Every finding on record at Menominee Health Services

Based on observation, interview, and record review, the facility failed to monitor and document wound assessments and measurements for one Resident (#5) of one resident reviewed for pressure injury.Findings include:Resident #5 (R5)On 4/20/26 at 1:51 PM, R5 was observed lying in bed on a low air loss mattress wearing an AFO (ankle foot orthotic - a medical device that supports the foot and ankle). R5 said he did not feel well and had pain in his lower extremity.The electronic medical record (EMR) of R5 disclosed an admission date to the facility on 4/1/22 with a primary diagnosis of paraplegia.A care plan for actual skin impairment dated as initiated 12/25/25 had a goal that read: Wound will show healing without complication as evidenced by decrease in measurements by review date.A Minimum Data Set (MDS) assessment dated [DATE] documented R5 was at risk for the development of pressure injuries but had no unhealed pressure injuries and had no venous or arterial ulcerations.A Nursing progress note dated 12/25/25 at 1:27 PM documented, in part: During routine cares resident is found to have a 1 cm [centimeter] x [by] 2 cm scabbed area to right outer ankle. New orders are received to apply Betadine bid [twice daily] to site until resolved.A progress note on 12/30/25 at 9:23 PM documented, in part: .Betadine applied to area on right lateral lower leg above malleolus [ankle].Area measures 1.0 cm x 0.5 cm and consists of intact dry, hard black skin present, with a non-blanchable with red peri wound [sic].A progress note on 3/22/26 at 9:53 PM documented, in part: .Dr. [physician's name redacted] saw [name of R5] today. Assessment included decubitus ulcer [outdated term for pressure injury] on right lateral leg over lateral boney area .Despite numerous progress notes from 12/30/25 through 4/7/25 that referenced the presence of a wound on the right lower lateral extremity of R5, there were no documented measurements, descriptions, or assessments of the wound from 12/30/25 until 4/7/26 when a document titled Pressure Injury Weekly Tracker - V3 was implemented. The pressure injury document on 4/7/26 assessed the wound on R5's right lower lateral extremity as a stage 3 pressure injury (full thickness loss of skin) measuring 6.4 cm x 2.5 cm x 0.5 cm (length, width, depth respectively). The wound was described as containing 30% slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) and 20% necrotic tissue (dead or devitalized tissue). The document revealed R5 was prescribed two, 10-day courses of antibiotics in March 2026 due to infection in the wound.A subsequent assessment of the pressure injury was completed on 4/14/26 and documented measurements of 6.4 cm x 2.6 cm x 0.5 cm with 75% slough and 25% necrotic tissue. Additionally, a new wound was identified in proximity to the pressure injury. The wound assessment documented, in part: .Scab area 1.8 cm long attached to wound.A pressure injury assessment dated [DATE] documented, in part: .RLE [right lower extremity] has contractures, manipulation of knee and ankle cause pain with repositioning. Wound painful with touch.On 4/22/26 at 11:55 AM, Licensed Practical Nurse (LPN) G and Registered Nurse (RN) E were observed completing an assessment and dressing change on R5's RLE pressure injury. The wound measured 6.5 cm x 2.6 cm x 0.6 cm with necrotic tissue evident in the wound bed. Tunneling (passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) and undermining (destruction of tissue or ulceration extending under the skin edges) were evident.There appeared to be an eschar covered wound superior to the area. LPN G said the wound was being reviewed as one total area. The superior eschar-covered wound was measured at 2.0 cm x 0.9 cm.The Director of Nursing (DON) and RN A were interviewed on 4/22/26 at 10:13 AM. When asked if wound assessments were completed prior to 4/7/26, RN A confirmed there were no documented wound assessments of the wound on R5's lateral RLE until 4/7/26. The DON said the expectation was for nurses to document wound assessments weekly. She said a past noncompliance (PNC - facility-identified noncompliance with regulatory requirements) was implemented on 4/10/26 to address the concern with wound assessment documentation.The PNC was reviewed. No documented audits or monitoring for compliance with the expectation had been completed. The DON said they did not have evidence of monitoring or a tracking form. The DON said the PNC had not yet been proposed to the QAPI (Quality Assessment Performance Improvement) committee (leadership team responsible for developing, implementing, and maintaining improvement programs for resident quality of care and quality of life).The policy Pressure injuries and Non Pressure Injuries dated as reviewed/revised 7/20/22 read, in part: . For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. Assess current wounds at least every seven days, or more frequently as needed .

Based on observation, interview, and record review, the facility failed to: 1. Accurately identify wounds as pressure injuries 2. Document accurately on wound types, and 3. Develop a care plan for pressure injuries, for one Resident (#11) of one resident reviewed for pressure injuries. Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted. Resident #11 (R11) R11 was admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction (stroke). According to a quarterly Minimum Data Set (MDS) assessment dated [DATE], R11 was at-risk for developing pressure injuries but did not have pressure injuries. The MDS coded R11 as having diabetic foot ulcers. On 3/10/25 at 3:45 PM, R11 was observed lying in bed with both heels lying directly on the mattress of the bed. A pair of pressure-reduction boots were observed laying in a chair in the room. On 3/10/25 at 4:41 PM, and on 3/11/25 at 7:30 AM additional observations of R11 were made with both heels directly on the mattress and the pressure-reduction boots laying in a chair in the room . A review of R11's Electronic Medical Record (EMR) revealed a physician's order for dressings to R11's right heel and the lateral plantar (bottom) portion of the right foot. There was no physician's order for pressure-reduction boots. A care plan for pressure injuries was not present in R11's medical record. An impaired skin integrity care plan was reviewed that read, in part: . [R11] has actual impairment to skin integrity, DM (diabetes mellitus)/non-pressure wounds to right heel and right lateral plantar area of foot . The care plan did not include pressure-reduction boots or directions indicating where and when pressure-reduction boots should be applied or removed. On 3/10/25 at approximately 1:23 PM, Regional Nurse J said R11's wound assessments were in the EMR under the non-pressure assessments because R11's wounds were not pressure injuries. Regional Nurse J said R11's wounds were diabetic ulcers. Review of the wound assessment form Non-Pressure Weekly Tracker dated 11/12/24 documented R11 developed a facility-acquired wound on the right heel on 11/9/24. The type of wound was documented as diabetic (neuropathic) ulcer. No documentation was found for the assessment of the wound when it was first identified on 11/9/24. Subsequent facility wound assessments of the right heel dated 11/26/24, 12/3/24, 12/10/24, 12/17/24, 12/24/24, 12/31/24, 1/7/25, 1/14/25, 1/21/25, 1/28/25, 2/4/25, 2/11/25, 2/18/25, 2/25/25, and 3/4/25 documented the wound on the right heel was a diabetic ulcer. Further review of wound documentation indicated R11 developed a facility-acquired right plantar wound on 1/7/25. The type of wound was documented as diabetic (neuropathic) ulcer. Facility wound assessments on 1/14/25, 1/21/25, 1/28/25, 2/4/25, 2/11/25, 2/18/25, 2/25/25, and 3/4/25 documented the wound on the right plantar was a diabetic ulcer. The EMR revealed R11 attended the wound clinic for the wounds on the right foot. Wound clinic documentation dated 12/5/24 documented in part .Pressure injury of right heel, stage 3 . Pressure injury of right foot, stage 3 . Wound clinic reports for the wounds on R11's foot dated 1/16/25, 1/23/25, 1/30/25, 2/6/25, 2/13/25, 2/21/25, 2/27/25, and 3/6/25 documented the right foot wounds as: stage 3 pressure injuries (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present). Handwritten documentation by R11's attending physician was scanned into the EMR. Physician documentation dated 1/8/25 read, in part: . Draining wound right heel, plantar surface. Severe ulcers despite wound clinic .Stage III [3] heel, unstageable distal right lateral foot with ulceration . The attending physician for R11 documented on 1/13/25, in part: . decubitus [pressure injury] right (illegible handwriting) and heel . The Director of Nursing was unavailable during survey. The Administrator (NHA) said clinical questions were to be referred to RN J or RN C. The NHA said RN C was the wound nurse and Infection Preventionist. RN C was interviewed on 3/11/25 at 10:04 AM. When asked about R11's wounds, RN C said R11 had non-pressure, diabetic wounds on the right heel and right lateral plantar surface of the right foot. RN C said R11 was expected to have both heels floated (pillows placed under the legs to lift the heels from the mattress) because he spilled coffee on his pressure-reduction boots over the weekend, so the boots were sent to the laundry. RN C said R11 went to the wound clinic and floor nurses were responsible for reviewing documentation from the wound clinic. Dressing changes were observed being completed by RN C on 3/11/25 at 11:22 AM. R11 had a stage 3 pressure injury on the right heel measuring approximately 0.5 centimeters (cm) long and 0.3 cm wide, and a stage 3 pressure injury on the lateral right plantar measuring approximately 0.7 cm long and 0.9 cm wide. When asked how R11's wounds were determined to be non-pressure diabetic wounds, RN C answered R11 was diabetic and went to dialysis. When asked if the wounds appeared as diabetic wounds, RN responded, I don't know how to describe them. They're not very big. Wound clinic documentation was reviewed with RN C on 3/11/25 at 11:40 AM. RN C admitted she had not read the wound clinic reports documenting the wounds as stage 3 pressure injuries and she had been erroneously documenting them weekly as diabetic wounds. RN C said R11's attending physician said the wounds were diabetic wounds. RN C was shown R11's attending physician's documentation of 1/8/25 and 1/13/25. RN C did not provide a comment regarding the documentation.

Based on observation, interview, and record review, the facility failed to provide the care and services to monitor and maintain acceptable parameters of nutritional status for two residents (R11 and R22) of three residents reviewed for nutritional concerns. This deficient practice resulted in the potential for fluid imbalance for R11 and unaddressed weight loss for R22. Findings include: All times are recorded in Eastern Daylight Time (EDT) unless otherwise noted. Resident #11 (R11) R11 was admitted [DATE] with diagnoses including stroke, dementia, diabetes, and dependence on renal dialysis. The diet order for R11 included a specialized renal diet with consistent carbohydrates and a 1500 ml (milliliters or cc cubic centimeters) fluid restriction per day. On 3/12/25 at 12:30 PM, the lunch meal tray for R11 was observed. The tray contained a 240 cc coffee and a 120 cc apple juice. The supper meal ticket was observed to have planned beverages including a 240 cc coffee and a 120 cc apple juice. The total fluids planned and served by the dietary department for each lunch equaled 360 cc and for each supper equaled 360 cc. The facility did not have an individualized plan for the allotment of the 1500 cc fluid restriction for R11. There was no guidance by the physician, nursing personnel or Registered Dietitian on the division of the fluids between the dietary department (with meals) and the nursing department (for fluids with medication pass and at bedside). The facility presented a form titled Fluid Restriction Template which indicated a plan for any residents on a 1500 cc fluid restriction was to be divided as follows 300 cc AM nursing, 200 cc PM nursing, 60 cc NOC (at night), 360 cc with breakfast, 240 cc with lunch and supper. The observed tray card plan exceeded the Fluid Restriction Template serving 360 cc at lunch and supper rather than the planned 240 cc at lunch and supper. A progress note was entered by Registered Dietitian (RD) K on 2/28/2025 at 9:22 AM included documentation of the fluid restriction but did not coordinate the amounts and times of the fluids to be given to R11. The progress note read, Nutrition/Dietary Note . RD Note . Continues with CCHO (consistent carbohydrate) Renal diet and 1500 cc FR (fluid restriction). Continues with phos (phosphorus) binder. Meal intakes avg (average) 50-100%. It was noted that resident ate meal in dining room on 2/27/25 with improved intakes noted. Continue to encourage resident to eat meals in dining room to optimize oral intakes/nutritional status. No new nutritional concerns/recommendations. Continue to monitor and follow up as needed. The care plan for R11 reviewed 3/11/25 included a focus of, At risk for nutritional status change r/t (related to) diabetes, end stage renal disease - on dialysis, on diuretics, potential for weight changes, wound to right foot. The interventions included: - Eating - independent - Fluid restriction as ordered, 1500 ml/24 hours - Offer large portions - Offer protein rich snack BID (twice daily) - Provide diet as ordered - CCHO Renal, regular texture, thin consistency. - Record weight per facility protocol - Review weights and notify RD, MD (physician), and responsible party of significant weight change - See tray card for specific food preferences. The Certified Nurse Aide (CNA) task list for amount of fluids taken was reviewed. On 2/10/25 and on 2/16/25 the fluid restriction was exceeded for R11 with 1920 cc fluids documented as given by the CNAs. These totals did not include the fluids given by the nurse with medications. During a telephone interview on 3/11/25 at 2:07 PM, RD K: stated she had not divided the 1500 cc fluid restriction between the dietary and nursing departments. She was not aware of the amount of fluid R11 was receiving. On 3/11/25 at 2:49 PM, Regional Registered Nurse (RN) J said there was a breakdown in the facility with this expectation. RN J added it was expected the facility nurse would coordinate with dietary and would designate the fluids between departments in the physician's fluid restriction orders. RN J said, We were certainly not doing the best documentation, and we will be focusing and working on this. The policy Fluid Restriction dated as implemented 7/21/22 read, in part: .The food and nutrition services department and the nursing department will determine how much fluid will be provided at meals and medication passes. Resident #22 (R22) On 3/9/25 at 2:04 PM, R22 was observed in the dining room being fed lunch by his wife. His wife stated the resident could not always fed himself, so she assisted him. She said his (R22) hands do not always work. On 3/10/25 at 9:15 AM, R22 was observed in the dining room being fed breakfast by staff. The electronic medical record indicated the following recorded weights for R22: - 11/2/24 - 216 pounds - 11/4/24 216 pounds - 12/1/24 - 215.5 pounds - 12/5/24 - 215.5 pounds - 1/1/25 - 213 pounds - 2/1/25 - 207 pounds - 3/5/25 - 195.5 pounds The Nutrition Assessment Note dated 2/20/25, noted a Current weight: 207.0 lb (pounds) . Gradual weight change present. Wt Hx (weight history) 1 mo (month) ago: 213# (pounds). There was no re-weight for the six pound weight loss from 1/2025 to 2/2025 or the 11.5 pound weight loss from 2/2025 to 3/2025. The care plan for R22 included a focus of at risk for nutritional status change including weight changes. The goal for this focus was R22 will maintain weight. This care plan included interventions of: - Record weight per facility protocol/MD orders and Review weights and - Notify RD, MD, and responsible party of significant weight change. During a telephone interview on 3/11/25 at 2:07 PM, RD K: stated there were At Risk resident meetings weekly on Wednesdays where weight loss was a part of the discussion. The RD confirmed they had written a nutrition progress note on 3/5/25 (the date of the last weight) but no recommendations to re-check the weight or any additional interventions had been made. RD K stated the expectation was weights were taken by the 7th of the month with re-weight taken if there was a five pound variance as soon as possible. RD K discussed the 12 pound weight loss recorded for R22 and stated they would not expect to wait six days to re-check the weight. RD K stated, I don't recall if we reviewed (R22) in the At Risk meeting. I notified them (the facility) on Saturday (3/8/25) for a reweigh. No follow up weight had been obtained. The facility policy titled Weight Monitoring and dated as last Reviewed/Revised on 12/21/2022 did have a statement of Any weight change of five (5) pounds or more since the last weight assessment will be retaken for confirmation. However, there were no parameters of the timeframe for this assessment.

Based on observation, interview, and record review, the facility failed to update infection control policies annually and implement appropriate infection prevention and control practices for two Residents (R28 and R4) of six residents reviewed for infection control. Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted. Resident #28 (R28) was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R28 was free from infections and had no pulmonary conditions or diseases. The MDS documented R28 had received the seasonal influenza vaccination on 10/18/24. According to a nurse's progress note in the Electronic Medical Record (EMR) dated 3/10/25 at 12:57 PM CT (Central Time), R28 experienced a cough with gray-colored sputum, chills, weakness, and decreased appetite. R28's physician ordered a Quad respiratory pathogen panel (a laboratory test for four respiratory pathogens). A nurse progress note on 3/10/25 at 2:36 PM CT documented R28 tested positive for influenza type A (a contagious viral respiratory infection that can lead to serious medical and health outcomes including death). On 3/11/25 at 8:57 AM, R28 was observed in his room lying in bed. The door to the room was open and did not contain signage indicating R28 was in Transmission-Based Precautions (TBP - isolation) for a transmissible respiratory illness. R28 had a room mate who was occupying the other bed in the room. The Administrator (NHA) was asked on 3/11/25 at 8:57 AM how staff and visitors were aware R28 had a contagious respiratory illness. The NHA said R28 should have a posting for isolation precautions on the door to the room. The NHA was informed the posting was not present. When asked if the facility posted signage at the entrance door to make visitors aware a contagious respiratory illness had been identified in the building and to instruct visitors on recommended infection control precautions while visiting, the NHA said they only post precautionary information at the entrance door when COVID-19 was identified in the facility. The door to R28's room was observed open on 3/11/25 at 8:57 AM, 11:20 AM, 11:44 AM, 2:36 PM, and 4:26 PM. Review of R28's EMR revealed no physician's order for droplet precautions (TBP for residents with known or suspected infectious pathogens transmitted by respiratory droplets). The physician ordered an antibiotic medication on 3/10/25 but there was no order for any antiviral medication. The antibiotic medication read, Give 1 tablet by mouth one time a day for influenza A . On 3/11/25 at 9:36 AM, during an interview, Infection Preventionist (Registered Nurse (RN) C) said a posting should be placed at the entrance door to let visitors know a contagious respiratory illness was identified in the facility and masks were encouraged while visiting and to perform hand hygiene upon entering and exiting the facility. RN C said residents with influenza should be placed on droplet precautions. RN C confirmed signage should be posted on the door of R28's room indicating droplet precautions, a physician's order was required to put a resident in any type of TBP, and infections should be care planned. When asked why an antibiotic medication was ordered instead of an antiviral medication, RN C said she was not aware an antibiotic had been ordered but said she would contact R28's physician. RN C stated the door to the room of a resident on droplet precautions for influenza A should remain closed unless closing the door was contraindicated for a resident's safety according to the resident's care plan. RN C did not say R28 required the door to the room to be open for safety. RN C confirmed the roommate of R28 had not tested positive for any respiratory illness including influenza A. RN C acknowledged unoccupied rooms were available in the facility. When asked why R28 had not been provided one of the unoccupied rooms when influenza A was identified, RN C said that decision was not hers to make. RN C confirmed she had never seen that done in the facility and said, but it would be a best practice. R28 did not have a care plan for influenza to direct staff on interventions to help prevent the spread of respiratory pathogens to other residents and staff. None of R28's care plans included a need to keep the door of the room open. R28's physician was interviewed on 3/11/25 at 3:37 PM. The physician stated an antibiotic was ordered for R28 due to suspected presence of a secondary infection that was most-likely bacterial in nature. The physician confirmed antiviral therapy was not started after R28 was identified with influenza A. Review of infection prevention and control policies disclosed the policies were not updated or reviewed annually. The policy Infection Outbreak Response and Investigation was dated as last reviewed/revised on 2/26/23. The policy COVID-19 Prevention, Response and Reporting was dated as last reviewed/revised on 5/18/23. The policy Antibiotic Stewardship Program was dated as last reviewed/revised on 11/18/22. The Centers for Disease Control (CDC) guidelines Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities (www.cdc.gov/flu/hcp/infection-control/ltc-facility-guidance.html) state, in part: . once a single laboratory-confirmed case of influenza has been identified in a resident, it is likely there are other cases among exposed persons . Implement Droplet Precautions . Droplet Precautions include: Placing ill residents in a private room. If a private room is not available, place (cohort) residents suspected of having influenza with one another . All long-term care facility residents who have confirmed or suspected influenza should receive antiviral treatment immediately. Initiation of antiviral treatment should not wait for laboratory confirmation of influenza . The policy Influenza Exposure Control dated as implemented 9/23/24 read, in part: .Droplet Precautions shall be implemented for residents with suspected or confirmed influenza . Request to limit visitation and exclude ill persons from visiting the facility via posted notices . The policy Transmission-Based (Isolation) Precautions dated as reviewed/revised on 9/24/24 read, in part: . The facility will use standard approaches, as defined by the CDC, for transmission-based precautions .When implementing transmission-based precautions, the facility will consider the following: . b. The provision of a private room as available/appropriate; c. Cohorting residents with the same pathogen . Visitors coming to visit a resident who is on transmission-based precautions or quarantine, will be informed by the facility of the potential risk of visiting and precautions necessary when visiting the resident .Signage that includes instructions for use of specific PPE (Personal Protective Equipment) will be placed in a conspicuous location outside the resident's room, wing, or facility wide . Droplet Precautions: . b. A private room is preferential, but if not available, the resident can be cohorted with a resident with the same infectious agent . 35981 Resident #4 (R4) Review of an Admission Record revealed R4 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: malnutrition. Review of the MDS assessment for R4, with a reference date of 1/9/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating R4 was cognitively intact. On 3/9/25 at 9:00 AM., during an observation, Registered Nurse (RN) A was setting up R4's medications to administer via G-Tube (gastrointestinal tube-for nutritional feeding and medications). RN A donned Personal Protective Equipment (PPE) including a gown, gloves and a surgical mask, while outside of R2's room. R4 had a sign on his door which indicated he was on Enhanced Barrier Precautions (EBP-Contact Precautions) due to having a G-Tube in place. While RN A was setting up R4's medication wearing the gloves she had put on, she opened the laptop computer, grabbing the control mouse to access the computers Electronic Medical Record (EMR) to view R4s medication orders. RN A grabbed the medication cart keys from her pocket, unlocked the medication cart, and opened the 2nd drawer pulling R2's medication cards out. RN A proceeded to open each medication to dispense into small clear medication cups. RN A wore the same gloves to unlock the narcotic drawer pulling out a medication and placing it into the small medication cups. RN A realized the narcotic count sheets in a 3-ring binder/book was not on the medication cart. RN A then walked to nurse's station wearing the gown, gloves and mask. RN A returned to the medication cart holding the narcotic book. The book was noted to be visibly soiled and was visibly old and worn. RN A grabbed onto the tab inside for R4's narcotic medication count sheet, proceeded to grab a pen from the top of the medication cart, and signed out the medication. RN A at no time changed the gloves she had initially put on. RN A then used the same gloves to reach into the med cart, drawing up a liquid medication with a syringe and dispensing it into the small med cup. RN A finished with the setup of R4's medications, grabbed the cups and a water cup, and entered R4's room. RN A then proceeded with the same gloves on to lift R4's shirt up to expose the G-Tube. RN A then grabbed her stethoscope from around her neck, placed the ear pieces into her ears and without cleaning it, she placed the end of it on R4s upper quadrant of his stomach to check placement of the G-Tube. RN A then put the stethoscope back around her neck. RN A took the opening of the G-Tube, uncapped it, pulling back on syringe she had inserted into it to check for residual (stomach contents). Once RN A pulled the syringe out of the opening of the G-Tube, liquid (stomach content) leaked out of the syringe onto R4s upper pant leg. RN A then began to administer R4's medication via his G-Tube. RN A at no time, changed her gloves or performed hand hygiene during this process. After administering R4's medication RN A cleaned up the supplies and placed them in a container in R4's room for future use. RN A then exited R4's room after taking her gloves, gown and mask off. RN A took her stethoscope from around her neck and hung it on the end of the medication cart. RN A did not sanitize the stethoscope nor use an appropriate amount of hand sanitizer to cover her entire hands, nor did RN A wash her hands with soap and water. In an interview on 3/10/25 at 10:10 AM., RN A reported R4 was in Enhanced Barrier Precautions (EBP) because of the feeding/G-tube. After being asked what the protocol was for EBP use for a resident on Contact Precautions-EBP and overall infection control measures, RN A reported she should have ensured she did not have PPE on while walking in hallway to the nurses' station, nor should she have used the same gloves as long as she did. RN A reported she should have taken her gloves off while setting up the medications, using hand sanitizer along the way. RN A reported that was not properly donning/doffing PPE per policy or proper infection control techniques. RN A reported she wasn't thinking about it when she was setting up the medications for R4, she was just trying to get through her medication pass. Review of a facility Policy and Procedure titled Transmission-Based (Isolation) Precautions with a revision date of 9/24/2024 revealed: Policy: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. For training and quick referencing purposes, a summary of precautions is contained at the end of this policy Definitions: Airborne precautions refer to actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infectious over long distances when suspended in the air . Droplet precautions refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Transmission-based precautions (a.k.a. Isolation Precautions) refer to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact and droplet) in order to prevent or control infections .10. Contact Precautions- a. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. b. Make decisions regarding private room on case-by-case basis, balancing infection risks to other residents, the presence of risk factors that increase the likelihood of transmission, and the potential adverse psychological impact on the infected or colonized resident. c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g. VRE (Vancomycin Resistant Enterococcus [bacteria difficult to treat with antibiotics]), C. difficile (Clostridium difficile [infection of the bowel]), noroviruses (respiratory viral infections) and other intestinal tract pathogens, RSV (Respiratory Syncitial Virus [respiratory virus]). e. Residents experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, should be placed on contact precautions even before a specific organism has been identified. f. Contact precautions will be used for residents infected or colonized with MDROs (Multi-drug resistant organisms) in the following situations: i. When a resident has wounds, secretions, or excretions that are unable to be covered or contained; and ii. On units or in facilities where, despite attempts to control the spread of the MDRO, ongoing transmission is occurring .

Based on interview and record review the facility failed to employ a full time dietitian, certified dietary manager or a certified food service manager to manage the food service department. Findings include: (All reported times are in EDT) On 4/2/24 at approximately 8:15 AM, an interview was conducted with Kitchen Manager (KM) A about her certification as a dietary manager. KM A stated she had not completed the Certified Dietary Manager's (CDM) course work, nor had begun or signed up for the course. Additionally, KM A stated she had no other food service training likened to a Certified Food Manager, Serve Safe certification or other. KM A stated the Registered Dietitian (RD) did not provide consultation on food service sanitation or other kitchen issues, rather, focused efforts on clinical needs. On 4/3/24 at approximately 1:30 PM, an interview with the Nursing Home Administrator (NHA) confirmed that the RD provided clinical support to the facility. A document provided by the NHA documenting the RD hours for the facility demonstrated the RD was on-site in the building a total of 13 hours for the three months January, February, and March 2024.

Based on observation, interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skill to carry out the functions of the food and nutrition services. Findings include: (All reported times in EDT) On 4/2/24 at approximately 8:15 AM, an interview was conducted with Kitchen Manager (KM) A about her certification as a dietary manager. KM A stated she had not completed the Certified Dietary Manager's (CDM) course work, nor had begun or signed up for the course. Additionally, KM A stated she had no other food service training likened to a Certified Food Manager, Serve Safe certification or other. On 4/2/24 between 8:00 AM and 10:30 AM continued interviews were conducted with KM A and learned she was not familiar with the testing of the sanitizing solutions used in the three compartment sink and spray bottles used on food preparation surfaces, was not familiar with the chemicals used as sanitizing agents in the kitchen, stated staff were not using cooling logs to track left over foods being cooled to be served at a later date. On 4/2/24 at approximately 11:15 AM, KM A was observed operating the mechanical dish machine. KM A was observed going from the soiled end to the clean end and handling clean dishes without washing her hands in between tasks. An interview was conducted at this time with KM A stating We just don't have the staff to get this done. A review of the facility's employee list revealed the kitchen had only 6 people to perform dietary services, which includes: food preparation, food service, dish washing, kitchen cleaning, food ordering, food storage, ordering and other tasks necessary to operate a kitchen.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: (All reported times are in EDT) On 4/2/24 at approximately 7:30 AM, during the initial observation period in the kitchen, a 2 gallon Lexan container was observed in the Traulsen refrigerator. A label on the top identified the contents as Spag sauce and had a date of 3/31 then UB (use by) or Freeze by 4/3. An interview with Kitchen Manager (KM) A was conducted at this time and learned the cook responsible for putting the product had not documented the cooling process. KM A stated she was working on making a form for staff to follow. On 4/3/24 at approximately 2:30 PM, the same container was observed in the same refrigerator. An interview was conducted with KM A at this time who stated that it would be discarded. At 3:30 PM, KM A reported the product had been discarded. On 4/2/24 at approximately 8:30 AM two buckets with wiping cloths were observed on a food preparation table in the kitchen. An interview with KM A revealed that one bucket contained a detergent and water mixture and the other a clear water. When asked about sanitizing solution, KM A pointed to and lifted a spray bottle and stated that staff sprayed the work surfaces with it and it was the sanitizer. When asked if the product was pre-mixed and ready-to-use (RTU), KM A stated yes. When further questioned, it was learned the contents of the bottle were filled with a mixing dispenser located at the three compartment sink, which was a quaternary ammonium product. KM A was requested to test the solution but was unable to locate any test strips. When the contents of the spray bottle were tested , using QAC test strips, (provided by the surveyor) the result was 0 (zero) parts per million (PPM). The dispenser was activated at the three compartment sink, a container filled and tested with a new QAC test strip. The result showed the absence of any level of sanitizer. A review of the bottle of Quat revealed that a concentration of between 200 and 400 ppm were to be present to provide a proper sanitizing solution. On 4/3/24 at approximately 7:30 AM an interview was conducted with KM A related to the sanitizer used in the spray bottle. KM A explained that she had filled the bottle at the housekeeper's sink dispenser down the hall. When asked what the chemical being used to sanitize, KM A did not know. When asked if she knew what the proper concentration of the chemical was for sanitizing, she did not know. When asked if there were test strips available to test the concentration of the chemical, she did not know. It was learned the chemical was a hydrogen peroxide, dispensed from a housekeeping closet from a mixing dispenser. No information was available related to the proper concentration of the peroxide for food service use. On 4/2/24 at approximately 10:15 AM, KM A was observed conducting dish washing operations in the kitchen at the mechanical dish machine. KM A was observed to go from handling the soiled dishes from returned resident trays to the clean end, removing dishes from the racks after exiting the machine, without washing her hands. When asked if she knew what she had done in the situation, KMA acknowledged she had not washed her hands between functions. KM A further stated that due to the limited staff in the kitchen appropriate procedures were missed. On 4/2/24 at approximately 7:45 AM Cook B was observed to have dropped a plastic container on the floor, proceeded to pick it up, take it to the dish machine area, then return to preparing the meal, without washing her hands. On 4/2/24 at approximately 10:25 AM KM A was requested to demonstrate proper sanitizing by the mechanical dish machine. A [NAME] digital maximum registering thermometer (MRT) was placed on a rack and placed into the machine. At the end of the cycle the MRT was removed and reported the temperature of sanitization was 145.7 F. When asked what the appropriate action would be, KM A stated she was not sure. The MRT was run an additional two cycles with similar results. KM A was asked if there were other mechanisms to test the machine. KM A produced test strips rated at 180 F. One of the strips was placed in the machine and allowed to run the entire cycle. When the dish machine was opened, the strip could not be located. It was explained these strips were not appropriate for testing the sanitizing cycle, in that, they confirmed the temperature of the water and not the temperature of the food contact surface. KM A stated she was not aware of this condition or procedure. KM A could not produce any previous logs demonstrating proper sanitizing of the machine. At 10:45 AM this surveyor returned to the kitchen and produced adhesive Thermolabels which were placed on a plate and allowed to run the entire cycle. Proper sanitizing was demonstrated using an appropriate and reliable test procedure. KM A was not aware of what the appropriate corrective action was necessary once the MRT did not validate the machine was properly sanitizing the food contact surfaces. KM A did not make any effort to re-wash the dishes that had been washed prior to the machine being identified as having a final rinse/food contact surface temperature of 160 F. KM A was not able to produce any testing mechanism which reliably ensured the dish machine was properly sanitizing food contact surfaces. On 4/2/24 at approximately 2:30 PM, the Folgers coffee machine located in the kitchen was observed to have a direct connection to the potable water supply. An approved (A.S.S.E. 1022) backflow preventer was not observed between the connection to the supply and the machine. On the back of the machine was stamped the following instructions to the installer: This dispenser is to be installed with adequate back flow protection to comply with local, state and federal regulations. On 4/3/24 at approximately 8:30 AM, an interview was conducted with Maintenance Supervisor (MS) C. MS C produced a picture on his phone showing a device on the water supply line. MS C stated there is an arrow on it, that what it is meaning an approved back flow prevention device. The device did not meet the standards for an approved back flow prevention device. On all days of the survey, (4/2 to 4/3/24) two hand sinks observed in the main kitchen (near the dietary office) and one near the dish washing room were noted to be constantly running. The faucets were unable to be shut off. An interview with Cook B revealed this condition had been ongoing for over two years. The FDA Food Code 2017 states: 2-102.11 Demonstration. Based on the RISKS inherent to the FOOD operation, during inspections and upon request the PERSON IN CHARGE shall demonstrate to the REGULATORY AUTHORITY knowledge of foodborne disease prevention, application of the HAZARD Analysis and CRITICAL CONTROL POINT principles, and the requirements of this Code. The PERSON IN CHARGE shall demonstrate this knowledge by: (A) Complying with this Code by having no violations of PRIORITY ITEMS during the current inspection; Pf (B) Being a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM; Pf or (C) Responding correctly to the inspector's questions as they relate to the specific FOOD operation. The areas of knowledge include: (1) Describing the relationship between the prevention of foodborne disease and the personal hygiene of a FOOD EMPLOYEE; Pf (11) Explaining correct procedures for cleaning and SANITIZING UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT; Pf 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands.P 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing. (A) In manual WAREWASHING operations, a TEMPERATURE MEASURING DEVICE shall be provided and readily accessible for frequently measuring the washing and SANITIZING temperatures. Pf (B) In hot water mechanical WAREWASHING operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the UTENSIL surface temperature.P 4-302.14 Sanitizing Solutions, Testing Devices. A test kit or other device that accurately measures the concentration in MG/L of SANITIZING solutions shall be provided. 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 5-202.14 Backflow Prevention Device, Design Standard. A backflow or backsiphonage prevention device installed on a water supply system shall meet American Society of Sanitary Engineering (A.S.S.E.) standards for construction, installation, maintenance, inspection, and testing for that specific application and type of device. P 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair.

Based on observation, Interview, and record review, the facility failed to perform process and outcome surveillance for all 34 facility residents. This deficient practice possibly contributed to an outbreak of Covid-19 resulting in the infection of 15 residents. Findings include: (All times are recorded in Eastern Daylight Time) On 4/2/24 at 7:18 AM, the facility door was observed to have a sign indicating there was a current Covid-19 outbreak in the facility. The Director of Nursing (DON) stated the Covid-19 outbreak included 15 residents and had begun with one Covid-19 positive resident on 3/28/24. On 4/3/24 at approximately 9:00 AM, the DON (who was also functioning as the facility Infection Preventionist [IP]) was interviewed on the infection control practices of the building. The DON/IP was asked about the tracking and trending of infections. The Covid-19 outbreak had started in March and the DON/IP was asked about her March tracking. She replied, I did not do my March infection control yet. We have QAPI (the Quality Assurance Performance Improvement meeting) on the third Tuesday of the month. I pull everything together from the previous month on the second or third week (to prepare for that meeting.) The facility did not have ongoing analysis of surveillance data and documentation of follow up activity in response to infections. The facility did not have real time tracking or a system of surveillance designed to identify possible communicable diseases or infections before they could spread to other persons in the facility. The policy titled: Infection Prevention and Control Program dated as reviewed/revised on 3/14/2023, read in part: . A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. On 4/2/24 at 9:20 AM, Administrative Staff D was observed to remove a breakfast meal tray from the food cart and carry it into R22's room. This room had signage on the doorway indicating Personal Protective Equipment (PPE) should be worn into the room as R22 was Covid-19 positive. Staff D did not put on a protective gown, nor face shield, nor gloves. When Staff D exited the room the door signage was pointed out and Staff D was asked if she should have worn PPE into the Covid-19 positive room. Staff D replied, Oh yes, I did not even realize he is positive. I have been gone from work. The policy titled: Infection Prevention and Control Program dated as reviewed/revised on 3/14/2023, read in part: Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. The policy titled: Personal Protective Equipment dated as reviewed/revised on 3/17/2023, read in part: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Definitions: Personal protective equipment, or PPE, refers to a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with pathogens. It includes gloves, gowns, face protection (facemasks, goggles, or face shields), and respiratory protection (respirators). Policy Explanation and Compliance Guidelines: 1. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. 2. PPE will be utilized as part of standard precautions regardless of a resident's suspected or confirmed infection status. 35103 During an observation on 4/2/24 at 7:42 a.m., CNA K exited room [ROOM NUMBER] wearing only an N95 face mask. CNA K removed the N95 mask with bare hands, set the dirty N95 mask on top of the PPE cart outside of room [ROOM NUMBER]. CNA D used her contaminated hands to go through the clean masks on the PPE cart to get a new surgical mask and placed it on her head. CNA K picked up the dirty N95 face mask by touching the front of the mask with her bare hands, picked up plastic bags, and a piece of garbage from the floor. CNA K walked down the entire length of the hall with the dirty PPE (in a plastic bag) and garbage in her bare hands to dispose of the garbage near the kitchen. CNA K returned back down the 300-hall and was not observed to complete hand hygiene anywhere during the above observation. During an interview at this same time, CNA K confirmed she had removed her dirty N95 face mask with bare hands and contaminated her hands. She had not performed hand hygiene since touching the dirty mask and the garbage. CNA K said she should have performed hand hygiene after picking up the garbage from the floor but acknowledged she had not done that. During an observation on 4/2/24 at 9:30 a.m., Maintenance Director (Staff) C exited a COVID positive room on the 300-hall wearing a face shield and face mask. Staff C was observed placing the face shield back on his head as he exited the room. Staff C did not disinfect the face shield following room exit. During an interview at this same time, when asked what he would do to the faceshield when he exited the room of a COVID-19 positive resident after delivering a meal tray into the room, Staff C stated, I probably need to sanitize it. I will get some wipes. During an observation on 4/02/24 at 12:50 p.m., CNA N exited a Covid positive resident room, removed all PPE, but did not perform hand hygiene. CNA N reached into the clean PPE supplies with contaminated hands. CNA N donned a new surgical mask and reached into the Covid-19 positive room and removed the partially eaten meal try from the room. The meal tray was removed with bare hands, and the tray rested on the front of her scrub uniform as she walked the meal tray down the hall to the kitchen. Signage posted on the PPE bin How to Safely Remove Personal Protective Equipment read: Wash hands or use an alcohol-based hand sanitizer immediately after removing all PPE. An observation of medication administration and tube feeding for R6 on 4/3/24 at 10:19 a.m., was completed with Registered Nurse (RN) G. RN G wore a gown, surgical mask, and face shield into R6's Enhanced Barrier Protection (EBP) room. No gloves were donned, and all medication and tube feeding administrations, including wiping of the feeding tube itself were performed with bare hands by RN G. RN G spilled water on R6's overbed table, and the overbed table was wiped with a permeable paper cloth and bare hands. At 10:45 a.m. on 4/3/24 RN G was observed with long, polished fingernails, as she used her bare hands to remove her isolation gown and face shield at the medication cart in the hallway, outside of R6's room. The isolation gown was placed in the medication cart small garbage can, sticking out of the top of the can. During an interview during this time RN G was asked what PPE was to be donned for tube feeding administrations with EBP. RN G stated, Gowns and Masks. Review of the Enhanced Barrier Precautions policy, dated 3/25/24, revealed the following, in part: Enhanced barrier precautions (EBP) refer 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 . 3. Implementation of enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray . d. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. 4. High-contact resident care activities include . g. Device care or use: central lines, urinary catheters, feeding tubes . Review of Contact/Droplet Precautions Signage on the PPE cart outside of room [ROOM NUMBER] read: Any resident on Contact/Droplet Precautions: 1. Keep privacy curtains pulled between residents. 2. Keep door shut and check on residents frequently. 3. Prior to entering room: a. Complete hand hygiene b. Put on gown. c. Put on N95 if fit, otherwise use a surgical mask. d. Put on face shield. e. Put on gloves. 4. Prior to leaving room: a. Remove gloves, b. Remove gown and discard in trash (DO NOT REUSE). c. Exit room and perform hand hygiene. d. Remove face shield (wipe off with bleach wipe, contact time 1 minute). e. Remove mask and discard in trash. f. Perform hand hygiene. g. Apply new mask. Remember: you must wear full PPE every time you enter a room with Transmission-based Precautions. If able, leave dedicated equipment in the resident's room (i.e. glucometer, stethoscope, etc.) All share equipment must be disinfected before using on another resident (i.e. lifts, thermometer, etc.) Any new or worsening symptoms noted for a resident: place on precautions, obtain a rapid COVID test, if negative, complete a PCR test.

Based on observation, interview, and record review, the facility failed to provide sufficient time for the Infection Preventionist (IP) to implement the Infection Control program for all 34 residents residing in the building. This deficient practice impacted the ability of the IP to perform the duties of infection surveillance activities. Findings include: (All times are recorded in Eastern Daylight Time.) On 4/2/24 at 7:18 AM, the facility door was observed to have a sign indicating there was a current Covid-19 outbreak in the facility. The Director of Nursing (DON) stated the Covid-19 outbreak involving 15 residents had begun on 3/28/24. The surveyors were advised the DON was also the Infection Preventionist (IP) but that day she would be working the floor or be taking on a floor nurse assignment passing medications and performing duties specifically for the residents on one assignment due to staffing issues. On 4/2/24 at approximately 11:00 AM, the DON/IP was asked when she could be interviewed to discuss the infection control practices in the facility. The DON/IP requested the discussion of the facility infection prevention and the current outbreak of Covid-19 take place on the following day as she was filling in for a floor nursing position and was short on time. On 4/3/24 at approximately 9:00 AM, the DON/IP was interviewed on the infection control practices of the building. The DON/IP was asked about the tracking and trending of infections. It was determined that the facility did not have ongoing analysis of surveillance data and documentation of follow up activity in response to infections. The facility did not have real time tracking or a system of surveillance designed to identify possible communicable diseases or infections before they could spread to other persons in the facility. Several infection control issues on Personal Protective Equipment and hand hygiene were discussed with the DON/IP who stated education had occurred, but maybe more was needed. During a further interview on 4/3/24 at 4:48 PM, the time necessary for the IP to properly assess, develop, implement, monitor, and manage the infection control program for the facility was discussed with the DON/IP. She stated, I have been working the floor due to staffing issues. The staffing schedule was reviewed with the DON/IP and it was noted that 12 of the last 23 days in March and 12 of the first 21days of April the DON/IP was scheduled as a floor nurse. (Five of the April shifts were scheduled for 12-hour shifts of 6 AM to 6 PM.) The DON/IP said this made it hard to do all the tasks for both positions of DON and IP. The policy titled: Infection Prevention and Control Program dated as reviewed/revised on 3/14/2023, read in part: Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a leader to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases . The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's QAA/QAPI (Quality Assurance Programs) . The Infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the antibiotic stewardship program . Information on various infectious diseases is available from our Infection Preventionist . The Infection Preventionist shall coordinate screening procedures in case of widespread exposure of staff to any infectious disease .

Based on interview and record review, the facility failed to notify the Resident/Representative in writing with the reason for a transfer out of the facility for three Residents (#3, #13 and #17) of three residents reviewed for transfers out of the facility. Findings include: (All times are recorded in Eastern Daylight Time) Resident #3 (R3) A review of R3's medical record revealed a transfer to the hospital on 3/30/24. There was not a written notification of transfer sent to R3's representative. Resident #13 (R13) A review of R13's medical record revealed a transfer to the hospital on 1/3/24. Nursing progress note read in part: 1/3/2024 22:11 (2:11 PM) Nursing Note Narrative: Resident sent to (hospital name) at 2200. There was not a written notification of transfer sent to R13's representative. Resident #17 (R17) A review of R17's medical record revealed a transfer to the hospital on 9/13/23. There was not a written notification of transfer sent to R3's representative. During an interview on 4/3/24 at 8:40 AM, Social Services Director M explained she kept a log but did not do a written notification to the resident or responsible party. During an interview on 4/03/24 at 2:41 PM, the Director of Nursing (DON) stated, We only call the POA (Power of Attorney). I'm not positive but social services might do that. Nursing does not send a (written) notification. During an interview on 4/03/24 at 2:43 PM, the Nursing Home Administrator was not aware of a written notification and stated .maybe the social worker does it. During a follow up interview on 4/03/24 at 3:18 PM, the DON stated the facility did have the form but .We have not been sending it out.

Based on observation, interview, and record review, the facility failed to ensure two controlled medications were labeled when opened and securely stored in two medication carts out of two medication carts reviewed during the medication storage and medication administration tasks. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. Observation of the ,d+[DATE] medication cart manned by Licensed Practical Nurse (LPN) B on [DATE] at 8:32 a.m., found an opened bottle morphine sulfate 100 mg (milligrams)/(per) 5 mL (milliliters) prescribed to R2 in the locked narcotic storage drawer. No 'open date' was noted on the open bottle of morphine. During an interview at this same time, LPN B confirmed the facility policy and practice was to date opened bottles and vials of medication when they were first opened. Review of R2's Resident Controlled Substance Record with LPN B, revealed the morphine sulfate was received by the facility on [DATE] at 0445 (4:45 a.m.) (Central Standard Time) (CST). Two doses had been administered: one on [DATE] at 0840 (8:40 a.m.) by LPN E, and a second dose on [DATE] by RN H. On [DATE] at 4:39 p.m., the 300-hall medication cart, manned by LPN O, was observed during medication pass to Resident R19. Seven medications had been prepared in a 30 cc (cubic centimeter) plastic medication cup, when R19's blister pack of Tramadol HCL 50 mg tablets was pulled from the locked narcotics drawer. A small white tablet was popped from the number four pill pocket on the blister pack but did not fall into the medication cup. LPN O and this Surveyor counted the medications in the cup, which should have totaled eight pills, and found only seven. This Surveyor had visualized the white pilled suspended from the aluminum backing of the blister pack as LPN O placed the blister pack back into the narcotics drawer. LPN O looked through the narcotics drawer three times, and this Surveyor also looked through the drawer, but the white tablet could not be found, and was not in the medication cup of the blister pack. LPN O stated, I hope it didn't go on the floor. This Surveyor found the pill on the floor, pointed it out to LPN O who immediately picked up the pill and placed it in the sharp's container. During an interview at this same time, LPN O was asked for the process of narcotic disposal, to which she replied she did need two nurses to dispose of narcotics, and they were disposed of in a drug buster, not in the sharp's container. Examination of R19's Tramadol blister pack with LPN O, found paper tape covering a previously opened number four pill slot on the back of the blister pack. When asked if it was acceptable to tape a previously opened narcotic package closed, LPN O confirmed it was not, and said the pill should have been wasted when it was found to be unsecured in the blister pack. During an interview on [DATE] at 4:30 p.m., the Director of Nursing (DON) confirmed that it was not acceptable for facility nursing staff to tape a previously opened narcotic closed and store it in the narcotic drawer for future use. Review of the Medication Administration General Guidelines, dated ,d+[DATE], revealed the following, in part: . 8. Check expiration date on package/container. No expired medication will be administered to a resident. a. Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date. b. The nurse shall place a 'date opened' sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened . Once removed from the package/container, unused medication doses shall be disposed of according to the nursing care center policy .

Based on interview and record review, the facility failed to ensure a minimum of 8 hours Registered Nurse (RN) coverage per day, as required. This deficient practice resulted in the potential for unmet nursing services for residents to maintain their highest practicable well-being. Findings include: A review of the payroll timesheets for March 6-23, 2022 revealed less than 8 hours on duty for the only RN working on the following days: 3/6, 3/7, 3/9, 3/10, 3/14, 3/16, 3/20, 3/21 - RN F (left work before the 2:30 pm time listed on staffing sheet) 3/8, 3/9, 3/15, 3/16 - RN E (total time worked ranged from 6.5-7.75 hours on these days) 3/18, 3/19, 3/20 - RN D (total time worked was 7.5 hours each of these days) On 3/23/22 at 1:00 pm an interview was held with the Administrator to discuss the amount of time an RN was onsite at the facility. The Administrator stated there used to be plenty of nurses but that was not the case currently. During the interview the Administrator was asked about the lack of staffing need assessment in the facility assessment, a copy of which was provided by the Administrator at 10:00 am on 3/23/22, with no dates or signatures of review. The Administrator stated the last Facility Assessment was completed 3/25/20, and the Quality Assurance (QA) committee was planning to meet and adopt a new one.

Based on interview and record review, the facility failed to ensure the required competency trainings were completed for licensed nursing personnel and certified nurse aides (CNAs). This deficient practice resulted in the potential for staff to exhibit inadequate skills needed to care for residents. Findings include: A review of five randomly chosen staff employee files provided by Business Office Manager/ Staff G found no recent competency evaluations. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. An interview was held on 3/23/22 at 12:25 pm with the Administrator and Staff G, who stated they had not done nursing competencies this past year, and they would be meeting soon to derive a plan for how to schedule these.

Based on observation, interview, and record review, the facility failed to store drugs and biologicals under proper temperature control in one medication room refrigerator, out of one medication room reviewed for medication storage. This deficient practice resulted in the potential for improper storage temperatures for resident drugs and biologicals and reduced efficacy of medications. Findings include: During an observation and interview on 3/22/22 at 9:25 a.m., of the medication storage room, in the present of the Director of Nursing (DON), the thermometer used to measure the temperature of the medication refrigerator was not clearly visible. The DON removed all medication, and the location of the thermometer was still not identified. Upon closer inspection, the thermometer was lying face side down, near the back wall of the refrigerator on top of a digital, locked box used for storage of controlled substances. When the thermometer was observed the temperature was approximately 26 degrees. Review of the Temperature Log for Refrigerator - Fahrenheit, Days 16-31, posted on the medication room refrigerator, five refrigerator temperatures between 3/16/22 and 3/21/22 were documented on the night shift only, with no temperatures recorded on 3/18 or 3/22. The Temperature Log for Refrigerator - Fahrenheit revealed the following, in part: Monitor temperatures closely! . If using TMD (temperature monitoring device) that does not record min (minimum)/ max (maximum) temps, document current temps twice, at the beginning and end of each workday .Put an X in the row that corresponds to the refrigerator's temperature . During an interview on 3/22/22 at approximately 9:30 p.m., the DON confirmed temperatures were to be monitored and recorded twice daily - on the night and afternoon shifts. When asked about the incomplete documentation on the March 2022 Temperature Log for Refrigerator - Fahrenheit form posted on the refrigerator, the DON said it did not appear that the afternoon nursing staff had be doing the temperature check on the refrigerator at all. On 3/22/22 at 9:50 a.m., the DON provided temperature logs for January 2022 through March 2022, which revealed the following temperature monitoring documentation: 1. January 2022, only one refrigerator temperature was recorded on January 1, 2, 9, 10, 12, 13, 14, 22, 23, 29, and 31. No refrigerator temperatures were documented on January 11, 15, and 30. 2. February 2022, only one refrigerator temperature recorded on February 1, 2 ,3 ,5, 6, 7, 9, 10, 11, 12, 13, 14, 18, 19, 20, 21, 23, 24, 25, 28. No refrigerator temperatures were documented on February 4, 8, 15, 16, 17, 22, 26, and 27. 3. March 2022, only one refrigerator temperature was recorded on March 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 14, 16, 17, 19, 20, and 21. No refrigerator temperatures were documented on March 8, 12, 13, 15, 18, and 22. Review of the Medication Storage in the Facility, policy, copyright 2006, revealed the following, in part; The Facility should maintain a temperature log in the storage area to record temperatures . F. The Facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC (Centers for Disease Control and Prevention) Guidelines . Observation of the medication room refrigerator on 3/22/22 at 4:06 p.m. found the medication room refrigerator empty. During an interview and observation on 3/23/22 at 8:37 a.m. and 9:24 a.m., the medication room refrigerator was observed with the DON. The DON stated, We (facility) got a new refrigerator. When I moved the thermometer forward in the refrigerator, the thermometer was warmer in the front and there was ice in the back on the refrigerator . The DON confirmed influenza vaccine, [MEDICATION(S)] (ppd) for [CONDITION(S)] testing, multiple insulin pens, and omeprazole suspension had been in the refrigerator when temperatures were not consistently monitored.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by the failure to maintain proper temperature in one refrigerator in the kitchen and provide appropriate corrective action when recorded temperatures were above 41°F. This deficient practice has the potential to result in food borne illness among any or all of the 29 residents in the facility. Findings include: (All reported times in EDT) ON 3/21/22 at 3:10 PM, the single door Artic Aire refrigerator in the kitchen was observed to have a temperature of 42°F, as reported by an exterior digital thermometer. At 3:15 PM the temperature had risen to 44°F. At 4:03 PM the temperature had again increased one degree to 45°F. At this time using a metal stem probe thermometer, the internal temperature of a sleeve of sliced cheese was measured and found to be 45°F. Using an infrared thermometer, the surfaces temperature of food containers and interior walls of the unit was measured to be 50°F. At this time Dietary Aide (DA) B was interviewed and learned the refrigerator had a history of elevated temperatures above 41°F. Staff B recalled notifying maintenance staff related to the elevated temperatures then stated they came in, looked at it and said everything was ok. A reviewed of the temperature logs on the door of the refrigerator were reviewed. On four days of the current month (March 2022), temperatures were recorded above the maximum holding temperature for a refrigerator. (42°F, 48°F, 49°F and 42°F respectively). Food being stored in the refrigerator was not removed until 5:15 PM after the facility Administrator was notified of the deficient holding temperature.

Based on interview and record review, the facility failed to develop and operationalize the required Facility Assessment based on the facility hazard based risk assessment. This deficient practice resulted in the potential for lack of adequate prepared staff and/or supplies and equipment in the event of emergencies. Findings include: On survey entrance at approximately 2:10 pm on 3/21/22, the current Facility Assessment was requested from the Administrator. On 3/23/22 at 1:00 pm an interview was held with the Administrator to review the Facility Assessment documents provided, which were a 2017 Facility Assessment Tool (provided on 3/22/22 at 12:40 pm) and the (Facility Name) Facility Assessment (provided at 10 am on 3/23/22). When asked about the lack of staffing plan in the facility assessment, and the absence of dates or signatures of review, the Administrator stated the last Facility Assessment was completed 3/25/20, and they were currently working on the updated version.

This citation had two parts, A. and B. A. Based on observation, interview and record review, the facility failed to ensure appropriate use and disinfection of personal protective equipment (PPE) when entering a transmission-based precaution (TBP) room for two Residents (#179 and #2) of two residents reviewed for TBP for COVID-19. This deficient practice resulted in the potential for transmission of COVID-19 (a highly transmissible infection). Findings include: All times recorded in eastern standard time (EST). An observation on 3/21/2022 at 1:50 p.m., revealed a stop sign on the door of Resident #179's room, alerting staff to see nursing prior to entering Resident #179's room. A cart containing PPE was observed in the hall outside of Resident #179's room. A sign posted on top of the PPE cart read, in part: Any resident on Contact/Droplet Precautions: 3. Prior to entering room: a. Complete hand hygiene, b. Put on gown, c. Put on N95 if fitted, otherwise us a surgical mask, d. Put on face shield, e. Put on gloves. 4. Prior to leaving room: a. Remove gloves, b. Remove gown and discard in trash, c. Exit room and perform hand hygiene, d. Remove face shield (wipe off with bleach wipe, contact time 1 minute), e. Remove mask and discard in trash, f. Perform hand hygiene, g. Apply new mask. During an interview at the time of the observation, Licensed Practical Nurse (LPN) E reported Resident #179 was a new admission and under observation (quarantine) for signs and symptoms of COVID-19. A review of Resident #179's electronic medical record (EMR) revealed an admitted [DATE]. On 3/22/2022 at 9:12 a.m., Business Office Manager (BOM) H was observed wearing goggles and a surgical mask. BOM H approached Resident #179's room, donned a protective gown and gloves, and entered Resident #179's room to deliver Resident #179's breakfast tray. BOM H was observed assisting Resident #179 to set up the tray on the wheeled table in his room. Upon exiting Resident #179's room, BOM H discarded her protective gown and gloves. BOM H performed hand hygiene but did not change into a clean surgical mask or disinfect the goggles she had worn in Resident #179's room. BOM H immediately approached a cart housing the meal trays yet to be delivered. BOM H picked up a meal tray from the cart, entered Resident #2's room and assisted the resident to arrange the meal tray on his table. BOM H did not change into a clean surgical mask or disinfect the goggles she had worn into Resident #179's prior to entering Resident #2's room. During an interview immediately following the observation, BOM H reported she was unsure of why Resident #179 was in TBP. LPN H, who was present during the interview, informed BOM H of the need to adhere to contact/droplet precautions when entering the room as Resident #179 was under observation for signs and symptoms of COVID-19. BOM H acknowledge she had not approached a nurse for guidance prior to entering Resident #179's room, despite the stop sign posted on the Resident's door. BOM H confirmed she did not change into a clean facemask or disinfect her goggles after exiting Resident #179's room and prior to entering Resident #2's room. BOM H proceeded to change into a clean facemask and disinfect her goggles at that time. In an interview on 3/22/2022 at 2:30 p.m., the Director of Nursing (DON) reported staff were expected to seek clarification from nursing staff if unsure why residents were in TBP and prior to entering a TBP room. The DON confirmed Resident #179 was a new admission to the facility and had not yet received all recommended doses of the COVID-19 vaccine, therefore Resident #179 and was in TBP for observation for signs and symptoms (quarantine) of COVID-19. The DON stated when entering the Resident's room, staff should adhere to appropriate use of PPE, as posted on the PPE cart outside Resident #179's room. The DON stated not all staff had been fitted for the use of N95 facemasks therefore, staff were allowed to wear a well-fitting surgical mask into the Covid-19 quarantine rooms. The DON reported staff were expected to change into a clean mask and disinfect their face shields upon exiting the TBP rooms and prior to entering other non-TBP rooms. The DON acknowledged the risk for transmission of infection when staff do not adhere to appropriate use of PPE in TBP rooms. A review of the facility policy titled, Coronavirus (COVID-19) Prevention and Response, dated 2/9/2022, revealed the following, in part: This facility will respond promptly upon suspicion of a COVID-19 infection in efforts to identify, treat, and prevent the spread of the virus . 5. Interventions to prevent the spread of respiratory germs within the facility: f. Educate staff on proper use of personal protective equipment and application of standard, contact, droplet, and airborne precautions, and source control, including eye protection. G. Promote easy and correct use of personal protective equipment by i. Posting signs on the door or wall outside of the resident room that clearly describe the type of precautions needed and required PPE . 10. Consideration for admitting or readmitting residents . c. All resident who are not up to date with all recommended COVID-19 vaccine doses and are new admission or readmissions should be placed in quarantine upon admission. B. Based on interview and record review, the facility failed to develop a comprehensive Water Management Plan (WMP) to address the control and spread of Legionella bacteria in the facility water system, in accordance with QSO 17-30 Hospitals/CAHs/NH, Revised 7-6-2018. The facility failed to Develop and implement a water management program that considers the ASHRAE 188 (American Society of Heating, Refrigerating and Air-Conditioning Engineers) and the CDC (Centers for Disease Control) tool kit. The failure to develop a comprehensive Water Management Plan has the potential for the proliferation and transmission of Legionella in the circulating water of the building and the spread of Legionella infections in all 47 residents. Findings include: On 3/21/22 at 3:06 PM, an interview with Maintenance Director/ Staff A was conducted to review the facility's WMP for the control of Legionella in the water supply system. Staff A produced copies of the CDC (Centers for Disease Control) Toolkt for Controlling Legionella in Common Sources of Exposure as the facility plan. No facility specific information was provided. At 4:15 PM Staff A produced a hand drawn schematic of the water system in the building. At 4:55 PM a form printed from Direct Supply Company, TELS was produced with hand written information including the maintenance director, facility administrator and Director of Nursing being the Water Management Program Team. The document did not identify the facility nor did it include a date or evidence of data collection or annual reviews. On 3/22/22 at 8:30 AM the facility administrator provided the document Legionella Water Management Program, Policy Statement. This document identified the necessary components which the facility was supposed to develop for a comprehensive Legionella control program, but did not include any facility specific components. The policy was not facility specific and was printed from 2001 MED-PASS, Inc. (Revised July 2017)). The following components were absent from the facility WMP: A. Designation of a Water Management Team (WMT) to meet the policy statement of requiring the medical director and infection preventionist to participate. B. An assessment of the facility's water system to identify risk locations. C. Identification of control points where effective mitigation measures can used. D. Identification of set critical limits related to the risk areas identified and which can be controlled. E. Identification of defined control measures and locations related to risk and the critical limits which are set. F. Implementation of regular scheduled monitoring program related to the set limits. G. An evaluation process to determine how the WMP is functioning related to the collected data.

Based on interview and record review, the facility failed to ensure resident medical records included documentation of resident/resident representative education regarding the risks and benefits of COVID-19 vaccination according to facility policy for three unvaccinated Residents (#11, #4 and #81) of 29 residents reviewed for COVID-19 vaccination. This deficient practice resulted in the potential for residents to be uninformed regarding the risks and benefits of COVID-19 vaccination, incomplete vaccination and the potential for serious illness and complications from COVID-19 infection. Findings include: All times recorded in eastern standard time (EST). A review of the facility's resident COVID-19 vaccination tracking log, provided by the Director of Nursing (DON), revealed Residents #11, #4 and #81 had declined COVID-19 vaccination. The log contained no date of the declinations or record of the three Resident's being education on the benefits of COVID-19 vaccination or on the risks associated with remaining unvaccinated. A review of the electronic medical record (EMR) for the Residents (#11, #4 and #81) revealed no signed documentation of resident/resident representative consent/declination of COVID-19 vaccination or whether any education or what type of education had been offered to residents or their legal representatives regarding the COVID-19 vaccine. On 3/23/2022 at 12:40 p.m., the DON confirmed no signed declination forms could be located for Residents #11, #4 and #81. The DON reported the only documentation in the Resident's medical records was that the Resident's had declined vaccination for COVID-19. The DON confirmed no documentation was available regarding if or when the Resident's or their representatives had been offered education on the risks versus benefits of the vaccine. On 3/23/2022 at 1:20 p.m., the Nursing Home Administrator (NHA) reported the facility did not use a written declination form that included education on the risks/benefits of COVID-19 vaccination for residents who refused COVID-19 vaccination. Further review of Resident Immunizations documented in the EMR revealed the following: Resident #11: Immunization - [CONDITION(S)]-COV-2 (COVID-19). Dose 1. Refused. Resident Refused . 10/5/2021. Education Provided to Resident/Family: (blank). Resident #4: Immunization - [CONDITION(S)]-COV-2 (COVID-19). Dose 1. Consent Refused. Dose 2. Consent Refused. Resident #81: No documentation of Resident #81 receiving or declining [CONDITION(S)]-COV-2 (COVID-19) vaccination was found in Resident #81's EMR. A review of the facility policy titled, Vaccination of Residents, updated 5/21/2021, revealed the following, in part: Policy Interpretation and Implementation - 1. Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. 2. Provision of such education shall be documented in the resident's medical record . 5. If vaccines are refused, educate resident/representative on risks/benefits and document conversation in medical record.

Based on interview and record review, the facility failed to accurately track staff COVID-19 vaccination status to ensure all staff were vaccinated for COVID-19 or exempted from vaccination. This deficient practice resulted in one of 51 staff members being partially vaccinated while eligible to complete the vaccination series and the potential for increased risk of exposure to COVID-19 for all 29 residents residing in the facility. Findings include: All times recorded in eastern standard time (EST). On 3/22/2022 at 8:00 a.m., the Director of Nursing (DON) presented the facility documentation for staff COVID-19 vaccinations and reported all staff were either up to date with vaccination or had been granted an exemption from vaccination. On 3/22/2022 at 2:30 p.m., a review of the facility matrix for staff COVID-19 vaccinations with the DON revealed Certified Nurse Aide (CNA) I was recorded as receiving only one dose of an mRNA COVID-19 vaccine of a two-dose series. Further review of the staff vaccination matrix revealed CNA I had received the first dose of the COVID-19 vaccine on 12/21/2021. The staff vaccination matrix included no indication as to why CNA I's second dose of the Covid-19 vaccine was delayed or how long the vaccination would be delayed. The DON reported CNA I had contracted the COVID-19 virus shortly after receiving his first dose of vaccine on 12/21/2021 and had been instructed by his pharmacist to wait until recovering from the illness to receive the second vaccination of the two-dose series. The DON stated CNA I had not provided documentation related to the pharmacist's recommendation. The DON reported CNA I had recovered and returned to work. The DON stated CNA I had been reminded to complete the COVID-19 vaccination series. The DON reported no documentation was available as to when the vaccinations were discussed with CNA I. The DON was unaware if the facility had provided CNA I with a deadline to complete the vaccination series or if CNA I was scheduled to receive the second dose of the vaccine. A review of CNA I's CDC COVID-19 Vaccination Record Card, provided by Business Office Manager (BOM) H revealed CNA I received the initial dose of the mRNA vaccination series on 12/21/2021. A review of the staff infection, Line List - January 2022, revealed CNA I had tested positive for COVID-19 on 1/4/2022 and had returned to work on 1/15/2022, with no symptoms of COVID-19 infection. A review of the Centers for Disease Control and Prevention (CDC) guidance titled, Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States. Last updated 2/22/2022, revealed the following, in part: COVID-19 Vaccination Schedule: (mRNA vaccine brand name redacted) Ages [AGE] years and older: 2nd Dose - 3-8 weeks after 1st dose . People with a current infection: Defer vaccination of people with known current [CONDITION(S)]-CoV-2 infection until the person has recovered from acute illness (if the person has symptoms) and until criteria have been met for them to discontinue isolation. This recommendation applies to any vaccine, including the first and second doses of COVID-19 vaccine. During an interview on 2/23/2022 at 1:20 p.m., the Nursing Home Administrator (NHA) reported CNA I had not been approved for a temporary exemption for completing the COVID-19 vaccination series. The NHA reported they had taken a verbal report from CNA I as to why he had not yet completed the vaccination series and had not received written documentation from a health care provider regarding the need for CNA I to defer receiving the second dose of the mRNA vaccination series. The NHA confirmed CNA I was not up to date on Covid-19 vaccination and had not been granted any type of exemption from vaccination. A review of the facility policy titled, Employee COVID-19 Vaccinations, dated 1/18/2022, revealed the following, in part: It is the policy of this facility to ensure that all eligible employees are vaccinated against COVID-19 as per applicable Federal, State and local guidelines . Fully Vaccinated - Individuals are considered fully vaccinated for COVID 14 days after receipt of . the second dose of a two-dose primary vaccination series . COVID-19 remains a threat to the population's health and those that reside in long-term care or congregate settings have been greatly affected by this pandemic. Vaccination against COVID-19 ensures that employees will provide a safe workplace and decrease the risk of transmission to this vulnerable population . 8. Clinical considerations for delayed vaccinations may include the following: a. Individuals with known current COVID-19 (should defer at least until recovery from the acute illness and criteria to discontinue isolation have been met) . 11. The facility will track and securely document the vaccination status of each staff member . to include - a. Individuals whose vaccination is delayed due to a clinical concern or consideration and the reason for the delay.

Based on observation, interview and record review, the facility failed to maintain infection control program practices to prevent continued spread of COVID-19 (a highly transmissible [MEDICAL CONDITION] infection) by failing to: 1. Ensure effective screening and prevention of staff from working with signs and symptoms consistent with COVID-19. 2. Ensure appropriate standards of infection control practice were maintained for respiratory equipment. 3. Ensure appropriate use of Personal Protective Equipment (PPE) in resident care areas. 4. Ensure proper infection control practice in performing routine glucometer testing. 5. Prevent contamination of multidose medication packaging during administration. 6. Perform appropriate hand hygiene. This deficient practice resulted in an Immediate Jeopardy (IJ) concern and the likelihood of continued spread of COVID-19 throughout the facility population. This IJ concern ultimately resulted in 36 total resident infections with eight resident deaths, and 25 total staff infections between 12/17/20 - 1/11/21. All times noted are in Eastern Standard Time (EST). The Immediate Jeopardy began on 12/22/20, when Certified Nurse Aide (CNA) I had two signs and symptoms consistent with COVID-19, and the facility screener CNA K allowed entry of CNA I to the facility. CNA I stated she had communicated her symptoms consistent with COVID-19 to Registered Nurse (RN) C. CNA I stayed in the facility and worked an entire eight hour shift with active symptoms consistent with COVID-19. Between 12/28/20 and 12/31/20, twenty-seven residents and nine staff members tested positive for COVID-19 including screener CNA K and RN C. Five of the twenty-seven residents who tested positive between 12/28/20 - 12/30/20 passed away, and one additional resident was hospitalized , and a total of eight residents passed away. The facility was notified of the IJ on 1/21/21 at 3:30 p.m. and an abatement plan was requested. The abatement plan was accepted on 1/21/21 at 6:18 p.m. which outlined the following steps: 1) Facility Executive Director (ED) and Director of Nursing (DON) were re-educated on 1/21/2021 by Director of Clinical Services on COVID 19 Screening Policy Procedure for staff, visitors, and those entering the facility. 2) Immediate re-education initiated on 1/21/2021 with in house staff and ongoing with facility staff prior to reporting to next scheduled shift, on COVID 19 screening procedure of staff, visitors, and those entering the facility by Director of Nursing or designee. This education included immediately reporting symptoms even if on duty and if off duty calling into facility to report illness. 3) Audits will be completed of facility screeners by Director of Nursing, Executive Director or designee 3 times per day with consideration to auditing after shift change to ensure that staff on duty did not report any symptoms of COVID 19, starting 1/21/2021 and continuing for 7 days and then will decrease to 2 times per day for a month, then will continue no less than daily for 12 weeks or until substantial compliance is maintained. Results of audits will be brought to QAPI (Quality Assurance Process Improvement (committee)) for review and recommendations. 4) Ad Hoc (temporary formed committee for a specific focus) QA (Quality Assurance) meeting- The QA (Quality Assurance)/PI (Process Improvement) Committee (composed of Director of Clinical Services, Director of Nursing, Infection Control Nurse and Medical Director or designee) met ad hoc to review the incident, discuss above action items and audits related to screener process on 1/21/2021. A formal QA/PI meeting is to be held and all items and information will be reviewed and follow up on as needed. The deficient practice continued with a potential for more than minimal harm at a widespread level until the full plan of correction is verified. Findings include: On 1/21/21 at 9:48 a.m., an interview with Infection Preventionist (IP) L was conducted for review of the infection control program and outbreak timeline for COVID-19. When asked about reuse of face masks, IP L stated, Masks are up front and staff reuse masks. We are using 5 dons (putting on and wearing) before disposing of the masks because we are extending PPE use. When asked if all masks were kept up front in the same area, IP L stated, Typically our management team members keep their masks in their offices, and the floor CNAs and nurses keep them on that table (at the front door). When asked where staff are supposed to store the masks for those who are working on the COVID-19 unit, IP L stated, When we had a full blown unit we had a break room where we kept all of our PPE. Now we just have our buffer zone where there is PPE carts on each side of the buffer as well as a place to discard our PPE. When asked if staff should be storing a mask used on the COVID-19 unit on the same table as where all the other staff are storing their masks, IP L stated, No, we haven't had a formal in-service yet from when the (state agency consultative team) came in and did their review of our practice. IP L stated this was one of the issues identified. When asked why some staff are wearing N-95's and others are just wearing surgical masks, IP L stated, We are going to include this in our in-service next week. We only had some of the staff fit tested so they were wearing the N-95s. IP L stated, (Infection Prevention and Control Consultant Team) visited on 1/14/21 and had the suggestion to use N-95 or KN-95 for all staff regardless of COVID recovered and consider them as COVID-19 suspected. We just had a call with Corporate and they recommended to implement signed off screening and training for screening (individuals for entry into the building) just to make sure staff are screening appropriately catching (visitor/staff) with symptoms, so they are not allowed in the building. When asked if a screening issue was identified, IP L stated, No, we just don't want anyone to enter the building with symptoms. On 1/21/21 at 11:08 a.m., an interview with CNA I revealed she tested positive for COVID-19 on 12/23/20 via rapid testing, and a PCR (Polymerase Chain Reaction) test was sent out for confirmation of the positive rapid test. CNA I stated she had symptoms of a sore throat, sores in her mouth and cold symptoms. My symptoms started on (12/22/20) before I came in to work . I worked (6:00 a.m. - 2 p.m.) on the 22nd (December 2020) on the 200 hall. I do remember going to the 300 hall to pick up a couple of trays. When asked about screening done on 12/22/20, CNA I stated, So I was screened by (CNA K) a midnight CNA. I told her I had cold symptoms and a sore throat, and I thought she had circled yes to some of the questions on the screening sheet. It was on 12/22/20. She didn't have a nurse come and review my symptoms or rapid test me, so I punched in and went to work. When asked if any guidance was given to her about the screening process for employees, CNA I stated, Normally, when you say yes to any of the screening questions they will go and inform the nurse to look into it further. So, (Transporter O), the Transporter screened me in the following day, and I still had the same symptoms, and he said he needed to go and get (Administrator) and ask her what to do. (Transporter O) came back and said (Administrator) directed him to tell me to go to the ramp in the back and get rapid tested . So, he did the right thing. When asked about symptoms experienced, CNA I stated she did develop a fever and pneumonia and I did tell my nurse (RN C) about my symptoms that day (12/22/20) and she stated she didn't think it was a cold, but then she also didn't direct me to do anything, she just let me continue to work. CNA I stated she, . told (Administrative Assistant P) about what had happened and said she was going to find out why I was allowed to work on the 22nd. A review of the mapping of COVID-19 infections dated December 2020 revealed 27 COVID-19 positive residents. A review of the line listing provided by the facility titled Outbreak starting 12/17/20, with a revised date of 1/18/21, revealed 36 total COVID-19 infections among residents between 12/23/20 -1/11/21. There were 31 total cases identified for December 2020. There were four total resident infections identified from 12/23/20 - 12/25/20. An additional 27 resident cases of COVID-19 were identified from 12/28/20 - 12/30/20. Five additional resident cases were identified from 1/4/21 - 1/11/21. There were a total of eight resident deaths and one hospitalization , from which five of those deaths occurred from infections identified from 12/28/20 - 12/30/20. A total of 25 staff tested positive from 12/17/20 - 1/11/21. Nine of the staff members tested positive for COVID-19 from 12/28/20 - 12/31/20. Among those who tested positive between 12/28/20 - 12/31/20 were CNA K on 12/28/20 and RN C on 12/31/20. The number of resident COVID-19 infections on the facility map for December 2020 did not coincide with the total number of infections on the line listing for the month of December 2020. During the interview on 1/21/21 at 9:48 a.m., the Outbreak Summary with a date range of 10/25/20 - 1/18/21 was reviewed with IP L. IP L stated, We (only) had staff members positive from the 25th of October (2020). Our most recent outbreak was December 17th (2020) when our first staff became positive . IP L stated after that CNA K and three residents tested positive on 12/23/20 for COVID-19, four PCR positive residents were identified on 12/28/20, then 8 residents were identified PCR positive on 12/29/20, and 15 additional residents were identified PCR positive on 12/30/20. There were 4 additional residents identified PCR positive on 1/4/21 and one additional resident identified PCR positive on 1/11/21. IP L stated that on 12/28/20 the four residents who had been identified with symptoms were rapid tested . Six PCR results also returned positive for staff who were tested on [DATE]. IP L stated most of those results returned for the staff on 12/30/20. On 12/29/20 several residents were symptomatic and returned positive results via rapid test. On 12/30/20, four new employee positives were identified via PCR. A total of 15 residents were confirmed as PCR positive for COVID-19 per IP L. On 1/21/21 at 1:07 p.m., during an interview Administrative Assistant P stated, .(CNA I) had a couple of the symptoms (consistent with COVID-19) but apparently (CNA K) didn't do anything about it . (CNA I) then told me she entered the building and told (RN C) about her symptoms and (RN C) didn't do anything about it either, and so (CNA I) continued to work for the whole day . I told (Administrator) and I went and grabbed the screening form for that day and (CNA K) did in fact circle two of the symptoms, and I told (Administrator) about this. I did highlight the entry and gave it to (Administrator), but beyond that I do not know where it went from there. On 1/21/21 at 01:32 p.m., an interview with RN C revealed the following: RN C stated she did not recall CNA I report any symptoms to her on 12/22/20. When RN C was informed CNA I stated she had told RN C she had a cough and a sore throat, RN C reiterated she could not recall the contents of the conversation with CNA I. RN C stated she tested positive for COVID-19 on 12/31/20. I woke up with a sore throat, headache and a slight cough on that morning and I called to let the nurse who was working night shift know. I came in and talked to the screener and (DON) was here at the time and they directed me to go around the back and be rapid tested . I had a PCR on (12/28/20) but I am not sure of those results. I went home. I was quarantined for 10 days and return to work on 1/11/21. On 1/21/21 at 1:42 p.m., an interview with the Administrator revealed the following: When asked about the screening log concern being brought to the Administrator by Administrative Assistant P, the Administrator stated she was under the impression CNA I was rapid tested on [DATE]. The screening logs for the month of December 2020 were reviewed and the word rapid was in the margin of the log for 12/22/20 with two symptoms circled as yes consistent with COVID-19. However, CNA I was not rapid tested until 12/23/20 according to the staff line listing and outbreak summary provided by the facility. CNA I was also documented on the screening log for 12/23/20 with positive symptoms identified. The Administrator then stated CNA I listed as being screened in on 12/22/20 and 12/23/20 did not make sense with her being rapid tested on [DATE] and being positive. When asked if screening concerns were addressed with CNA K, the Administrator stated CNA K had been off work recently (not illness related), so nothing was addressed with her. A review of a timecard for CNA I, with a printed date of 1/21/21 at 12:51 p.m., revealed CNA I worked at the facility on 12/22/20 from 6:02 a.m. - 2:07 p.m. A review of the Instructions for Employee/Vendor/Medical Partner Screening, no date, read in part: 4. Circle YES or NO to all symptoms on screener. If YES to ANY symptoms, restrict them from entering the building. If situations arise that you need help working through - please reach out to the Infection Preventionist, the DON, or the ED (Executive Director(Administrator)) for assistance. If NO to all symptoms, proceed to #3B on the screener . .d. If any questions as to whether individual should be allowed into the Center, err on the side of caution. Talk to the Infection Control Nurse, DON, or ED ASAP. A review of the policy SUSPECTED OR CONFIRMED POSITIVE COVID 19 MANAGEMENT POLICY, with a revised date of 6/18/20 read in part: . e. The center ' s Infection Preventionist will follow the center ' s Infection Control surveillance policy and CMS (Centers for Medicare/Medicaid)/CDC (Centers for Disease Control)/state agency/local and state public health department guidance for resident and staff monitoring to promote early detection . .b. Monitoring staff 1) The center will ensure staff are aware of sick leave policies and the requirement that they stay home if they are ill with fever or respiratory/COVID-19 symptoms and if they have been tested for COVID-19 and results are pending. 2) The center will advise employees to check for any signs of illness before reporting to work each day and notify the Executive Director, Infection Preventionist, or designee if they become ill. 3) The center will follow CDC/DPH (Department of Public Health) recommendations regarding the staff screening process for COVID-19. At a minimum, staff will be screened for signs/symptoms of COVID-19 and have their temperature checked at the beginning of their shift. Staff will be instructed to immediately notify their supervisor should they develop symptoms of COVID-19 during a shift and shall be re-screened by nursing supervisor and sent home if screening dictates . A review of the PANDEMIC PREPAREDNESS AND RESPONSE POLICY (effective date 3/23/20) read in part: . d. Monitoring staff 1) Ensure staff are aware of sick leave policies and the necessity of staying home if they are ill with fever or respiratory symptoms. 2) Advise employees to check for any signs of illness before reporting to work each day and notify the Executive Director, Infection Preventionist, or designee if they become ill. 3) Follow CDC/DPH recommendations regarding staff screening process for each pandemic. The Infection Preventionist will determine, in consultation with the Pandemic Outbreak committee, how the screening will be implemented should the need arise Resident #13 Respiratory Care On 1/20/21 at 11:15 a.m., an interview with Resident #13 revealed she had contracted COVID-19, pneumonia, and was hospitalized prior to admission to the facility. During this interview, the nebulizer machine was observed laying on the bed with tubing not dated, the chamber and mouthpiece were still attached to the tubing, and nebulizer solution residue was present in the chamber. Resident #13 stated she did not know if staff cleaned the nebulizer parts after her breathing treatments. A Continuous Positive Airway Pressure ([MEDICAL CONDITION]) machine with an attached nasal pillows type mask for delivering the airway pressure was also observed laying on the bed. Resident #13 stated she had a (Name Brand) device for sanitizing her mask and tubing at home. Resident #13 did not know if the facility staff were cleaning the [MEDICAL CONDITION] tubing and nasal piece daily or not. Resident # 13 stated she had never seen it be cleaned. The reservoir, tubing, and nasal pillow mask were still attached to the machine from use during the previous night. On 1/22/21 at 8:40 a.m., the tubing for Resident # 13's nebulizer was observed and remained undated. On 1/22/21 at 9:20 a.m., RN C was asked about how changing the oxygen tubing used for the nebulizer was done at the facility. RN C stated there should be an order for [REDACTED]. RN C was also asked what the policy stated about entering tubing changes into the order system, and stated the tubing order was missed. On 1/22/21 at 9:25 a.m., the DON was interviewed about the process for assuring regular oxygen tubing changes, and stated, When we put in batch orders on admission, you have to select the tubing change order, and somehow it got missed. It should have been put in (the orders) on admission. The DON confirmed Resident #13 was on a nebulizer since admission. Documentation of [MEDICAL CONDITION] cleaning was requested at this time; no documentation was found or provided by the DON to support evidence of regular [MEDICAL CONDITION] cleaning by the time of survey exit. A review of the Face Sheet for Resident #13 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the EMR (Electronic Medical Record) orders revealed an order present for [MEDICATION NAME] (steroid containing respiratory nebulizer medication) 0.5 mg (milligram)/2 ml (milliliters) to be administered twice daily. There was also an active order present for [MEDICATION NAME]/[MEDICATION NAME] (respiratory nebulizer medication) 0.5-2.5 (3) mg/ 3 ml every six hours as needed. A review of the electronic Medication Administration Record/electronic Treatment Administration Record (eMAR/eTAR) for January 2021 revealed no orders or guidance to staff on cleaning the nebulizer components, when to change the tubing, or timing of cleaning/disinfecting [MEDICAL CONDITION] equipment. Review of the Respiratory Care Plan for Resident #13 revealed no interventions about regular tubing changes for her nebulizer, and no interventions related to cleaning of [MEDICAL CONDITION] equipment. A review of the facility policy Oxygen Administration with an effective date of June 2017, read in part: .g. Label humidifier with date and time opened. Change humidifier and tubing per facility policy . .9. At regular intervals, check and clean oxygen equipment, masks, tubing and cannula. Also check skin condition beneath cannula or mask . A review of a facility document titled PAP EQUIPMENT CARE AND CLEANING, no date, read in part: Daily: Wipe off PAP mask with a warm damp cloth Empty and set out water chamber to dry Drain excess water from tubing and hang dry Refill water chamber nightly; do not fill with chamber in the PAP device Weekly: Soak mask, headgear, tubing and water chamber in warm soapy water for 30 minutes, rinse well and allow to dry Monthly: change intake filter wipe down machine as needed . A review of a facility Clinical Competency TITLE: Nebulizer Treatment, Administering, no date, read in part: .15. Opens medication cup and rinses with tap water. Shakes out excess water and allows to air dry. Personal Protective Equipment (PPE) On 1/20/21 at 4:20 p.m., Certified Nurse Aide (CNA) F and CNA G were observed on the 200 hall without N95/KN95 face masks. Both CNAs were wearing only a surgical mask and a face shield when observed entering and exiting resident rooms on the 200 hall. During an interview at this same time, both CNAs said they had N95 masks available for use. CNA F and CNA G retrieved and donned their KN95 face masks and returned to the 200 hall with a surgical mask covering their KN95 mask. On 1/20/21 at 4:21 p.m., Registered Nurse (RN) H was observed standing at the 300-hall medication cart with a surgical face mask, without a N95/KN95 face mask. When asked if she was wearing an N95 mask under her surgical mask RN H stated, No I am not. When asked if the facility PPE guidance required her to wear an N95 face mask, RN H stated, Yes . I will go and get one right now. On 1/21/21 at 8:15 a.m., CNA I and CNA J were observed without the facility required PPE. CNA I wore a surgical mask and face shield but had not donned a KN95 face mask. CNA J was observed without eye protection upon entrance and exit from an unidentified resident room. During an interview on 1/21/21 at 8:45 a.m., CNA I was asked if she was wearing an N95/KN95 mask underneath her surgical mask. CNA I stated, No, I am not wearing an N95. I think when we go on (the) quarantine (unit) we have to wear an N95, but just a surgical mask and face shield are required now . We are not wearing an N95 through the whole facility. CNA I said she had an N95 mask in her pocket that she could be wearing and pulled out a folded blue N95 face mask. CNA I said she had worked in the COVID isolation hall and upon exit from the COVID unit her N95 mask (used in the COVID-19 unit) went into a white paper storage bag on the table by the facility entrance door. CNA I confirmed the same mask was worn when she returned to work for her next scheduled shift. She stated, We don't change them (face masks) unless they were soiled. On 1/21/21 at 9:12 a.m., LPN D was observed wearing a KN/95 face mask and face shield. When asked if an N95/KN95 face mask and face shield were required PPE in the facility (on all halls), LPN D stated, Yes, that is what I was told: N95 and face shield. On 1/21/21 at 3:53 p.m., the Nursing Home Administrator (NHA) entered the conference room occupied by the survey team wearing only a surgical face mask and prescription corrective eyewear. No N95 face mask was donned and no eye protection in the form of goggles, trauma glasses, or a face shield was observed. The NHA office, near the main facility entrance, required going through a resident care hall to access the survey team conference room location. Observation of entrance signage posted on the facility door included Facility PPE Information, Last updated: 12/30/2020, read in part: The following PPE must be worn in all patient care areas at all times: Recommended N95 with surgical (mask) Placed over the top . Eyewear: Face Shield at all times . At this time, full PPE (Gown, gloves, mask, and eyewear) must be worn in all rooms. The facility COVID-19 status is: POSITIVE . Observation on 1/21/21 at 3:57 p.m., of the Infection Control bulletin board located in the administrative wing, included the same sign as detail above and the following undated posting Infection Control Information: .Please continue to follow PPE guidelines as indicated by signage in building. At this time, entire building is on full Contact and droplet precautions (gown, gloves, face shield, mask). Remember to perform hand hygiene BEFORE and AFTER interaction with resident and/or patient environment . If you have any questions please ask (Registered Nurse (RN)/Infection Preventionist (IP) L), or (NHA). During an interview on 1/21/21 at 01:09 p.m., IP L was asked what PPE all facility staff should be wearing while in the facility. IP L stated, Face masks and eyewear . Some people have had surgical masks on - but I am planning to educate them that if they are COVID-19 recovered or not they need to have an N95 on. IP L said an Infection Prevention and Control Consultant Team had been in the facility the previous week and donning of N95 face masks was one of the recommendations they made - that all staff need to wear N95 face masks with an outbreak of COVID-19 in the building and high community spread of COVID-19. IP L confirmed education regarding the recommendations provided by the Infection Prevention and Control Consultant Team had not yet been provided to facility staff. IP L stated, I am having an (educational) in-service next week (on the Infection Prevention and Control Consultant Team recommendations). During an interview on 1/21/21 at 3:33 p.m., IP L confirmed she was employed full-time by the facility. IP L stated, I am given three days to complete Infection Control (tasks), but two of those days are COVID testing days, which can take me all day to complete. I know that I am not given enough time and resources to complete the things that I know in my head we need to be doing. During an interview on 1/21/21 at 9:25 a.m., the DON was asked about the level of PPE staff were required to wear within the facility. The DON stated, All staff that are in contact (with residents) should be wearing N95/KN95 face masks and eye protection. Glucometer Testing and Cleaning/Environmental Surfaces/Hand Hygiene On 1/21/21 at 8:30 a.m., Licensed Practical Nurse (LPN) D brought a small, brown, plastic tray containing the blood glucose glucometer (for blood sugar testing) from the 300-hall medication cart into Resident #18's room and placed it on Resident #18's overbed table without a barrier. LPN D donned gloves and used a lancet on Resident #18's finger, and repeatedly squeezed the finger (gloves donned) with inadequate blood produced to complete the blood glucose test. LPN D obtained another blood glucose test strip from a small vial containing multiple test strips, using her soiled gloves. LPN D's soiled gloves were inserted into the same test strip vial four times, prior to successful completion of the blood glucose test on the fourth attempt. The glucometer and testing supply tray were returned to the top of the 300-hall medication cart. On 1/21/21 at approximately 8:35 a.m., LPN D used an alcohol wipe to clean the glucometer by wiping all surfaces for approximately 5-10 seconds. The wet glucometer was placed immediately into the brown plastic storage tray with the other testing supplies and placed into the 300-hall medication cart. Review of the manufacturer's Cleaning & Disinfecting the (Name Brand) Blood Glucose Meter, revealed the following, in part: (Company Name) cleaning and disinfecting guidelines are as follows: . (Name Brand) Disinfecting Guidelines: To disinfect the meter, dilute 1 mL (milliliter) of household bleach (5%-6% sodium hypochlorite solution in 9 mL of water to achieve a 1:10 dilution (final concentration of (0.5% - 0.6% sodium hypochlorite). The solution can then be used to dampen a paper towel (do not saturate the towel). Then use the damped (sic) towel to thoroughly wipe down the meter .Please note that there are commercially available 1:10 quaternary/alcohol wipes and bleach wipes from a variety of manufactures .Please follow the disinfectant product label instructions to ensure proper drying time . Review of an undated Glucometer Sanitation facility audit form, provided by the DON on 1/22/21 at 9:50 a.m., revealed the following Procedure/Step(s) observed for correct glucometer use and cleaning: .3. Place the glucometer on a barrier/non-porous surface (glove/baggie/paper towel) . 7. Using a Super-Sani Germicidal Wipe, clean visible contaminants off the glucometer .8. Remove gloves, sanitize hands, don a new pair (gloves). 9. Wrap the glucometer in SECOND, CLEAN Super-Sani Germicidal Disposable Wipe for TWO MINUTES, being sure to keep the surface of the glucometer wet the entire time. Use a fresh wipe if needed .11. Remember that the glucometer is not ready to use for over two minutes PLUS drying time! During an observation on 1/21/21 at 8:56 a.m., LPN D entered Resident #26's room, on the 300 hall, to administer a prescribed nasal spray. The nasal spray was set on a tissue barrier on the Resident's overbed table. LPN D attempted to don gloves resulting with one torn glove. LPN D removed both gloves and threw them into the garbage can. LPN D touched Resident #26's bathroom doorknob with a bare right hand and donned new gloves from the Resident bathroom without performing hand hygiene. The nasal spray was administered, and the tissue barrier removed from the overbed table and thrown away in the garbage. LPN D placed the nasal spray bottle back into the medication box and set it back down onto Resident #26's bedside table without a barrier, two separate times, before returning the medication box into the 300-hall medication cart. Review of the undated facility Handwashing/Hand Hygiene policy revealed the following, in part: All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub . for all the following situations: . Before and after direct contact with residents . Before preparing or handling medications .After contact with a resident's intact skin .After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and . After removing gloves .The use of gloves does not replace handwashing/hand hygiene . During an interview regarding medication pass observations on 1/21/21 at 9:12 a.m., LPN D confirmed she had wiped the glucometer with one cleaning (alcohol) wipe and immediately placed the glucometer into the storage box and into the 300-hall medication cart. LPN D stated, I understand that I should have let it (glucometer) sit out and dry. LPN D said that she was aware it had been done incorrectly. When asked about placing resident medication boxes directly on resident overbed tables without a barrier, LPN D stated, It (medication box) would have been contaminated and acknowledged that a barrier was necessary to prevent cross contamination between resident environmental surfaces and the medication cart. When asked about the use of soiled gloves to reach into the glucose test strip vial to retrieve four separate test strips, LPN D said she understood the concern with contamination of the vial and test strips within the vial. When asked about touching the bathroom doorknob with her right bare hand, without performing hand hygiene before donning new gloves, LPN D stated, I should have washed my hands. On 1/22/21 at 8:15 a.m., LPN D was asked to provide the brand name of the glucometer and blood glucose test strips used to perform Resident #18's blood glucose testing on 1/21/21. LPN D pulled the glucometer and test strip vial out of the 300-hall medication cart. The name brand of the glucometer and blood glucose test strips was obtained. When asked what wipe was used to cleanse the glucometer (on 1/21/21), LPN D stated, I usually have bleach wipes, but I didn't have any yesterday, so I used an alcohol pad to wipe it (following use). During an interview with the DON on 1/21/21 at 10:05 a.m., the DON was asked about the observations during medication pass including: 1. Cleaning of the glucometer: The DON stated, We use a bleach wipe to wipe down the glucometer. We leave it (glucometer) wet for five minutes. We briskly wipe it off - and it is obviously wet, and leave it sit on the top of the medication cart, with a barrier, until it is d (TRUNCATED)

Based on observation, interview and record review, the facility failed to prevent rough treatment of [REDACTED].#202, #203 and #204) of eight residents reviewed for abuse/mistreatment, of a sample of nine residents. This deficient practice resulted in injury to Resident #202, and the potential for injury for all 28 residents needing transfer assistance. Findings include: All times in this report are in Central Standard Time. An extended abbreviated survey was conducted 10/16/14 - 10/17/14 and 10/27/14 - 10/29/14 in response to two complaints and a facility reported incident involving Resident #202, who sustained bruises to her right arm, first reported to the facility as an allegation of abuse on 10/15/14. The facility Investigation Summary dated 10/20/14, revealed Certified Nurse Aide (CNA) "R" reported to Registered Nurse (RN) "B" she had worked with CNA "T" the night before (10/14/14) and CNA "T" had been "too rough with the residents". CNA "R" reported she felt the way CNA "T" treated the residents was "disturbing". In an interview with RN "B" on 10/16/14 at 3:55 p.m. she was asked what specifics CNA "R" had reported to her regarding rough treatment of [REDACTED]. RN "B" stated, "(CNA "R") was quite upset about it... (Resident #203) and (Resident #204) were mentioned... It hurts me to think about it... (CNA "R") described (Resident #204) as saying "ouch, ouch" (when being transferred)... they are fragile." In an interview with Licensed Practical Nurse (LPN) "S" on 10/28/14 at 3:12 p.m., she stated she was working the afternoon shift on 10/13/14 when CNA "T" reported a bruise on Resident #202. LPN "S" stated, "(CNA "T") assisted her (Resident #202) to bed about 6 p.m. I was on the phone about 9:50 p.m. with (Director of Nursing (DON)) about another resident's bruise and (CNA "T") said, 'Oh yes, since you're telling her about a bruise, there's a bruise on (Resident #202) that I noticed.'" When LPN "S" was asked if she assessed Resident #202 after learning of the bruise, she stated, "I did... I measured the bruise (on her right arm) and contacted (DON), the Administrator, the doctor, and told the p.m. shift to let her son know (about the bruise) in the morning... that was a big bruise (for CNA "T") to forget about." A review of the facility face sheet for Residents #202, 203, and 204 revealed the following information: Resident #202 is a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS)assessment (dated 8/13/14) for Resident #202 revealed she had severe cognitive impairment and was total dependence for transfers with a two person assist. Resident #203 is an [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment (dated 9/3/14) for Resident #203 revealed he was assessed with [REDACTED]. Resident #204 is an [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment (dated 8/1/14) for Resident #204 revealed she had severe cognitive impairment and was total dependence for transfers with a two person assist. None of the above residents were interviewed due to their cognitive impairment. Resident #202's bruises were observed on 10/16/14 at 2:00 p.m. in her room as she sat in her wheelchair. The bruised area was observed on the underside of Resident #202's right forearm, from her wrist to her elbow; the right thumb had a dried blood blister and a bruise on the pad below her right thumb; another bruise extended from the base of her middle finger to the little finger, and down to the wrist on the back side of her right hand. The bruises were dark purple in color. ( ) During an interview with CNA "R" on 10/16/14 at 3:28 p.m., she was asked about her concerns regarding the care provided by CNA "T". CNA "R" stated, "I worked yesterday and the night before with CNA "T"... I felt strongly enough about (how she treated residents) that I talked to (RN "B") about it... I understand we don't have enough people here and cares can be rushed, but people here deserve better treatment. (CNA "T") handled people roughly." CNA "R" confirmed she was referring to residents on the 300 Hall, which included Residents #202, 203 and 204. CNA "R" was asked to describe further the treatment she saw CNA "T" provide. CNA "R" stated, "(Resident #203) would say 'Ow' when (CNA "T") handled him... I was so upset that night... It wasn't right treatment in my eyes." CNA "R" stated another staff member also reported CNA "T's" treatment of [REDACTED]. here anymore." A review of the time sheet reports for CNA "T" indicated she worked a 12-hour night shift starting at 9 p.m. on 10/10/14-10/11/14, 11.75-hour shift starting at 5 p.m. from 10/13/14-10/14/14, and a 12-hour shift starting at 5 p.m. from 10/14/14-10/15/14. A review of the employee file for CNA "T" revealed three forms entitled "Employee Corrective Discipline": dated 1/21/14 for "Advisory Counseling - 1st Offense... unsatisfactory performance: discourteous treatment of [REDACTED].") gave cares independently resulting in a large skin tear"; dated 10/14/14 for "Termination... a substantiated allegation of rough treatment of [REDACTED]. A review of four "Written Statement of Witness" all dated 9/17/14, indicated concerns were raised by LPN "S", CNA "R", CNA "Q" and CNA "U", regarding the actions and verbal exchanges between CNA "T" and residents on the 300 Hall. A review of the facility investigation file for the allegation made regarding CNA "T's" treatment of [REDACTED].") was becoming rough in her treatment of [REDACTED]. Conclusion: (CNA "T") has violated the resident rights to be free of harm and has a disregard for the residents feelings and medical conditions when she performs her job." In an interview with the Interim Administrator on 10/28/14 at 10:10 a.m. he confirmed CNA "T" was "no longer working here". ( ) --

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO SEARCH THE OUTSIDE OF THE BUILDING WHEN EXIT DOOR ALARMS SOUNDED, FAILED TO ENSURE ALL FACILITY STAFF WERE ADEQUATELY TRAINED ON THEIR "MISSING RESIDENT" POLICY AND PRACTICE OF DRILLS, AND FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT ACCIDENTS SECONDARY TO AN ELOPEMENT IN FIVE (#100, #101, #102, #103, AND #104) OF FIVE RESIDENTS REVIEWED FOR ELOPEMENT RISK OUT OF NINE RESIDENTS IDENTIFIED AS BEING AT RISK FOR THE POTENTIAL OF UNAUTHORIZED EXIT FROM THE FACILITY. FINDINGS INCLUDE: ALL TIMES IN THIS REPORT ARE IN CENTRAL STANDARD TIME (CST). RESIDENT #100 WAS KNOWN TO BE AT RISK FOR ELOPEMENT. RESIDENT #100 WAS SEVERELY COGNITIVELY IMPAIRED AND REQUIRED THE ASSISTANCE OF ONE PERSON AND A WALKER FOR SAFE AMBULATION. ON 6/22/13 AT APPROXIMATELY 2:30 P.M., THE FACILITY'S EXIT DOOR ALARM SYSTEM SOUNDED. REGISTERED NURSE "B" RESPONDED TO THE ALARMING DOOR BUT DID NOT SEARCH THE AREA OUTSIDE OF THE BUILDING TO DETERMINE THERE WERE NO RESIDENTS OUT OF THE FACILITY. ON 6/22/13 AT APPROXIMATELY 3:00 P.M., RESIDENT #100 WAS DISCOVERED APPROXIMATELY 300 FEET AWAY FROM THE FACILITY, STANDING ALONE, WITH HER WALKER, ON THE SIDEWALK ALONG SIDE OF A ROAD, BY OFF-DUTY LAUNDRY STAFF "D" WHO WAS DRIVING IN A VEHICLE ON THE SAME ROAD. OFF-DUTY LAUNDRY STAFF "D" LEFT RESIDENT #100 ON THE SIDEWALK AND DROVE TO THE FACILITY TO NOTIFY THEM. THE FACILITY WAS UNAWARE RESIDENT #100 WAS NO LONGER UNDER THEIR SUPERVISION FOR APPROXIMATELY 30 MINUTES. THIS DEFICIENT PRACTICE RESULTED IN IMMEDIATE JEOPARDY TO THE HEALTH AND SAFETY OF RESIDENT #100. ON 6/27/13 AT 7:30 A.M., THE FACILITY WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT WAS IDENTIFIED ON 6/26/13 AND BEGAN ON 6/22/13 WHEN THE FACILITY FAILED TO IMPLEMENT THEIR "MISSING RESIDENT" POLICY AND SEARCH THE OUTSIDE/INSIDE OF THE BUILDING WHEN AN EXIT DOOR ALARM SOUNDED AND FAILED TO ENSURE FACILITY STAFF WERE ADEQUATELY TRAINED ON THE "MISSING RESIDENT POLICY" TO PREVENT A POSSIBLE ACCIDENT WITH SERIOUS INJURY WHEN RESIDENT #100 EXITED THE FACILITY WITHOUT THEIR KNOWLEDGE. DURING THE COMPLETION OF THE EXTENDED SURVEY ON 6/26/13 THROUGH 6/27/13, THE IMMEDIATE JEOPARDY WAS REMOVED ON 6/27/13 BY THE FOLLOWING FACILITY ACTIONS: 1. REVISION OF RESIDENT #100'S PLAN OF CARE TO INCLUDE 15 MINUTE VISUAL CHECKS. THESE VISUAL CHECKS ARE TO BE CONTINUED UNTIL A ROOT CAUSE FOR THE INCREASED ANXIETY CAN BE IDENTIFIED AND ADDRESSED. 2. ELOPEMENT RISK ASSESSMENTS HAVE BEEN RE-DONE FOR ALL CURRENT RESIDENTS, WITH CARE PLAN REVISIONS AS NECESSARY. 3. REVIEW OF "MISSING RESIDENT POLICY AND PROCEDURE" TO ENSURE ALL NECESSARY COMPONENTS ARE INCLUDED. 4. STAFF RE-EDUCATION REGARDING MISSING RESIDENT POLICY AND PROCEDURE, ALARM PANELS, MULTIPLE ALARMS CONTINUED THROUGH 6/26/13. 5. ON 6/27/13, FACILITY STAFF BEGAN TO PRACTICE "MISSING RESIDENT DRILLS". THESE DRILLS WILL OCCUR ON ALL THREE SHIFTS. EVALUATION TO BE COMPLETED ON EACH DRILL FOR AREAS OF IMPROVEMENT AND ADDITIONAL EDUCATION AS NEEDED. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE DEFICIENT PRACTICE REMAINED AT A PATTERN LEVEL WITH POTENTIAL FOR MORE THAN MINIMAL HARM, POTENTIALLY AFFECTING RESIDENTS (#100, #101, #102, #103, AND #104) PENDING: - COMPLETION OF SAFETY AND ELOPEMENT TRAINING OF ALL STAFF. - VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH ENSURING ADEQUATE SUPERVISION AND EFFECTIVE RESPONSE TO ALARMING EXIT DOORS TO PREVENT RESIDENTS FROM EXITING THE FACILITY WITHOUT PROPER AUTHORIZATION TO ENSURE THEIR SAFETY AND WELL-BEING. FINDINGS INCLUDE: A REVIEW OF A FACILITY "24 HOUR REPORT" DATED 6/24/13, REVEALED: "RESIDENT ELOPED FROM FACILITY, RETURNED WITHOUT INCIDENT." AN INVESTIGATION BEGAN AT THE FACILITY ON 6/25/13 AT 3:15 P.M. WITH AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON). SHE REPORTED SHE WAS CONTINUING HER INVESTIGATION ON RESIDENT #100'S ELOPEMENT OF 6/22/13. THE DON INDICATED RESIDENT #100 HAD left the faciity on [DATE] AND WAS FOUND AT APPROXIMATELY 3:00 P.M. BY OFF DUTY LAUNDRY STAFF "D" A COUPLE OF BLOCKS DOWN THE ROAD. ON 6/26/13 AT 10:35 A.M., THIS SURVEYOR AND THE DON WALKED THE PRESUMED PATH RESIDENT #100 TOOK ON 6/22/13. APPROXIMATELY THREE FEET OUT THE RECEIVING DOOR ARE THREE CONCRETE STEPS GOING DOWN. JUST BEYOND THE STEPS IS A RESIDENTIAL SIDE ROAD. TO THE LEFT, ACROSS THE RESIDENTIAL SIDE ROAD IS A SIDEWALK WITH AN UPWARD INCLINE. THE DON AND THIS SURVEYOR WALKED THE INCLINE UP TO THE SIDEWALK AND CONTINUED TO WALK TO JUST BEYOND 322 5TH AVENUE, A RESIDENTIAL STREET, WHERE RESIDENT #100 WAS FOUND AFTER EXITING THE FACILITY. APPROXIMATELY 4-6 BLOCKS IN THE OTHER DIRECTION IS GREEN BAY (THE BAY OFF LAKE MICHIGAN). ACCORDING TO THE ADMISSION MINIMUM DATA SET (MDS) assessment dated [DATE], RESIDENT #100 IS AN [AGE] year-old FEMALE RESIDENT admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #100 WAS ASSESSED BY THE FACILITY TO BE "SEVERELY COGNITIVELY IMPAIRED" INDICATING SHE IS UNABLE TO MAKE DECISIONS AND UNABLE TO CARE FOR HERSELF. A REVIEW OF THE MOST RECENT QUARTERLY MDS dated [DATE] REFLECTS RESIDENT #100 NEEDED OVERSIGHT TO WALK IN HER ROOM OR THE CORRIDOR AND ASSISTANCE OF ONE STAFF TO MOVE "TO AND FROM" DISTANT AREAS. A REVIEW OF RESIDENT #100'S CARE PLAN DATED 1/13/2013, ENTITLED "THOUGHT PROCESS", REFLECTS RESIDENT #100 HAS THE FOLLOWING PROBLEMS LISTED: WANDERING, ANXIETY, LONG/SHORT TERM (MEMORY) LOSS, POOR DECISION MAKING, RECALL PROBLEMS. THIS CARE PLAN DIRECTS STAFF TO BE ON ALERT FOR "TARGETED BEHAVIOR: ...WANDERING..." AND TO "REDIRECT IF OUT OF AREA" RELATED TO [DIAGNOSES REDACTED]. RESIDENT #100'S CARE PLAN ENTITLED "MOBILITY" AND DATED 10/15/12, INDICATES RESIDENT #100'S "NEED/PROBLEM" TO BE: BALANCE PROBLEMS, UNSTEADY, WEAKNESS/ FATIGUE, HISTORY OF FALLS, POOR SAFETY AWARENESS...", AND INSTRUCTS STAFF TO "CUE AS NEEDED-USE WALKER AT ALL TIMES... TRANSFER WITH 1 ASSIST... HAS WHEELCHAIR FOR LONGER DISTANCES OR WHEN GOING OUT OF THE BUILDING." AN INTERVIEW WAS CONDUCTED WITH RESIDENT #100 ON 6/26/13 AT 10:45 A.M. RESIDENT #100 WAS UNABLE TO REMEMBER WHAT HAPPENED ON 6/22/13 WHEN SHE EXITED THE BUILDING. RESIDENT #100 WAS OBSERVED WEARING A WANDERGUARD BRACELET ON HER RIGHT ANKLE AND APPEARED CONTENT AND UNINJURED. A WANDERGUARD IS A BRACELET WHICH ALERTS/SOUNDS AN ALARM WHEN A RESIDENT IS NEAR AN EXIT DOOR EQUIPPED WITH A WANDERGUARD MONITOR. DURING AN INTERVIEW CONDUCTED WITH REGISTERED NURSE (RN) "B" ON 6/26/13 AT 9:40 A.M., IT WAS LEARNED THE FACILITY FAILED TO CORRECTLY IMPLEMENT A SEARCH FOR RESIDENT #100 WHEN AN EXIT DOOR/WANDERGUARD ALARM SOUNDED. RN "B" STATED, "IT WAS AT SHIFT CHANGE AROUND 2:30 (P.M.). THERE WERE ALARMS GOING OFF BY THE COURTYARD AND THEN I HEARD THE RECEIVING DOOR ALARM (INDICATOR OF BEING OPENED). I PEEKED OUT THE DOOR AND LOOKED BOTH WAYS AND NO ONE WAS OUT THERE. NO ONE WAS BY THE RECEIVING DOOR AND WHEN I TURNED AROUND, (RESIDENT #103) WAS COMING FROM WHERE THE ELEVATOR ALARM WAS GOING OFF. I TURNED IT OFF THEN TOLD (LICENSED PRACTICAL NURSE "C") ALL CLEAR... ABOUT 15 MINUTES LATER, (STAFF "D") CAME IN AND SAID (RESIDENT #100) WAS BY HER HOUSE... (LPN "C") TOOK OFF TO ASSIST (STAFF "D") AND FOUND ANOTHER CNA TO HELP... I DIDN'T KNOW WE WERE SUPPOSED TO CIRCLE THE ENTIRE BUILDING AND DO A BUILDING SWEEP..." IN AN INTERVIEW CONDUCTED WITH LAUNDRY STAFF "D" ON 6/26/13 AT 7:35 A.M., SHE REPORTED "I WORKED THAT DAY AND LEFT AT 2:30 (P.M.) AND I SAW HER SHORTLY BEFORE THAT AND I DIDN'T SEE HER OUTSIDE. WHEN I FOUND HER (RESIDENT #100) IT WAS 3:00 (P.M.) ON MY CAR CLOCK." A REVIEW OF THE INSERVICE TRAINING RECORDS FOR RN "B" REFLECTED SHE HAD NOT RECEIVED QUARTERLY DRILL PRACTICES REGARDING MISSING RESIDENTS. AN INTERVIEW WAS CONDUCTED WITH LICENSED PRACTICAL NURSE (LPN) "C" ON 6/26/13 AT 8:25 A.M. LPN "C" REPORTED SHE WAS SITTING AT THE NURSES STATION WITH RN "B". SHE STATED SHE WAS ALERTED BY OFF DUTY LAUNDRY STAFF "D" THAT RESIDENT #100 WAS BY HER HOUSE. SHE FURTHER EXPLAINED SHE WENT OUT TO RESIDENT #100. LPN "C" STATED, "...SHE WASN'T IN DISTRESS BUT SHE THOUGHT THE COPS WERE AFTER HER FOR STEALING THE WALKER. I BROUGHT HER BACK AND THE ADMINISTRATOR INTERVIEWED HER... I HONESTLY DON'T BELIEVE SHE GOT OUT THAT DOOR (RECEIVING DOOR)... I THOUGHT SHE GOT OUT THE COURTYARD DOOR....". A TELEPHONE INTERVIEW WAS CONDUCTED WITH THE ADMINISTRATOR ON 6/26/13 AT 12:20 P.M. THE ADMINISTRATOR STATED, "I WENT OUT BECAUSE I HEARD THEY WERE OUT TRYING TO GET HER (RESIDENT #100) IN THE BUILDING. I BROUGHT HER IN AND TALKED TO HER. SHE SAID SHE WAS ON HER WAY TO JAIL AND THE GATE WAS LEFT OPEN..." THE FACILITY POLICY "MISSING PERSONS" DATED 8/1/99 WITH A REVIEW/REVISED DATE OF 12/16/11 DOCUMENTS, "...A) IF WANDER ALARM IS SOUNDING, STAFF WILL IMMEDIATELY CHECK DOOR/WANDER PANEL, FOR DESIGNATED TRIGGERED DOOR, COMPLETE SEARCH OF IMMEDIATE AREA INSIDE AND OUTSIDE OF BUILDING... IF RESIDENT NOT FOUND, CONTINUE WITH PROCEDURE. B) ...IF UNABLE TO LOCATE, ANNOUNCE A CODE WHITE AND COMPLETE MISSING RESIDENT ASSESSMENT." SECTION 3.2(A) OF THE FACILITY POLICY "MISSING PERSONS", READ: "DRILLS WILL BE COMPLETED TO KEEP STAFF PROFICIENT... QUARTERLY ON EACH SHIFT..." THE FOLLOWING INTERVIEWS WERE CONDUCTED ON 6/26/13 WITH STAFF: CNA "F" AT 8:25 A.M., RN "G" (DAY SHIFT) AT 8:30 A.M., LPN "M" AND CNA "L" AT 3:15 P.M. (AFTERNOON SHIFT) AND ON 6/27/13 AT 7:27 A.M. WITH CNA "H" AND AT 7:58 A.M. WITH CNA "I" (MIDNIGHT SHIFT). NO STAFF COULD IDENTIFY WHEN THEY PARTICIPATED IN THEIR LAST ELOPEMENT DRILL. A "MISSING RESIDENT DRILL RECORD" DATED 5/1/12 PROVIDED BY MAINTENANCE DIRECTOR "J" REFLECTS THAT RN "B", CNA "F", RN "G", CNA "L", AND CNA "H" DID NOT PARTICIPATE IN THIS DRILL. THE "MISSING RESIDENT DRILL" CONDUCTED ON 5/1/12 SHOWS 18 STAFF MEMBERS PARTICIPATED. A EMPLOYEE LIST PROVIDED BY THE FACILITY, DATED 6/25/13, SHOWS THE FACILITY HAS A TOTAL OF 71 STAFF MEMBERS CURRENTLY. ON 6/27/13 AT 11:35 A.M., THE DON WAS GIVEN THE OPPORTUNITY TO PROVIDE MORE RECENT DOCUMENTATION THAT DEMONSTRATED FACILITY STAFF HAD RECEIVED THE QUARTERLY PRACTICE DRILLS AS REQUIRED BY THEIR FACILITY POLICY. THE DON STATED THERE WAS NO OTHER DOCUMENTATION REFLECTING FACILITY STAFF HAD CONDUCTED A "MISSING RESIDENT DRILL" SINCE 5/1/12. THE CARE PLAN FOR RESIDENT #101 DATED 4/24/13, SHOWED RESIDENT #101 "MAKES STATEMENTS OF GOING TO GET OUT OF HERE" AND HAS "SIGNS/ SYMPTOMS" OF SHORT/LONG TERM (MEMORY) LOSS, RECALL PROBLEMS, AND POOR DECISION MAKING. IT IS CARE PLANNED FOR RESIDENT #101 TO WEAR A WANDERGUARD. A REVIEW OF RESIDENT #101'S MDS dated [DATE], SHOWED RESIDENT #101 REQUIRED OVERSIGHT WITH NO PHYSICAL ASSIST, AND NO ASSISTIVE DEVICES TO AMBULATE TO AND FROM DISTANT AREAS. THE CARE PLAN FOR RESIDENT #102 DATED 5/9/13, SHOWED RESIDENT #102 WILL TRY TO FOLLOW PEOPLE THROUGH EXIT DOORS, HAS LONG/SHORT TERM (MEMORY) LOSS, RECALL PROBLEMS, AND POOR DECISION MAKING. IT IS CARE PLANNED FOR RESIDENT #102 TO WEAR A WANDERGUARD. A REVIEW OF RESIDENT #102'S MDS assessment dated [DATE], SHOWED RESIDENT #102 REQUIRED ONE STAFF ASSIST TO PROVIDE "GUIDED MANEUVERING" AND REQUIRED NO ASSISTIVE DEVICE TO AMBULATE TO AND FROM DISTANT AREAS. THE CARE PLAN FOR RESIDENT #103 DATED 3/6/13, SHOWED RESIDENT #103 TALKS OF GOING TO FLORIDA/MOVING, AT RISK FOR ELOPEMENT, HAS SHORT TERM MEMORY LOSS, DEMENTIA, DEMENTIA-ALZHEIMER TYPE, AND PARKINSON'S DISEASE. IT IS CARE PLANNED FOR RESIDENT #103 TO WEAR A WANDERGUARD. A REVIEW OF RESIDENT #103'S MDS assessment dated [DATE], SHOWED RESIDENT #103 REQUIRED ONE STAFF ASSIST TO PROVIDE "GUIDED MANEUVERING" TO AND FROM DISTANT AREAS AND REQUIRED A WALKER AS A ASSISTIVE DEVICE. THE CARE PLAN FOR RESIDENT #104 DATED 5/2/13, SHOWED RESIDENT #104 HAS HISTORY OF TALKING ABOUT GOING HOME, PACKING BELONGINGS, SEEKS OUT EXIT DOORS, AT RISK TO ELOPE, LONG/SHORT TERM (MEMORY) LOSS, RECALL PROBLEMS PHYSICAL AGGRESSION, AND DEMENTIA. IT IS CARE PLANNED FOR RESIDENT #104 TO WEAR A WANDERGUARD. REVIEW OF RESIDENT #104'S MDS assessment dated [DATE], SHOWED RESIDENT #104 REQUIRED EXTENSIVE ASSIST OF ONE STAFF TO AMBULATE TO AND FROM DISTANT AREAS AND REQUIRED A WALKER OR WHEELCHAIR AS ASSISTIVE DEVICES. ( ) --

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO DEVELOP A SYSTEM TO FULLY ASSESS, CARE PLAN, AND USE PROPERLY FITTING SLINGS WHEN MECHANICAL LIFTS ARE REQUIRED FOR TRANSFERS BETWEEN SURFACES IN FIVE RESIDENTS (#1, #5, #6, #7, #8) AND FAILED TO ADEQUATELY SUPERVISE ONE RESIDENT (#1) OF EIGHT TOTAL RESIDENTS REVIEWED FOR MECHANICAL LIFT TRANSFERS. THE SYSTEMIC FAILURE RESULTED IN RESIDENT #1 FALLING TO THE FLOOR DURING A TRANSFER AND HAD THE POTENTIAL FOR SERIOUS INJURY, HARM, IMPAIRMENT OR DEATH PLACING THESE FIVE RESIDENTS IN IMMEDIATE JEOPARDY TO THEIR HEALTH AND SAFETY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 12/18/12 AT 11:00 A.M. (CENTRAL TIME). ALL TIMES GIVEN IN THIS REPORT ARE CENTRAL TIME ZONE. THE IMMEDIATE JEOPARDY BEGAN ON 12/8/12 AT APPROXIMATELY 7:45 A.M. WHEN CERTIFIED NURSE AIDE (CNA) "A" DID NOT FOLLOW RESIDENT #1'S PLAN OF CARE AND ATTEMPTED TO TRANSFER RESIDENT #1 BY USING A MECHANICAL LIFT WITHOUT ADEQUATE STAFF ASSISTANCE AND USED A SLING TO PHYSICALLY SUPPORT RESIDENT #1 WHILE MOVING THAT WAS NOT DETERMINED BY A FACILITY ASSESSMENT TO FIT HER CORRECTLY. RESIDENT #1 fell FROM THE MECHANICAL LIFT, SLIDING OUT OF THE SLING, AND LANDED ON THE FLOOR. FOR THE MECHANICAL LIFTS USED IN THE FACILITY, THE MANUFACTURER'S RECOMMENDATION IN THE "OPERATION MANUAL" (DATED 7/23/10) UNDER "SAFE WORKING LOADS", ON PAGE 13, REGARDING SLINGS SHOWED, "...DUE TO THE VARIETY OF RESIDENT SHAPES AND DIMENSIONS, THE APPROPRIATE SIZE SHOULD BE SELECTED TO ACCOMMODATE SPECIFIC PATIENTS..." DOCUMENTED ON PAGE 5 OF THIS OPERATION MANUAL IS, "THE MOST IMPORTANT PART OF THE LIFTING EXPERIENCE IS APPLYING THE SLING PROPERLY... TIGHTEN BY HOLDING ONTO THE STRAP, NOT THE BUCKLE... AS THE PERSON SITS, THE ABDOMEN IS WIDE. AS A PERSON STANDS, THE ABDOMEN WILL BECOME MORE NARROW; THEREFORE YOU MUST TIGHTEN THE SECURITY STRAP AS YOU LIFT THE PERSON..." THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 12/18/12 AT 11:15 A.M. AND A WRITTEN PLAN FOR REMOVAL WAS REQUESTED. ON 12/19/12 AT 12:39 P.M., THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THIS SURVEYOR VERIFIED THE FOLLOWING: - THE FACILITY REVISED THEIR POLICY AND PROCEDURE TITLED "MINIMAL LIFT/NO LIFT PROGRAM" TO INCLUDE "...AN ASSESSMENT TO DETERMINE APPROPRIATE INDIVIDUAL RESIDENT MECHANICAL LIFT AND SLING SIZE ..." AND RESIDENT TRANSFER ASSESSMENTS WOULD OCCUR "...AT ADMISSION, WITH ANY CHANGE OF TRANSFER ABILITY... AND AT A MINIMUM OF QUARTERLY..." - ALL RESIDENTS USING A MECHANICAL LIFT WITH SLING DEVICE WERE REASSESSED TO ENSURE THE APPROPRIATE MECHANICAL LIFT AND SLING SIZE ARE USED. THE INDIVIDUAL RESIDENT CNA COMMUNICATION SHEETS (ALSO CALLED CNA CARE CARDS) WERE UPDATED TO INCLUDE THE APPROPRIATE LIFT AND SLING SIZE. THE REASSESSMENTS OCCURRED DURING THE NEXT RESIDENT MECHANICAL LIFT TRANSFER FOLLOWING THE IDENTIFICATION OF THE IMMEDIATE JEOPARDY. - ALL CNAS AND LICENSED NURSES WERE BEING RE-EDUCATED ON THE REVISED POLICY AND PROCEDURE REGARDING MECHANICAL LIFTS AND THE DETERMINATION OF THE INDIVIDUAL RESIDENT'S APPROPRIATE SLING SIZE PRIOR TO THEIR NEXT SCHEDULED SHIFT. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT A PATTERN LEVEL OF POTENTIAL FOR MORE THAN MINIMAL HARM, DUE TO: - CONTINUATION OF THE FACILITY'S QUALITY ASSURANCE PROCESS TO COMPLETE RESIDENT TRANSFER ASSESSMENTS ON ALL RESIDENTS WITH UPDATES TO RESIDENT CARE PLANS AND CNA COMMUNICATION SHEETS WHERE INDICATED. - RESIDENT TRANSFER ASSESSMENTS WILL BE COMPLETED UPON RESIDENT ADMISSION, QUARTERLY AND WITH ANY CHANGE IN A RESIDENT'S MENTAL AND/OR PHYSICAL CONDITION OR CHANGE IN A RESIDENT'S TRANSFER ABILITIES. - VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH RESIDENT SUPERVISION AND USE OF APPROPRIATE SLING SIZES DURING MECHANICAL LIFT TRANSFERS TO PREVENT ACCIDENTS. FINDINGS INCLUDE: THE FACILITY'S INVESTIGATION REPORT DATED 12/12/12 DOCUMENTED ON 12/8/12 AT APPROXIMATELY 7:45 A.M., CNA "A" WAS ASSISTING RESIDENT #1 FROM THE BED INTO HER WHEELCHAIR. THE REPORT SHOWED A MECHANICAL STAND-UP LIFT WAS BEING USED FOR THE TRANSFER. THE INVESTIGATION REPORT DOCUMENTED CNA "A" RECALLED, AS RESIDENT #1 WAS STANDING IN THE LIFT, RESIDENT #1 "SLIPPED OUT OF THE LIFT" AND fell TO THE FLOOR. THE REPORT SHOWED CNA "A" SAID, "I WILL NEVER NEVER TRANSFER SOMEONE ELSE BY MYSELF AGAIN..." THE REPORT SHOWED AFTER THE FALL, THE LEFT CLIP ON THE MECHANICAL LIFT HOLDING THE LEFT TAB OF THE SLING WAS BROKEN. THE REPORT DOCUMENTED RESIDENT #1 WAS ASSESSED AND NO INJURIES WERE FOUND. THE MINIMUM DATA SET (MDS) assessment dated [DATE] FOUND IN RESIDENT #1'S MEDICAL RECORD REFLECTS RESIDENT #1 ENTERED THE FACILITY ON 12/8/11 AND IS [AGE] years OLD. HER [DIAGNOSES REDACTED]. THE MDS DOCUMENTED RESIDENT #1 MADE HER OWN MEDICAL DECISIONS. RESIDENT #1'S MDS AND CARE PLAN DATED 11/12 SHOWED SHE UNDERSTOOD WHAT WAS SAID TO HER, WAS UNDERSTOOD WHEN SHE SPOKE BUT USUALLY ANSWERED WITH YES OR NO RESPONSES OR VERY SHORT ANSWERS. THE CURRENT (NO DATE) "CNA COMMUNICATION SHEET" FOUND ON RESIDENT #1'S CLOSET DOOR SHOWED RESIDENT #1 USED A "STAND-UP (MECHANICAL) LIFT ALL SHIFTS WITH 2 ASSIST..." FOR TRANSFERRING BETWEEN SURFACES. THE "CNA COMMUNICATION SHEET" CONTAINED NO INFORMATION REGARDING THE SPECIFIC SIZED SLING THAT WAS TO BE USED WITH THE LIFT TO MEET RESIDENT #1'S NEEDS. RESIDENT #1 WAS INTERVIEWED ON 12/17/12 AT 4:00 P.M. DURING THE INTERVIEW, THE MECHANICAL STAND-UP LIFT WAS OBSERVED IN HER ROOM. RESIDENT #1 STATED, "YES" WHEN ASKED IF SHE REMEMBERED FALLING FROM THE LIFT. WHEN ASKED IF SHE HAD SLID OUT OF THE SLING ONCE SHE STOOD UP IN THE LIFT, SHE SAID, "YES" AND POINTED TO THE LEFT CLIP AND SAID THE CLIP "LET GO" OF THE SLING. ON 12/17/12 AT 2:20 P.M., AN INTERVIEW WAS CONDUCTED WITH CNA "A" FOLLOWED BY A TELEPHONE INTERVIEW ON 12/18/12 AT 8:45 A.M. CNA "A" CONFIRMED AN ADDITIONAL CNA SHOULD HAVE BEEN ASSISTING HER WITH THE TRANSFER. CNA "A" SAID, "WE'RE SUPPOSE TO HAVE TWO STAFF ASSIST WITH ALL TRANSFERS WHEN WE USE LIFTS..." SHE EXPLAINED, "...I WAS IN A HURRY... I DON'T KNOW IF THE SLING WAS TOO BIG OR IF I DIDN'T PUT IT ON RIGHT... (RESIDENT #1) DID SLIDE OUT OF THE SLING..." WHEN ASKED IF SHE KNEW WHAT SIZE SLING RESIDENT #1 USED, CNA "A" SAID, "...THERE'S TWO OR THREE STAND-UP LIFTS, WE JUST USE THE SLING THAT'S ON THE LIFT..." CNA "A" EXPLAINED, "...I DON'T THINK ANY RESIDENT HAS A SPECIAL SLING..." CNA "A" EXPLAINED SHE DID NOT KNOW IF THE SLING WAS IN THE CLIP CORRECTLY AND WHEN RESIDENT #1 fell , THE LIFT CLIP BROKE OR IF THE CLIP WAS ALREADY BROKEN PRIOR TO THE FALL. DURING THE INTERVIEW WITH CNA "A" ON 12/17/12 AT 2:20 P.M., THE #6 MECHANICAL STAND-UP LIFT WAS OBSERVED. LAYING ACROSS THE HANDLE OF THE MECHANICAL LIFT WAS A BLUE COLORED (EXTRA) X-LARGE SLING. CNA "A" IDENTIFIED THE #6 MECHANICAL LIFT AND X-LARGE SLING WERE USED AT THE TIME RESIDENT #1 fell FROM THE LIFT ON 12/8/12. A REVIEW OF THE FACILITY'S "CNA COMMUNICATION SHEETS" FOR RESIDENTS #5, #6, #7 AND #8 DOCUMENTED THESE RESIDENTS REQUIRED MECHANICAL LIFTS FOR TRANSFERS BETWEEN SURFACES. HOWEVER, DIRECTION REGARDING AN APPROPRIATE FITTING SLING SIZE WAS NOT PROVIDED. AN INTERVIEW WITH PHYSICAL THERAPIST (PT) "P" WAS CONDUCTED ON 12/18/12 AT 9:45 A.M. PT "P" SAID SHE DID NOT ASSESS THE RESIDENTS FOR SLING SIZES WHEN MECHANICAL LIFTS WERE DETERMINED TO BE REQUIRED FOR TRANSFERS. INTERVIEWS WERE CONDUCTED ON 12/17/12 AT 2:08 P.M. WITH CNA "B" AND 3:20 P.M. WITH CNA "G", ON 12/18/12 AT 8:20 A.M. WITH CNA "J" AND 9:15 A.M. WITH CNA "K", AND ON 12/19/12 AT 8:00 A.M. WITH CNA "L" AND 8:45 A.M. WITH CNA "M". THE SIX CNAS STATED THEY WOULD USE ANY AVAILABLE STAND-UP MECHANICAL LIFT AND THE SLING THAT WAS AVAILABLE WITH THAT LIFT. THE CNAS SAID THEY WERE NOT AWARE OF ANY FACILITY DIRECTION INDICATING THE RESIDENTS WERE TO USE A SPECIFIC SLING BASED ON SIZE. INTERVIEWS WERE CONDUCTED ON 12/18/12 AT 8 A.M. WITH RN "I" AND 8:30 A.M. WITH LPN "H", ON 12/19/12 WITH RN "E" AT 12:25 P.M. AND RN "F" AT 12:50 P.M. THESE FOUR NURSES EXPLAINED, IF A RESIDENT WAS ASSESSED TO NEED A MECHANICAL LIFT, NO SPECIFIC SLING ASSESSMENT WAS CONDUCTED. THEY ALSO CONFIRMED CNAS WERE NOT GIVEN INFORMATION AS TO WHAT SPECIFIC SIZE SLING TO USE WITH EACH INDIVIDUAL RESIDENT USING A MECHANICAL LIFT. OBSERVATIONS OF THE FACILITY'S MECHANICAL LIFTS WERE CONDUCTED ON 12/18/12 AT 8:55 A.M. WITH MAINTENANCE DIRECTOR "C". MAINTENANCE DIRECTOR "C" IDENTIFIED 4 MECHANICAL STAND-UP LIFTS, #3, #4, #6 AND #8. EACH LIFT CONTAINED A SLING. MECHANICAL LIFT #3 CONTAINED AN EXTRA LARGE UNIVERSAL SLING, LIFT #4 A LARGE UNIVERSAL SLING, LIFT #6 AN EXTRA LARGE SLING AND LIFT #8 CONTAINED A LARGE SLING. DURING AN INTERVIEW WITH MAINTENANCE DIRECTOR "C" CONDUCTED ON 12/18/12 AT 10:15 A.M., HE PRODUCED WHAT HE CALLED A "MAINTENANCE FILE" FOR LIFTS. THE FILE INCLUDED A "SLING SIZING CHART", DATED AS SENT to the facility on [DATE]. WHEN ASKED WHO HAD ACCESS TO A COPY OF THE "SLING SIZING CHART", MAINTENANCE DIRECTOR "C" EXPLAINED STAFF DO NOT HAVE ACCESS TO HIS FILES AND HE DID NOT KNOW IF ANOTHER COPY EXISTED. THE FOLLOWING OBSERVATIONS OF FACILITY STAFF TRANSFERRING FIVE RESIDENTS WITH A MECHANICAL STAND-UP LIFT WERE MADE: ON 12/17/12 AT 4:25 P.M., CNA "D" AND CNA "G" TRANSFERRED RESIDENT #1; ON 12/17/12 AT 4:13 P.M., CNA "R" AND CNA "S" TRANSFERRED RESIDENT #5; ON 12/18/12 AT 1:15 P.M., CNA "M" AND CNA "T" TRANSFERRED RESIDENT #6; ON 12/18/12 AT 8:15 A.M., CNA "K" AND CNA "V" TRANSFERRED RESIDENT #7; ON 12/18/12 AT 10:50 A.M., CNA "K" AND CNA "M" TRANSFERRED RESIDENT #8. ALL FIVE RESIDENTS WERE TRANSFERRED USING AN EXTRA LARGE SLING. THESE RESIDENTS' WEIGHTS AS DOCUMENTED IN THEIR MEDICAL RECORDS, WERE CHECKED AGAINST THE "SLING SIZING CHART". ACCORDING TO MANUFACTURER'S RECOMMENDATIONS, A MEDIUM SIZED SLING SHOULD HAVE BEEN USED FOR THESE RESIDENTS. AT THE TIME OF THE SURVEY, THE FACILITY FAILED TO CONDUCT A FULL SLING ASSESSMENT TO DETERMINE THE MOST APPROPRIATE FITTING SLING TO MAINTAIN EACH RESIDENT'S SAFETY. AN INTERVIEW WAS CONDUCTED WITH THE ADMINISTRATOR ON 12/18/12 AT 10:30 A.M. THE ADMINISTRATOR STATED SHE WAS NOT AWARE OF THE "SLING SIZING CHART". SHE CONFIRMED THE FACILITY HAD NOT BEEN ASSESSING INDIVIDUAL RESIDENTS FOR SLING SIZES WHEN THE RESIDENTS HAD BEEN ASSESSED TO NEED MECHANICAL LIFTS FOR TRANSFERS. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT INTERVENTIONS TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS IN FIVE RESIDENTS (#1, #3, #5, #7 AND #10) OF SIX RESIDENTS REVIEWED WITH PRESSURE ULCERS IN THE TOTAL SAMPLE OF 12 RESIDENTS FROM A FACILITY POPULATION OF 54. THIS DEFICIENT PRACTICE RESULTED IN RESIDENTS #1, #3, #5, #7 AND #10 DEVELOPING FACILITY ACQUIRED STAGE II PRESSURE ULCERS, RESIDENTS #1, #3, #5 AND #7 DEVELOPING MULTIPLE REOCCURRING STAGE II PRESSURE ULCERS AND RESIDENT #3 DEVELOPING A STAGE II PRESSURE ULCER THAT BECAME INFECTED AND PROGRESSED TO A STAGE IV PRESSURE ULCER REQUIRING SURGICAL INTERVENTION. FINDINGS INCLUDE: ACCORDING TO THE MINIMUM DATA SET (MDS) assessment dated [DATE], RESIDENT #3 IS AN [AGE] year OLD WOMAN WITH [DIAGNOSES REDACTED]. THE MDS INDICATED RESIDENT #3 HAD SEVERE MEMORY IMPAIRMENT AND WAS ONLY ABLE TO COMMUNICATE ON A BASIC LEVEL, OFTEN BEING NON-VERBAL. THE 10/12/12 MDS ALSO REFLECTED RESIDENT #3 WAS TOTALLY DEPENDENT ON STAFF FOR BED MOBILITY, TRANSFERRING, HYGIENE, TOILETING AND ALWAYS INCONTINENT OF BOTH BOWEL AND BLADDER. ON THE 5/10/12 MDS, RESIDENT #3 WAS NOTED TO BE "AT RISK" FOR SKIN BREAKDOWN AND WAS IDENTIFIED WITHOUT SKIN PROBLEMS OR PRESSURE ULCERS. ACCORDING TO NURSING NOTES AND TO A "TIME LINE SUMMARY" PREPARED BY THE DIRECTOR OF NURSING (DON), ON 5/15/12, RESIDENT #3 DEVELOPED A FACILITY ACQUIRED STAGE II PRESSURE ULCER ON HER COCCYX THAT MEASURED 1.5 CM (CENTIMETERS) X 2.0 CM X DEPTH OF LESS THAN 0.1 CM. ACCORDING TO THE NURSING NOTES, ON 7/24/12, A SECOND STAGE II PRESSURE ULCER DEVELOPED ON RESIDENT #3'S RIGHT BUTTOCK AND BY 8/14/12, BOTH PRESSURE AREAS WERE HEALED. ON 8/21/12, THE NURSING NOTES REFLECT RESIDENT #3'S RIGHT ISCHIAL FOLD HAD A NEWLY HEALED STAGE II PRESSURE AREA THAT RE-OPENED, MEASURING 1.0 CM X 0.4 CM X 0.1 CM. ON 9/4/12, THE WOUND HAD BEGUN TO DETERIORATE. IT WAS DESCRIBED AS A "STAGE III WITH 80% YELLOW SLOUGH SCATTERED IN WOUND BED ..." THE PRESSURE ULCER MEASURED 2.0 CM X 2.0 CM WITH DEPTH UNDETERMINED "DUE TO SLOUGH PRESENT". ON 9/11/12, THE WOUND MEASURED 2.7 CM X 2.0 CM X 0.8 CM WITH "80% BROWN SLOUGH ". BY 9/18/12, THE NURSING NOTES REFLECTS "WOUND NOW UNSTAGEABLE (STAGE IV) AS ISCHIAL FOLD IS NOW 100% BROWN ESCHAR IN WOUND BED... WOUND MEASURES 3.0 CM X 3.0 CM X UNKNOWN." ON 9/19/12, A WOUND CULTURE WAS COMPLETED AND WAS FOUND TO BE INFECTED. ON 9/25/12, RESIDENT #3 WAS SENT TO A SPECIALITY PHYSICIAN FOR DEBRIDEMENT OF THIS PRESSURE ULCER. FOLLOWING THE DEBRIDEMENT, ON 10/2/12, RESIDENT #3 HAD "A SURGICAL WOUND THAT MEASURED 4.0 CM X 3.5 CM X 2.0 CM. HAS 2.4 CM TUNNELING AT 6:00 POSITION AND 2 CM TUNNELING AT 2:00 POSITION, SCATTERED YELLOW SLOUGH AT 60%...." ON 10/17/12 AT 1:00 P.M., RESIDENT #3 WAS OBSERVED TO BE USING A YELLOW INCONTINENCE PAD THAT WAS WRINKLED AND BUNCHED UP BETWEEN RESIDENT #3'S LEGS PROVIDING LITTLE PROTECTION TO THE RIGHT ISCHIAL FOLD WOUND. WOUND CARE OF RESIDENT #3'S RIGHT ISCHIAL FOLD WAS OBSERVED BY NURSE SURVEYOR # . THE AREA WAS CLEAN, AND FREE OF DRAINAGE AND ODOR. THE WOUND WAS CLEANSED WITH "WOUND WASH" AND THEN PACKED WITH (2) 2 INCH BY 2 INCH MOIST GAUZE PADS AND COVERED WITH AN OCCLUSIVE DRESSING. ON 10/17/12 AT 3:10 P.M., IT WAS CONFIRMED BY OBSERVATION AND INTERVIEW WITH WOUND CARE NURSE "B", THAT RESIDENT #3'S WHEELCHAIR CUSHION WAS NOT THE PRESSURE REDUCTION CUSHION CALLED FOR IN THE CARE PLAN. A REVIEW OF RESIDENT #3'S SKIN CARE PLAN DATED 9/18/12, READS IN PART, "REPOSITION FROM BACK TO LEFT SIDE ALTERNATING. KEEP OFF RIGHT SIDE." THIS INTERVENTION ALSO APPEARED ON THE CURRENT "CNA (CERTIFIED NURSE AIDE) COMMUNICATION SHEET", WHICH WAS FOUND INSIDE THE CLOSET DOOR OF RESIDENT #3 ON 10/17/12 AT 9:00 A.M. AN OBSERVATION OF RESIDENT #3 ON 10/17/12 FROM 9:15 A.M. TO 10:15 A.M., FOUND RESIDENT #3 SLEEPING ON HER RIGHT SIDE. AT 10:15 AM., THIS OBSERVATION WAS CONFIRMED BY NURSE "D" WHO SAID, "OH, DEAR. I'LL GET SOMEONE TO REPOSITION HER RIGHT AWAY." AT 12:50 P.M. ON 10/17/12, NURSE "B" WAS BROUGHT TO RESIDENT #3'S ROOM TO CONFIRM THAT AFTER LUNCH, RESIDENT #3 HAD AGAIN BEEN LAID DOWN ON HER RIGHT SIDE, CONTRARY TO CARE PLAN INSTRUCTIONS. ON 10/18/12 AT 11:00 A.M., CNA "G" WAS INTERVIEWED. WHEN ASKED ABOUT THE POSITIONING/TURNING SCHEDULE FOR RESIDENT #3, CNA "G" STATED, "I ALWAYS TURN HER FROM ONE SIDE TO THE OTHER SIDE. I DON'T EVER PUT HER ON HER BACK BECAUSE SHE'S UP FOR MEALS." UPON QUESTIONING, CNA "G" STATED SHE HAD NEVER BEEN TOLD BY THE NURSES TO DO ANYTHING DIFFERENT IN THE TURNING AND POSITIONING OF RESIDENT #3. THE FACILITY'S POLICY AND PROCEDURES FOR PRESSURE ULCER TREATMENT (DATED NOVEMBER 2009) WAS REVIEWED. ON PAGES 4 AND 5 UNDER THE SECTION "DIETARY INTERVENTIONS FOR STAGE III (AND IV) PRESSURE ULCERS", THE FOLLOWING INTERVENTIONS (IN PART) WERE IDENTIFIED: "[MEDICATION NAME]: [MEDICATION NAME] EXTRA ( 8 OZ (OUNCES)) BID (TWICE A DAY); VITAMIN C: 500 MG ONCE/DAILY... IF WOUND IS INFECTED OR NON-HEALING MAY ADD IMPACT (8 OZ) BID." ON PAGE 5 UNDER THE SECTION "DIETARY INTERVENTIONS FOR STAGE IV PRESSURE ULCERS", THIS ADDITIONAL NUTRITIONAL SUPPLEMENT WAS RECOMMENDED: "ZINC: ZINC SULFATE 100 MG ONCE/DAY." ON 10/18/12 AT 9:45 A.M., THE DIETARY MANAGER WAS INTERVIEWED. SHE COULD PRODUCE NO EVIDENCE THE FACILITY OFFERED, OR THAT RESIDENT #3 RECEIVED, ANY OF THE ABOVE MENTIONED NUTRITIONAL SUPPLEMENTS, PER THE FACILITY'S PRESSURE ULCER TREATMENT POLICY. FURTHERMORE, THE DIETARY MANAGER COULD PRODUCE NO EVIDENCE RESIDENT #3 WAS OFFERED THE ADVANCED RECOVERY SUPPLEMENT WHICH WAS IDENTIFIED AS AN INTERVENTION ON THE SKIN CARE PLAN DATED 9/18/12. THE DIETARY MANAGER STATED RESIDENT #3 DID RECEIVE EXTRA PROTEIN WHEN HER PRESSURE ULCER WAS INFECTED, BUT SHE STATED ONCE IT WAS NO LONGER INFECTED, THE SUPPLEMENT WAS DROPPED, EVEN THOUGH THE PRESSURE ULCER REMAINED UNHEALED.( ) ACCORDING TO THE MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #1 IS AN [AGE] year OLD MALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS SHOWED RESIDENT #1'S NUTRITION COMES FROM A GASTROINTESTINAL FEEDING TUBE ([DEVICE]). THE MDS dated [DATE], IDENTIFIED RESIDENT #1 "AT RISK" FOR DEVELOPING PRESSURE ULCERS. RESIDENT #1'S CARE AREA ASSESSMENT CONCERNS (CAAs) READ, "HAS A HISTORY OF STAGE 2 PRESSURE ULCERS ON BUTTOCK. INTERVENTIONS IN PLACE TO ASSIST WITH PRESSURE RELIEF. WILL CONTINUE WITH INTERVENTIONS TO RELIEVE PRESSURE AND KEEP SKIN INTACT." THE WOUND PRESSURE ULCER CHARTING REVEALED RESIDENT #1 DEVELOPED FACILITY ACQUIRED PRESSURE SORES TO HIS LEFT AND RIGHT BUTTOCK, AND COCCYX OVER A TWO MONTH PERIOD OF TIME THAT HEALED AND REOPENED MULTIPLE TIMES. " ...7/24/12 - IDENTIFY A "STAGE 2 ULCER TO LEFT BUTTOCK ...8/7/12 - LEFT BUTTOCK WOUND HEALED ....8/14/12 - AREA OF CONCERN IS THE LEFT BUTTOCK, STAGE 2 PRESSURE ULCER. THIS IS A WOUND THAT WAS RECENTLY HEALED AND NOW DEVELOPED AND OPEN AREA TO THE NEWLY [MEDICATION NAME] TISSUE ...8/27/12 - STAGE 2 LEFT BUTTOCK ...AREA OF CONCERN IS THE LEFT BUTTOCK. THIS AREA WAS PREVIOUSLY HEALED. STAGE 2 PRESSURE ULCER THAT HAS NOW RE-OPENED WOUND IS SUPERFICIAL ...9/4/12 - THE WOUND PRESSURE ULCER CHARTING IDENTIFIED A STAGE 2 ON LEFT BUTTOCK, STAGE 2 ON COCCYX, AND STAGE 2 ON RIGHT BUTTOCK ....9/18/12 - STAGE 2 COCCYX WOUND HEALED TISSUE PINK EPITHELIZATION, STAGE 2 RIGHT BUTTOCK ...9/25/12- AREAS OF CONCERN ARE THE STAGE 2 PRESSURE ULCER TO THE BILATERAL BUTTOCK AT THE ISCHIAL FOLD AREA AND THE COCCYX. THE COCCYX WOUND WAS HEALED AND REOPENED." RESIDENT #1'S CARE PLAN DATED 9/4/12, IDENTIFIED "SKIN INTEGRITY" AS A PROBLEM WITH AN INTERVENTION AND ALSO DATED 9/4/12, WHICH READ: "RESIDENT UP IN WHEELCHAIR MAXIMUM TWO HOURS EVERY SHIFT UNTIL PRESSURE ULCERS HEALED". ANOTHER CARE PLAN INTERVENTION WAS ADDED AND DATED 9/25/12. IT READ: "UP FOR MEALS ONLY". RESIDENT #1'S MEALS WERE ORDERED BY THE PHYSICIAN TO BE GIVEN VIA THE [DEVICE] FOUR TIMES A DAY. AN OBSERVATION OF THE treatment for [REDACTED].M. IT REVEALED A PARTIAL THICKNESS LOSS OF THE DERMIS, PRESENTING AS A SHALLOW OPEN ULCER (STAGE II PRESSURE ULCER) ON THE COCCYX AREA MEASURING 2.5 CENTIMETERS (CM) IN LENGTH BY 1.0 CM WIDTH AND 0.1 CM IN DEPTH, AND A STAGE II PRESSURE ULCER MEASURING 0.3 CM IN LENGTH, 0.5 CM IN WIDTH AND 0.1 CM DEPTH LEFT BUTTOCK. IN ADDITION, AN AREA WAS OBSERVED ON THE RIGHT BUTTOCK MEASURING 2.2 CM IN LENGTH, 0.8 CM IN WIDTH AND 0.1 CM IN DEPTH. AN INTERVIEW WITH THE WOUND SPECIALIST "STAFF B" AFTER THE ABOVE OBSERVATION ON 10/16/12 AT 10:15 A.M., REVEALED RESIDENT #1'S PRESSURE ULCERS TO THE COCCYX AND BUTTOCK AREA KEEP REOCCURRING BECAUSE RESIDENT #1 IS LEFT IN HIS WHEELCHAIR TOO LONG. AN OBSERVATION WAS MADE ON 10/16/12 FROM 10:30 A.M. TO 2:00 P.M. RESIDENT #1 WAS OBSERVED IN HIS WHEELCHAIR AND NOT PLACED BACK IN BED WITHIN THE TWO HOURS OR AFTER HIS TUBE FEEDING MEAL WAS COMPLETED. AGAIN ON 10/17/12, RESIDENT #1 WAS OBSERVED UP IN HIS WHEELCHAIR FROM 8:30 A.M. TO 11:15 A.M. THIS TIME AGAIN EXCEEDED THE TWO HOUR LIMIT AS DIRECTED BY RESIDENT #1'S CARE PLAN. THUS, RESIDENT #1'S RECURRING STAGE II PRESSURE ULCERS WERE EXACERBATED FROM DIRECT PRESSURE WHILE SITTING UP IN HIS WHEELCHAIR FOR EXTENDED PERIODS OF TIME. ( ) ACCORDING TO THE FACE SHEET, RESIDENT #7 IS A [AGE] year OLD WOMAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS assessment dated [DATE], REVEALED RESIDENT #7 WAS COGNITIVELY IMPAIRED, NON-AMBULATORY, AND IS TOTALLY DEPENDENT UPON STAFF FOR ALL AREAS OF CARE. RESIDENT #7 WAS DEEMED "AT RISK" FOR PRESSURE ULCER DEVELOPMENT ACCORDING TO THE MDS. A REVIEW OF RESIDENT #7'S SKIN CONDITION NOTES FROM 11/01/11 THROUGH 10/09/12, SHOWED RESIDENT #7 DEVELOPED MULTIPLE STAGE I AND STAGE II FACILITY ACQUIRED PRESSURE ULCERS THAT WOULD HEAL AND RE-DEVELOP. THESE ULCERS HAD BEEN ON HER RIGHT AND LEFT BUTTOCK, RIGHT UPPER AND LOWER THIGH, LEFT THIGH, LEFT HEEL, AND AT THE BASE OF HER PELVIC GIRDLE. DETAILS INCLUDED: - ON 8/27/12, RIGHT BUTTOCKS STAGE II PRESSURE ULCER MEASURED 6.0 CM (CENTIMETERS) IN LENGTH BY 5 CM IN WIDTH BY <0.1 CM DEEP. - ON 7/03/12, LEFT BUTTOCKS STAGE II PRESSURE ULCER MEASURED 2.5 CM BY 1.0 CM BY <0.1 CM. - RIGHT LOWER THIGH WAS RECORDED AS BEING OPEN 7 TIMES AND HEALED 2 TIMES. THE LARGEST MEASUREMENT WAS RECORDED AS 0.3 CM BY 0.3 CM BY 0.1 CM. - RIGHT UPPER THIGH WAS RECORDED AS OPENED 2 TIMES AND HEALED 2 TIMES. - ON 2/07/12, LEFT HEEL OPENED AND HEALED ON 3/20/12. - ON 1/24/12, LEFT THIGH HEALED. - RIGHT ISCHIAL (BASE OF PELVIC GIRDLE) TUBEROSITY WAS RECORDED AS OPENED 4 TIMES AND RECORDED HEALED 2 TIMES WITH NO RECORD OF FINAL HEALING. AN OBSERVATION OF RESIDENT #7'S PRESSURE AREA WAS DONE ON 10/17/12 AT 1:20 P.M. WITH REGISTERED NURSE "B". RESIDENT #7 WAS WEARING A YELLOW INCONTINENCE PRODUCT THAT HAD NUMEROUS CREASES AND FOLDS AND IT APPEARED TO BE BUNCHED UP BETWEEN THE LEGS. CURRENTLY, RESIDENT #7 HAS NO OPEN SKIN AREAS. ACCORDING TO THE FACE SHEET, RESIDENT #10 IS A [AGE] year OLD WOMAN WHO WAS admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. A REVIEW OF A "SKIN COMMITTEE MEETING NOTE" DATED 10/16/12, REVEALED RESIDENT #10 HAS A STAGE II PRESSURE ULCER ON HER RIGHT BUTTOCK MEASURING 0.5 CM (CENTIMETERS) IN LENGTH; BY 0.3 CM IN WIDTH; BY 0.1 CM IN DEPTH. THIS NOTE READS, " ....RESIDENT (#10) WILL NOT LEAVE DRESSING IN PLACE FOR MORE THAN SEVERAL HOURS DAILY...". THE SKIN COMMITTEE MEETING NOTE REFLECTS AN AIR FILLED CUSHION TO HER WHEELCHAIR FOR TWO WEEKS WAS RECOMMENDED. A REVIEW OF RESIDENT #10'S 10/24/09 SKIN INTEGRITY CARE PLAN REFLECTS THE RECOMMENDATION OF PROVIDING AN AIR FILLED CUSHION TO RESIDENT #10'S WHEELCHAIR WAS NOT ADDED. ON 10/18/12 AT 11:15 A.M. (CST), RESIDENT #10 WAS OBSERVED SITTING UP IN HER WHEELCHAIR IN HER ROOM ON A STANDARD CUSHION, NOT AN AIR FILLED CUSHION. AN INTERVIEW WAS CONDUCTED WITH REGISTERED NURSE (RN) "B" ON 10/18/12 AT APPROXIMATELY 1:00 P.M. RN "B" STATED SHE WANTED THE AIR FILLED CUSHION ON RESIDENT #10'S WHEELCHAIR BECAUSE RESIDENT #10 IS "NON-COMPLAINT WITH KEEPING A DRESSING ON THE PRESSURE ULCER... I THINK IT WILL BE MY JOB TO ENSURE NEW INTERVENTIONS ARE IMPLEMENTED FROM THE SKIN MEETING." RN "B" COULD NOT EXPLAIN WHY THE AIR CUSHION HAD NOT BEEN IMPLEMENTED FOR RESIDENT #10. ( ) ACCORDING TO THE MINIMUM DATA (MDS) SET assessment dated [DATE], RESIDENT #5 IS A [AGE] year OLD WOMAN admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE MDS ASSESSMENT REVEALED RESIDENT #5 WAS CONSIDERED SEVERELY COGNITIVELY IMPAIRED. BRADEN SCALE FOR PRESSURE ULCER RISK DATED 5/30/12, INDICATED RESIDENT #5 WAS ASSESSED AT "HIGH RISK" FOR PRESSURE ULCERS. SKIN CONDITION PROGRESS NOTES FOR RESIDENT #5 WERE REVIEWED. ON 7/24/12. RESIDENT #5 DEVELOPED A FACILITY ACQUIRED STAGE II PRESSURE ULCER TO HER COCCYX THAT HEALED ON 9/4/12 AND REOPENED ON 10/9/12, AS A STAGE II PRESSURE ULCER WITH MEASUREMENT OF 1 CENTIMETER (CM) BY 0.5 CM. SKIN CONDITION NOTES BY THE WOUND CARE NURSE DATED 9/18/12, REFLECTED RESIDENT #5 DEVELOPED A NEW STAGE II PRESSURE ULCER TO HER RIGHT FOOT/LATERAL ANKLE THAT MEASURED 0.8 CM BY 0.6 CM, WITH DEPTH OF 0.1 CM. THESE NOTES REFLECT THAT "FOOT PROTECTORS" WERE RECOMMENDED BY THE WOUND CARE NURSE FOR RESIDENT #5 AT THIS TIME. A REVIEW OF THE "SKIN INTEGRITY CARE PLAN" DATED 3/21/12 AND UPDATED 9/25/12, REFLECTED THE FOOT OR HEEL PROTECTORS WERE NOT INCLUDED ON THE "SKIN INTEGRITY CARE PLAN". THIS CARE PLAN LISTS INTERVENTIONS OF "PILLOW BETWEEN LEGS AND REPOSITION EVERY 1 HOUR". AN OBSERVATION OF RESIDENT #5'S PRESSURE ULCER DRESSING CHANGE WAS CONDUCTED ON 10/16/12 AN 10:15 A.M. RESIDENT #5 WAS OBSERVED TO HAVE A 0.5 CM X 0.5 CM SPHERICAL PRESSURE ULCER SCABBED OVER ON HER RIGHT LATERAL ANKLE. THE COCCYX PRESSURE ULCER WAS OBSERVED TO BE 7 CM X 3 CM WITH GRANULATION TISSUE PRESENT IN THE WOUND BED. ON 10/17/12, RESIDENT #5 WAS OBSERVED LYING IN BED ON HER LEFT SIDE AT 12:30 P.M., 1:40 P.M., 2:40 P.M. AND 3:30 P.M., WITH NO EVIDENCE OF HAVING BEEN REPOSITIONED BY STAFF. IN ADDITION, THERE WERE NO PILLOWS POSITIONED BETWEEN RESIDENT #5'S LEGS AS INDICATED IN THE CARE PLAN AND SHE DID NOT HAVE FOOT PROTECTORS ON. AN INTERVIEW WAS CONDUCTED WITH CERTIFIED NURSE AIDE (CNA) "F" ON 10/16/12 AT 10:30 A.M. WHEN ASKED ABOUT RESIDENT #5'S REPOSITIONING SCHEDULE, SHE STATED, "I WOULD THINK IT'S EVERY 2 HOURS" AND, "SHE'S SUPPOSED TO HAVE BLUE BOOTS ON, THEY'RE PROBABLY IN THE CLOSET." ( ) --

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT AN ELOPEMENT FOR ONE (#1) OF FIVE SAMPLED RESIDENTS IDENTIFIED WITH DEMENTIA AND EXIT SEEKING BEHAVIORS OUT OF THE FACILITY POPULATION OF 52. THIS FACILITY'S DEFICIENT PRACTICE RESULTED IN RESIDENT #1 RECEIVING CONTUSIONS, LACERATIONS, AND MULTIPLE ABRAISIONS TO HER FACE AND HEAD WHEN SHE fell OUT OF HER WHEELCHAIR AS SHE WAS EXITING THE FACILITY DOWN A SET OF STAIRS AND LANDED ON A CEMENT SIDEWALK. THIS FAILURE RESULTED IN IMMEDIATE JEOPARDY TO THE HEALTH AND SAFETY FOR RESIDENT #1. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 11/22/11 AT 1:00 P.M. CENTRAL STANDARD TIME. ALL TIMES SHOWN IN THIS REPORT WILL BE SHOWN AS CENTRAL STANDARD TIME. THE IMMEDIATE JEOPARDY BEGAN ON 11/19/11 AT APPROXIMATELY 4:00 P.M., WHEN RESIDENT #1, EFFECTIVELY LEFT THE FACILITY THROUGH THE WANDERGUARD ALARMED LOBBY DOOR, WHEELED HERSELF APPROXIMATELY TEN ADDITIONAL FEET THROUGH A SECOND DOOR, FALLING DOWN TWO STEPS EQUALING A HEIGHT OF 13 INCHES AND LANDING ON HER FACE AND KNEES ON THE SIDEWALK. RESIDENT #1 RECEIVED CONTUSIONS, LACERATIONS, AND MULTIPLE ABRASIONS TO HER FACE AND HEAD DUE TO THIS FALL. A WANDERGUARD ALARM SYSTEM IS A MECHANISM INTENDED TO ALERT FACILITY STAFF WHEN A RESIDENT WHO IS KNOWN TO BE AT RISK FOR EXIT SEEKING HAS OPENED AN EXIT DOOR. REGISTERED NURSE (RN) "E" EXPLAINED SHE HEARD AN ALARM BUT DID NOT RECOGNIZE THE ALARM AS THE WANDERGUARD DOOR ALARM. RN "E" STATED, IT TOOK HER ADDITIONAL TIME TO ASSESS WHAT TYPE OF AN ALARM SHE WAS HEARING AND THEREFORE, IT TOOK HER LONGER TO GET TO THE DOOR. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 11/22/11 AT 2:28 P.M. THE IMMEDIATE JEOPARDY WAS REMOVED ON 11/22/11 AT 3:45 P.M. AFTER THIS SURVEYOR VERIFIED THE FOLLOWING: - ON 11/22/11 AT 10:45 A.M., EIGHT EXIT DOOR ALARMS WERE OBSERVED WORKING WITH THE DOOR ALARM MAKING A DIFFERENT NOISE THAN THE ADDITIONAL WANDERGUARD ALARMS. - THE LOBBY EXIT DOOR WAS OBSERVED TO HAVE A STAFF PERSON SITTING AT THE DOOR ON 11/21/11 AT 5:15 P.M., 11/22/11 FROM 7:00 A.M. UNTIL 4:00 P.M. AND 11/23/11 FROM 7:00 A.M. UNTIL 12:00 P.M. THE ADMINISTRATOR EXPLAINED THE LOBBY EXIT DOOR WOULD REMAIN MANNED UNTIL THEY DETERMINED AN APPROPRIATE ALARM SYSTEM FOR THE DOOR. - STAFF TRAININGS AND WANDERGUARD ALARM DRILLS ON 11/20/11 & 11/21/11, WERE DOCUMENTED FOR THE STAFF WORKING ON THE 3 DAYS OF THE ON-SITE INVESTIGATION. THESE TRAININGS AND DRILLS INCLUDED TIMED RESPONSES TO DOOR ALARMS AND EXIT SEEKING/MISSING PERSON TRAININGS. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT AN ISOLATED LEVEL, WITH ACTUAL HARM TO RESIDENT #1, AND POTENTIAL FOR HARM TO OTHER RESIDENTS, DUE TO: - THE FACILITY'S NEED TO COMPLETE THEIR ASSESSMENT OF THE LOBBY DOOR ALARM SYSTEM TO ENSURE THE ALARM IS RECOGNIZABLE AND THEREFORE, RESPONDED TO PROMPTLY. - THE NEED TO ASSESS/REASSESS ALL RESIDENTS FOR THE POTENTIAL OF EXIT SEEKING BEHAVIORS. - COMPLETE THE TRAININGS AND DRILLS WITH ALL STAFF REGARDING EXIT SEEKING RESIDENTS AND THE FACILITY'S DOOR ALARM SYSTEMS. THESE DRILLS MUST INCLUDE THE PROCEDURES TO FOLLOW FOR A MISSING PERSON WHO MAY NOT HAVE TRIGGERED THE WANDERGUARD/DOOR ALARM SYSTEM. FINDINGS INCLUDE: A REVIEW OF THE FACILITY'S 11/19/11 INCIDENT REPORT SHOWS RN "E" RESPONDED TO THE FRONT DOOR (LOBBY) WANDERGUARD ALARM. WHEN RN "E" OPENED THE 2ND DOOR, SHE WITNESSED RESIDENT #1 "FALL FORWARD IN HER W/C (WHEELCHAIR) DOWN THE STEPS TO THE GROUND..." THE REPORT DOCUMENTED RESIDENT #1 "SUSTAINED CONTUSION (RIGHT) FOREHEAD, LACERATION TO MID-FOREHEAD, BRUISING, EDEMA..." RESIDENT #1'S CLINICAL RECORD WAS REVIEWED. THE FACE SHEET DOCUMENTED RESIDENT #1 IS [AGE] years OLD AND HAS RESIDED AT THE FACILITY SINCE 2003. THE FACE SHEET ALSO DOCUMENTED HER [DIAGNOSES REDACTED]. RESIDENT #1'S 10/12/11 MINIMUM DATA SET (MDS) ASSESSMENT AND CURRENT CARE PLAN SHOW HER DEMENTIA AS PROGRESSING, SHE HAS DISORGANIZED THINKING, LACKS SAFETY AWARENESS AND IS IDENTIFIED AS A WANDERING RESIDENT WITH A WANDERGUARD ALERT ON HER WHEELCHAIR. HER CURRENT CARE PLAN DOCUMENTS SHE NEEDS EXTENSIVE ASSIST WITH TRANSFERS, BUT SHE CAN WHEEL HERSELF IN HER WHEELCHAIR. THE 11/18/11 NURSING NOTES DOCUMENTED, "...RESIDENT (#1) WAS TRYING TO ELOPE ON THE PM SHIFT OUT THE SECOND STREET DOOR. RESIDENT WAS REDIRECTED BY ANOTHER RESIDENT THE FIRST TIME AND BY STAFF THE SECOND TIME... WILL MONITOR..." RESIDENT #1 WAS OBSERVED IN THE DINING ROOM BEING ASSISTED WITH BREAKFAST ON 11/22/11 AT 8:30 A.M. BENEATH BOTH EYES, ON EITHER SIDE OF HER NOSE, WERE 2 INCH BY APPROXIMATELY 1 INCH WIDE PURPLE-BLUE-RED BRUISES. FOUR SMALL SCABBED AREAS WERE OBSERVED DOWN THE BRIDGE OF HER NOSE. RESIDENT #1 HAD A SMALL DIME SIZE REDDISH CONTUSION ON HER RIGHT FOREHEAD BY HER HAIRLINE. A WANDERGUARD WAS OBSERVED ATTACHED TO HER WHEELCHAIR AND WORKING. THE ADMINISTRATOR WAS INTERVIEWED ON 11/22/11 AT 10:00 A.M. SHE EXPLAINED THE LOBBY DOOR ALARM IS TURNED OFF BETWEEN 8:00 A.M. AND 8:00 P.M. THE ADMINISTRATOR SAID THE WANDERGUARD ALARM SYSTEM IS NEVER TURNED OFF. SHE STATED IT WAS THE WANDERGUARD ALARM THAT WAS ACTIVATED WHEN RESIDENT #1 LEFT THROUGH THE LOBBY DOOR. AN INTERVIEW WAS CONDUCTED WITH RN "E" ON 11/22/11 AT 10:30 A.M. SHE SAID THE INCIDENT REPORT WAS CORRECT. RN "E" SAID SHE WAS AT THE OPPOSITE END OF THE 300 HALL AWAY FROM THE LOBBY DOOR AT HER MEDICATION CART, WHEN SHE HEARD AN ALARM SOUNDING. SHE SAID SHE COULD TELL THE ALARM SOUND WAS COMING FROM SOMEWHERE DOWN THE HALL TOWARD THE LOBBY DOOR. RN "E" SAID AS SHE WAS COMING DOWN THE HALL, SHE WAS MAKING SURE IT WAS NOT AN ALARM SOUNDING FROM A RESIDENT'S ROOM. SHE EXPLAINED WHEN SHE GOT TO THE END OF THE HALL, LICENSED PRACTICAL NURSE (LPN) "D" CAME OUT OF A RESIDENT'S ROOM AND SAID SHE WAS NOT SURE WHERE THE ALARM WAS COMING FROM EITHER. RN "E" EXPLAINED AT THAT SAME TIME, RESIDENT #6 LOOKED AT THE LOBBY DOOR AND SAID, "IT'S (RESIDENT #1)." RN "E" STATED AS SHE LOOKED AT THE DOOR, SHE SAW RESIDENT #1 OUTSIDE ON THE LANDING. SHE SAID AS SHE OPENED THE SECOND DOOR, RESIDENT #1 fell DOWN THE STEPS. RN "E", EXPLAINED, "IF I WOULD'VE KNOWN IT WAS THE DOOR ALARM, I THINK I COULD'VE GOTTEN TO HER IN TIME... I WOULD'VE GONE DIRECTLY TO THE DOOR AND NOT CHECKED RESIDENT ROOMS AS I WENT, TRYING TO FIGURE OUT WHERE IT (THE ALARM) WAS COMING FROM... SOME OF THESE ALARMS SOUND THE SAME..." LPN "D" AND CERTIFIED NURSE AIDE (CNA) "F" WERE INTERVIEWED ON 11/22/11 AT 1:55 P.M. AND 2:50 P.M. RESPECTIVELY. LPN "D" SAID, WHEN SHE CAME OUT OF RESIDENT #7'S ROOM AND HEARD THE ALARM, SHE WAS NOT SURE WHAT KIND OF ALARM IT WAS. CNA "F" ALSO SAID THE WANDERGUARD DOOR ALARM SOUNDS "SIMILAR" TO OTHER ALARMS SUCH AS CHAIR OR BED ALARMS. LPN "D" EXPLAINED, IF IT WOULD HAVE SOUNDED LIKE A "DISTINCT" DOOR ALARM OR BUZZER, BOTH SHE (LPN "D") AND RN "E" WOULD HAVE GONE DIRECTLY TO THE DOOR AND HAD TIME TO STOP RESIDENT #1 BEFORE SHE WOULD HAVE MADE IT OUT THE SECOND DOOR ONTO THE SMALL LANDING. MAINTENANCE DIRECTOR "L" WAS INTERVIEWED ON 11/22/11 AT 11:30 A.M. HE STATED THE FACILITY USES "A LOT" OF DIFFERENT ALARMS. HE EXPLAINED, "WE'RE GOING TO MAKE SURE THAT LOBBY DOOR IS SAFE FOR OUR CONFUSED RESIDENTS..." RESIDENTS #2, #3, #4, AND #5 CLINICAL RECORDS WERE REVIEWED. THEIR INDIVIDUAL CARE PLANS DOCUMENTED THEIR WANDERING OR EXIT SEEKING BEHAVIORS AND INTERVENTIONS. OBSERVATIONS WERE MADE ON 11/22/11 SHOWING RESIDENTS #1 AND #2'S WANDERGUARDS WERE ATTACHED AND WORKING AT 2:40 P.M. AND 12:10 P.M. RESPECTIVELY. RESIDENTS #3, #4, AND #5'S WANDERGUARDS WERE OBSERVED IN PLACE AND WORKING ON 11/23/11 AT 8:45 A.M., 7:10 A.M. AND 8:30 A.M. RESPECTIVELY. ( )