA) #1 performed PROM on Resident #2's left hand. Resident #2 twitched and moaned during manipulation of the left hand. During an interview in Resident #2's room on 3/23/11 at 9:35 AM, Nurse #1 was asked if she thought Resident #2 was in pain. Nurse #1 stated, "No." Nurse #1 was asked what nonverbal signs of pain did she observe for. Nurse #1 stated, "We were taught to watch the facial expressions for frowning or grimacing." During an interview in Resident #2's room on 3/23/11 at 3:00 PM, CNA #1 was asked what she considered nonverbal signs of pain. CNA #1 stated, "Grimacing and moaning." CNA #1 was asked how often PROM was performed on Resident #2. CNA #1 stated, "Every 2 hours." During an interview in the conference room on 3/23/11 at 3:25 PM, the Speech Therapist (ST) was asked who the restorative coordinator was for the facility. The ST stated, "Me." The ST stated, "...I work with all the patients... perform therapeutic screenings and make recommendations ..." The ST was asked about restorative care. The ST stated, "...I write a restorative consult and give instructions to the direct care staff..." The ST was asked when was the last inservice with the staff on how to perform ROM. The ST stated, "In the fall." The ST brought a sign-in sheet from an inservice dated 6/10. There was no documentation of training provided at that time related to ROM. During a telephone interview on 3/23/11 at 4:50 PM, Physician #1 was asked if he was aware of any problems with Resident #2. Physician #1 stated, "No." Physician #1 was asked if he was notified by the staff that Resident #2 exhibited symptoms of pain during PROM. Physician #1 stated "No." Physician #1 was asked if he had been notified on 3/23/11 of any pain issues involving Resident #2. Physician #1 stated, "No, not to my knowledge..." Resident #2 exhibited signs and symptoms of pain during PROM by twitching and moaning on 3/23/11. The failure to implement measures to prevent pain during PROM resulted in actual harm to Resident #2. 2. Medical record review for Resident #17 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#17 was not on the list to be weighed. Review of Resident #17's weight record flow sheets dated 2010 and 2011 revealed, Resident #17 had not been weighed weekly since May 2010. During an interview at the 100 hall nurses' station on 3/23/11 at 4:15 PM, Nurse #1 stated, "They (weights) have not been done weekly."

Based review of the "Tennessee CNA (Certified Nursing Assistant) Candidate Handbook", review of the roster sample matrix (802) and the census and condition form (672) completed by the facility, medical record review, observations, and interviews, it was determined the facility failed to ensure residents with limited range of motion did not experience a decline in range of motion (ROM) by not providing the necessary treatment for 2 of 5 (Residents #2 and 13) sampled residents with limited range of motion. The failure to administer ROM appropriately without causing pain resulted in actual harm when Resident #2 exhibited symptoms of pain during ROM. The findings included: 1. Review of the "Tennessee CNA Candidate Handbook, version 4.5 October 1, 2010 documented, "...Range of Motion... 13. Does not cause discomfort or pain and does not force any joint beyond the point of free movement. (Candidates must ask if they are causing any pain or discomfort)..." 2. Review of the facility's roster sample matrix (802) form completed by the facility documented Resident #2 and 13 had contractures and limited ROM. The facility documented on the census and conditions form (672) that there were three residents with contractures and one of those residents was admitted to the facility with contractures. During an interview in the conference room on 3/23/11 at 11:50 AM, the Minimum Data Set (MDS) coordinator, the Administrator and the Director of Nurses (DON) were asked to clarify the form 672 Resident Census and Condition of Residents. The MDS coordinator stated, "...Resident #13 admitted with left side [MEDICAL CONDITION] on 9/9/99 and first documented of contracture 6/1/02... Resident #2 admission MDS 6/2/03 shows loss of voluntary movement and [MEDICAL CONDITION]" 3. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's standing orders dated 12/10/10 documented, "...Tylenol 325 mg (milligrams) -- (to) 650 mg, po (by mouth) or per PEG (Percutaneous Endoscopy Gastrostomy) tube or suppository p.r. (per rectum) every 4 hours PRN (as needed) for headache, pain..." Review of the medication administration records documented the resident had not received Tylenol for pain. Observations in Resident #2's room on 3/23/11 at 9:30 AM, Nurse #1 began PROM on Resident #2's left forearm. With the elbow on the bed, Nurse #1 attempted to pull the left forearm forward. Resident #2 started to twitch and jerked her arm. Nurse #1 continued to attempt to extend the left arm, and Resident #2 twitched and attempted to pull away. During an interview in Resident #2's room on 3/23/11 at 9:35 AM, Nurse #1 was asked if she thought Resident #2 was in pain. Nurse #1 stated, "No." Nurse #1 was asked what nonverbal signs of pain did she observe for. Nurse #1 stated, "We were taught to watch the facial expressions for frowning or grimacing." Observations in Resident #2's room on 3/23/11 at 3:00 PM, Certified Nursing Assistant (CNA) #1 performed PROM on Resident #2's left hand. Resident #2 twitched and moaned during manipulation of the left hand. During an interview in Resident #2's room on 3/23/11 at 3:00 PM, CNA #1 was asked what she considered nonverbal signs of pain. CNA #1 stated, "Grimacing and moaning." CNA #1 was asked how often PROM was performed on Resident #2. CNA #1 stated, "Every 2 hours." During an interview in the conference room on 3/23/11 at 3:25 PM, the Speech Therapist (ST) was asked who the restorative coordinator was for the facility. The ST stated, "Me." The ST stated, "...I work with all the patients... perform therapeutic screenings and make recommendations ..." The ST was asked about restorative care. The ST stated, "...I write a restorative consult and give instructions to the direct care staff..." The ST was asked when was the last inservice with the staff on how to perform ROM. The ST stated, "In the fall." The ST brought a sign-in sheet from an inservice dated 6/10. There was no documentation of training provided at that time related to ROM. During a telephone interview on 3/23/11 at 4:50 PM, Physician #1 was asked if he was aware of any problems with Resident #2. Physician #1 stated, "No." Physician #1 was asked if he was notified by the staff that Resident #2 exhibited symptoms of pain during PROM. Physician #1 stated "No." Physician #1 was asked if he had been notified on 3/23/11 of any pain issues involving Resident #2. Physician #1 stated, "No, not to my knowledge..." Resident #2 exhibited signs and symptoms of pain during PROM by twitching, grimacing, and moaning on 3/23/11. The failure to implement measures to prevent pain during PROM resulted in actual harm to Resident #2. 4. Medical record review for Resident #13 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 8/9/10 and reviewed on 1/24/11 documented "...Risk for joint pain and contractures due to [MEDICAL CONDITION] and immobility. Has flexion contractures of BLE (bilateral lower extremities) and BUE (bilateral upper extremities)... Pt's (patient's) joints are stiff and difficult to move... Position for comfort with devices... Passive range of motion to comfort to be done per restorative nursing..." Observations in Resident #13's room on 3/22/11 at 6:10 PM, and on 3/23/11 at 8:55 AM, revealed Resident #13 seated in a reclined geri-chair with bilateral hand contractures, and bilateral plantar flexion. Observations in Resident #13's room on 3/23/11 at 5:45 PM, CNA #9 was asked to demonstrate ROM on Resident #13. CNA #9 brought CNA #6 into the room to assist. CNA #9 moved Resident #13's arms around, and then moved her legs around. CNA #9 did not support the joints while performing ROM, and did not perform ROM on all of the resident's joints. CNA #9 was asked if she had had any training on ROM at the facility. CNA #9 stated, "...I used to do restorative..." CNA #6 was asked if she had had any training on ROM at the facility. CNA #6 stated, "...no training here (at the facility)... had training in CNA class..." Resident #13 was not observed with any type of hand or feet splints to help support the joints. During an interview in the conference room on 3/23/11 at 11:50 AM, the Director of Nursing stated that the resident was admitted with left sided [MEDICAL CONDITION], and that the first documentation of the resident's contractures was 6/1/02.

Based on medical record review, observations, and interviews, it was determined the facility failed to ensure hazardous substances were not left at a residents' bedside, that portable oxygen tanks were secured, and that a resident that was at risk for falls had interventions implemented after each fall to prevent further falls for 3 of 18 (Residents #5, 7, and 11) sampled residents observed. The failure to develop interventions after a fall to prevent further falls, resulted in actual harm when Resident #7 had a subsequent fall requiring medical intervention with sutures to her head. The facility failed to ensure that 1 of 3 (Housekeeping Cart #1) carts had hazardous items secured. The facility failed to ensure 12 of 31 wheelchairs and 1 of 7 gerichairs were maintained to prevent potential skin tears to residents. The findings included: 1. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 6/8/10 and reviewed on 3/7/11 documented Resident #7 had falls on 6/27/10, 9/10/10, 11/9/10, 11/17/10, 12/13/10, and 2/4/11. The fall interventions put in place for Resident #7 were documented as followed: a. 6/27/10 - "Physical Therapy Evaluation." b. 9/10/10 - "Physical Therapy, Speech Therapy, and Occupational Therapy." c. 11/9/10 - "6:30 PM Offer toileting p (after) meals." d. 11/17/10 - "7:15 PM Chair/bed pad alarm applied." e. 12/13/10 - "9:50 PM Low bed." f. 2/4/11 - "7:30 PM Start putting on bedpan at HS (bedtime)." Review of a nurse event note dated 11/9/10 at 6:30 PM documented, "...Found lying in (on) floor unknown as to what she was doing, c/o (complained of) bilateral hip pain... Immediate Steps Implemented to Prevent Recurrence: Offer toileting p (after) meals..." An event note dated 11/17/10 at 7:15 PM documented, "...I heard a loud noise went to see what is (it) was look in pt (patient) room found pt behind door face down walker at feet... send to ER (emergency room )... Immediate Steps Implemented to Prevent Recurrence: chair/bed pad alarm applied..." Review of the daily skilled nurse's note dated 11/17/10 documented, "...8pm Sent to ER per MD (Medical Doctor) on call d/t (due to) Res (resident) hitting head when she fell Res had skin tear to R (right) arm... 1130 pm Res. return from ER NO (new order) for wound care to remove sutures after 7 days Report if wound has any bleeding or foul smelling discharge. Head injury f/u (follow up) c (with) PCP (primary care provider) in 24 - (to) 48 hours... 11/18/10 (no) S/S (signs and symptoms) of adv. (adverse) react. (reaction) r/t (related to) fall, bruise to (R) (right) head (no) c/o pain or discomfort..." Review of the nurse's event note dated 12/13/10 at 9:50 PM documented, "...Pt was found sitting on floor behind bed dresser drawer in floor. Pt unclipped bed alarm from self & (and) it was laying in bed... Immediate Steps Implemented to Prevent Recurrence: low bed needed for Pt d/t confusion level oriented only to name..." Review of Resident #7's care plan dated 6/18/10 and reviewed on 3/7/11 documented, "...11-9-10 Pt fell ... offer toileting after meals... 11-17-10 Pt fell ... offer bedpad at night... Patient sent to ER. returned with sutures to head... Remove sutures after 7 days - Report if wound has bleeding or foul-smelling discharge..." Observations of Resident #7 in her room revealed the following: a. 3/21/11 at 3:03 PM, resident seated in a recliner at the bedside with no body alarm in place. b. 3/21/11 at 4:30 PM, resident seated in a wheelchair at the bedside with no body alarm in place. c. 3/21/11 at 5:50 PM, resident seated in a wheelchair at the bedside with no body alarm in place. d. 3/22/11 at 2:30 PM, resident seated in a recliner at the bedside with no body alarm in place. e. 3/23/11 at 7:15 AM, resident seated in a wheelchair at the bedside, and was taken to the dining room by staff with no body alarm in place. f. 3/23/11 at 8:06 AM, resident seated in a wheelchair at the bedside with no body alarm in place. g. 3/24/11 at 4:15 PM, resident seated in a wheelchair at the bedside with no body alarm in place. Observations in Resident #7's room on 3/23/11 at 4:05 PM, Certified Nursing Assistant (CNA) #9 took Resident #7 to the bathroom in a wheelchair. Resident #7 was instructed to use the grab-bar on the wall and pivot on to the commode. CNA #9 was asked if Resident #7 was able to ambulate. CNA #9 stated, "...can't walk long distances..." Observations in Resident #7's room on 3/24/11 at 9:10 AM, Nurse #1 walked Resident #7 to the door of her room and back to a chair at the bedside. During an interview at the 100 hall nurses' station on 3/24/11 at 8:00 AM, the Physical Therapy Assistant (PTA) was asked if Resident #7 could walk. The PTA stated, "...she can walk, but it's not pretty..." The PTA was asked if Resident #7 was able to walk to the dining room when she was discharged from therapy to the restorative program in 12/10. The PTA stated, "...yes..." The PTA was asked, if Resident #7 had had a decline and was no longer able to walk to the dining room, would she expect them to be referred back to the therapy department. The PTA stated, "...No... because they live here... not Part B (medicare reimbursed skilled services)... that would not be a skilled service to keep her walking...it's restorative..." During an interview in Resident #7's room on 3/24/11 at 9:10 AM, Nurse #1 was asked when Resident #7 stopped walking to the dining room. Nurse #1 stated, "...I'm not sure..." Nurse #1 was asked to clarify that Resident #7 was able to walk to the dining room when she was admitted to the restorative program in 12/10. Nurse #1 stated, "Yes." Nurse #1 was asked if she would consider that a decline. Nurse #1 stated, "Yes." During an interview in Resident #7's room on 3/23/11 at 10:09 AM, the Minimum Data Set (MDS) coordinator verified that there was no body alarm on Resident #7's chair. The failure to ensure adequate interventions were implemented after a fall on 11/9/10, resulted in actual harm when Resident #7 fell on [DATE] and required medical intervention with sutures to her head. 2. Observation in Resident #5's room on 3/21/11 at 3:00 PM revealed, an open beside table drawer containing 2 bottles of skin cleanser. The label on the skin cleanser documented, "...personal cleanser - no rinse... Antimicrobial skin cleanser. Keep out of reach of children. In case of accidental ingestion get medical help or contact a poison control center immediately. For external use only. Avoid contact with eyes..." During an interview in Resident #5's room on 3/21/11 at 3:50 PM, Nurse #3 was asked where the skin cleanser was usually kept. Nurse #3 stated, "Normally it's kept locked in the supply room." During an interview in the conference room on 3/23/11 at 6:00 PM, the Director of Nursing (DON) stated, "...we do not have a policy for ...chemical storage..." 3. Observations on the 100 hall on 3/22/11 at 9:25 AM, revealed housekeeping cart #1, was out of the housekeeper's sight. The housekeeping cart #1 contained three bottles of foaming medicated handwash. The bottles were labeled for external use only, keep out of the reach of children, and if swallowed get medical help or contact a poison control center right away. During an interview on the 100 hall on 3/22/11 at 9:25 AM, Housekeeper #1 stated, "I normally set it (medicated handwash) there (on the cart)..." 4. Observations during the initial tour on 3/21/11 beginning at 10:30 AM, revealed the following: a. room 201 - an emergency oxygen tank (e tank) sitting on the floor unsecured. b. room 202 - an e tank laying on the bedside chair unsecured. Observations in room 202 on 3/21/11 revealed the following: a. 11:05 AM an e tank unsecured laying in the chair. b. 5:15 PM, an e tank unsecured laying in the floor. During an interview in room 202 on 3/21/11 at 5:15 PM, Nurse #2 stated, "It (e tank) should be (secured) in the closet..." 5. Observations on the 100 and 200 halls on 3/22/11 beginning at 11:30 AM, revealed 12 of 31 wheelchairs with cracked vinyl material on the arm rests and 1 of 7 geriatric chairs with cracked vinyl material. The cracked vinyl posed a potential skin tear risk for the residents using the chairs.

Based on review of the "Tennessee CNA (Certified Nursing Assistant) Candidate Handbook", review of the roster sample matrix (802) and the census and condition form (672) completed by the facility, policy review, medical record review, observations, and interviews, it was determined the facility failed to be administered in a manner that maintained the highest practical physical and psychosocial well being for all residents by failing to identify pain and notify the physician of pain with range of motion (ROM); failed to ensure staff were competent in administration of ROM exercises and Foley catheter care; failed to ensure adequate communication and training was conducted for changes to the abuse policy; failed to ensure the facility was maintained in a manner which prevented the potential for accidents from environmental needs or ensure adequate interventions were put into place to prevent further falls; failed to ensure the kitchen was maintained in in a clean and sanitary manner; failed to ensure there was emergency water and a three day supply of emergency food available; failed to ensure adequate practices were maintained to prevent the potential spread of infections and failed to ensure the Quality Assurance committee identified and assessed concerns for 9 of 20 (Residents 1, 2, 5, 7, 8, 10 , 11, 13 and 16) sampled residents. The failure of administration to identify and address these concerns resulted in actual harm when Resident #2 experienced pain during ROM, actual harm when Resident #7 had a fall with injury after having had a previous fall, and having substandard quality of care for all the residents in the facility by not reviewing and communicating changes to the abuse policy. The findings included: 1. The administration failed to identify and address staff competency in administering ROM to residents without causing pain, that staff were knowledgeable on how to identify pain symptoms, and that staff notified physicians of symptoms of pain when Resident #2 experienced signs and symptoms of pain during ROM by the Restorative Nurse (Nurse #1). The administrative staff failed to ensure staff notified physicians of elevated blood sugars on 12/27/10 and on 1/17/11 for Resident #8. Resident #2 experienced actual harm when the staff did not identify symptoms of pain, did not stop ROM exercises, and did not notify the physician of the pain symptoms. Certified Nursing Assistant (CNA) #7 did not perform appropriate ROM to Resident #13. Refer to F157, F309, and F318. 2. The administration failed to identify and address that adequate communication and training of policy changes were addressed in their abuse policy, which resulted in a substandard quality of care affecting all residents in the building. Staff were not familiar with the policy, and there was no method identified on communication of changes to residents residing at the facility. Refer to F226. 3. The administration failed to identify and address environmental hazards by not securing chemicals, and by not securing portable oxygen tanks for Resident #5 and 11. The staff failed to identify and address fall interventions to ensure adequate interventions were implemented to ensure further falls did not occur. Resident #7 experienced actual harm when she sustained an injury which required medical intervention after a fall. Refer to F323. 4. The administration failed to identify and address unsanitary conditions in the kitchen and did not maintain hot food at 135 degrees Fahrenheit (F) or above. The staff failed to identify and address the need for emergency water to be maintained within the facility, and to ensure that a three day supply of food was maintained in the event of a disaster. Refer to F371, F465, and F466. 5. The administration failed to identify and address infection control practices during wound treatments for Resident #1 and 10, for isolation needs for Resident #16, and during meal service. Refer to F314 and F441. 6. The administration failed to identify and address CNA competency when administering peri-care, Foley catheter care, and ROM exercises. Refer to F498. 7. The administrations failed to ensure the Quality Assurance committee established a method for identifying concerns, developed a process for implementing interventions to identified concerns, and for evaluating the effectiveness of the implementation of a solution when a concern was identified. Refer to F520.

Based on review of the "Tennessee CNA (Certified Nursing Assistant) Candidate Handbook", review of the roster sample matrix (802) and the census and condition form (672) completed by the facility, policy review, medical record review, observations, and interviews, it was determined the facility's administrative staff failed to identify and address quality of care issues such as identifying pain and notifying the physician of pain with range of motion (ROM); failed to ensure staff were competent in administration of ROM exercises and Foley catheter care; failed to ensure adequate communication and training was conducted for changes to the abuse policy; failed to ensure the facility was maintained in a manner which prevented the potential for accidents from environmental needs and to ensure adequate interventions were put into place to prevent further falls; failed to ensure the kitchen was maintained in a clean and sanitary manner providing for emergency water and a three day supply emergency food supply was maintained; and failed to ensure adequate practices were maintained to prevent the potential spread of infections for 9 of 20 (Residents 1, 2, 5, 7, 8, 10 , 11, 13 and 16) sampled residents. The failure of the Quality Assurance (QA) committee to identify and address these concerns resulted in actual harm when Resident #2 experienced pain during ROM and when Resident #7 sustained a fall with injury after having had a previous fall, and resulted in a substandard quality of care for all the residents in the facility by not reviewing and communicating changes to the abuse policy for all the 63 residents residing in the facility. The findings included: 1. The QA committee staff failed to identify and address staff competency in administering ROM to residents without causing pain, staff were knowledgeable on how to identify pain symptoms, and that staff notified physicians of symptoms of pain when Resident #2 experienced signs and symptoms of pain during ROM by the Restorative Nurse (Nurse #1). The administrative staff failed to ensure staff notified physicians of elevated blood sugars on 12/27/10 and on 1/17/11 for Resident #8. Resident #2 experienced actual harm when the staff did not identify symptoms of pain, did not stop ROM exercises due to exhibited pain, and did not notify the physician of the pain symptoms. Certified Nursing Assistant (CNA) #7 did not perform appropriate ROM to Resident #13. Refer to F157, F309, and F318. 2. The QA committee staff failed to identify and address adequate communication and training of policy changes were addressed in their abuse policy, which resulted in a substandard quality of care affecting all residents in the building. Staff were not familiar with the abuse policy, and there was no method identified on communicating changes to residents residing in the facility. Refer to F226. 3. The QA committee staff failed to identify and address environmental hazards by not securing chemicals, and by not securing portable oxygen tanks for Resident #5 and 11. The staff failed to identify and address fall interventions to ensure adequate interventions were implemented to ensure further falls did not occur. Resident #7 experienced actual harm when she sustained an injury which required medical intervention after a fall. Refer to F323. 4. The QA committee staff failed to identify and address unsanitary conditions in the kitchen, including low food temperatures on the tray line. The staff failed to identify and address the need for emergency water to be maintained within the facility, and to ensure that a 3 day supply of meals was maintained in the event of a disaster. Refer to F371, F465, and F466. 5. The QA committee staff failed to identify and address infection control practices during wound treatments for Resident #1 and 10, for isolation needs for Resident #16, and during meal service. Refer to F314 and F441. 6. The QA committee staff failed to identify and address CNA competency when administering peri-care, Foley catheter care, and ROM exercises. Refer to F498. 7. During an interview in the Administrator's office on 3/23/11 at 2:35 PM, the Administrator indicated that she was over the QA committee. The Administrator was asked how the QA committee identifies concerns. The Administrator could not provide a clear answer to the question. The Administrator was not able to provide information on how the committee would address or track a concern once it was identified, and did not provide a process for evaluating the effectiveness of the implementation of a solution if a concern was identified. The Administrator did state that Nurse #2 (Treatment Nurse/Staffing Coordinator) was responsible for monitoring the Certified Nursing Assistants when providing pericare and Foley catheter care.