Every finding on record at Promenade Health and Rehabilitation

Based on observations, interviews, facility document review, and facility policy and procedure review, the facility failed to ensure residents were free from physical restraints, for 1 (Resident #82) of 2 residents reviewed. Based on facility document review, interviews and facility policy review, the facility failed to ensure residents were free from physical restraints, for one (Resident #82) of two residents reviewed. The findings include: Review of the Facility's Incident Report involving Resident #82 on 12/15/2025, indicated that on 04/16/2025 during the evening shift, no time specified, per Certified Nursing Assistant (CNA) #2's witness statement, upon entrance into Resident #82's room CNA #3 and CNA #4 were tying a sheet around resident's waist and to the back of the chair. Licensed Practical Nurse (LPN) #5 was also in the room with the resident at the time the incident occurred. CNA #2 reported the incident to Lead Certified Nursing Assistant (LCNA) #1 on 04/17/2025 at 6:00 PM. LCNA #1 immediately reported the incident to the Director of Nursing (DON) and the Administrator. The Administrator reported the incident to appropriate authorities, and called in the involved staff (LCNA #1, CNA #2, CNA #3, CNA #4, LPN #5). All involved staff provided witness statements, and CNA #3, CNA #4 and LPN #5 were suspended pending the outcome of the investigation. Body Audits and Psychosocial Assessments were taken of Resident #82 with no negative outcome. Abuse and Neglect in-services were initiated specifically on physical restraints. The facility Incident Report indicated that CNA #3 stated Resident #82 had been very agitated and hitting at staff, so a folded sheet was placed in Resident #82's lap and tucked in the chair to make the resident feel secure. According to CNA #3, this was done with the assistance of two other staff members. CNA #4's witness statement indicated that Resident #82 had behaviors of aggression on the evening of the alleged incident and CNA #4 along with two other staff members had tucked a blanket around Resident #82 while in a chair. CNA #4 also indicated in the witness statement that Resident #82 had expressed being cold prior to the blanket being tucked in. LPN #5 provided a witness statement that stated nothing unusual was observed while giving Resident #82 medications on the shift. Resident #82 had been cold, and the staff provided blankets to the resident while the resident was sitting in the chair in the bedroom. The findings of the facility's investigation indicated that the accused staff, CNA #3, CNA #4, and LPN # 5, were terminated from employment with the facility. Discharge Minimum Data Set (MDS) dated [DATE] indicated Resident #82 had a Staff Assessed Mental Status (SAMS) score of 03, which indicated severe cognitive impairment. The MDS also indicated the resident had medical diagnoses which included dementia with anxiety. The MDS did not indicate that the resident had an order for physical restraints. Review of Resident #82's Progress Notes prior to the incident indicated that the resident had episodes of agitation and anxiety that included yelling out and striking at staff. Review of Resident #82's Care Plan with revised date of 07/08/2025, indicated that the resident had not been care planned for physical restraint use. Review of a Police Report with a reported date of 04/17/2025 at 5:51 PM indicated, the Administrator made the report to the police department stating that CNA #3, CNA #4, and LPN #5 had been involved in physically restraining Resident #82 to the chair in the bedroom with a bed sheet. The report indicated an investigation had begun with witness statements from the accused and suspension from employment pending the outcome of the investigation. Psychosocial and Skin Audits were initiated on the resident, witness statements from residents and staff were obtained and re-education and in servicing on the abuse and neglect policies which included physical restraints were completed. Review of CNA #3, CNA #4 and LPN #5's Personnel Files indicated that a Restraint Guidance was reviewed and signed by staff upon hire. The Restraint Guidance indicated that the facility strives to be restraint free, however in unusual and extreme circumstances, restraints may be considered. The Restraint Guidance stated, Physical restraints will not be used to limit patient's mobility for convenience of staff, and Restraints will only be used when authorized in writing by physician for a specified and limited period of time except in emergencies when DON or Charge Nurse authorize use until physician is contacted. Review of an in service titled Abuse and Neglect dated 01/31/2025, indicated Physical Restraints was included in the education and was signed by CNA #3, CNA #4, and LPN #5. During an interview on 12/17/2025 at 11:23 AM, LCNA #1 confirmed that staff at the facility are educated and in-serviced on restraints and that this facility did not have residents with care planned restraints. LCNA #1 also recalled the incident regarding Resident #82 and stated that CNA #2 had reported to LCNA #1 that three staff, two CNAs and one nurse was involved in what appeared to be physical restraint usage. LCNA #1 described Resident #82 as having dementia with agitation which sometimes included being combative towards staff as well as yelling out. During an interview on 12/17/2025 at 11:43 AM, CNA #2 recalled the incident involving CNA #3, CNA #4, and LPN #5. CNA #2 stated that upon entering Resident #82's room, CNA #3 and CNA #4 were tying a sheet around the resident's waist and to the back of the chair while LPN #5 observed. CNA #2 stated she reported the incident to LCNA #1 on the following shift. During an interview on 12/17/2025 at 12:13 PM, LPN #5 recalled the incident but denied having participated or observed anything abnormal or against policy. LPN #5 stated that Resident #82 was covered with a blanket because earlier the resident had expressed being cold. During an interview on 12/17/2025 at 2:22 PM, the Assistant Director of Nursing (ADON) recalled the incident and doing skin audits on Resident #82. The ADON stated re-education was provided to the staff involved on how to handle agitated residents. The ADON confirmed that all facility staff are educated and in-serviced on restraint usage. During an interview on 12/18/2025 at 8:35 AM, the DON confirmed that LCNA #1 reported the alleged physical restraint incident involving Resident #82 and that the facility conducted an internal investigation. The DON stated that Resident #82 was assessed, a body audit was conducted, and the accused staff members were interviewed and suspended. The DON stated that CNA #3 and #4 stated a blanket was put on Resident #82 while in a chair in the bedroom and that LPN #5 denied being present during the incident. The DON stated camera footage indicated LPN #5 was present in the room during the incident. The DON confirmed that all three staff members accused were terminated from employment. During an interview on 12/18/2025 at 10:31 AM, the Administrator stated that the incident involving Resident #82 being allegedly restrained was reported on 04/17/2025 by LCNA #1. The staff accused, CNA #3, CNA #4, and LPN #5, were immediately contacted, interviewed, witness statements were taken, and the staff members were suspended pending the outcome of the investigation. The Administrator stated that the three accused staff members were terminated from employment with the facility based on the inability to prove that the incident occurred as reported. Review of a facility policy titled Abuse and Neglect revised on 08/10/2022 indicated the policy read in part, The facility is charged with the safeguard of each resident and will follow a comprehensive plan of pursuit of maintaining a safe environment. Defines restraints as imposed for purposes of discipline or convenience that are not required to treat the resident's medical symptoms. Review of the facility's Residents' [NAME] of Rights revealed that residents will have freedom from abuse and restraints, and be free from chemical and physical restraints except when authorized in writing by a physician for a specific and limited period of time and only to protect resident from injury to self or others. The facility terminated CNA #3, CNA #4 and LPN #5 on 04/16/2025 per a termination checklist located in each employee file. The facility re-educated all staff on a Abuse & Neglect facility policy and procedure, as well as Restraint Usage, verified by the ADON and Employee Attendance Sign in Sheets for in-services. These actions were performed before the survey team entered the facility, resulting in this finding being cited at past non-compliance.

Number of residents sampled: Number of residents cited: Based on record review, observation, interview and facility policy review, the facility failed to ensure a mechanical lift was in safe operational condition prior to the lift and transfer of one (Resident #34) of one resident reviewed for mechanical lifts and transfers. The findings include: Review of Medical Diagnosis for Resident #34 indicated the resident had diagnoses which included hemiplegia [paralysis of one side of the body], kidney failure, and atrial fibrillation [irregular heart rhythm]. Review of a quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of11/06/2025 revealed, a Brief Interview of Mental Status [BIMS] score of 10, which indicated moderate cognitive impairment. The MDS also indicated Resident #34 was dependent on staff for toileting, personal hygiene, bathing and lower body dressing. Maximum assistance was required for dressing the upper body. Review of a Care Plan for Resident #34 revised 06/23/2022, indicated a self-care deficit related to limited mobility, paralysis on one side of the body, and balance impairment and that Resident #34 required a mechanical lift with two person assistance. Review of Certified Nursing Assistant [CNA] #7's Employee Record indicated, an in-servicing on mechanical lift use was done on 12/12/2023. CNA #8's Employee Record indicated, on 06/03/2025 CNA #8 was in-serviced on transfers including use of mechanical lifts. Part of the mechanical lift in-service included a return demonstration. Review of Transfer Competencies for CNA #8 dated 12/07/2025 and CNA #7 dated 12/03/2025 indicated during mechanical lift transfers staff assembles weight appropriate lift and sling, but the competency did not include assessing the equipment. During an observation on 12/15/2025 at 1:27 PM, CNA #8 was observed placing a mechanical lift around Resident #34's wheelchair with the legs of the lift in an open position. CNA #7 assisted in lifting Resident #34 with the mechanical lift and rolled Resident #34 in position over resident's bed. A metal clip on the arm of the lift used on the right side of the resident's upper body was noted to be missing from the hook. Resident #34 was lowered by CNA #8 to the bed with the legs of the mechanical lift in the open position, and rear casters unlocked. During an observation on 12/15/2025 at 1:35 PM, this surveyor observed the mechanical lift pushed against the left side of the wall on 200 Hall and asked CNA #7 and CNA #8 if they noticed anything of concern about the mechanical lift. CNA #7 stated It is missing a clip. CNA #8 confirmed there was a missing clip on the outer arm hook used to attach a lift pad when lifting a resident. CNA #8 stated the missing clip, is a safety measure that can keep the lift pad from slipping off the hook. CNA #7 and CNA #8 revealed the mechanical lift should not be used on a resident if not in good repair because accidents can happen at any time. CNA #8 stated the lift had been sent out for repair and recently came back to the facility and was missing a clip at that time. CNA #7 stated they were not sure how long the metal clip had been missing from the arm hook, but it had been reported to maintenance and CNA #8 revealed the maintenance request was written in a Maintenance Log at the nurse's station. CNA #7 and CNA #8 agreed the mechanical lift should not have been used with a missing clip, and both reported in-service training on use of a mechanical lift. During an interview on 12/17/2025 at 11:50 AM, Licensed Practical Nurse [LPN] #9 confirmed that maintenance request was in a binder at the nurse's station. Review of the Maintenance Log revealed on 12/07/2025 a mechanical lift was reported as Weight [lift brand name] legs are opening by themselves, by the 7-3 shift. Maintenance documented Can't fix. [Proper] will replace them. LPN #9 revealed equipment not in good working order should be removed from service, and a missing clip concern could not be found in the Maintenance Logbook. During an interview on 12/17/2025 at 11:56 AM, the Administrator revealed three mechanical lifts had to be sent for repair and stated that a mechanical lift with a misting clip had been found on 200 Hall. The Administrator stated that the lift had been removed from service and [Proper] had brought a second lift for the facility to use, because they had at least 20 residents requiring a lift. The Administrator stated his expectation was equipment not in good repair would be removed from service and tagged for a safety perspective and Maintenance checks mechanical lifts monthly. Six months of lift inspections, and lift policy and/or procedures were requested. During an interview on 12/17/2025 at 12:50 PM, the Maintenance Director stated, I was notified that one of the lifts was missing a clip when it was discovered on 12/15/2025 and it was removed from service and [Proper] was contacted to repair the clip or mail a clip to maintenance for repair. Maintenance Director revealed the job of the missing clip was to prevent the lift pad from coming off the arm hooks while lifting or transferring a resident. The maintenance director stated It is a safety hazard to use a lift without a clip. If the strap moved while lifting a resident it could drop them. It is an added security for safety. During an interview on 12/18/2025 at 9:09 AM, the Medical Director stated he had not noticed any equipment not in good working order and would expect equipment in poor repair to be removed from service and not used on any resident because it would not be safe. During an interview on 12/18/2025 at 9:22 AM, the Director of Nursing [DON] stated, if something we use a lot like a mechanical lift is not working then staff should notify administration immediately, and it should be taken out of service. It would not be okay to use equipment not in good repair, because it is a resident safety issue. The DON stated staff, should put a sign on it that says broken, do not use and notify the Administrator, DON, and the maintenance worker and let the nurse know so she/he can write it in the maintenance book. Review of a policy titled, Safe Lifting and Movement of Resident, revised 03/24/2014, revealed mechanical lifts are used for heavy lifting to lift and transfer residents safely. Staff providing direct resident care should be trained in how to use the lift, and maintenance staff should perform routine checks and maintenance of equipment to make sure it is in proper working order. Review of a Mechanical Lift User Manual, dated 2022, revealed maintenance safety inspection includes a visual inspection for missing hardware. Bolt/hooks should be inspected for visual wear or damage. The hangar bar has three hooks that attach to the sling that provide support to the residents during lifting. It is important to inspect all stressed parts including the hangar bar for signs of cracking, fraying and deterioration. Replace any defective parts immediately and ensure the lift is not used until repairs are made.

Based on record review observation, interview and facility policy review, the facility failed to ensure proper hand hygiene was maintained during perineal care for one (Resident #34) of one resident reviewed.The findings include:Review of Medical Diagnosis revealed, Resident #34 had diagnoses which included hemiplegia [paralysis of one side of the body], kidney failure, and atrial fibrillation [irregular heartbeat.] Review of a quarterly Minimum Data Set [MDS] with an Assessment Reference Date of 11/06/2025, revealed a Brief Interview of Mental Status score of 10, which indicated moderate cognitive impairment. The MDS also indicated Resident #34 was dependent on staff for toileting, personal hygiene, bathing, and lower body dressing.Review of a Care Plan for Resident #34 revealed a self-care deficit related to limited mobility, hemiplegia, and balance impairment (revised 06/23/2022), and that Resident #34 required two staff assistance for incontinent care. Review of a Perineal Care Competency for Certified Nursing Assistant [CNA] #8, dated 12/07/2025, and CNA #7, dated 12/03/2025, revealed staff would wash hands and change gloves after cleansing the pubic area and again after wiping the buttocks and across the sacrum. Staff would then apply a moisture barrier and wash and change gloves again. During an observation of perineal care for Resident #34 on 12/15/2025 at 1:27 PM, CNA #7 and CNA #8 put on gloves and assisted Resident #34 to residents' bed with a mechanical lift. CNA #8 removed a wet brief and threw it away, and then the lift pad was removed from under Resident #34 and CNA #8 rolled the lift pad up and set it to the side. CNA #8 proceeded to wipe the buttocks and sacral area with wipes in one direction. CNA #7 and CNA #8 did not change gloves or perform hand hygiene during the procedure. CNA #7 opened the drawer to the left side of the bed and removed a clean brief and placed it under Resident #34. Resident #34 rolled to his back and CNA #7 attached the tabs to the front of the clean brief. CNA #7 and CNA #8 removed a bag of trash and linens from the foot of the bed. CNA #7 adjusted the bed with controls and assisted CNA #8 in straightening the linens and clothing while touching bed rails and drawer to the left side of the bed, still wearing the same pair of dirty gloves. Both CNAs wore the same gloves throughout the entire procedure. During an interview on 12/15/2025 at 1:40 PM, CNA #8 stated during perineal care, We knock and sanitize hands, put on gloves, and place two trash bags at the foot of the bed. CNA #8 revealed he was doing the dirty role, and did not know why CNA #7 removed Resident #34's clean brief from the left bedside drawer and put the clean brief on Resident #34 without changing gloves and performing hand hygiene. CNA #7 confirmed she was supposed to keep her hands clean, and both CNA's confirm hand hygiene was not done during perineal care which was concerning for spreading germs. CNA #7 stated perineal care in-services are done at least once a year, and CNA #8 revealed every other month they receive training. During an interview with Director of Nursing [DON] on 12/18/2025 at 9:19 AM, the DON stated, CNAs should follow the directions of peri care competencies and they should wash their hands and glove up before peri care and change gloves during perineal care after cleaning the peri area and buttocks. The DON stated they should not touch any clean areas with their dirty gloves because of cross contamination. Review of a policy titled Perineal Care, revised 10/03/2026, revealed hands should be washed thoroughly and gloved before peri[[NAME]] care, and after cleaning the peri[[NAME]] area and/or buttocks soiled gloves should be removed and the hands washed thoroughly.

Based on observation, interview, and policy review, the facility failed to ensure opened food was dated for food service safety in 1 of 1 kitchen. The failed practice had the potential to affect all 85 residents. Specifically, the facility failed to date an opened bag of salad mix. The findings are: On 07/22/2024 at 11:00 AM, the surveyor observed an 18 ounce bag of salad mix opened in the refrigerator with no date on it. The Dietary Manager took the bag and placed it in a box of other salad mixes. On 07/23/2024 at 10:05 AM, the District Dietary Manager and this surveyor observed the same bag of salad mix without a date on the bag. At 10:10 AM, the Dietary Manager pulled out the salad bag and showed the top of bag and reported that he had placed the date there the day before, but no visible date was observed. The Dietary Manager removed the bag at that time to place a date on the bag. On 07/24/2024 at 10:35 AM, an interview with the Dietary Manager revealed that all items should be dated upon opening, and all employees are responsible for dating food when opening food. The Dietary Manager also reported that it is important to date all food once it is opened to ensure that it does not go bad. On 07/24/2024 at 11:44 AM, an interview with the Infection Preventionist revealed that all items should be dated the day the food is opened. It is important so that residents are not served out-of-date food and get sick. All dietary employees are responsible for dating opened food, but the dietary manager is responsible for ensuring that it is done. On 07/24/2024 at 11:50 AM, an interview with the Director of Nursing (DON) revealed that foods are to be dated as soon as they arrive and opened. It is important to date opened food to see if it is old and if bacteria is growing in it and to see if it is within date. Anyone that opens food should be the one to date the food. A facility policy titled Food Storage: Cold Foods stated, .5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination .

Based on observation, record review, and interviews, the facility failed to ensure a resident was free from the use of an unnecessary restraint for 1 (Resident #23) of 1 sampled resident reviewed for the use of restraints. Specifically, Resident #23 had a seat belt attached to a wheelchair and fastened around resident's waist preventing resident from standing. Findings include: A review of a facility policy titled, Use of Restraints, with a revised date 03/01/2022, indicated, Policy Statement Restraints shall only be used for the safety and well-being of the resident . shall only be used to treat the resident's medical symptom(s) and never for .the prevention of falls .2 .resident cannot remove a device in the same manner in which the staff applied it . and this restricts his/her typical ability to change position or place, that device is considered a restraint .4. Practices .prevent resident mobility are considered restraints .c. Placing a resident in a chair that prevents the resident from rising .6. Prior to placing a resident in restraints .pre-screening assessment and review to determine the need for restraints .9. Restraints shall only .written order of physician .a. The specific reason for the restraint (as it relates to the resident's medical symptom) .15. Should a resident not be capable of making a decision, the surrogate or sponsor may . (Note: The surrogate/sponsor may not give permission to use restraints .is not necessary to treat the resident's medical symptoms.) . A review of a facility document titled, Residents' [NAME] of Rights undated, indicated, Freedom from Abuse and Restraints As a resident you have the right to be: .Free from . and physical restraints except when authorized in writing by a physician for a specific and limited period of time and only to protect you from injury to yourself or others . A review of the Admission Record, indicated the facility admitted Resident #23 with diagnoses that included dementia, anxiety, intracerebral hemorrhage, polymyalgia rheumatica, and abnormalities of gait and mobility. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/10/2024 revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 2 which indicated the resident had severe cognitive impairment. The resident had a wheelchair for mobility, was dependent on staff for toileting, bathing, dressing, footwear and personal hygiene and required substantial to maximum assistance for oral hygiene. No restraint use was indicated. A review of Resident #23's Care Plan, revised, revealed the resident had Activity of daily living (ADL) self-care performance deficit related to dementia, and will not develop any complications from mobility deficits. Interventions included: 10/23/23 per order, check seatbelt on chair and have resident release every 2 hours for compliance. Date Initiated: 10/24/2023; 5/22/24 per order .Resident to have seatbelt per family request as personal reminder related to lack of safety awareness Date Initiated: 05/23/2024 .[Resident #23] is high risk for falls r/t [related to] Confusion, Gait/balance problems . 10/12/23 Fall out of wc [wheelchair] (undid wc seatbelt and stood up) .10/17/23 Fall from wc (undid wc seatbelt) . 10/17/23 fall from wc (undid wc seatbelt) . 10/22/23 Fall out of w/c (undid wc seatbelt and stood-up) . Interventions included: Fall mat, dump wc, [nonslip material] to wc, anti-rollbacks, non-skid socks, beveled edge mattress, fidget blanket, 1 hour checks, nurse and CNA (Certified Nursing Assistant) monitoring, redirection, offer snacks, provide independent activities, replace non-slip barrier to wheelchair, rearrange room fall mat to right side of bed, staff offer to transfer to chair in evening until bedtime, pommel cushion, seat belt, company companion. A review of the Order Summary Report, revealed Resident #23 had a verbal order to check resident's seatbelt is in place and secured every shift, dated 07/19/2024, with a start date of 07/23/2024. The order provided no further instruction on applying, removing, or monitoring the seatbelt. An order on 07/19/2024 indicated, Resident #23 was to have a seatbelt per family request as personal reminder related to lack of safety awareness. The order provided no additional instruction on a start date, applying, removing, or monitoring the seatbelt. A review of the Clinical Physician Orders revealed, Resident #23 had an order to check seatbelt on chair and have resident release every 2 hours, that was discontinued on 10/23/2023. An order to check resident's seatbelt is in place and secured every 2 hours was discontinued on 04/16/2024. An order to check residents seat belt is in place and secured every shift was discontinued on 07/23/2024. A review of the Medication Administration Record for July revealed, Check resident seat belt is in place and secured every shift with an order date of 07/19/2024. Checks were documented beginning on 07/23/2024 7P-7A shift through 7/24/2024 7P-7A shift; Check residents seatbelt is in place and secured every 2 hours with an order date of 02/05/2024 and a D/C (Discontinue) date of 07/03/2024. A review of a facility document titled, Physical Device Consent and Acknowledgement, with a revised date of 01/01/2015 indicated, Understanding Restraint Use revealed, Physical restraints are any manual method . adjacent to the resident body that the individual cannot remove easily and that restricts freedom of movement . Examples of what may be a restraint . wheelchair safety belts . Type of Device Recommended by Inter-Disciplinary Team . Trunk Restraint . x Safety Belt, not self-releasing . medical symptom for use of this device is: Confusion, forgetfulness . will this device improve the resident's ability to function . Safety awareness cue . IDT has determined the use of this devices is a . x Positioner . Consent For Device Use . x I Do . consent to the use of this device if the appropriate healthcare professional has assessed the need for such and the device is indicated as part of the recommended plan of care E-signed . on 2024-07-23 09:54:54 . Date: July 23, 2024 . Facility Staff Member: .E-Signed .on 2024-07-22 17:06:52 . A review of the facility assessment titled, Initial Assessment for Use of Physical Restraint, dated 05/18/2024 at 11:53 AM revealed the status of the assessment was, In Progress and no lock date was entered. Section A. indicated, Restraint use is only mandated if the resident is in imminent danger of injuring him/herself or others. Describe resident behavior prompting restraint use: .4. frequent falls, 5. sliding out of chair/wheelchair 6. unbuckles seatbelt 7. attempts self-transfer, 8. Oher 'resident is able to undo seat belt on command' B. Alternatives attempted . 4. High-low bed 5. 1:1 activities . Describe the reasons for the ineffectiveness of the alternatives 'resident is spontaneous and takes seat belt off and falls trying to self-transfer C. Decision to Restrain 1. State who decided to apply the restraint and the reason for it: 'family request' .2a. Was responsible party notified of the potential risks of restraint usage? If yes, describe . 'yes'. Date and time of notification: 3. Name and status of person providing explanation to family: 'DON / ADM' . Section D. Restraint Order was not completed. Initial Assessment for Use of Physical Restraint was not completed. A review of a Medical Director document titled, Progress Notes dated 10/12/2023 indicated, .primary encounter diagnosis was Hemorrhagic stroke ., and did not include documentation on falls, the safety belt, or a review of the safety belt. A review of a facility document titled, Comprehensive Fall Evaluation Form dated 11/05/2023 indicated, .Identify environmental hazards and individual resident risk of accident, including the need for supervision . Evaluate/analyze the hazards . Adequate Supervision to meet Resident needs . Implement interventions, including adequate supervision, consistent with the resident's needs . Diagnosis or pre-existing condition . and did not indicate monitoring devises as an intervention. A review of a Medical Director document titled, Progress Notes dated 11/17/2023 indicated, .Diagnosis .Falls frequently ., did not include documentation on a safety belt or review of the safety belt. A review of a Medical Director document titled, Progress Notes dated 02/02/2024 indicated, .Nursing Home Visit .admitted after [resident] was having falls and increased decline secondary to Alzheimer's .still getting around the facility with the use of [resident] wheelchair .Current problems . Falls frequently .Psychiatric/Behavioral: Positive for memory loss .has had two or more falls in the past year . and did not include documentation on the safety belt or a review of the safety belt. A review of a Medical Director document titled, Progress Notes dated 03/15/2024 indicated, .Difficult to ascertain whether [resident] is currently being affected .much more active around the facility .Current problems .Falls frequently . and did not include documentation on the safety belt or a review of the safety belt. A review of a Medical Director document titled, Progress Notes dated 05/10/2024 indicated, .family here today . Diagnosis . Falls frequently .Psychiatric/Behavioral: Positive for memory loss. The patient is nervous/anxious . and did not include documentation on the safety belt or a review of the safety belt. A review of a facility document titled, Promenade dated 06/07/2024, indicated, .New Order: Change diagnosis to Dementia . and did not include documentation on the safety belt or a review of the safety belt. A review of the facility progress notes from 01/01/2024 to 07/25/2024 revealed the following entries regarding the seat belt: i) On 02/05/2024, a new order for a seatbelt with checks q (every) 2 hr. (hours). ii) On 03/23/2024 the note indicated the seat belt was broken and staff were doing frequent checks on the resident. A later note on 03/23/2024 indicated the resident's wheelchair was caught on the door jamb while entering an office and fell on to the floor with an intervention to keep office door closed when not occupied. iii) On 03/28/2024, a Weekly Subcommittee note indicated the resident had a fall on 03/27/2024 due to self unbuckling of the seatbelt. iv) On 04/11/2024, the Weekly Subcommittee note indicated the intervention was to toilet resident every hour while awake. A separate therapy note indicated the seatbelt was not fastened at the time of the fall and resident was able to immediately release the seatbelt when asked. v) On 04/16/2024, Resident #23 was found on the floor in front of their wheelchair, in another resident room, and had removed their seatbelt prior to incident. vi) On 04/18/2024 at 03:24 AM, the resident was found in the hallway on the floor in front of their wheelchair and had removed the seatbelt prior to the incident. The note stated, Resident to be assisted to bed after evening medications. vii) On 04/24/2024 indicated fall precautions in place . Poor safety awareness. It did not include seatbelt documentation. viii) On 07/01/2024 at 2:25 PM, Nurses Notes indicated staff discussed removal of seatbelt with family who agreed with decision to remove seatbelt. ix) On 07/17/2024 at 2:11 PM, the Weekly Subcommittee note indicated the resident had a fall on 7/13/2024 and an intervention of pommel cushion is in place and effective. The intervention for the fall that occurred on 7/15 was to return the seatbelt to the wheelchair and offer to go to bed after dinner. During a concurrent observation and interview on 07/22/2024 at 12:48 PM, Resident #23 was sitting upright in a wheelchair, using hands to pull on railings and table to propel wheelchair. Resident #23's shirt was raised and black textured belt strap, fastener with red and white label and loop holding the tail of strap, was visible. Certified Medication Aide (CMA) #4 stated it was a wheelchair belt used to keep resident from falling and remind resident to remain seated. It does not prevent the resident from falling and it does not restrain [resident] because at times the resident unfastens the belt, attempts to stand and falls. During an interview on 07/25/2024 at 8:29 AM, Certified Medication Aide (CMA) #4 stated Resident #23 was unstable during transfers and had falls. The family requested the seatbelt about 4 months ago to prevent the resident from falling on the floor face first when moving forward. When asked what the benefit of the seatbelt was, CMA #4 stated there is no benefit from the seatbelt except possibly preventing injury during a fall. The belt is on when the resident is in the wheelchair. During a concurrent observation and interview on 07/25/2024 at 8:46 AM, Resident #23 was self-propelling a wheelchair in the hall, while holding hands with the Infection Control Preventionist (ICP), seat belt is in place. The ICP stated the seatbelt is a reminder to hopefully trigger, on a good day, that [Resident #23] needs assistance to stand and is used per family request. The ICP denied it is considered a restraint and nothing really reminds the resident not to stand, because the resident wants to be independent. The family has been educated that the resident has a right to fall and a right to stand, and they insist the resident has the belt. The IPC stated if a resident is unable to remove the seat belt they could be stuck in the chair or be injured. The IPC asked the resident to remove the seatbelt three times. Three times the resident was unable to remove the seat belt. The IPC asked the resident to remove the seatbelt three times. Twice Resident #23 held the belt in their hands, tugged on the tail of the seatbelt. Once the resident stated, No. During a concurrent observation and interview on 07/25/2024 at 9:09 AM, the IPC asked Resident #23 to remove the seatbelt three times. Resident #23 did not respond and made no attempt to remove the seat belt. The IPC asked Resident #23 if they would like to walk or stand, and Resident #23 stated No. Resident #23 became visibly upset. The IPC stated Resident #23 is able to remove the belt when she wants to. During an interview on 07/25/2024 at 9:12 AM, the Director of Nursing (DON) stated the belt was off a month ago with other interventions in place. There was a discussion with the family, they thought the belt was effective, and wanted it on as a reminder to sit down. The DON stated Resident #23 was able to remove the belt themself and that it is a reminder. The resident's family member releases the belt when they are here.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene when providing resident meal trays to the residents who eat in their room and receive meals from the dining room on the 100 Hall; failed to ensure hand hygiene was performed between residents, and failed to ensure staff did not touch medication with bare contaminated hands for 1 (Resident #31) of 2 sampled residents observed during medication pass to prevent the potential spread of infections. Findings include: A review of a facility policy titled, Handwashing/Hand Hygiene, dated 07/17/2012, indicated, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents .7. Use an alcohol-based hand rub .soap . and water for the following situations .p. Before and after assisting a resident with meals . A review of a facility Course Completion History titled, Infection Control: Basic Concepts Self-Paced dated 07/23/2024, indicated Certified Nursing Assistant (CNA) #3 completed the training on 05/23/2024 with a score of 100. A review of a document titled Infection Control: Basic Concepts Self-Paced, dated 2021, indicated, .Section 2: Concepts of Infection Control .Hand Hygiene is the most important intervention to reduce the transmission of infections and the first component of standard precautions. Hand hygiene is a general term that describes hand washing .or the use of alcohol-based hand rub (ABHR) to destroy harmful pathogens, such as bacteria or viruses, on the hands. You should always perform hand hygiene .After touching a patient or their immediate environment .In addition, you must wash your hands: Before eating, preparing, handling or serving food . During an observation on 07/22/2024 at 12:27 PM, Certified Nursing Assistant (CNA) #3 opened a silver insulated meal cart, removed a meal tray, and closed the cart door. CNA #3 then entered a resident's room, placed the meal tray on an overbed table in front of a resident. CNA #3 then exited the room and returned to the insulated meal cart. CNA #3 opened the meal cart and removed a meal tray and closed the cart door. CNA #3 served the meal tray to a resident, returned to the meal cart, opened the door, removed a meal tray, closed the door and served the meal tray to a resident. CNA #3 did not perform hand hygiene prior to or after serving meal trays to the residents. During an interview on 07/22/2024 at 12:43 PM, CNA #3 stated staff are only required to sanitize if I touch something with another person. CNA #3 stated, the facility here, they don't push it on us. CNA #3 stated the only items touched were the meal trays, and the handle of the food cart and did not know who touched the handle of the cart prior to the cart being brought to the hall. During an interview on 07/24/2024 at 8:58 AM, the Director of Nursing (DON) stated the Infection Control: Basic Concepts Self-Paced training included Hand Washing/Hand Hygiene training. Hands should be washed or sanitized during meal service after every tray to prevent the spread of bacteria and infections to residents. 39316 Review of a facility policy titled, Administering Medications, dated 11/25/2017, indicated, Medications shall be administered in a safe and timely manner, and as prescribed .22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications, as applicable . Review of a facility policy titled, Handwashing/Hand Hygiene, dated 07/17/2012, indicated, This facility considers hand hygiene the primary means to prevent the spread of infections .7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; .l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . A review of an Admission Record, indicated the facility admitted Resident #31 with a diagnosis that included chronic obstructive pulmonary disease (COPD). A review of Resident #31's Physician Orders for the month of 07/2024, revealed an order, dated 12/15/2022, for amlodipine (blood pressure), 10 milligram (mg), one tablet daily for hypertension. A review of Resident #31's Physician Orders for the month of July 2024, revealed orders, dated 12/15/2022, for cholecalciferol (vitamin d), one tablet daily; and loratadine (allergy medication), one tablet daily. On 07/23/2024 at 9:34 AM, Licensed Practical Nurse (LPN) #1 was observed to administer medications to Resident #232. LPN #1 left Resident #232's room and did not perform hand hygiene. On 07/23/2024 at 9:36 AM, Licensed Practical Nurse (LPN) #1 gathered medication bottles from the top of the medication cart and placed them on top of the medication cart. LPN #1 did not perform hand hygiene. LPN #1 removed Resident #31's cards of medications, an inhaler, and liquid medication and placed them on top of the medication cart. LPN #1 gathered medications and a cup of water and knocked on Resident #31's door. LPN #1 opened the door with her right bare hand and entered the room. LPN #1 placed the cup of pills to the resident lips and dumped the medicine cup of pills into the resident's mouth. LPN #1 offered Resident #31 a drink of water using a straw. One single white tablet/pill fell on to Resident #31's chest/shirt. With her bare right hand, LPN #1 picked the white tablet/pill off of Resident #31's shirt, and placed the pill into the resident's mouth, and continued to administer water to the resident. On 07/23/2024 at 9:48 AM, an interview with Licensed Practical Nurse (LPN) #1 revealed LPN #1 could not describe what the process was for dropping the resident's medication and administering the medication with her bare hands. LPN #1 replied, I shouldn't have done that, but I did. During the interview, LPN #1 was asked why medication should not be administered with bare hands, and LPN #1 revealed, There is a lot of reasons, but I shouldn't have done that. An interview with Licensed Practical Nurse (LPN) #2 on 07/24/2024 at 10:59 AM, revealed LPN #2 would Discard the medication like it fell on the floor, if a pill fell out of a resident's mouth during medication administration and landed on the resident's shirt, and that hand hygiene is performed before and after each resident to protect the spread of bacteria to the resident, and that the resident is not protected and possibly entering infections orally if the nurse administers a pill they picked up with their bare contaminated hands. An interview with the Infection Control Preventionist (ICP) on 07/24/2024 at 11:05 AM, revealed the ICP would Glove up and discard the medication and re-administer it, if the pill fell out of the resident's mouth during medication administration, and that hand hygiene is performed before and after and in between residents to protect the residents, and that the resident would not be protected and it wasn't good practice, if the nurse administered a pill orally to a resident they picked up with their contaminated bare hand. An interview with the Director of Nursing (DON) on 07/24/2024 at 11:10 AM, revealed the DON would discard the pill and pop a new one if a pill fell out of a resident's mouth during medication administration and landed on the resident's shirt, and that hand hygiene is performed before and after medication administration to prevent the spread of bacteria to the resident, and residents are not protected if the nurse administers a pill orally to a resident they picked up with their contaminated bare hand.

Based on observation, record review, and interview, the facility failed to ensure food items stored in the refrigerator and freezer were covered or sealed and expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 97 residents who received meals from the kitchen (total census: 97), as documented on a list provided by the Dietary Supervisor on [DATE]. The findings are: 1. On [DATE] at 9:22 AM, an opened box of bacon was on a shelf in the walk-in refrigerator. The box was not covered or sealed. 2. On [DATE] at 9:25 AM, the following observations were made in the freezer: a. An opened box of omelets was on a shelf in the freezer. The box was not covered or sealed. b. 2 opened boxes of cookies were on a shelf in the freezer. The boxes were not covered or sealed. 3. On [DATE] at 9:50 AM, the area above the ice machine panel had an accumulation of pink/grayish slimy residue on it. The Surveyor asked the Dietary Supervisor to wipe the top of the panel where the residue was observed. He used tissue papers to wipe the areas affected and stated, The pink/grayish slimy residue came off. The Surveyor asked, Who uses the ice from the ice machine and how often do you clean it? He stated, That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms, and we clean it once a week. At 9:53 AM, CNA #1 stated, I don't know who cleans it. I usually clean the outside but not the inside. 4. On [DATE] at 9:58 AM, the following expired food items were observed in the refrigerator in the Unit Dining Room: a. A bottle of lemon juice was on a shelf with an expiration date of [DATE]. b. A bottle of better than bouillon was stored with an expiration date of [DATE]. c. One tub of original crescents was on a shelf with an expiration1 date of [DATE]. d. A bag of Mexican style cheese was on a shelf with an expiration date of [DATE]. e. A bag of provolone and mozzarella cheese was on a shelf with an expiration date of [DATE]. f. A bottle of strawberry preserves was on a shelf with an expiration date of [DATE]. g. A container of parmesan cheese was on a shelf with an expiration date of [DATE]. h. Another container of parmesan grated cheese was on a shelf with an expiration date of [DATE]. i. A bottle of barbecue sauce was on a shelf with an expiration date of [DATE]. 5. On [DATE] at 10:06 AM, the following observations were made in the freezer in Unit Dining Room: a. An opened loose chocolate stick. b. A bucket of vanilla ice was on a shelf with an expiration date of [DATE]. c. A cup with strawberry vanilla shake in it was on a shelf in the freezer. The cup was not covered exposing the shake to freezer burn. 6. On [DATE] at 3:36 PM, the Surveyor asked the Maintenance Director, How often do you clean the ice machine on the 100 Hall [Unit]? He stated, I do a deep clean every 3 months and I wipe it down every month.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1meals observed. This failed practice had the potential to affect 68 residents who received regular diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 05/16/23. The findings are: 1. The menu for the lunch meal documented residents on regular diets were to receive 3 ounces of honey glazed ham. 2. On 05/16/23 at12:20 PM, residents on regular diets were served a small piece of ham. 3. On 05/16/23 at 1:14 PM, Dietary Employee #1 was asked to weigh the same amount of ham served to the residents. She did and stated, It weighed 1.5 ounces.

Based on observation, record review, and interview, the facility failed to ensure meals were served in a method that maintained the appearance of cold products and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 19 residents on the 100 Hall, 18 residents on the 200 Hall, 16 residents on the 300 Hall, and 16 residents on the 400 Hall who received meal trays in their room as documented on a list provided by Dietary Supervisor on 05/16/23 at 2:10 PM. The findings are: 1. On 05/16/23 at 12:34 PM, an unheated cart that contained 18 trays for lunch was delivered to the 200 Hall by Certified Nursing Assistant (CNA) #1. At 12:49 PM, immediately after the last resident received their tray in their room on 200 Hall, the temperatures of the food items on a test tray were checked and read by the Dietary Supervisor with the following results: a. Milk - 47.5 degrees Fahrenheit. b. Ground meat with gravy - 107 degrees Fahrenheit. c. A carton of ice cream on the tray was melted. The Surveyor asked the Dietary Supervisor to describe the appearance of the ice cream served to the residents. He stated, It was slightly melted. 2. On 05/16/23 at 12:45 PM, an unheated cart that contained trays for lunch was delivered to the 300 Hall by CNA #2. At 1:06 PM, the cart from the 300 Hall contained 4 more trays and was pushed to the 400 Hall by CNA #3. At 1:06 PM, immediately after the last resident received their tray in their room on the 400 Hall, the temperatures of the food items on a test tray were checked and read by the Dietary Supervisor with the following results: a. Milk - 46 degrees Fahrenheit. b. Ground meat with gravy - 108 degrees Fahrenheit. c. Ham - 97.7 degrees Fahrenheit, d. Candy yams - 110 degrees Fahrenheit. 46724

Based on observation and interview, the facility to ensure an ice scoop holder in 1 of 2 ice machines was maintained in clean condition; dietary staff washed their hands before handling clean equipment or food items; leftover food items were promptly used or discarded; foods stored in the freezer, refrigerator, and dry storage area were covered, sealed and dated; and expired bread products were promptly removed / discarded to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 66 residents who received meals from the kitchen (total census: 67), as documented on a list provided by Dietary Manager on [DATE] at 4:29 PM. The findings are: 1. On [DATE], initial rounds were made in the kitchen with following observations: a. At 11:48 AM, on a shelf to the right of the entrance door of the walk-in freezer, there was a bag of chicken patties not tightly re-sealed after opening. The Dietary Manager was asked how previously opened food should be stored. He said, Closed up where no air can get to it. b. On a shelf to the left of the walk-in freezer at 11:49 AM, there was a box of French toast which was not tightly resealed after opening. The Dietary Manager was asked if the food item was stored properly and he said, No. c. At approximately 12:00 PM, a blue ice scoop holder by the ice machine had a blackish unidentified substance in the bottom of it. The Dietary Manager was asked to describe what he saw and stated, It's dirty. It could use some thorough cleaning. The Dietary Manager removed the bottom of the holder and said, It's dirty and needs some love. The Dietary Manager was asked how often the scoop holder was cleaned and stated, Once a week. d. At 12:30 PM, on the left side of the storeroom, toward the back, on the top shelf, there was a bag of small elbow noodles that was not tightly closed. The Dietary Manager was asked how the noodles should be stored and he said, They should not be open. They should be closed up. 2. On [DATE] at 4:41 PM, the ice machine in the kitchen had a wet black and grayish residue on the interior panel. The Dietary Manager was asked to wipe the black residue on the panel of the ice machine. He did so, and the black residue easily transferred to the tissue. The Dietary Manager was asked, How often do you clean the ice machine? He stated, Once a week. He was asked, Who uses the ice from the machine? He stated, We use it in the kitchen to fill beverages served to the residents at meals. 3. On [DATE] at 3:46 PM, an open box of salt was stored on a shelf above the food preparation counter. The box was not closed. 4. On [DATE] at 3:53 PM, Dietary Employee #1 walked into the kitchen from the dining room. Without washing her hands, she picked up clean dishes and stacked them on the plate warmer, with her fingers touching inside the dishes. 5. On [DATE] at 3:55 PM, an open bag of coffee filters was in an unsealed box on a shelf below the food preparation counter. The bag was not sealed. 6. On [DATE] at 3:56 PM, a bag of hamburger buns was on a shelf in the kitchen with an expiration date of [DATE]. 7. On [DATE] at 3:57 PM, the following observations were made in the walk-in refrigerator: a. Ziplock bags of leftover sausage and leftover scrambled eggs were on a shelf in the refrigerator. The Dietary Manager was asked what was in the bags on the shelf. He stated, They are leftover sausage and eggs from breakfast. We will use them for pureed food the next day. On [DATE] at 8:17 AM, Ziplock bags of leftover scrambled eggs and leftover ground sausage were on the counter in the kitchen. Dietary Employee #3 was asked, What do you do with the food items in the Ziplock bags. She stated, We will use them the next day for pureed breakfast. b. An open box of bacon was on shelf in the walk-in refrigerator. The box was not covered or sealed. c. Three 8-ounce (oz) cartons of whole milk were on a tray in the refrigerator with an expiration date of [DATE]. 8. On [DATE] at 3:58 PM, the following observations were made in the walk-in freezer: a. An open box of dinner rolls was on a shelf in the freezer. The box was not covered or sealed. b. An open box of cut green beans was on a shelf in the freezer. The box was not covered or sealed. 9. A facility policy titled, Hand Washing, provided by the Dietary Manager on [DATE] at 3:55 PM documented, .When Should You Wash Your Hands? . Upon returning to the kitchen from other areas . Before putting on gloves or after removing them . Whenever necessary to help hands clean. 10. A facility policy titled, Food Storage: Dry Goods, provided by the Dietary Manager on [DATE] at 11:30 AM documented, .All packaged and canned food items will be kept clean, dry, and properly sealed . 11. A facility policy titled, Food Storage: Cold Foods, provided by the Dietary Manager on [DATE] at 11:30 AM documented, .All foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination . 12. A facility policy titled, Ice, provided by the Dietary Manager on [DATE] at 11:30 AM documented, .Procedures 3. The exterior of the ice machine will be cleaned weekly. 4. Ice bins will be cleaned monthly and as needed, 5. Ice scoops will be cleaned and stored in a separate container that limits exposure to dust and moisture retention .

Based on record review and interview, the facility failed to ensure written information regarding the right to formulate an Advanced Directive was provided to residents or their responsible parties to enable them to make informed decisions regarding what measures would be provided or withheld at end of life for 1 (Resident #53); and failed to ensure written information regarding residents' decisions regarding what measures would be provided or withheld at end of life was readily available in the electronic medical record for 3 (Residents #15, #41, and #45) of 17 (Residents #3, #4, #7, #15, #18, #19, #34, #37, #39, #40, #41, #42, #45, #46, #51, #53 and #55) sampled residents who had formulated Advanced Directives in the form of a Living Will. This failed practice had the potential to affect all 67 residents who resided in the facility, as documented on the Facility Matrix provided by the Minimum Data Set (MDS) Coordinator on 01/10/2022 at 1:39 PM. The findings are: 1. Resident #53 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. On 01/12/22 at 10:15 AM, Resident #53's electronic health record (EHR) did not contain documentation to indicate Advanced Directive information was provided to her or her responsible party. b. On 01/11/22 at 12:34 PM, Resident #53 was being placed on a gurney for transport to an emergency room by Emergency Medical Technicians (EMTs). Licensed Practical Nurse (LPN) #1 was heard verbally informing the EMTs, She [Resident #53] is a DNR [Do Not Resuscitate]; please inform the ER [emergency room ]. c. On 01/11/22 at 12:36 PM, LPN #1 was asked, Do you send Advanced Directives with the EMTs when residents are sent out? LPN #1 stated, Yes. She was asked, I was unable to locate her [Resident #53] Advanced Directives in the Electronic Health Record, can you guide me? LPN #1 stated, Here, I'll show you where it is [in the facility's EHR software.] LPN #1 directed the surveyor to a document titled Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's Advanced Directives Acknowledgement form dated 02/11/2020 documented Resident #15 had placed a check mark on, .I choose to formulate the following Advanced Directives .Living Will . The EHR did not contain a copy or documentation of the Living Will. 3. Resident #41 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. Resident #41's Advanced Directives Acknowledgement form dated 06/15/2021 documented Resident #41 had placed an X on, .I choose to formulate the following Advanced Directives .Living Will . The EHR did not contain a copy or documentation of the Living Will. b. A POLST dated 10/19/2021 and an Advanced Directive Acknowledgement dated 09/21/2019 provided by the Administrator on 01/12/2022 at 10:24 AM documented, .I choose to formulate the following Advanced Directives .Living Will . 4. Resident #45 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #45's Advanced Directives Acknowledgement form dated 11/21/2017 documented Resident #45 had placed a check mark on, .I choose to formulate the following Advanced Directives .Living Will . The EHR did not contain a copy or documentation of the Living Will. 5. On 01/12/22 at 10:49 AM, the Administrator was asked, You provided documentation for [Residents #15, #41, #45, and #53] in response to our request for Advanced Directives; is this the only documentation you have? The Administrator stated, Yes, I provided you all I have. For [Resident #41], I provided you her POLST and Advanced Directive Form. She was asked, [Resident #41] checked marked the option for a Living Will. Do you have a copy of her Living Will? The Administrator stated, No, I gave you all we have. She was asked, Would the Business Office Manager or Social Services have this resident's living will? The Administrator stated, No, I gave you all the documentation we have for the Advance Directives you requested. 6. On 01/13/22 at 4:20 PM, the Business Office Manager (BOM) provided a Declaration of Living Will for Resident #41 dated 02/18/2020 and a Living Will Declaration for Resident #45 dated 11/21/2017. The BOM was asked, Where were these documents located? The BOM stated, In my office. She was asked, Is your office available to staff every day? The BOM stated, I am here Monday through Friday. She was asked, What about weekends, do the nurses have access to these documents? The BOM stated, We have management who has access to my office. 7. A facility policy titled, Advance Directives, provided by the Administrator on 01/14/22 at 8:10 AM documented, .Prior to or upon admission .The Social Services Director or designee will provide written information to the resident .the right to formulate advanced directives; .The Social Services Director or designee will inquire .about the existence of any written advanced directives .Information about .and advance directive will be uploaded to [Electronic Health Record] documents tab and shall be displayed prominently in the resident's chart; .The nurse supervisor will be required to inform emergency medical personnel of a resident's advanced directive .and provide such personnel with a copy of such directive when transfer from the facility via ambulance .

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 8 residents who received a regular diet, and 10 residents who received a mechanical soft diet from the kitchen, according to a list provided by the Dietary Supervisor on 1/12/2022. The findings are: 1. On 1/11/22, the menu for the supper meal documented the residents on regular and mechanical soft diets were to receive 1 square of chicken enchilada each (3 by 4-inch square per the quantified recipe), residents on pureed diets were to receive 8 ounces (oz) of pureed chicken enchiladas each. a. On 1/11/22 at 4:26 PM, during the supper meal preparation Dietary Employee #2 stated, We have 8 residents on pureed diets. He then used a #8 scoop (4 ounces) to place 8 servings of chicken enchiladas into a blender to puree. He poured the pureed chicken enchiladas into a pan, covered the pan with foil and placed it in the oven b. On 1/11/22 at 5:24 PM, Dietary Employee #2 used a #8 scoop to serve a single portion of pureed chicken enchiladas to the residents who were on a pureed diet. The menu specified 8 ounces of pureed chicken enchilada for each person. c. On 1/11/22 at 5:33 PM, Dietary Employee #2 used a #8 scoop to serve a single portion of chicken enchilada to the residents who were on a mechanical soft diets. The menu specified 1 square of mechanical chicken enchilada for each person. d. On 1/12/22 at 1:26 PM, Dietary Employee #2 was asked, What scoop size did you use to serve pureed chicken enchilada? He stated, I used a #8 scoop (gray), and I gave a serving of pureed chicken enchilada to each resident on pureed diets. He was asked, What scoop size did you use to serve mechanical soft chicken enchilada? He stated I used a #8 scoop (gray), and I gave a serving of ground chicken enchilada to each resident on a mechanical soft diet.

Based on record review and interview, the facility failed to ensure the comprehensive care plan addressed use of anticoagulant medications to promote continuity of care and monitoring for 1 (Resident #41) of 4 (Residents #3, #4, #17, and #41) sampled residents who were on anticoagulant medications. The findings are: Resident #41 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date of 11/22/2021 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and received an anticoagulant medication on 5 of the last 7 days. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Care Plan with a revision date of 01/04/2022 did not address the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 01/13/2022 at 2:34 PM, the MDS Coordinator was asked, Should an anticoagulant be care planned? The MDS Coordinator stated, Yes. She was asked, Does [Resident #41] have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? The MDS Coordinator stated, Yes, she is on [MEDICATION(S)]. She was asked, Should that be care planned? The MDS Coordinator stated, Yes. She was asked, Why should anticoagulant therapy be care planned? The MDS Coordinator stated, For risks of bleeding. She was asked, Is [Resident #41] care planned for bleeding risks or other risks associated with anticoagulant therapy? The MDS Coordinator stated, No, she is not .

Based on observation, record review, and interview the facility failed to ensure recipes were prepared and served according to the approved, planned, written menu signed by the Dietitian to meet the nutritional needs of the residents on diets for 1 of 1 meal observed. This failed practice had the potential to affect 76 residents who received meal trays from 1 of 1 kitchen, according to the list provided by Dietary Employee #2 dated 11/03/2020. The findings are: 1. On 11/02/2020 at 11:57 A.M., during the lunch meal Dietary Employee (DE) #3 served shredded pork loin using tongs. DE #3 would place 2 or 3 servings with the tongs on some of the trays and some of the trays would only receive 1 serving. DE #3 was asked, What size of serving are they supposed to be receiving of the pork loin? DE #2 replied, 3 ounces. 2. On 11/02/2020 at 12:28 P.M., DE #3 poured an unmeasured amount of Tater Tots into the fryer for 3 residents. DE #2 took the Tater Tots out of the fryer and poured them in a bowl and served an unmeasured amount of Tater Tots onto a plate using tongs. 3. The Week 4 menus provided by the Administrator on 11/02/2020 at 12:46 P.M., documented, . Monday Encrusted Pork Loin 3 ounces . 4. On 11/03/2020 at 10:50 A.M., DE #4 poured an unmeasured amount of frozen dumplings in a pan. DE #5 asked DE #4, How much dumplings are you supposed to use? DE # 4 replied, A bag. DE #5 asked DE #4, Where is your recipe? DE #5 picked up the recipe and said, You are supposed to use 7 1/2 pounds. These bags are 5 pounders, so you need a half bag of the other bag of dumplings. She then added a half bag of the other dumplings in the pan. 5. On 11/03/2020 at 10:58 A.M., DE #4 poured an unmeasured amount of Au Gratin potatoes in a pot of milk and water. She was asked, How many residents are getting the Au Gratin potatoes? She replied, 10, so I just pour in a half box. 6. On 11/03/2020 at 11:07 A.M., DE #4 poured an unmeasured amount of dried noodles in a pan of water. 7. On 11/03/2020 at 2:45 P.M., DE #2 was asked, Should your staff follow the recipe when preparing a meal? The DE #2 replied, Yes. 8. The Menus Policy provided by the Administrator on 11/03/2020 at 3:50 P.M. documented, . Menus will be planned in advance to meet the nutritional needs of the residents / (and or) patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide .

Based on observation, record review, and interview the facility failed to ensure dietary staff washed their hands before and during the serving of a meal, failed to ensure dietary staff wore hairnets to cover their hair and beards; failed to ensure staff did not touch their face or clothes before handling clean equipment or food; failed to ensure food items stored in the freezer were covered or sealed; failed to ensure dented cans were removed and failed to ensure the kitchen was clean and sanitary to decrease the potential for food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 76 residents who received a tray as documented on a list provided by the Dietary Manager on [DATE]. The findings are: 1. On [DATE] at 11:26 A.M., the dry storage area had a can of blueberry pie filling and a can of peaches with a dent in the rim of the cans. Dietary Employee (DE) #2 was asked, Tell me, what do you see? The DE #2 replied, A dent. DE #2 was asked, What could happen with the dent in the cans? The DE #2 replied, It could be contaminated. DE #2 was in the kitchen without hair net or a beard cover on. 2. On [DATE] at 11:28 A.M., a package of dry spaghetti noodles was open on a shelf in the dry storage area. (Photo taken.) DE #2 was asked, Should that be sealed? DE #2 replied, Oh my, yes. A flour bin was open with flour in a container not sealed, a container with sugar not sealed or closed and a container of milk powder not sealed. DE #2 was asked, Should the containers have their lids closed? The DE #2 replied, Yes. 3. On [DATE] at 11:35 A.M., in the walk in refrigerator, there was celery with a brown substance on the leaves (Photo taken), a bag of shredded lettuce with an expiration date of [DATE] and a package of ham not sealed. DE #2 was asked, Is that bag of lettuce expired? The DE #2 replied, Yes. DE #2 was asked, Should that ham be sealed? The DE #2 replied, Yes. A bag of hash browns, a bag of green peas and a bag of okra were in the walk in freezer not sealed. 4. On [DATE] at 11:47 A.M., there were brown crumbs in brown cooking oil in the fryer. The side of the fryer had crumbs all along the edges of the cooker. The back of the fryer had a brown/black greasy film residue on the back where the baskets sit. DE #2 was asked, When was the last time the oil was changed? The #2 replied, Last Thursday. DE #2 was asked, Do you think they cleaned the fryer? The DE #2 replied, No. The stove top had 6 burners with debris and crumbs all over the stove top. The burners had a dark brown greasy residue on them. (Photos taken). 5. On [DATE] at 11:50 A.M., DE #2 was asked to take a white napkin and wipe the inside of the ice maker from the top where the ice drops. A light brown residue substance was on the napkin from the ice machine. DE #2 was asked, Does that look clean? The DE #2 replied, No. (Photos taken). 6. On [DATE] at 11:52 A.M., the commercial grade can opener was pulled it up from the base and there was black slimy debris on the can opener and the blade. The blade also had a white and yellow substance on it. DE #2 was asked, What is that on the can opener? DE # 2 replied, Build up and dirt and metal pieces. The area where the base of the can opener sits had a brown sticky/slimy residue on it. (Photos taken.) 7. On [DATE] at 11:54 A.M., underneath the warmer was a dried brown substance. (Photos taken.) 8. On [DATE] at 11:55 A.M., on the floor behind the stove was old grease. In the clean area there was a grill scraper in a box sitting under a counter. The scraper had a thick black greasy residue on the handle and the scraper. (Photo taken.) DE #2 was asked, What is the scraper used for? DE # 2 replied, For scraping the grill. DE #2 was asked, Does it ever get cleaned or covered. DE # 2 replied, It is for scraping the grill, we use to keep it covered. A meat saw was also on the bottom of the counter next to grill scraper that was not covered. 9. On [DATE] at 11:57 A.M., there were crumbs and a brown residue in the microwave. DE #2 was asked, Does the microwave look dirty to you? The DE #2 replied, Yes. (Photo taken.) DE #3 washed her hands and donned clean gloves. She then touched her mask with her right hand and touched a plate on the inside of the rim with her right thumb. She then served food on the plate to the residents. 10. On [DATE] at 12:20 P.M., DE #2 was not wearing a hair net. He went into the refrigerator and retrieved a package of cheese and placed it the counter. DE #2 washed his hands and donned gloves, he picked up a loaf of bread and opened it and retrieved 6 slices of bread using tongs. He buttered the bread and placed it on the grill and then placed a slice of cheese on each slice of bread. 11. On [DATE] at 12:28 P.M., DE #1's hair net was not pulled all the down in the back and approximately 3 inches of hair was sticking out of her hairnet. 12. On [DATE] at 02:45 P.M., DE #2 was asked, Should the dry storage area have opened dry spaghetti on the shelf? DE #2 replied, No. DE #2 was asked, Should you have expired lettuce in the refrigerator? DE #2 replied, No. DE #2 was asked, Should the deep fryer be free of debris and dirty grease? DE #2 replied, No. DE #2 was asked, Should the stove top be clean? DE #2 replied, Yes. DE #2 was asked, How often do you clean the ice machine? DE said, Once a week. Was it clean when we looked at it? DE #2 replied, No. DE #2 was asked, Should the dietary staff wear hair nets with their hair completely covered while in the kitchen? DE #2 replied, Yes. DE #2 was asked, Should you finger touch the inside of the rim of a plate or a bowl while serving the resident's? DE #2 replied, No. 13. The Handwashing Procedure policy provided by the Administrator on [DATE] at 3:50 P.M. documented, . Employees must wash their hands immediately (or as soon as feasible) after they remove gloves or other Personal Protective Equipment . 14. The Food: Preparation policy documented, . All foods are prepared in accordance with the FDA Food Code. 1. All staff will practice proper hand washing techniques and glove use. 2. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. 3. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use. 15. All staff will use serving utensils appropriately to prevent cross contamination. 15. The Staff Attire policy provided by the Administrator on [DATE] at 3:50 P.M. documented, . All employees wear approved attire for the performance of their duties . 1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained . 16. The Environment policy provided by the Administrator on [DATE] at 3:50 P.M. documented, .All food preparation areas, food service areas, and dining areas will be maintained clean and sanitary condition . 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting and ventilation. 2. The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces. 3. All food contact surfaces will be cleaned and sanitized after each use .

Based on observation, record review and interview, the facility failed to ensure potentially infectious materials discarded in biohazard boxes were contained with a top and/or lid and behind closed doors to decrease the potential spread of infection for 3 (Residents #39, #49, and #74) of 6 (Residents #74, #175, #49, #39, #8, and #34) sampled residents on quarantine and/or isolation and failed to ensure infection control practices were consistently implemented for removal of bio-hazard bags from isolation rooms. This failed practice had the potential to affect 12 residents who were on isolation based on a list provided by the Director of Nursing (DON) on 11/04/2020. The facility failed to ensure implementation of proper infection prevention and control practices to prevent the development and transmission of COVID-19 and other communicable diseases by wearing a face mask to cover both the mouth and nose. This failed practice had the had the potential to affect 77 residents who resided in the facility according to the Daily Census provided by the Administrator on 11/02/2020. The facility failed to ensure residents on quarantine for COVID-19 precautions were located on a designated Quarantine Hall and to have a plan for a dedicated space in the facility for managing care of residents with the potential of COVID-19 to reduce the potential for spreading COVID-19 for 12 residents who were on quarantine/isolation. This failed practice had the the potential to affect all 77 residents residing in the facility based on the Daily Census provided by the Administrator on 11/02/2020. The findings are: 1. Resident #39 has a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/13/2020 documented the resident scored 7 (0 - 7 indicates severely impaired) per a Brief Interview for Mental Status (BIMS) and required extensive assistance with bed mobility, transfers, dressing, toilet use and bathing. a. On 11/02/2020 at 12:21 P.M., Resident #39 was in isolation precautions and the door to her room was open. The red and yellow isolation cardboard boxes in Resident #39's room were open and uncovered. b. On 11/03/2020 at 3:11 P.M., Resident #39's room continued to be set up for isolation precautions and the red and yellow isolation boxes continued to be open and uncovered. c. On 11/04/2020 at 03:27 P.M., the Administrator was asked if the isolation containers in (Resident #39's) room, who is on isolation or quarantine, should be left open with no lid. The Administrator stated, No it should be covered. 2. Resident #49 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 09/01/2020 documented the resident scored 0 (0-7 indicate severe impairment) per a Brief Interview for Mental Status and required the extensive assistance of two plus persons with bed mobility, transfers, toilet use, and personal hygiene. a. The November 2020 Physician order [REDACTED]. Order Date: 10/17/2020. b. On 11/03/2020 at 10:32 A.M., Resident #49 had two biohazard boxes in his room sitting close to the door that had no top or covering on them. (Photo taken.) 3. Resident #74 had a [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 10/06/2020 documented the resident scored 15 (13-15 indicates cognitively intact) per a BIMS and required extensive assistance of 2+persons for all activities of daily living tasks except bathing which required total dependence of 1 person and was frequently incontinent of bowel and bladder. a. On 11/03/2020 at 3:17 P.M., Resident # 74 was on droplet precautions and had isolation boxes inside her room, one for linens and one for trash, neither one was covered with a lid, and the door was open. 4. On 11/04/2020 at 8:46 A.M., Certified Nursing Assistant (CNA) #1 was carrying a red bio-hazard bag containing trash and a yellow bio-hazard containing linen with both bags touching her scrub top. She sat the red bag on the floor next to the bio-hazard room door. She sat the yellow bag on the sidewalk outside of the exit door toward the laundry room. CNA #1 was asked, Are you supposed to be setting the red bags on the ground? She replied, I don't know. She was asked, Are the bags supposed to touch your clothes? She replied, No. 5. On 11/02/2020 at 11:24 A.M., Dietary Employee (DE) #1 was in the kitchen wrapping silverware in napkins with her mask pulled down to her chin. DE #1 was asked, Did you have your mask pulled down when I entered the kitchen? She replied, Yes, I did. a. On 11/03/2020 at 9:54 A.M., DE # 6 came out of the dishwasher area. Her mask was down below her nose. 6. On 11/04/2020 at 10:56 A.M., there were 6 isolation rooms on the 300 Hall, 3 isolation rooms the 200 Hall and 2 isolation rooms on the 100 Hall. a. The Infection Surveillance documents from June 2020 to October 2020 identified that residents placed in quarantine were located on multiple halls in the facility. b. On 11/05/2020 at 3:25 P.M., the Director of Nursing (DON) was asked, When does a resident go into isolation or quarantine? The DON stated, Whenever they go out to the hospital or show any symptoms. They usually stay 14 days, and anytime they have symptoms that may be extended to 21 days. The doctor directs us on what to do. The Director of Nursing was asked, Why are the residents in quarantine located on 3 different halls within the facility? The DON stated, 300 Hall was designated as the quarantine hall, but it filled, so we started using the 200 Hall. A lot of what we do is based on availability of beds. The Administrator and DON were asked, How long do you leave people in isolation? The DON stated, 14 days if no symptoms and 21 days if the doctor directs them. The Administrator and DON were asked, Where do you keep your isolation residents? The DON stated, We try to keep them on the end of 200 Hall in case we get a COVID outbreak. The Administrator was asked for a planned strategy to prevent a potential COVID-19 outbreak. She provided a copy of the COVID-19 Focused Survey for Nursing Homes pathway from 03/20/2020. She stated, We have not decided which hall it will go on. c. On 11/05/2020 at 3:35 P.M., the Administrator was asked if they had an action plan for when a resident becomes positive for COVID -19. The Administrator stated, Yes, we have talked about it. The Administrator was asked if she had a hall empty and ready to go, should someone become positive. The Administrator stated, I will have a hall empty, yes. We have tried to start clearing a hallway out. We have the plastic built and ready to go. We had discussed on 200 hall if someone is positive. The Administrator was asked for a copy of the plan. She stated, We do have a plan on scratch paper, I will type it up and get it to you. d. A copy of the Update COVID-19 Plan 11/01/2020 provided by the Administrator on 11/05/2020 at 3:53 P.M. documented, .On Thursday 10/29/2020, OLTC (Office of Long Term Care) through the AHCA (Arkansas Health Care Association) included a slide that said it is better practice to have dedicated staff on not only COVID-19 Positive residents but also to those under Quarantine 1. We are not going to do immediate room moves because we do not want to inadvertently expose residents by moving a Quarantined existing residents and their belongings through the facility .

Based on observation and interview the facility failed to allow or ensure the resident council group was provided a private space to conduct their monthly meeting to promote privacy and prevent the potential for their meetings to be overheard by staff not invited to the meetings. This failed practice had the potential to affect all 77 residents who resided in the facility, as documented on the Daily Census provided by the Administrator on 11/02/2020. The findings are: 1. On 11/05/2020 at 08:25 A.M., the monthly Resident Council meeting notes for May, June, July, August and September provided by the Activity Director documented, . Resident council was not conducted due to COVID-19 restrictions . 2. On 11/09/2020 at 8:27 A.M., the Administrator was asked, Why have they not had Resident Council meetings? She replied, Because we were not allowed to have group meetings. The Administrator was asked, Could you go to each resident room? She replied, I guess. The Administrator was asked, Did you QA (Quality Assurance) that? She replied, If we thought we done something wrong, we would have?

Based on observation, record review, and interview the facility failed to notify the resident and or the resident's representative(s) of a transfer or discharge and the reasons for the move in writing in a language and manner they understand, to identify the reason for transfer or discharge, the effective date of transfer or discharge, and the location to which the resident is transferred or discharged for 2 (Resident #3, and Resident #49) who had been transferred or discharged from the facility. This failed practice had the potential to affect 43 residents according to a list provided by the Administrator on 11/06/2020. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. a. Resident #3 was sent to the hospital on [DATE] and returned to the facility on [DATE]. b. On 11/04/2020 at 3:05 P.M., the Administrator provided a notification of transfer/discharge. The transfer/discharge notice was blank. The reason for transfer was not completed. The location of transfer was not completed. The Administrator was asked if the notice should be filled out. The Administrator stated, Yes it should have been. I am not sure why it was sent out blank. 2. Resident #49 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 09/01/2020 documented the resident scored 0 (0-7 indicates severe impairment) per a BIMS and required extensive assistance of two plus persons with bed mobility, transfers, toilet use, and personal hygiene. a. A Discharge Return Anticipated MDS was completed with an ARD of 07/04/2020. b. A Nurses Note dated 07/04/2020 documented .Pt (patient) discovered at 1600 (4:00 P.M.) with dark coffee ground type discharge [MEDICAL CONDITION]. Diaphoretic and pale . Attempted (Doctor) to notify. No answer. (Advanced Practice Nurse) aware of transfer to (Hospital) ER per DON (Director of Nursing). Family aware . c. On 11/05/2020 at 3:23 P.M., the Administrator was asked to provide the written notification of transfer for 07/04/2020. The Administrator stated, I don't have 7/4, it was missed. 4. A Discharge/Transfer Letter Policy provided by the Administrator on 11/05/2020 at 12:10 P.M. documented, 1. The following items must be included in the written notice of transfer or discharge, unless specified differently by State authority. A. The reason for transfer or discharge; B. The effective date of transfer or discharge; C. The location to which the resident is transferred or discharged . 2. The resident and the resident's representative(s) must be notified of the transfer or discharge in a language and manner they will understand.

Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed to ensure the resident received the needed care and services in the most appropriate setting for 2 (Resident #57 and #39) of 3 (Resident #67, #39, #57) sampled residents who had a [DIAGNOSES REDACTED]. This failed practice had the potential to affect 8 residents who required a PASARR, according to a list provided by the Administrator on 11/05/2020 at 1:29 p.m. The findings are: 1. Resident #57 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/22/2020 documented the resident scored 14 (13-15 indicate cognitively intact) per a Brief Interview for Mental Status (BIMS) and was independent requiring no setup help with bed mobility, transfers, toilet use, and personal hygiene. a. The Care Plan with a revision date of 10/20/2020 documented . (Resident #57) has a behavior problem r/t (related to) being manipulative with other peers and staff, refusing to have roommate, verbally abusive to other resident's at times . (Resident #57) at risk for unstable mood r/t depression (Resident #57) uses anti-anxiety medications r/t Anxiety disorder secondary to [MEDICAL CONDITION] . b. On 11/04/2020 at 9:25 A.M., the Administrator was asked for the PASARR on (Resident #57). The Administrator stated, I'll have to email (Agency) to see if they have any documentation on her. c. On 11/04/2020 at 1:36 P.M., a fax dated 11/04/2020 provided the Administrator from (Agency) documented .Special Instructions: The above client will require a PASARR /Level II Screening to be completed at your nursing facility per the Office of Long Term Care. An assessor from (Agency) will contact your facility to make arrangements for this appointment . The Administrator stated, Well we did some things and we didn't do some things. We had the prescreen done back then but when she came, we never told (Agency) that she came for the follow up. So, I just submitted a new (form) and now she has to have a Level 2 done. 2. Resident #39 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 10/13/2020 documented the resident scored 7 (0 - 7 indicates severely impaired) per a Brief Interview for Mental Status (BIMS) and required extensive assistance with bed mobility, transfers, dressing, toilet use and bathing. a. A Care Plan with an initiated date of 04/04/2020 documented, (Resident #39) had a (Agency) screening according to regulatory guidelines. (Resident #39) had a (Agency) screening according to regulatory guidelines. a. On 11/05/2020 at 1:39 P.M., A letter from (Agency) dated 10/13/2020 provided by the Social Service Director on 11/05/2020 documented, The above-named client will require a PASARR /Level II Screening to be completed at your nursing facility per the Office of Long-Term Care. An assessor from (Agency) will contact your facility to make arrangements for this appointment. The Social Service Director stated, I started doing the PASARR's about 6 weeks ago. I was going through notes for a meeting and realized that she did not have a PASARR when she was admitted in April. I completed the paperwork and received this notice on 10/13/20. I received a call from (Name) at (Agency) on 10/19/20. I informed her that the resident was in the hospital. She stated that she would complete the visit at the hospital. I have not heard anything since that time. I will follow up with them today.

Based on observation, interview and record review the facility failed to ensure smoking was included in a resident's care plan for 1 (Resident #71) of 5 (Residents #20, #71, #31, #19, and #177) sampled residents who smoke. Failed to ensure pain management was included on a resident's care plan for 1 (Resident #22) of 20 (Residents #3, #8, #10, #13, #19, #20, #22, #27, #28, #31, #39, #51, #52, #56, #57, #63, #67, #71, #74, and #175) sampled residents with a [DIAGNOSES REDACTED].#67 and #63) of 13 (Residents #17, #19, #31, #34, #42, #49, #50, #52, #60, #63, #66, #67 and #74) sampled residents with orders for oxygen. Failed to ensure antipsychotic medication was included on a resident's care plan for 1 (Resident #39) of 3 (Residents #39, #34, and #67) sampled residents who had orders for antipsychotic medications. These failed practices had the potential to effect 9 residents who smoked based on a list of smokers provided by the Administrator on 11/02/2020 at 1:00 p.m., 44 residents who had a [DIAGNOSES REDACTED]. The findings are: 1. Resident #71 had a [DIAGNOSES REDACTED]. a. A Safe Smoking assessment dated [DATE] documented, Resident is safe to smoke with supervision. b. On 11/04/2020 at 10:45 a.m., Licensed Practical Nurse (LPN) #3 was asked if a resident smokes, should it be included on his care plan. She replied, Yes. She was asked to review the care plan and show where it is documented on the care plan. She replied It isn't 2. Resident #22 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 08/04/2020 documented the resident scored 15 (13-15 indicates cognitively intact) per a BIMS and required limited assistance with bed mobility, transfers, dressing, toilet use and bathing. a. The November 2020 Physician order [REDACTED]. Give 1 tablet by mouth every 4 hours as needed for pain. Start date 03/09/2020, [MEDICATION NAME] Sodium Tablet 220 MG. Give 2 tablet by mouth two times a day related to PAIN, UNSPECIFIED TAKE WITH FOOD. Start date 08/11/2020, [MEDICATION NAME] Capsule 300 MG. Give 1 capsule by mouth at bedtime related to PAIN, UNSPECIFIED. Start date 09/13/2020, [MEDICATION NAME] HCl Tablet 5 MG. Give 1 tablet by mouth at bedtime related to PAIN. Start date 10/02/2020. b. The Care Plan did not address pain. c. On 11/05/2020 at 10:48 a.m., the MDS Coordinator was asked if (Resident #22) received scheduled pain medication and medication PRN. The MDS Coordinator stated, Yes she receives both scheduled and PRN pain medications. The MDS Coordinator was asked if (Resident #22's) pain was addressed in the care plan. The MDS Coordinator stated, It is mentioned under the influenza and fall section, but there is not a pain focus identified on the care plan. The MDS Coordinator was asked if it should be addressed on the care plan. She stated, Yes, it should be. 3. Resident #63 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 09/22/2020 documented the resident scored 4 (0-7 indicates severe cognitive impairment) per a BIMS and required extensive assistance with bed mobility, transfers, dressing, toilet use and bathing. a. The November 2020 Physician order [REDACTED]. Start date 11/03/2020 b. The Care Plan did not address oxygen therapy or proper care and storage of oxygen tubing and nasal cannula. c. On 11/03/2020 at 8:05 a.m., Resident #63 was asleep in bed with oxygen being administered via nasal cannula. d. On 11/04/2020 at 2:38 p.m., the MDS Coordinator was asked if (Resident #63's) oxygen was addressed on the care plan. The MDS Coordinator stated, No I do not see it on the care plan. She was asked if oxygen should be addressed on the plan of care. The MDS Coordinator stated, Yes, it should be addressed. 4. Resident #67 had [DIAGNOSES REDACTED]. a. The November 2020 Physician order [REDACTED]. b. The Care Plan did not address oxygen therapy or proper care and storage of oxygen tubing and nasal cannula. c. On 11/03/2020 at 08:06 a.m., Resident #67 was asleep in bed with oxygen being administered via nasal cannula. d. On 11/04/2020 at 2:38 p.m., the MDS Coordinator was asked if (Resident #67's) need for Oxygen was on his care plan. The MDS Coordinator stated, I don't know why I am not seeing it. I know he has a PRN order for it. I hate to say I am not seeing it. The MDS Coordinator was asked if it should be on the care plan. The MDS Coordinator stated, Oh yes ma'am it should be on the care plan. I will add it now. The only thing I can think of is it is not on there because it is as needed (PRN), but I guess I still should have put it on there anyway. 5. Resident #39 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 10/13/2020 documented the resident scored 7 (0 - 7 indicates severely impaired) per a Brief Interview for Mental Status (BIMS) and required extensive assistance with bed mobility, transfers, dressing, toilet use and bathing. a. On 11/05/2020 at 10:37 a.m., The Care Plan did not address Resident #39's [DIAGNOSES REDACTED]. b. On 11/05/2020 at 10:48 a.m., the MDS Coordinator was asked to identify on the care plan where (Resident #39's) [DIAGNOSES REDACTED]. The MDS Coordinator reviewed the plan of care and stated, Nope it's not on here. The MDS Coordinator was asked if it should be on the Care Plan? She stated, Yes it should be. 6. The Care Plans - Comprehensive Policy provided by the Administrator on 11/05/2020 at 1:58 p.m. documented, 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain . 3. Each resident's Comprehensive Care Plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems .

Complaint # (AR 639) substantiated, all or in part, in these findings Based on record review and interview, the facility failed to ensure a mechanical lift transfer to the shower bed was conducted by 2 staff in accordance with the resident's assessed transfer needs and failed to ensure the shower bed's side rail locking pins were in place and 2 staff were involved in the bathing procedure as per the plan of care, to prevent the resident from falling off of the shower bed onto the floor for 1 (Resident #2) of 2 (Residents #2 and 3) case mix residents who required the use of the shower bed for bathing. These failed practices resulted in Past Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Resident #2, who fell off of the shower bed and sustained a hip fracture, and had the potential to affect 9 residents who used the shower bed for bathing, as per a list provided by the Director of Nursing (DON) on 12/8/16 at 5:16 p.m. The findings are: Resident #2 had [DIAGNOSES REDACTED]. An Annual Minimum Data Set with an Assessment Reference Date of 8/21/16 documented the resident was severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status; totally dependent on 2 plus persons for bathing, transfers, locomotion on and off the unit; and did not have a history of falls. a. A Care Plan, dated as last reviewed on 1/28/16, documented, Focus (Resident #2) has an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) late effect CVA (Cerebrovascular Accident) and dementia . Revision on 1/26/16 . Interventions . requires 2 staff participation with bathing. Bathing/shower . uses hoyer loft with all transfers x (times( 2 staff assist with transfers . b. The CNA (Certified Nursing Assistant) Closet Care Plan, not dated, documented, .D = Dependent Or Total Care Required . Bathing Level D Shower . X 2 stretcher . c. A document titled Fall' documented, Resident: (Resident #5). Incident Location: Shower . Date: 11/14/16 16:10 (4:10 p.m.) . Incident Description: . CNA had resident in a shower bed and forgot to put pin in (side rails). After lathering up the resident, she slid out of the shower bed and onto the floor on her left side . c. Progress Notes documented, Nurses Notes dated 11/14/16 16:30 (4:30 p.m.) . New orders to x-ray left hip per (physician). d. An X-Ray Report dated 11/14/16 at 5:25 p.m. from an onsite radiology service provider documented, .3 views of the pelvis and hip without comparison is technically limited secondary to patient's inability to cooperate with positioning. There is an acute fracture involving the left subtrochanteric region with overriding fracture fragments. The fracture is just inferior to the cannulated screws . IMPRESSION: 1. Acute fracture involving the left subtrochanteric region, inferior to the cannulated screws. 2. Post-surgical changes of the right femur without complications . e. The hospital Emergency Documentation documented the resident was admitted to the Inpatient Unit on 11/14/16 at 11:15 p.m. with a [DIAGNOSES REDACTED]. The Discharge Summary dated 11/15/16 at 5:27 p.m. documented the resident was transferred back to the nursing home due to the resident's, .Dementia and contracted state and bed-bound state and not in significantly distressful pain. f. An OLTC (Office of Long Term Care) Witness Statement Form, Division of Medical Services (DMS) form 762, page 7 of 10, documented, Date 11/15/16 Witness Full Name (DON) . I was summoned to the shower room by nurse . stating resident (Resident #2) fell from the shower chair to the floor. After assessment, the resident was taken to her room and assisted to bed. An X-ray was obtained which revealed a fracture of the left hip. (Resident #2) was then transferred to the hospital. I immediately began investigating this incident. I requested a statement from (CNA #1) to determine how (Resident #2) fell . (CNA #1) indicated in her statement that two other CNAs brought (Resident #2) to the shower room on the shower bed with the safety rails disengaged. (CNA #1) then indicated that she recognized the rails were unsecure, and that she was going to secure them, but became distracted and then forgot. I asked her who brought the resident to the shower room, and she stated she doesn't remember. I reminded (CNA #1) that she should have secured the rails as soon as she recognized they were unsecure and she acknowledged this. I then suspended (CNA #1) and escorted her from the building. I began interviewing staff, and all staff denied bringing the resident to the shower room for (CNA #1). It is our standard of practice to not use the shower bed or the shower chairs as a means of transport. (Resident #2) should have been brought to the shower room in her wheelchair and then transferred to the shower bed, using a mechanical lift. I interviewed staff and all acknowledged understanding that keeping the safety rails on the shower bed secured while in use is the accepted standard of practice. The mechanical lift was in the shower room when I arrived immediately after the fall. This indicated to me that (CNA #1) had transferred (Resident #2) to the shower bed alone, which is not only a breech of our policy, but is also a breech of a industry wide accepted standard of practice to always having two staff members present when transferring a resident with a mechanical lift. I attempted to reach (CNA #1) by phone on 11/15/16, and left her a voice mail, and again on 11/16//16 to question her further. These attempts were unsuccessful. On 11/17/16 a certified letter was mailed to (CNA #1) terminating her employment at (Facility Name) for failure to adhere to accepted standards of practice and failure to follow policies and procedures. On 12/8/16 at 11:30 a.m., the DON was asked about the 11/14/16 incident and stated, .when I was summoned to the shower room, (Resident #2) was on the floor. The Hoyer Lift was in shower room. The shower bed is not designed for transport. (Resident #2) should have been brought to the shower room in her wheelchair and the lift used to transfer (Resident #2) from the wheelchair to the shower bed. I feel (CNA #1) put her on the shower bed by herself, but she kept saying 2 other CNAs had brought her in there, but couldn't remember who they were. All CNAs were interviewed, and no one had brought (Resident #2) to the shower room. (CNA #1) admitted to forgetting to put the pins in the rail of the shower bed. (CNA #1) was placed on suspension immediately and staff was inserviced. When I attempted to call her (CNA #1) to terminate her employment, she didn't answer or return any call. I sent her a certified letter terminating her employment. g. An OLTC Witness Statement Form, DMS-762 Page 7 of 9, documented, Date 11/14/16. Witness Full Name: (CNA #1) . Two other CNA got resident up and put her on the shower bed. I noticed that they had forgot to brought the safety pin for the shower bed so the first thing I was gonna do was to put the safety pin on when I get in the shower but I got distracted by doing something else and I forgot. I gave shower to resident and when I done I was pulling her out of the shower and while I was doing it I saw starting to roll out of the bed. I tried to ran to catch her but I only got to half of her body. I couldn't really hold her cause she .was wet and slippery. h. On 12/8/16 at 12:30 p.m., the facility's Consultant provided the Operation Instructions for the shower bed, which documented, Shower Bed Models: . USG 1200 . USAGE RECOMMENDATION - Recommended for showering people who are unable to stand or sit in a chair . OPERATING INFORMATION . lift opposite siderail and INSERT BOTH CORNER LOCK PINS into position . i. The facility removed the immediate jeopardy and corrected the failed practices on 11/14/16, prior to the survey, as evidenced by the following: 1.) An In-service sheet dated 11/15/16 and signed by all of the facility's CNAs documented, Subject: 1. The shower bed and the shower chairs are not designed for resident transport. You must transfer the resident to the shower room then move them to the shower bed or the shower chair. 2. You must have 2 staff members present when using the shower bed. 3. Side rails must be in the up position when using the shower bed. Presented by: (DON) . 2.) On 12/8/16 at 2:43 p.m., the DON provided Shower Bed Audits for the dates of 11/16/16, 11/17/16 and 11/21/16, which documented the shower bed side rails were correctly utilized and 2 staff were present for all showers observed. 3.) On 12/8/16 and 12/9/16, interviews were conducted with 4 CNAs who had been employed by the facility from 7 months to 5 years, and they all verbalized the appropriate steps for use of the shower bed and all stated this information was provided to them during their orientation upon hire. 4.) On 12/8/16 and 12/9/16, the survey team conducted observations of 3 non-case mix residents being placed onto the shower bed while in the shower room. Two staff were present throughout the procedure and the side rails and locking pins were appropriately used.

Complaint # (AR 980) and complaint # (AR 043) were substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure necessary care and services were provided to attain or maintain the highest practicable physical and mental well-being, in accordance with the plan of care for Resident #2: The facility failed to ensure all physician orders [REDACTED]. The facility failed to ensure staff responsible for providing care for a peripherally inserted central catheter (PICC) line was knowledgeable in the care of PICC lines; staff was aware when and who to report problems to regarding the PICC line; and dressing changes were completed as ordered by the physician to prevent infections and complications for 1 (Resident #2) of 2 (Residents #2 and #6) case mix residents who had a PICC line. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #2 who was readmitted to the hospital with [REDACTED]. The findings are: 1. Resident #2 was admitted to the facility 1/9/15 and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 1/16/15 documented the resident scored 12 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status had no pressure ulcers on admission; and had [MEDICAL CONDITION]. a. A Physician Clinic Note dated 1/28/15 documented, "Seen in the nursing home. He is seen in follow up for decubitus on his toes. He has had history of Guillain-Barre with significant motor loss. He has developed ulcers on his toes, he is moderately obese. Weakness of arms and legs, chronic pain, [MEDICAL CONDITION], Diabetes, [MEDICAL CONDITION]" b. A Nurse's Note dated 2/13/15 at 1:00 a.m. documented, "Tx (treatment) done to foot as ordered. Presents very foul odor. Resident continues on antibiotic for wound infection... Noted resident coughing..." c. A Nurse's Note dated 2/13/15 at 6:30 a.m. documented, "Resident heard mumbling, then yelling at unseen stimuli. When asked, resident yelled about green people and purple people. Resident noted pale, blood tinged green mucous noted in corner of mouth. MD (Medical Doctor) notified. New order received - send to (hospital emergency room ) for decreased LOC (level of consciousness) with hallucinations..." d. A Hospital Discharge Summary dated 2/20/15 documented, "Adm (admitted ): 2/13/15 ...Upon arrival to the ED (Emergency Department) the patient was found to have a LLL (left lower lobe) pneumonia and to have infected right heel decubitus ulcer. A central line was placed due to poor access and the patient was started on IV (intravenous) vanc ([MEDICATION NAME]), [MEDICATION NAME], and [MEDICATION NAME]. According to the nursing home the patient has been on Bactrim DS (Double Strength) since 2/8/15 for the infection on his right heel. The patient has a known history of Guillain-Barre with significant motor weakness, diabetes, CAD [MEDICAL CONDITION](hypertension)... Patient was admitted [MEDICAL CONDITION] and started on broad spectrum antibiotics... His source was found to be his infected RLE (right lower extremity) heel ulceration. Orthopedics was consulted and recommended amputation however patient refused. He was taken to OR (operating room) and had debridement and wound vac was placed. His cultures have grown proteus. (He also has culture from facility [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus))... There is a soft tissue defect overlying the right calcaneus with exposed calcaneus to the open environment... ID (Infectious Disease) was consulted and recommended long term antibiotics with IV vanc and [MEDICATION NAME] Patient has had many discussions with physicians regarding possible need for amputation however he would like to continue to try to avoid this. Patient will continue IV antibiotics and wound care at the nursing home... Discharge medications and new prescriptions: Start taking these medications - ertapenem 1 gram Recon (reconstituted) Soln (solution), Commonly known as: [MEDICATION NAME]. Inject 1,000 mg (milligrams) by intravenous injection every 24 hours... [MEDICATION NAME] 1000 mg Recon Soln, Commonly known as [MEDICATION NAME]. Inject 1,500 mg by intravenous infection every 12 hours..." e. A facility admission orders [REDACTED]. The February 2015 MAR did not have [MEDICATION NAME] listed as a medication to be administered. 1) On 3/17/15 at 1:44 p.m., LPN #1 was asked if he remembered Resident #2. He stated, "Yes. He was my first admission, and it was a complicated one." He was asked what he meant by that and he stated, "The hospital changed the report like three different times." He was asked what they changed and he stated, "It was all about the [MEDICATION NAME]. First they wanted it given, then they changed their minds and wanted it held. It was all about the Vanc." He was asked about the process of getting information from the hospital and admitting a resident. He stated, "They fax the information and they call and give report." He was asked what kind of information the hospital faxed. He stated, "Discharge paperwork, orders for treatments..." He was asked if he remembered looking at the discharge orders from the hospital and he stated, "(Social) brought me the copy of the discharge orders from the hospital. I have to have the paperwork from the hospital in order to get the medication orders. They don't give that over the phone." At this time, the LPN was shown the discharge order sheet from the hospital and the IV [MEDICATION NAME] that he did not add to the facility admission sheet. He stated, "I don't remember seeing that because I would have had to look that medication up to even know what it was." As of 3/17/15 at 2:00 p.m., the hospital discharge information that the facility used to admit Resident #2 on 2/20/15 could not be located in the closed record. On 3/17/15 at 2:17 p.m., the Medical Records clerk was asked about the missing information. He stated, "That information normally goes in the back of the chart under miscellaneous. If it's not there, I don't know where it's at." 2) On 3/18/15 at 2:00 p.m., the Medical Director was asked if he remembered Resident #2. He stated, "I do." He was told about the IV [MEDICATION NAME] being left off of the Admission Order sheet at the facility. He was asked about the process of signing the facility Admission Order sheet, specifically the readmission orders [REDACTED]. He stated, "I look at what the nurse writes down and that's what I sign. I would not know if the nurse left a medication off. Maybe I had better compare them starting today." He was asked if he was aware there had been a problem with this involving Resident #2. He stated, "I was aware there was a problem with the PICC line from the hospital. I did not know there was a medication problem. I work at the hospital too so I am notified from them also." He was asked if the facility has asked him to participate in any Quality Assurance meetings about any problems like this. He stated, "I have been to QA meetings about regular stuff, but nothing like this." f. The Plan of Care updated 2/20/15 documented, "Infection related [MEDICAL CONDITION]; gangrene, severe [MEDICAL CONDITION] ... interventions ...Administer meds, PO (by mouth) and via PICC (Peripheral Inserted Central Catheter) line per MD (Medical Doctor) orders... Change PICC line dressing per MD orders..." g. A Physician order [REDACTED]." h. The February 2015 Treatment Administration Record (TAR) documented, "2/20/15 - Sterile dressing change every 3 days by RN (Registered Nurse) to LUE (Left Upper Extremity) PICC." The TAR documented the PICC line dressing was changed on 2/22/15 and 2/28/15. i. A Physician order [REDACTED]." j. An SBAR (Situation Background Assessment Recommendation) Communication Form dated 2/28/15 at 8:00 a.m. and completed by LPN #2 documented, "Change in mental status, temperature, right foot 4+ (plus), PICC line not functioning... Temp 100.5... Wound vac to right heel... Stage 3 to 4 wound right heel, wound coccyx..." k. A Nurse's Note dated 2/28/15 at 7:30 a.m. and written by LPN #2 documented, "Resident, definite change in mental status, unable to swallow breakfast, left side of mouth droopy, PICC line... not functioning, right foot to wound vac, right foot 4+ [MEDICAL CONDITION], left foot 4+ [MEDICAL CONDITION] (blood pressure) 118/94, (Temperature) 100.5, (Pulse) 86, (Respiration) 24. Pulse ox 94%... 8:40 a.m. - EMTs (emergency medical technicians) here to transport to (hospital)..." l. A Hospital ED (Emergency Department) Provider Note dated 2/28/15 documented, "...Male presents to the ED with a chief complaint of fever. Recently DC (discharged ) from hospital [MEDICAL CONDITION] - [MEDICAL CONDITION]/decubitus - heels - has wound vac and pneumonia. Has Pic line but apparently has only been getting IV vanc and it is in question when his last dose was given - pic line is reported to not be functioning and is not bandaged or secured properly..." An ED Nurse's Note dated 2/28/15 documented, "PICC team was called to replace left arm picc line due to malfunction line. Upon inspection of picc line... the red port had an extension tubing without a leurlock on the port. (RN #1) at (nursing home) was called. (RN #1) is the acting DON of (nursing home). Instructed that this was not the proper way to care for a central line." m. A Hospital History and Physical (H&P) note dated 2/28/15 at 3:15 p.m. documented, "...Pt presents from SNF (skilled nursing facility) with fever. Recently discharged after being treated for [REDACTED]. He was discharged on vanc + ertapenem but apparently has not been getting the latter according to MAR and discussion with nurse at the facility. PICC line malfunctioning and not being maintained properly... Will send blood cx (culture) and cx cath tip. Wound care consult. Vanc + ertapenem." A Hospital Inpatient H&P dated 2/28/15 documented, "...The patient was sent back to the nursing home on IV Vanc and [MEDICATION NAME] with a wound vac on his right heel. This morning the patient was found to have a fever of 101 so he was sent to the ED. Upon arrival he was found to have a malfunctioning PICC line... Upon reviewing the patient's nursing home MAR it was discovered that the patient has been getting IV [MEDICATION NAME] but has not been getting [MEDICATION NAME]." A Hospital IV Catheter Culture dated 3/3/15 documented, "IV Cath tip; Cath PICC 2/28/15, 3:50 p.m. - Staphylococcus hominis subsp (subspecies) hominis, Staphylococcus epidermidis, Diphtheroids." n. On 3/18/15 at 10:39 a.m., LPN #2 was asked about 2/28/14 when she sent (Resident #2) to the hospital. She stated, "He was running a temp, he was lethargic, his left face was drooping, his leg was swollen and his PICC was occluded." LPN #2 was asked about the condition of the PICC line when the resident was sent out to the hospital. She stated, "There was no dressing on his PICC and a hub was missing off of one. It was a double lumen. I don't know how or when it came off. There was one piece of tape holding it in place. The foot with the wound vac was terribly inflamed. (Physician) from the hospital called me really upset. She asked about the PICC. I told her I had been off. The Vanc was scheduled to be given that morning and I couldn't give it because it was occluded. Then the doctor called back and asked about when the [MEDICATION NAME] was hung. I went to the MAR and there was no [MEDICATION NAME]. So I went to the chart and the first medication on the hospital discharge orders was [MEDICATION NAME]. I don't know how it got missed." LPN #2 was asked to clarify if she saw the hospital discharge orders and that the [MEDICATION NAME] was on the order sheet. She stated, "Yes. I saw them. They were in the miscellaneous section of the chart and [MEDICATION NAME] was the first medication listed." She was told the facility could not locate the hospital discharge orders now and she was asked if she had any idea where they might be. She stated, "I don't understand that. They were in the chart. I looked at them." LPN #2 was asked if she placed a dressing on the resident's PICC line before sending him out to the hospital. She stated, "I did not put a dressing on it. I left it just like it was. What I was told was if I couldn't show my IV certificate, I couldn't touch it. But that morning I asked (RN #2) if she was going to hang the Vanc and she told me to go ahead. The day before she told me no." LPN #2 was asked about the TAR and the initial on 2/28/15 documenting that the PICC line dressing had been done that day. She looked at the TAR and stated, "I've never seen that initial before. I have no idea who that is and I know everyone's initials. The dressing was not done because I am the one who sent him out that morning and there was no dressing on it." At this time, LPN #2 reviewed the resident's MAR and TAR and stated, "See? That initial is nowhere else on here. I don't know who that is." LPN #2 was asked if she ever did his PICC line dressing from 2/20/15-2/28/15. She stated, "No, I never did it." o. On 3/18/15 at 2:10 p.m., RN #1 was asked about the phone call she received from the hospital on [DATE] concerning the resident's PICC line. She stated, "It was a short phone call... I think it was the ER supervisor and he wanted to know who had been caring for the PICC line. I told him the IV certified nurses, and he basically told me he didn't agree with the technique. That was pretty much it. I didn't know anything about it because I had been gone." She was asked if she did any of the PICC line dressing changes for the resident. She stated, "No." She was asked if she did any of the wound vac dressing changes for the resident. She stated, "No. I didn't do any of them." p. On 3/18/15 at 2:30 p.m., the Administrator was asked if he was aware of the above issue involving Resident #2. He stated, "No." 2. The facility's policy for Dressing Change for Vascular Access Devices received from the Registered Nurse Consultant on 3/17/15 documented, "Policy: To prevent local and systemic infection related to the IV site... For Midlines and all [MEDICAL CONDITION] (Central Venous Access Devices)... Apply Biopatch around catheter at insertion site after alcohol has dried. (Biopatch is a small dressing containing cholrhexidene) A transparent dressing must be placed over the Biopatch dressing..." 3. The immediate jeopardy was removed and the scope and severity lowered to an "E" when the facility implemented the following plan of removal: a. The following plan constitutes our abatement of the immediate jeopardy deficiency cited on 3/24/15: Reeducation was conducted by DON (Director of Nursing)/Designee with nursing staff regarding following: changing and dressing PICC lines, ensuring discharge orders for antibiotics are implemented, performing treatments as ordered by physician, following physician orders, immediately assessing condition of wounds and obtaining treatment orders, performing treatments utilizing proper technique. This was initiated on 3/24/15 at 10:30. This will be completed by 3/24/15 at 11:00 p.m. b. Any nursing staff member not completing the above required reeducation will not be allowed to return to work until the reeducation is complete. c. Facility wide skin reviews conducted for each resident, initiated 3/24/15 at 10:30 a.m. by DON/Designee and will be completed 3/24/15 by 11:00 p.m. d. Any wounds identified during skin reviews will be communicated with physician and treatment orders will be obtained by DON/Designee by 3/24/15 at 11:00 p.m. e. Dressing change/treatment observations, including PICC line dressing changes at 3x/week x 4 weeks, then weekly x 4 weeks will be conducted by DON/Designee starting 3/24/15 at 1300 (2:00 p.m.). f. Admissions from last 30 days will be reviewed by Medical Records/Designee to ensure any orders for antibiotics were implemented. This will be initiated on 3/24/15 at 2 pm and will be completed by 11:00 p.m. DON/Nurse management will review readmit orders weekly x 6 weeks. g. Treatment Administration Records will be reviewed daily by nurse management to ensure treatments are performed according to physician orders. Negative findings will be corrected immediately and reported to DON. h. Physician orders [REDACTED]. Negative findings will be corrected immediately and reported to Administrator. i. In all of the above steps, negative findings will be reported to QAPI (Quality Assurance Performance Improvement) committee for further review and/or recommendations.

Complaint # and # was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure necessary treatment and services to promote healing of pressure sores, to prevent/decrease infection, and to prevent continued skin breakdown was provided to Residents #2 and #6. The facility failed to ensure intravenous (IV) antibiotics were administered as prescribed upon discharge from hospital for a wound infection for 1 (Resident #2) of 2 (Residents #2 and #6) case mix residents who had a pressure ulcer. The facility failed to ensure a thorough skin assessment was completed and documented upon admission/readmission and at least weekly to enable prompt identification and prompt consultation with physician regarding treatment of [REDACTED].#2) ) of 2 (Residents #2 and #6) case mix residents who had a pressure ulcer. The facility failed to ensure pressure ulcer treatments were provided as ordered by the physician to promote healing for 1 (Resident #2) ) of 2 (Residents #2 and #6) case mix residents who had a pressure ulcer. The facility also failed to ensure correct technique was provided when cleansing a wound to prevent potential spread of infection for 1 (Resident #6) of 2 (Resident #2 and #6) case mix residents who had pressure sores. The failures to ensure IV antibiotics were administered as prescribed and that orders for treatments were promptly obtained resulted in immediately jeopardy which caused or could have cause serious harm, injury, or death to Resident #2 who experienced further deterioration in his wounds resulting in hospitalization and had a potential to cause more than minimal harm to 3 residents with pressure sores according to a list provided by the Administrator on 3/24/15 at 11:40 a.m. The Administrator was informed of the Immediate Jeopardy on 3/24/15 at 11:40 a.m. The findings are: 1. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/16/15 documented the resident scored 12 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS); required extensive to total assistance for activities of daily living; had [MEDICAL CONDITION]; had no pressure ulcers and was at risk for developing pressure ulcers. The hospital history and physical examination [REDACTED]. Stage II coccygeal ulcer..." The resident's hospital discharge orders for continued services dated 1/9/15 documented, "...Wound/skin Care (described): Pressure off load relief to sacral wound, turn as much as possible. Heels sheepskin boots..." The facility's admission-data collection form dated 1/9/15 documented, ".... (Resident's) Skin: Pressure Sore (Stage I-IV) toes, Bilat (bilateral) Heels, Coccyx..." The Braden Scale assessment form dated 1/9/15 documented the resident had a score of 13; with a total score between 13-14 indicating moderate pressure sore risk. a. The January 2015 physician's orders [REDACTED]...1/11/15: Send to wound care clinic for bilateral feet wounds." The resident's initial visit to the wound clinic was dated 2/5/15; 25 days after the order had been written. b. The first treatment order for the pressure sores to the lower extremities which were present upon admission (1/9/15) documented, "1/15/15 N.O. (new order) written 1/14/15 ... 1) clean all 10 toes with Saf-clens and apply [MEDICATION NAME] daily ... 2) Clean (L) (left) heel/diabetic ulcer with Saf-clens and apply skin prep ... 3) clean R (right) heel/diabetic ulcer with Saf-clens and apply skin prep." The order did not include a treatment order for the coccyx area also noted on admission. c. The February 2015 Physicians Orders dated documented, "2/5/15 Clean wound to Rt. (right) heel with NaCl (sodium chloride), pat dry, apply 50/50 mix [MEDICATION NAME] ointment (and) Santyl ointment to wound bed only. Apply moist gauze, cover (with) foam, wrap (with) cling gauze. Secure with tape daily and PRN (as necessary)." As of 3/24/15 there was no order found in the clinical record or on the current physician orders [REDACTED]. d. The wound care measurement from 1/9/15 through 2/11/15 documented on Wound Care reports as follows: 1) 1/9/15 - " Right Heel Stage III 4 (centimeters (cm)) x 1.5 (cm) heavy yellow drainage." This measurement was not documented on the facility's admission data-collection form dated 1/9/15. 1/13/15, 1/22/15, and 1/29/15 - " ...Right Heel- Stage III 4 x 1.5 cm"1/29/15, 2/6/15, and 2/11/15 - " ...Right Heel, Stage III 4 x 2 cm" 2) 1/9/15, 1/13/15, 1/22/15, 1/26/15 - " ...Left Heel, NAS (not able to stage) -1.5 x 1.5cm." 1/29/15, 2/6/15, and 2/11/15 - " ...Left Heel, NAS - 2 x 2cm." 3) 2/4/15 - " ...Toes times 10 - NAS scattered area of necrosis with worsening to (B) (bilateral) fifth toe." 4) The Wound Care Report did not address the size of the coccyx wound from 1/9/15 through 2/11/15. e. A Nurse's Note dated 2/13/15 at 6:30 a.m. documented, " ...Resident heard mumbling, then yelling at unseen stimuli. When asked, resident yelled about green people and purple people. Resident noted pale, blood tinged green mucous noted in corner of mouth. MD (Medical Doctor) notified. New order received, 'send to (hospital) ER (emergency room ) for decreased LOC (level of consciousness) with hallucinations'..." f. A Hospital Discharge Summary dated 2/20/15 documented, "Adm (admitted ): 2/13/15 ...Upon arrival to the ED (Emergency Department) the patient was found to have a LLL (left lower lobe) pneumonia and to have infected right heel decubitus ulcer. A central line was placed due to poor access and the patient was started on IV (intravenous) vanc ([MEDICATION NAME]), [MEDICATION NAME], and [MEDICATION NAME]. According to the nursing home the patient has been on Bactrim DS (Double Strength) since 2/8/15 for the infection on his right heel. The patient has a known history of Guillain-Barre with significant motor weakness, diabetes, CAD [MEDICAL CONDITION](hypertension)... Patient was admitted [MEDICAL CONDITION] and started on broad spectrum antibiotics... His source was found to be his infected RLE (right lower extremity) heel ulceration. Orthopedics was consulted and recommended amputation however patient refused. He was taken to OR (operating room) and had debridement and wound vac was placed. His cultures have grown proteus. (He also has culture from facility [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus))... There is a soft tissue defect overlying the right calcaneus with exposed calcaneus to the open environment... ID (Infectious Disease) was consulted and recommended long term antibiotics with IV vanc and [MEDICATION NAME] Patient has had many discussions with physicians regarding possible need for amputation however he would like to continue to try to avoid this. Patient will continue IV antibiotics and wound care at the nursing home... Discharge medications and new prescriptions: Start taking these medications - ertapenem 1 gram Recon (reconstituted) Soln (solution), Commonly known as: [MEDICATION NAME]. Inject 1,000 mg (milligrams) by intravenous injection every 24 hours... [MEDICATION NAME] 1000 mg Recon Soln, Commonly known as [MEDICATION NAME]. Inject 1,500 mg by intravenous infection every 12 hours..." g. The resident was readmitted to the facility on [DATE]. The facility admission orders [REDACTED]. The facility admission orders [REDACTED]. The February 2015 MAR did not have [MEDICATION NAME] listed as a medication to be administered. 1) On 3/17/15 at 1:44 p.m., LPN #1 was asked if he remembered Resident #2. He stated, "Yes. He was my first admission, and it was a complicated one." He was asked what he meant by that and he stated, "The hospital changed the report like three different times." He was asked what they changed and he stated, "It was all about the [MEDICATION NAME]. First they wanted it given, then they changed their minds and wanted it held. It was all about the Vanc." He was asked about the process of getting information from the hospital and admitting a resident. He stated, "They fax the information and they call and give report." He was asked what kind of information the hospital faxed. He stated, "Discharge paperwork, orders for treatments..." He was asked if he remembered looking at the discharge orders from the hospital and he stated, "(Social) brought me the copy of the discharge orders from the hospital. I have to have the paperwork from the hospital in order to get the medication orders. They don't give that over the phone." At this time, the LPN was shown the discharge order sheet from the hospital and the IV [MEDICATION NAME] that he did not add to the facility admission sheet. He stated, "I don't remember seeing that because I would have had to look that medication up to even know what it was." 2) On 3/18/15 at 10:39 a.m., LPN #2 was asked about 2/28/14 when she sent (Resident #2) to the hospital. She stated, "He was running a temp, he was lethargic, his left face was drooping, his leg was swollen and his PICC was occluded." LPN #2 was asked about the condition of the PICC line when the resident was sent out to the hospital. She stated, " .... The foot with the wound vac was terribly inflamed. (Physician) from the hospital called me really upset. She asked about the PICC. I told her I had been off. The Vanc was scheduled to be given that morning and I couldn't give it because it was occluded. Then the doctor called back and asked about when the [MEDICATION NAME] was hung. I went to the MAR and there was no [MEDICATION NAME]. So I went to the chart and the first medication on the hospital discharge orders was [MEDICATION NAME]. I don't know how it got missed." LPN #2 was asked to clarify if she saw the hospital discharge orders and that the [MEDICATION NAME] was on the order sheet. She stated, "Yes. I saw them. They were in the miscellaneous section of the chart and [MEDICATION NAME] was the first medication listed." She was told the facility could not locate the hospital discharge orders now and she was asked if she had any idea where they might be. She stated, "I don't understand that. They were in the chart. I looked at them ...." h. The care plan dated 2/20/15 documented, " ...Problem: Impaired skin integrity R/T (related to) [MEDICAL CONDITION], occlusion of femoral vein. ...Interventions: A: Change wound vac dressing per MD order B: wound vac place to R (right) heel pressure area C: cleanse diabetic ulcer on R foot per MD order D: Treat F/U (follow up) to coccyx per MD order." i. A Nurses Note dated 2/20/15 at 4:45 p.m. documented, "Resident admitted back to here. Wound vac on (R) heel change dressing M,W, F (Monday, Wednesday, Friday) till healed ..." There was no documentation of a skin assessment to determine current status of skin breakdown. A Telephone order dated 2/20/15 documented "Change wound vac dressing M, W, F til Dr. (doctor) DC (discontinue) wound vac." j. The Nurse's note dated 2/21/15 documented, "0500 - Eval. (evaluated) R (resident) bottom during pericare by CNA's (Certified Nursing Assistants), dirty drsg (dressing). noted to coccyx dated 2/16/15. Removed drsg., several open areas clustered in area approx. (approximately) 5cm x 6cm, Stage II PU (pressure ulcer). Obtained Tx (treatment) order -" ...1) clean with wound cleanser, pat dry, apply collagen drsg. cover with dry drsg, and change every day and PRN (as necessary) - also noted 2 skin tears to top of (R) foot, no drsg. noted. Obtained Tx order - 1) clean wound (with) wound cleanser, pat dry, apply TAO (triple antibiotic ointment) and cover with dry drsg. QD (everyday) and PRN orders noted. Will notify POA (power of attorney) later in am (morning)..." A Telephone order dated 2/21/15 documented, " ...Clean wound to coccyx (with) wound cleaner, pat dry, apply collagen drsg (dressing) cover (with) dry drsg (and) (change every ) 3 days (and) prn (as needed) soiling or dislodgement." A Telephone order dated 2/21/15 documented, " ...Clean wound to top of R (right) foot (with) wound cleaner, pat dry, apply TAO (triple antibiotic) (and) cover (with) dry drsg. QD (every day) (and) prn soiling or dislodgement ..." k. The February 2015 TAR did not document the ordered treatment as being provided for the resident's coccyx area on the following dates: 2/23/15, 2/24/15, 2/25/15 and 2/26/15. The wound vac to the right heel pressure sore was scheduled to be changed on 2/25/15; the date was blank on the February 2015 TAR. 1) On 3/17/15 at 1:44 p.m., LPN #1 who was scheduled to work with the resident on 2/23/15 and 2/26/15 was shown the resident's TAR. When asked about the reason for the blanks on the TAR for the resident's coccyx treatment on 2/23/15 and 2/26/15, LPN #1 had no comment. 2) On 3/18/15 at 10:39 a.m., LPN #2 who was scheduled to work with Resident #2 on 2/25/15 was shown the February 2015 TAR and the blanks on the TAR. When asked why the TAR was blank for the resident's coccyx and right heel treatment and the wound vac change on Wednesday 2/25/15 LPN #2 stated, "The ADON (Assistant Director of Nursing) asked me if I was okay with doing the wound vac dressing and I told her I wasn't comfortable with doing it. I asked her (ADON) if she would show me how (to change wound vac). She (ADON) never came down (to resident's room) so it (wound vac change) wasn't done." LPN #2 was asked about the blanks on the TAR for the coccyx wound treatments for 2/23/15 and 2/26/15?" LPN #2 stated, "I know. There's no excuse for that." 3) On 3/18/15 at 2:10 p.m., Registered Nurse (RN) #1 was asked if she had done any of the wound vac dressing changes for Resident #2. She stated, "No. I didn't do any of them." l. A Situation Background Assessment Recommendation (SBAR ) Communication Form dated 2/28/15 (not timed) and completed by LPN #2 documented, " ...Change in mental status, temperature, right foot 4+([MEDICAL CONDITION])... Temp 100.5... Wound vac to right heel... Stage 3 to 4 wound right heel, wound coccyx..." A Nurse's Note dated 2/28/15 at 7:30 a.m. by LPN #2 documented, "Resident, definite change in mental status, unable to swallow breakfast, left side of mouth droopy, ...right foot 4+ [MEDICAL CONDITION], left foot 4+ [MEDICAL CONDITION] 118/94, 100.5, 86, 24. Pulse ox (oximeter) 94%... 8:40 a.m. - EMTs (emergency medical technicians) here to transport to (hospital)..." m. A hospital history and physical dated 2/28/15 at 3:15 p.m. documented, "...Pt. (patient) presents from SNF (Skilled Nursing Facility) with fever. Recently discharge after being treated for [REDACTED]. He was discharged on vanc + Ertapenem but apparently has not been getting the latter according to MAR (medication administration record) and discussion with nurse at the facility... Wound Care Consult: Coccyx, dorsal right foot, and Stage IV right heel. Wound Assessment: Right Dorsal foot dry abrasion covered with 4x4 (gauge) [MEDICATION NAME]. Moisture skin damage to sacrum... Removed wet to dry dressing from Stage IV Right Heel. Debrided portion of wound improving, 7.8 x 8.3 x 2.8cm, beefy red, moist, clear drainage with no odor. Peri-wound distal to open wound non-viable necrotic tissue area 5 x 9 cm unable to determine depth at this time. ...Wound vac dressing noted to right heel dated 2/23/15." The hospital's Physician's Progress notes dated 3/1/15 at 1:04 p.m. documented, "...Assessment: Fever: likely due to untreated R heel decub (decubitus) with [MEDICAL CONDITION] and osteo[DIAGNOSES REDACTED]; wound cx (culture) previously with proteus [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus Aureus)." 2. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 12/23/14 documented the resident scored 9 (8-12 indicates moderately impaired) on the BIMS; required extensive assistance from staff for activities of daily living; and had no pressure ulcers. a. The Plan of Care updated 3/11/14 documented "9/30/13 - Resident is at risk for skin breakdown and pressure ulcers related to incontinence, decreased mobility, fragile skin." b. A Physician order [REDACTED]." c. On 3/18/15 at 1:39 p.m., LPN #2 provided wound care to the resident's coccyx area. The open area measured approximately 2 centimeters (cm) x 2 cm. The LPN used Kerlix and normal saline to clean the wound. She stated the facility was out of 4x4s. When cleaning the wound , the LPN wiped across the wound bed five times instead of starting in the center of the wound and working outward away from the open area. Collagen fluff was placed in the wound bed, skin prep was applied around the wound and it was covered with a foam dressing. There were no signs of infection. The LPN was asked if she had ever been taught to clean wounds by starting in the center and using a circular pattern while going outward away from the wound. She stated, "No." 3. The immediate jeopardy was removed and the scope and severity lowered to an "E" when the facility implemented the following plan of removal: a. The following plan constitutes our abatement of the immediate jeopardy deficiency cited on 3/24/15: Reeducation was conducted by DON (Director of Nursing)/Designee with nursing staff regarding following: changing and dressing PICC lines, ensuring discharge orders for antibiotics are implemented, performing treatments as ordered by physician, following physician orders, immediately assessing condition of wounds and obtaining treatment orders, performing treatments utilizing proper technique. This was initiated on 3/24/15 at 10:30. This will be completed by 3/24/15 at 11:00 p.m. b. Any nursing staff member not completing the above required reeducation will not be allowed to return to work until the reeducation is complete. c. Facility wide skin reviews conducted for each resident, initiated 3/24/15 at 10:30 a.m. by DON/Designee and will be completed 3/24/15 by 11:00 p.m. d. Any wounds identified during skin reviews will be communicated with physician and treatment orders will be obtained by DON/Designee by 3/24/15 at 11:00 p.m. e. Dressing change/treatment observations, including PICC line dressing changes at 3x/week x 4 weeks, then weekly x 4 weeks will be conducted by DON/Designee starting 3/24/15 at 1300 (2:00 p.m.). f. Admissions from last 30 days will be reviewed by Medical Records/Designee to ensure any orders for antibiotics were implemented. This will be initiated on 3/24/15 at 2 pm and will be completed by 11:00 p.m. DON/Nurse management will review readmit orders weekly x 6 weeks. g. Treatment Administration Records will be reviewed daily by nurse management to ensure treatments are performed according to physician orders. Negative findings will be corrected immediately and reported to DON. h. Physician orders [REDACTED]. Negative findings will be corrected immediately and reported to Administrator. i. In all of the above steps, negative findings will be reported to QAPI (Quality Assurance Performance Improvement) committee for further review and/or recommendations.

Complaint # (AR 911), was substantiated (all or in part) in these findings. Based on observation, record review, and interview the facility failed to ensure assessments of elopement risk were accurate and updated as conditions changed; interventions were developed and communicated to staff; and those interventions were monitored to ensure consistent implementation and effectiveness to ensure the safety for 5 of 5 (Resident #s 2, 4, 5, 6, and 7) case mix residents with documented or reported history of exit seeking behaviors. The facility failed to routinely monitor window slide locks to ensure the locks were secured to prevent possible elopement for 5 of 5 (Resident #s 2, 4, 5, 6, and 7) case mix residents at risk for elopement and failed to ensure the sliding window locks were re-evaluated for safety after 1 (Resident #5) case mix resident, who was at risk for elopement removed the sliding window lock, opened the room window, and eloped from facility. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident # 5 who eloped from the facility through a window secured with a sliding window lock and had the potential to affect 7 residents in the facility who were at risk for elopement according to a list provided by the Director of Nurses (DON) on 2/8/15. The facility was notified of the Immediate Jeopardy on 2/8/14 at 12:00 p.m. The findings are: 1. The facility's policy titled "Elopement Risk" received from the DON on2/3/15 documented, "Policy: It is policy ... that on admission, re-admission, significant change and quarterly, all residents will be assessed for elopement risk. Procedure: 1. An elopement risk assessment will be completed by nursing. 2. If the resident is identified as an elopement risk based on the assessment, the care plan will reflect the interventions ... Review and/or revise care plan following attempt to leave the facility ..." 2. Resident # 5 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. a. The (name of previous long term care facility) Progress Notes dated 5/20/14 documented, "... The patient request evaluation every week for psychiatric evaluation to be cleared to live on his own. He continues to have bizarre behavior ..." The (name of previous long term care facility) Progress Notes dated 7/22/14 documented, "... At this time, he does continue to have some exit-seeking behaviors ..." b. The facility ' s Admission Data Collection Form dated 10/6/14 at 8:30 p.m. documented, "... Elopement Risk Assessment...1. Is resident cognitively impaired? Yes. 2. Is the resident independently mobile...? Yes. 3. Does the resident have poor decision making skills? Yes. 4. Has the resident demonstrated exit seeking behavior? No. 5. Does the resident wander oblivious to safety needs? No. 6. Does the resident have a history of elopement? No. 7. Does the resident have the ability to exit the facility? Yes. (Yes to number 4 or 6 is automatically determined AT RISK). Resident is determined to NOT be at risk for elopement ... Admission Nurses Notes: (Resident # 5) arrived at our facility at (about) 8:30 p.m. via van (with) CNA (Certified Nurse Assistant) from previous facility ... " The resident was admitted to the secure men's unit. The Initial Social Service History dated 10/7/14 documented, "... Has been in numerous facilities for several years - unable to manage his medications, ADLs (Activities of Daily Living) ... No family involvement ... Has Public Guardian. Does not understand reason for this and does not feel it is fair to him ..." A physician progress notes [REDACTED]. c. The clinical record documented vocalization of wanting to leave and exit seeking behaviors: 1) A Nurse's Notes dated 10/11/14 documented, "... Was moved to (Room number still on men's secure unit) ... stated 'I don't' want in this (room) either. I want thru them doors. (off secure unit)'..." 2) A Nurse's Note dated 10/16/14 documented, "Resident talking (with) CNA this a.m. about wanting to leave. Wanting RNA (Restorative Nurse Assistant) to take (him) to (store name). Set off alarm at double doors by business office (off of men's secure unit (see facility floor plan with date by exit door)) ... Spoke with DON (Director of Nurses) she stated to put him in men's unit in room (Number) ...". There was no documentation found for an updated Elopement Risk Assessment and no update to the Care Plan. 3) A Physician's Progress Note dated 10/22/14 documented, "... (Patient) wants to be out of lock down unit." A Nurse's Note dated 10/22/14 at 3:00 p.m. documented, "Resident very agitated wanting out of men's unit. Came out of men's unit, refused to go back in ..." 4) A Nurse's Note dated 10/23/14 at 11:00 a.m. documented, "I went back to unit to pass my pills when resident again angry with me. When I went to go out of the men's unit he pushed me out of the way and come out on the main floor ..." A Physician's Progress Note dated 10/23/14 documented, "... He has recently tried to escape from facility..." The Nurse's Notes dated 10/23/14 at 5:45 p.m. documented "I was coming out of men's unit when resident pushed me out of the way, came out to main floor, yelling, screaming that he had a right to out here ..." d. A physician's orders [REDACTED]. A Nurse's Note dated 11/18/14 documented, "Resident (room number) complained that this resident (Resident #5) would not quit coming in his (room) and bothering him even though this resident (room number) had asked him numerous times not to just come in and to not come in (room) when he wasn't in there and he would do it anyway. (Room number of yet another resident) resident (and) some CNAs (Certified Nursing Assistants) have seen this resident coming out from behind the nurses desk (and) this resident (room number) seen him putting something in pocket which she states looked like cigarettes. Resident (a third resident room number) company complained that he won't leave him alone when he is here - constantly wanting him to take him (Resident # 5) out for a cigarette ..." e. The clinical record documented more incidents of vocalization of wanting to leave and exit seeking behaviors: 1) A Nurse's Note dated 11/20/14 at 9:00 p.m. documented, "Resident voiced unhappiness regarding living on men's unit 'I'm going to get out of here' ..." 2) A Nurse's Note dated 11/21/14 at 2:15 p.m. documented, "... (Continues) to voice desire to leave with statements 'I'll just take off walking someday (and) ya'll will never find me' ..." 3) A Nurse's Note dated 11/29/14 at 10:40 a.m. documented, "Remains in men's secure unit, asking to come out to main floor, continuously asking when he can come out to main floor ..." 4) A Nurse's Note dated 12/3/14 at 3:15 p.m. documented, "Remains to be able to come to in and out of men's unit per Administrator order." 5) A Nurse's Note dated 12/4/14 at 3:30 p.m. documented, "(Resident) (out of facility) to podiatry (appointment) this a.m. on return to facility at noon, CNA reported (resident) had attempted to force his way past them (and) get outside while making statements of wanting to smoke (and) not returning to facility ..." There was no documentation found for an updated Elopement Risk Assessment. f. The clinical record documented more incidents of vocalization of wanting to leave and exit seeking behaviors as well as other behavioral issues: 1) A Nurse's Note dated 12/9/14 at 5:10 p.m. documented, "CNA reported (resident) smoking in his room. On entry writer (observed) (wheelchair) against door, smell of (cigarette) smoke strong in the air (and) room cloudy. Also noted (resident) window opened all the way ... window lock replaced ..." 2) A Nurse's Note dated 12/11/14 at 12:30 a.m. documented, "... Remains on men's secure unit ... became upset because he was on unit, banged on door for a while ..." 3) A Nurse's Note dated 12/10/14 at 1:00 a.m. documented, "... Resident was in and out of men's unit this p.m. ..." 4) A Nurse's Note dated 12/27/14 at 3:00 p.m. documented, "(Telephone order) (physician's name) Resident is to stay in men's lock down unit (at) all times due to going in other's (rooms), unable to redirect ..." 5) A Nurse's Note dated 12/29/14 at 3:15 p.m. documented, "... (Resident) yelling (at) staff this a.m. wanting off unit ... After lunch (resident) walked out of unit (with) staff (and) when writer attempted to re-direct (resident) back to unit, (resident) became agitated, stomping cane on ground (and) banging it against desk, raised voice stated I'm not going back, (refused) to return to unit ..." g. A Nurse's Note dated 12/31/14 at 2:30 p.m. documented, "(Telephone order) (physician name) Move to room (room number on open, main unit) ..." h. The Quarterly Data Collection Tool dated 1/11/15 and signed by Registered Nurse (RN) # 1 documented, "... Elopement Risk Assessment 1. Is resident cognitively impaired? No. ... 4. Has the resident demonstrated exit seeking behaviors? No ... 6. Does the resident have a history of elopement? No ...Resident is determined to NOT be at risk for elopement ..." i. The care plan with a review date of 1/22/15 documented: "Focus: Resident has potential for psychological distress of psychosocial well being ... Date initiated: 12/08/15 ..." The care plan did not address elopement risk/exit seeking behaviors or interventions to address elopement risk/exit seeking behaviors. j. The clinical record documented more incidents of vocalization of wanting to leave and exit seeking behaviors as well as other behavioral issues: 1) A Nurse's Note dated 1/30/15 at 7:30 p.m. documented, "Resident was seen going into female resident room. Was reprimanded at that time and he walked away ..." A Nurse's Note dated 1/30/15 at 9:35 p.m. documented, "Female resident made complaint to nurse that male resident entered her (room) asked (her) to give (him) money (and) proceeded to take off all his clothes. Female told him to put clothes on (and) leave room. Male resident put clothes on (and) then sat down in chair to watch TV. Again he was asked to leave. Upon him leaving (room) female reported to nurse (and) made written complaint ... Male resident placed 1 on 1 observation ..." 2) A Nurse's Note dated 1/31/15 at 2:00 p.m. documented, "Resident taken off of 1 on 1 per (name) Administrator. Resident moved to room (number), men's secure unit ..." 3) A Nurse's Note dated 2/2/15 at 10:37 a.m. documented, "... (Resident) pacing hallway on unit wanting to talk to (management) (and) verbalizing (complaints of) being on unit ... unable to redirect ..." k. A Nurse's Note dated 2/2/15 at 8:55 p.m. and signed by Licensed Practical Nurse (LPN) # 1 documented "Upon entering (room), very cold, bathroom door closed. Resident not in (room). Found window open (with) linens in opening, screen on ground." A Nurse's Note dated 2/2/15 at 9:00 p.m. documented, " elopement protocol enacted ... Police notified ..." On 2/7/14 at 6:45 a.m., Licensed Practical Nurse (LPN( # 1 was asked, "Do you know of any residents who have eloped?" LPN # 1 stated "(Resident # 5)." LPN # 1 was asked, ""Was he at risk for elopement before he eloped?" LPN # 1 stated, "Yes." LPN # 1 was asked, "Did he have exit seeking behaviors?" LPN # 1 stated, "Demanded to go outside, always roaming, was on locked unit, then general population, then to men's unit, always standing in front of doors." LPN # 1 was asked, "Were you working on 2/2/15 when (Resident # 5) eloped?" LPN # 1 stated, "Yes." LPN # 1 was asked, "When did you last see the resident prior to elopement?" LPN # 1 stated, "I had not yet seen him on my shift. I come in at 7:00 p.m." LPN # 1 was asked, "When did you discover (Resident # 5) was missing?" LPN # 1 stated, "8:55 p.m." LPN # 1 was asked, "How did you know (Resident # 5) was missing?" LPN # 1 stated, "The window was open, room was cold, resident was not in his bed. I checked the air conditioner and noticed the window open with linens there and the screen on the ground?" LPN # 1 was asked, "Did he come back while you were here?" LPN # 1 stated, "Yes at 1:50 a.m." LPN # 1 was asked, "Did you talk with (Resident # 5)?" LPN # 1 stated, "Yes." LPN # 1 was asked, "Did you ask him what happened?" LPN # 1 stated, "He said he wanted to see his mother." LPN # 1 was asked, "Did he say how he got there?" LPN # 1 stated, "Taxi." LPN # 1 was asked, "How long were you on the unit before you found he was missing?" LPN # 1 stated, "I was there while the CNA was at lunch and I was passing my meds. I was there about 30 minutes before I noticed he was missing. His door to his room was shut and that's the last room of meds. He's the last one I do because he argues." l. The (town name) Police Department Summary dated 2/2/15 documented "... Incident Type: Missing Person. Occurred From: 2/2/15 9:08 p.m. Occurred Thru: 2/3/15 1:40 a.m. On February 2nd, 2015, at 9:08 p.m. (Officer name) was dispatched to (facility address and name), in reference to a missing resident. ... Prior to officers arriving in the area, dispatch advised that (Resident # 5) was the missing resident. They further updated that he had left the facility through a window... I was taken to the 'Men's Dementia Unit' which was described by employees as a secure area. I met with (LPN # 1) and began collecting information regarding (Resident # 5) ... It should be noted that I had checked (Resident # 5's) room and noticed that there was interior lock on his window that was easily manipulated. Based on (LPN # 1's) statement (Resident # 5) had fled through the window sometime between 8:00 p.m. and the time of the call. (LPN # 1) advised she had found (Resident # 5's) window open as well as the exterior screen laying on the grass below the window ... At approximately 12:45 a.m. (Officer name) who had been assigned a grid area that included the (store name), responded to the (store name) after the (fire department) had located individuals that identified (Resident # 5) as having been in the store around 9:00 p.m. While attempting to review surveillance video to confirm (Resident # 5) had been in the store, (Officer name) located an employee that believed (Resident # 5) had left the (store name) in a taxi. The employee stated that a female customer had come across (Resident # 5) and felt sorry for him as he was trying to trade items. The unknown customer asked to the cell phone of an employee to contact a taxi for (Resident # 5), which the unknown customer paid for. (Officer name) was able to contact the taxi company identified as (name of taxi company) ... confirmed the company had picked up a male, matching (Resident # 5's) description. (Officer name) was able to speak with the driver ... who had picked up the male ... and identified (Resident # 5) via photograph ... informed (Officer name) of where he had taken (Resident # 5), which was identified as (address), Rogers. Rogers PD (police department) was contacted and requested to check the afore mentioned address. Within a few minutes, Rogers PD notified the command post that they had located (Resident # 5) at the address provided. He was taken into custody and transferred back to (facility name) ..." The Rand McNally Driving Directions and Maps documented the distance from the facility to the store where Resident # 5 took a taxi was 1.4 miles. The distance from the store to Resident # 5's mother's address in Rogers was 6.31 miles. The distance from the facility to Resident # 5's mother's house in Rogers was 6.49 miles. A Nurse's Note dated (2/3/15) documented, "Resident returns with police escort. Returned resident to same room ... starting 1 on 1 watch for resident's safety ..." m. On 2/7/15 at 11:50 a.m., RN # 1 stated she had worked in the facility for 2 years. RN # 1 was asked, "Do you know of any residents who have eloped?" RN # 1 stated, "(Resident # 5) recently." RN # 1 was asked, "Was he at risk for elopement before he eloped?" RN # 1 stated, "I can't be sure of that." RN # 1 was asked, "When you do quarterly risk assessments for elopement, what do you base your assessments on?" RN # 1 stated, "What I see, what behaviors I see." RN # 1 was asked, "Did he have any exit seeking behaviors?' RN # 1 stated, "I never saw any." Staff members were interviewed about resident ' s exit seeking behaviors prior to elopement: 1) On 2/6/15 at 2:20 p.m., CNA # 2 was asked, "Did (Resident #5) have behaviors?" CNA # 2 stated, "Yes. He tried to get out before and I took him on transport and he didn't want to stay at the foot clinic. He would ask family members if could go out with them or if they would hold it (door) open." CNA # 2 was asked, "When was this?" CNA # 2 stated, "When he was out in the general population." CNA # 2 was asked, "When did he try to get out before?" CNA # 2 stated, "He'd pushed on the front door until the alarm sounded and then he got back in." CNA # 2 was asked, "How often did you see this?" CNA # 2 stated, "Once." CNA # 2 was asked, "When?" CNA # 2 stated, "A couple of months ago." 2) On 2/6/15 at 2:32 p.m., LPN # 2 stated she had worked in the facility for 1 1/2 years. LPN # 2 was asked, "Did he (Resident #5) have behaviors?" LPN # 2 stated, "Yes." LPN # 2 was asked, "What were they?" LPN # 2 stated, "Constantly begging for money, to go outdoors and I'd have to tell him repeatedly to get away for the door. It was constant." 3) On 2/6/15 at 4:10 p.m., LPN # 3 was asked, "Did he (Resident #5) have behaviors?" LPN # 3 stated, "Yes." LPN # 3 was asked, "What were they?" LPN # 3 stated, "He was easily agitated, always talking about leaving, constant mood swings." LPN # 3 was asked, "Was he at risk for elopement before he eloped?" LPN # 3 stated, "Yes." LPN # 3 was asked, "Did he have exit seeking behaviors?" LPN # 3 stated, "Talking about leaving, when he went to appointments he would try to exit the doctor ' s office, he was always trying to exit out the back door." 4) On 2/6/15 at 4:12 p.m., CNA # 3 was asked, "Did he (Resident #5) have behaviors?" CNA # 3 stated, "... He'd stand at doors when people go in and out and tried to go out or stick his cane in the door ..." CNA # 3 was asked, "Was he at risk for elopement before he eloped?" CNA # 3 stated, "I would say yes." CNA # 3 was asked, "Did he have exit seeking behaviors?" CNA # 3 stated, "Yes, he'd go to the door, talked about going home, called people on the phone, trying to get out of here." 5) On 2/7/15 at 9:32 a.m., CNA # 5 was asked, "Did he (Resident #5) have behaviors?" CNA # 5 stated, "Yes." CNA # 5 was asked, "What were they?" CNA # 5 stated, "Constantly wanting to leave, did not want to be here." CNA # 5 was asked, "Was he at risk for elopement before he eloped?" CNA # 5 stated, "Yes." CNA # 5 was asked, "Did he have exit seeking behaviors?" CNA # 5 stated, "Followed you to doors, stood at doors, told you he wanted to leave, constantly asked family members to let him out." 6) On 2/7/15 at 10:30 a.m., CNA # 9 was asked, "Did he (Resident #5) have behaviors?" CNA # 9 stated, "Yes." CNA # 9 was asked, "What were they?" CNA # 9 stated, "Wanting to go out to smoke every 5 minutes, argued with other resident, said I want to get out." CNA # 9 was asked, "Was he at risk for elopement before he eloped?" CNA # 9 stated, "Yes." CNA # 9 was asked, "Did he have exit seeking behaviors?" CNA # 9 stated, "Saying he wanted to get out, stood by door taking on phone trying to get rides." CNA # 9 was asked, "Did he ever try to open or exit the windows?" CNA # 9 stated, "I saw him in (room number) trying to open the screw lock with a coke can. I went and told the nurse." CNA # 9 was asked, "When was this?" CNA # 9 stated, "A couple of months ago when he was on the unit. Then they took him off. He's been in and out of the unit. Later he opened the window to smoke in his room." CNA # 9 was asked, "Were you working on 2/2/15 when (Resident # 5) eloped?" CNA # 9 stated, "Yes." CNA # 9 was asked, "From the time report you clocked out for lunch at 8:32 p.m., does that sound right?" CNA # 9 stated, "Yes." CNA # 9 was asked, "Did you see (Resident # 5) before you went to lunch?" CNA # 9 stated, "Yes, he was in the TV room, drinking a soda and watching TV. That was about 8:10 p.m. and he was the only one waiting to smoke. I told him I haven't been to lunch yet, so if the nurse doesn't take you to smoke I will when I get back. Then he went to his room. When the nurse showed up on the men's unit I left for lunch." CNA # 9 was asked, "What time is smoke time?" CNA # 9 stated "8:30 p.m." 7) On 2/7/15 at 12:03 p.m., LPN # 5 was asked, "Did he (Resident #5) have behaviors?" LPN # 5 stated, "Yes." LPN # 5 was asked, "What were they?" LPN # 5 stated, "... wandered the hall, tried to learn codes to get off the unit and out of the facility ..." LPN # 5 was asked, "Was he at risk for elopement before he eloped?" LPN # 5 stated, "Yes." LPN # 5 was asked, "Did he have exit seeking behaviors?" LPN # 5 stated, "Tried to follow people out of doors, tried to get codes to go out, tried to get family members to let him out." n. The Elopement Risk Assessment, that was in the elopement book, dated 2/2/15 and signed by LPN #1 documented, "... 4. Has the resident demonstrated exit seeking behaviors? Yes ... 6. Does the resident have a history of elopement? Yes ... Yes to Number 4 or 6 is automatically determined AT RISK. Resident is determined at risk for elopement? Yes..." The care plan updated 2/3/15 documented, "2/3/15 Elopement on 2/2/15 ... Resident found at mother's house in Rogers placed on 1:1 upon return to facility at 1:45 a.m. Transferred to ER (emergency room ) for psych placement." o. On 2/4/15 at 11:05 a.m., the Administrator stated, "(Resident # 5) eloped Monday 2/2/15 out his window." On 2/4/15 at 11:27 a.m., the Maintenance Supervisor entered room (Resident # 5's) room. The Maintenance Supervisor stated, "There was a stop on this window, the resident was able to unsecure it." The room had a single sliding glass window that opened from the left to the right. (Window measurements: Open window width = 33 inches, open window height = 53.5 inches, floor to window sill on inside = 30.5 inches, window sill to ground = 35 inches). The Administrator was asked, "What has been done to ensure this does not happen again?" The Administrator stated "Updated every ones elopement assessments." On 2/4/15 at 12:25 p.m., the Administrator stated, "(Resident # 5) was gone from the facility for 4 to 5 hours. It was less than 30 minutes since someone had seen him. He had said he was going to bed. The nurse went to give him meds and he was gone. I was notified around 9:00 p.m. Found at mother's asleep. Police found him. Police got back at 1:35 a.m. Remained 1:1 until transferred to the hospital." p. On 2/6/15 at 10:40 a.m., the window in room (Resident #5 ' s room) had a sliding window lock in place. The sliding window lock was approximately 1 inch wide with a square shape. The bottom of the lock had an opening that allowed it to be slid in or out of place over the window raised slide track edge when in place. The lock was held in place by a screw which had a flat rounded end that was approximately 3/8 inches wide preventing the window from being opened. On 2/7/14 at 12:15 p.m., the Maintenance Supervisor was asked, "(Resident # 5) eloped from (Resident #5 ' s room number) correct?" The Maintenance Supervisor stated, "Yes." The Maintenance Supervisor was asked, "Do you know when you last checked that window stop?" The Maintenance Supervisor stated, "It was the day he was moved there the last time (also documented in the resident's medical record) on 1/31/15. (Administrator) told me to check it because (Resident # 5) might try to get out. I went back there when they were moving his clothes and getting his room set up. I grabbed hold of it and made sure it was firmly in place and not loose." The Maintenance Supervisor was asked, "Were you called to come in 2/2/15, when (Resident # 5) eloped?" The Maintenance Supervisor stated, "Yes." The Maintenance Supervisor was asked, "Was the stop in place?" The Maintenance Supervisor stated, "No and it was not to be found and I even looked for it outside." The Maintenance Supervisor was asked, "Did any staff report to you that the resident was trying to open or had opened the screw stop and opened the window?" The Maintenance Supervisor stated, "No." q. On 2/8/15 at 9:40 a.m., the Director of Nursing (DON) and Administrator were asked, "Did he (Resident #5) have behaviors?" The DON stated, "Agitated, upset when he couldn't smoke, wanted to go to assisted living and not to have a guardian, had physical behaviors toward other residents." The Administrator stated, "Annoying, most of his behaviors were just annoying. He always asked if he could go but he wasn't an elopement risk." The DON and Administrator were asked, "Was he at risk for elopement?" The Administrator stated, "Per the assessment tool he was not and to my knowledge had no history of elopement and no exit seeking behavior." The Administrator and DON were asked, "Who reviews the information regarding taking or accepting residents that is sent before the resident is accepted?" The Administrator stated, "I review the financial and the DON reviews the clinical." The DON was asked, "Did you see the documentation sent to you from his previous facility that documented the resident had exit seeking behaviors?" The DON stated, "I can't recall. 10/3/14 was my hire date and on 10/6/14 when the resident was admitted I cleaned my office." The DON was asked, "Why was the resident placed on the secure men's unit?" The DON stated, "Because (previous facility name) orders said may live on secure unit so that's why he was there." The DON and Administrator were asked, "How did the resident get off the secure unit on 10/16/14 to thru the double doors/exit door at the business office?" The Administrator stated, "We moved him out to the unit on 10/14/14." The Administrator and DON were asked, "Why?" The Administrator stated, "His behaviors were worse on the unit. We were trying to find the best place for him. We moved him back to the unit on 10/16/14." The Administrator was asked, "On 11/18/14 the resident was in room (room number) behind the nurses station, etc. per the nurses notes. What was he doing off the secure unit?" The Administrator stated, "I decided he could come off the unit with supervision and once he was calm we stopped the constant 1:1 when he was off the unit. He was not 1:1 on 11/18/14." The Administrator and DON were asked, "On 12/9/14 at 5:10 p.m., the nurses notes documented the resident was smoking in his room, what position was the window in?" The Administrator stated, "I couldn't tell you." The Administrator and DON were asked, "The Nurses Notes documented the window was opened all the way. Did you know his window was opened?" The Administrator stated, "No, but I do now." The DON stated, "Now that I think back, she (charge nurse) did tell me he did open the window and it was fixed." The DON was asked, "Fixed how?" The DON stated, "I assume they called (Maintenance Supervisor)." The DON and Administrator were asked, "Did you do anything different with his windows after this?" The DON stated, "No, just fixed it." The DON and Administrator were asked, "The resident eloped on 2/2/15 out of a window?" The DON and Administrator stated, "Yes." The DON and Administrator were asked, "What did you do after the elopement to prevent a reoccurrence for (Resident # 5) or other residents at risk for elopement?" The Administrator stated, "1:1 supervision with (Resident # 5). We checked the windows on the men's and women's unit for screw stops. We did an in-service on elopement drills and reassessed all residents in the building for elopement risk." The Administrator was asked, "Prior to the elopement were the window stops checked at any interval or frequency?" The Administrator stated, "No." The Administrator was asked, "Did you check all the window stops in the facility after the elopement since you have residents at risk for elopement on the open units?" The Administrator stated, "No, we just did spot check with other surveyors on 2/4/15. (Maintenance Supervisor) might have. Did you ask him?" 3. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 12/23/14 documented the resident scored 3 (0 - 7 indicates severe impairment) on the BIMS; was understood and usually understands; had no wandering behavior and ambulated with supervision. a. The Admission-Data Collection Form dated 6/4/14 documented, "... Elopement Risk Assessment... 4. Has the resident demonstrated exit seeking behavior? Yes ... 6. Does the resident have a history of elopement? (Blank) ... (Yes to number 4 or 6 is automatically determined to be AT RISK)...Resident is determined at risk for elopement ..." This form was not signed. The Care Plan dated 6/19/14, with a review date of 12/30/14 documented, "Resident is ... an elopement risk/wanderer ..." There were no interventions specified. On 2/7/15 at 11:30 a.m., LPN # 4 was asked, "Do you know of any residents who have eloped?" LPN # 4 stated, " ... (Resident # 7) went out the door once about 6 months ago..." On 2/8/15 at 8:50 a.m., the DON and Administrator were asked to review the Admission Data Collection form dated 6/4/14 for (Resident #7). The DON and Administrator were asked, "For question # 4, has the resident demonstrated exit seeking behaviors, what is the answer?" The DON stated, "Yes." The DON was asked, "Is the resident at risk for elopement, what is the answer?" The DON stated, "Yes." The DON was asked, "Question 6, does the resident have a history of elopement, what is the answer?" The DON stated, "It's not answered." The DON was asked, "Is the resident at risk for elopement, what is the answer?" The DON stated, "Yes." The DON was asked, "What is on the care plan for elopement?" The DON stated, "Nothing." The DON was asked, "Can you find any other quarterly assessments since 6/4/14?" The DON stated, "It may be in a folder in the doctor's office to be filed. I'll look." The DON was asked, "Is the resident an elopement risk?" The DON stated, "She wanders but I'm not sure she's an elopement risk." The DON was asked, "When I talked with your staff they told me she eloped about 6 months ago, so is she an elopement risk?" The DON stated "Yes." The DON was asked, "Should she be care planned with interventions to minimize the risk for elopement?" The DON stated, "Yes." b. The Nursing Assistant Care Plan (not dated) documented, "Wanders." The Care Plan did not document the resident was at risk for elopement. c. The Elopement Risk Assessment, located in the elopement book dated 2/2/15 and signed by LPN #1 documented, "... 4. Has the resident demonstrated exit seeking behaviors? Yes ... 6. Does the resident have a history of elopement? Yes ... Yes to Number 4 or 6 is automatically determined AT RISK. Resident is determined at risk for elopement? Yes... Report all residents at risk to the Director of Nursing and on the twenty-four hour report." d. As of 2/7/15 at 4:15 p.m., there was no Elopement Risk Care Plan in the resident's medical record or in the elopement book for review. The January and February 2015 Behavior Monthly Flow sheet did not include monitoring for wandering or exit seeking behaviors. e. On 2/6

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure Cardiopulmonary Resuscitation was continued without interruption to provide basic life support while awaiting emergency medical service assistance for 1 (Resident #6) case-mix resident who was a Full Code. The failed practice resulted in past Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Resident #6 who was without a pulse or respirations and required cardiopulmonary resuscitation. The facility was informed of the Past Immediate Jeopardy on [DATE] at 3:45 p.m. This failed practice had the potential to cause more than minimal harm for 12 residents who were a full code, according to a list provided by the Administrator on [DATE] at 5:45 pm. The findings are: Resident #6 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 8 (,[DATE] indicates moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS); had an additional active [DIAGNOSES REDACTED]. a. A DNR (Do Not Resuscitate) / CPR (Cardiopulmonary Resuscitation) Instructions form that was copied from the resident's record on [DATE] at 3:15 pm documented, "Resident's Name (Resident #6) ...I WANT CPR I want cardiopulmonary resuscitation to be provided in the event I have a cardiac or respiratory arrest ...Legal Representative (Daughter) [DATE]..." b. Nurse's Notes entries dated [DATE] documented: "2235 (10:35 p.m.) called to room by CNA (Certified Nursing Assistant). Resident had collapsed during transfer to toilet. B/M (bowel movement) noted on resident and toilet. Appears to be a vagal response. Transferred resident (with) (oxygen) intact to shower room. Resident alert but not verbal..." "2239 (10:39 p.m.) Resident not alert, not responding to verbal or painful stimuli. Transferred back to room. V/S (vital signs) difficult to obtain. Resp (respirations) (at) ,[DATE]. (oxygen) (saturation) (at) 90%. Increased (oxygen) to 5 L (liters) per N/C (nasal cannula). Unable to get response (with) painful stimulation." "2240 (10:40 p.m.) (no) (vital signs). (no) (respirations) noted. CPR initiated (at) this time. Chest compression by this nurse, Ambu bag (respirations) by CNA. Call placed to 911 by 2nd nurse on duty. "2245 (10:45 p.m.) per protocol in facility nurse info sheet CP (chest compressions) stopped (at) this time. (no respirations), (no) carotid pulse, (no) L/S (lung sounds). Pupils pinpoint no reaction bilat (bilaterally)." "2247 (10:47 p.m.) Paramedic / Amb (ambulance) staff arrived (with) CPR initiated (at) this time by them..." c. An OLTC (Office of Long Term Care) Witness Statement Form dated [DATE] documented, "...Witness Full Name (Director of Nursing (DON)) Job Title DON ...I received phone call from nurse (Licensed Practical Nurse (LPN) #3) last night just before 2300 (11:30 p.m.). Informed me that res. (resident) (Resident #6) had coded, CPR was started then stopped just prior to emergency medical personnel entering res. (resident) room, states that he had stopped CPR because other nurse had read what she had said was policy for stopping CPR. States res has left facility and is on his way to hosp (hospital). States EMT's (Emergency Medical Technicians) restarted CPR (after) entering room..." d. An OLTC Witness Statement Form from CNA #1 documented, "...Date: [DATE] Time: 9:00 a.m. Witnessed Full Name: (CNA #1) ...Nurse (LPN #4) came in the room and stated that 'If certain signs were visible that he could stop CPR.' States Nurse (LPN #3) did stop CPR, paramedics came and restarted CPR." e. An OLTC Witness Statement Form documented, "Date: [DATE] Time: 1500 (3:00 pm) Witness Full Name: (LPN #3) ...Call to me by CNA of need to return to shower room. Upon entering shower room, resident is unresponsive to verbal command unresponsive to painful stimuli. O2 (oxygen) gauge placed on (right) index finger (with) noted O2 sat (saturation) (at) 91% pulse unsteady (at) 62. Assisted CNA to transfer resident to own room ...Requested 2nd nurse to call 911 to prep (prepare) for transfer to hosp. When assisting CNA to return resident to bed noted single gasp of air then (no) resp. Weak / thready apical pulse noted ...unable to obtain B/P (blood pressure), (no) resp noted, CPR initiated by me ...After several more minutes 2nd nurse entered room to inform me that 911 was called and transport was in route. Cont (continued) C/P (chest compressions) and rescue breathing r/t (related to) fact that resident (with) Full Code status. After several more minutes 2nd nurse re-entered room (with) corporate protocol book in hand. She reported to me that CPR may be stopped according to protocol if these s/s (signs and symptoms) are accurate. It was stated to me that (no) carotid pulse, (no) noted breathing, (no) V/S (vital signs) noted that CPR may be stopped. Informed 2nd nurse that I was unaware of this policy. Cont. C/P (at) this time. I did not have my reading glasses (with) me (at) this time so I asked 2nd nurse to read list again. Repeat to me, 'CPR may be stopped if above mentioned s/s (signs and symptoms) were present.' Stopped C/P at this time. (no) carotid pulse noted, (no) femoral pulse noted, (no) breath or L/S (lung sounds) noted. Reported this to 2nd nurse (at) this time CPR was stopped. Exited resident room to retrieve eye glasses to read protocol for myself however paramedics were arriving on scene. Reported to them of resident condition (at) this time. Paramedics entered room and restarted CPR (at) that time ...Paramedics report to me of (no) L/S other than mechanical however made the statement that pt (patient) has not been down long enough to determine survivability and transfer to hospital would continue..." f. On [DATE] at 12:30 p.m., the Administrator was asked when CPR could be stopped. She stated, "CPR can be stopped after it has been initiated only when you have immediate relief from someone." g. On [DATE] at 12:34 p.m., the Administrator provided a copy of Act 718 of 2009; [DATE] Protocol For Withholding CPR and stated, "This is what (LPN #4) was reading from." The form documented the following: "ACT 718 of 2009; [DATE] The nursing facility shall document the presence of these listed conditions in the resident's record. PROTOCOL FOR WITHHOLDING CPR... Licensed nurses employed by nursing facilities may withhold cardiopulmonary resuscitation from residents of the facility, regardless of the presence of a Do Not Resuscitate (DNR) order, when: 1) The death of the resident was unwitnessed; and 2) The body evidences clear and unmistakable dependent lividity*; or 3) The body evidences clear and unmistakable rigor**. *"Dependent lividity" means clear demarcation of pooled blood within the body. **"Rigor" means that major joints such as the jaw, shoulders, elbows, hips, or knees are immovable... THE FOLLOWING CONDITIONS ALSO MUST BE PRESENT FOR WITHHOLDING CPR: 1) Respirations are absent for at least thirty (30) seconds. 2) Carotid pulse is absent for at least thirty (30) seconds. 3) Lung sounds auscultated by stethoscope bilaterally are absent for at least thirty (30) seconds; and 4) Both pupils, if accessible are nonreactive to light." h. On [DATE] at 12:37 p.m., Nursing Consultant #1 was asked if she had reviewed the resident's record. She stated, "Yes." She was then asked if CPR should have been stopped. She stated, "No, it should not have been stopped." i. On [DATE] at 12:43 p.m., CNA #1 was asked if she was present the night Resident #6 coded. She stated, "Yes." CNA #1 was asked who initiated the CPR on the resident. She stated, "(LPN #3) was the one who started it." She was asked if there was any time after the CPR was initiated that it was stopped. The CNA stated, "Yes, (LPN #3) did stop CPR. I remember him reading in the book that (LPN #4) had brought in there. Him and (LPN #4) were still in the room and he read it and told me to stop the rescue breathing." CNA #1 was asked if there was any time LPN #3 left the room to retrieve his glasses. She stated, "Yes he did." When asked how long he was gone she stated, "I don't remember, I don't think too long. The EMT's (Emergency Medical Technicians) came and restarted the CPR." j. On [DATE] at 1:15 p.m., Nursing Consultant #1 stated, "We have a Self Imposed Immediate Jeopardy Process. Upon completion of this one we identified there was a problem with the code being stopped. Then the self improvement plan was initiated, education to staff, audits to check that code status was correct for all residents, all licensed nurses to have certification in CPR. This was QA'd (reveiwed by the Quality Assurance team) and all codes were reviewed for the last quarter and no other resident had coded in the facility. There was a code approximately 2 to 3 weeks ago and it ran smoothly. There was no interruption until the EMS here and immediately took over." k. The facility took the following actions to remove the Immediate Jeopardy, correct the failed practices prior to the survey entrance date and lower the scope and severity to a "G": 1) An Employee List report of Nurses and CNAs dated [DATE] included the names of 13 Licensed Practical Nurses (LPN) currently employed at the facility. The list documented that 5 of the LPNs had CPR certification on file. On [DATE], the Administrator provided copies of CPR certification cards for all of the facility's nurses. 2) Level of Care Reports dated [DATE] that listed all residents and documented, "Care Plan Audit" and "Code Status Audit." By the name of each resident was their code status, whether there was a physician order [REDACTED]. 3) The Policies and Procedures for Cardiopulonary Resuscitation CPR) documented, "Effective Date: ,[DATE] ([DATE]) ...POLICY: Cardiopulmonary Resuscitation (CPR) is initiated to support the ventilation and circulation function until: aid arrives and the resident is placed on advanced life support systems; he/she is stimulated to function on his/her own; and/or he/she is pronounced dead ...Procedure: ...CPR is continued until life support systems are available, or it may be discontinued if: A. The resident responds. B.The physician orders [REDACTED]. 4) An untitled form that documented, "...If Resident was a full code: Staff started and continued CPR until 911 services arrived? NO ...If CPR was called to cease, was it the ER (emergency room ) physician or 911 staff who made the call to stop? NO..." Nursing Consultant #1 stated, "This (untitled form) is our self imposed immediate jeopardy for residents who are a full code." An Inservice Education Report dated [DATE] that documented, "... Inservice Conducted By: (DON) Topic: Nurses please remember that once you start CPR you cannot stop until emergency personnel arrive and take over." Attached to this was a sign-in sheet that had been signed by 8 nurses. An Inservice Education Report dated [DATE] that documented, "...Inservice Conducted By: (DON) ...Topic: Once CPR is started on a res. (resident) it can not be stopped until emergency personnel arrive." This was signed by LPN #3. 5) An Ad Hoc (Self Identified Areas, Self Imposed IJ) Meeting Minutes: Privileged Work form that documented, "...Issues ...CPR was started on a (resident) and stopped prior to emergency personnel arrived. Resolution ...1) One on one inservice (with) nurse running code. 2) In-serviced other nurses that once CPR is started it cannot be stopped until emergency personnel arrives to take over. 3) Removed protocol for withholding CPR guidelines from nursing info (information) binder. 4) Although this (resident) chart did reflect that he was a full code a chart audit was done to ensure all code status info was in front of charts, has been careplanned and is on CNA care plans. 5) Social Services noted residents code status. 6) Scheduled CPR certification class for [DATE] so all nurses will be certified. 7) Restock crash cart."

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure physician orders for wound care were consistently implemented to promote wound healing for 1 (Resident #1) of 5 (Residents #1 through #5) case mix residents who had pressure ulcers. This failed practice resulted in a pattern of actual harm for Resident #1 who experienced avoidable deterioration of pressure ulcers resulting in infection and hospitalization ; and had the potential to cause more than minimal harm for 5 residents who had pressure ulcers, according to a list provided by the Administrator on 10/4/13 at 5:45 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 9/20/13 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status, had total dependence for activities of daily living (ADL), was at risk for the development of pressure ulcers and had no pressure ulcers. a. The resident's Admission Care Plan last updated 9/25/13 documented, "...(Problem) Skin Care / Pressure Ulcers ...Goal: Prevent / Heal skin breakdown / pressure ulcers ...Tx (treatment) ordered: (blank). Turn every 2 hours. Preventative devices: (blank). Weekly skin audit by licensed nurse. 9/18/13 Clean wound L (left) ischial ...left (lower) buttock (and) coccyx (with) 1/4 st (strength) Dakins, pack wound (with) Dakins moistened 4 (by) 4 or [MEDICATION NAME] gauze (and) cover (with) foam drsg (dressing). (Change) TID (three times a day) (and) prn (as needed) until resolved or (change) per WCC (Wound Care Clinic). ...(Problem) Infection Alert ...goal: Infection will resolve without complication. Site: coccyx. Vital signs q (every) shift. Antibiotics as ordered... Monitor for S&S (signs and symptoms) of new infection. 9/25/13 Clean wounds on (right) ischial (hip area) ...Left lower buttock (and) coccyx (with) 1/4 st (strength) Dakins, pack (with) Dakins moistened 4 by 4 gauze and cover (with) Abd (abdominal) pad, then tape TID until resolved..." b. Records obtained from the Wound Clinic on 10/3/13 documented the resident was first admitted to the Wound Clinic on 1/21/13 for evaluation of Pressure Ulcers. The wound clinic notes for the first visit documented, "Wound #1 Right Buttocks ...pre-debridement: 6.4 x 5 x 2.4 with partial eschar, minimal slough, large amount necrotic tissue, with odor and moderate to heavy yellow drainage. Post-debridement measurements: 6.4 x 5 x 4 cm (centimeters). Wound #2: Coccyx: pre-debridement: 3.8 x 3.2 x 2.3 with partial eschar, minimal slough, large amount necrotic tissue, with odor and moderate to heavy yellow drainage. Post-debridement measurements: 3.8 x 3.2 x 4 cm. ...Wound care as follows: Wet to dry with 1/4 strength Dakin's twice daily..." A Physician order dated 1/22/13 documented, "...TX (treatment): Buttock wound 1, 2 - Wet / Dry with [MEDICATION NAME] soaked in 1/4 strength Dakins twice daily everyday. Cover with 4 (by) 4s, Abdominal pad (and) [MEDICATION NAME] tape. - twice daily everyday." c. The resident's Wound Clinic visit notes dated 2/5/13 documented, "...Right buttocks... Pre-debridement measurements: ...2/5/2013: 6 x 5 x 3.5 cm... Eschar: partial. Slough: minimal... Necrotic tissue: large... Wound base color: red / yellow. Granulation tissue... No. Wound Odor: yes. Drainage amount Moderate to heavy. Drainage color: yellow... Indication for debridement: abnormal wound edge, abnormal wound base... I performed sharp, selective, excisional debridement... Post-debridement measurements: date 2/5/2013: 6 x 5 x 3.5 cm... Coccyx... Pre-debridement measurements: ...2/5/2013: 4.5 x 3.5 x 3 cm... Eschar: partial. Slough: minimal ...Necrotic tissue: large ...Wound base color: red / yellow. Granulation tissue... No ...Wound Odor: yes ... Drainage amount: moderate to heavy. Drainage color: yellow ... Indication for debridement: abnormal wound edge, abnormal wound base... I performed sharp, selective, excisional debridement... Post-debridement measurements: ...4.5 x 3.5 x 3 cm... Assessment... Wound / ulcer #1: Pressure ulcer of the right buttocks, stage 3 - improved. Wound / ulcer #2: Pressure ulcer of the coccyx, stage 3 - improved... I feel a [MEDICAL CONDITION] to divert stool from this area will help this wound to heal and prevent recurrent ulceration. She still has a large amount of necrotic tissue that would do better with an operative debridement. I will refer to general surgery for [REDACTED]. We can then use a VAC when wound are clean... Wound care... Wet to dry with 1/4 strength Dakin's twice daily..." d. The resident's hospital Discharge Summary dated 2/20/13 documented, "...admitted : 02/18/2013. discharged : 02/20/2013... Operations: On 02/18/2013 sigmoid colon resection with end [MEDICAL CONDITION] and Hartmann pouch, debridement of right ischial and sacral decubitus ulcers (stage IV)..." e. The wound clinic notes dated 2/26/13 documented, "...Chief Complaint: Pressure ulcers of buttocks... Location: Right buttock and over coccyx... Necrotic tissue extends to muscle layer... Current treatment is: KCl [DEVICE] Pressure ulcer ...right buttock and over coccyx ...Necrotic tissue extends to muscle layer... The following changes have occurred: [MEDICAL CONDITION] and wound debridement... Wound #1... right buttocks / ischium ...Eschar: partial. Sough: minimal. Necrotic tissue: large... Wound base color: Red / yellow... Granulation tissue... No. ...bone exposed. Wound Odor: yes. Drainage amount: moderate to heavy... I performed sharp, selective, excisional debridement... Wound #2... Coccyx... Eschar: partial. Sough: minimal. Necrotic tissue: large... Wound base color: red / yellow. Granulation tissue... No... yes bone visible. Wound Odor: yes. Drainage amount: Moderate to heavy. Drainage color: yellow... I performed sharp, selective, excisional debridement... Assessment... right buttocks, now stage 4 previously stage 3-improved... coccyx, now stage 4 previously stage 3-improved. Bothe of these ulcers have undergone operative debridement down to bone and are much cleaner... spoke with (name of physician) by phone he is concerned about possible bone infection. He will order bone scan. Wound care as follows: Wet to dry with 1/4 strength Dakin's twice daily..." The resident's Physician Orders / Patient Instructions form dated 2/26/13 and signed by the wound clinic physician documented, "...Outpatient ADM (admission): 2/26/13... (Right) hip measures 6 cm x 5 cm by 3.4 cm... Coccyx 4.1 cm x 3.5 cm x 2.7 cm... Wet to dry with 1/4 (strength) Dakin's twice a day..." f. A Related encounter note from the resident's visit to the Wound Clinic on 3/7/13 documented, "...called (Nursing Home) and spoke with floor nurse (LPN #2) and gave verbal orders. They are to continue with WTD (wet to dry) dressing to wound #1 - right gluteal twice daily with 1/4 dakins. They are to start KCl (Potassium Chloride) wound vac (vacuum) to wound #2 - coccyx on Friday (3/8/13). (LPN #2) verbalized an understanding. Orders were also sent with aid that was with patient today..." A Physician order dated 3/8/13 documented, "Continue wound care order: Change canister weekly and dressing every (Monday)-(Wednesday)-(Friday) (and) PRN (as needed). Notify MD (medical doctor) for any problems - PRN..." g. The Wound Clinic Progress and Procedure note dated 3/14/13 documented, "Pressure Ulcers ...Right buttock and over coccyx... Necrotic tissue extended to muscle layer, (physician) debrided both wounds in OR (operating room) and now both extend to bone. Wounds are now much cleaner... Current treatment is: Wet to dry with 1/4 strength Dakin's for right buttock, KCl wound VAC for coccyx wound... Wound #1... Right buttocks / ischium... Post-debridement measurements... 4.8 x 5 x 3 cm... Wound #2... Coccyx... Pre-debridement measurement... 4 x 2.5 x 1.2 cm... Post-debridement measurements... 4 x 2.5 x 1.2 cm... Wound care as follows: #1 (right buttock) KCl VAC black foam 125 continuous three times per week. Wound / ulcer #2 (coccyx): Wet to dry with 1/4 strength Dakin's twice daily..." A related encounter note from the resident's visit to the Wound Clinic on 3/14/13 documented, "...Wound vac dressing is on to the coccyx's wound, however, it wet and not intact and (Nursing Home) did not send the wound vac machine with patient. I called and spoke to her floor nurse (LPN #2) and she stated patient had a shower today and she did not have time to hook vac up after patients bath. Instructed (LPN #2) that I would place a wet to dry dressing today and she would need to place the wound vac back on today or tomorrow. Also instructed (LPN #2) that vac dressing needs to be changed on the day patient has her shower as the dressing is getting wet underneath and they need to be using more black foam (had a very small piece of black foam in wound today). Instructed her to fill the wound with black foam..." h. A Physician order dated 4/1/13 documented, "Clean Wound on Coccyx with 1/4 St (strength) Dakins, Cut Silver Foam to fit wound, cover exposed bone with [MEDICATION NAME], Apply transparent dressing, connect to suction tubing & to vac (vacccum) - once daily. Specific days of the week: Mon (Monday), Wed (Wednesday), Fri (Friday)." A Physician order dated 4/1/13 documented, "Clean wound on right hip with 1/4 St Dakins, Cut Silver Foam and Pack wound, cover with clear transparent dressing, connect suction tubing to wound Vac at 150 mm/hg (millimeters mercury) cont (continue)- once daily specific days of the week: Mon, Wed, Fri..." i. The resident's Wound Clinic visit notes dated 4/17/13 documented, "...Wound #1 Right buttocks / ischium: Pre-debridement measurements: ... 4.5 x 2.8 x 4 cm, partial eschar, minimal slough, heavy necrotic tissue, with odor and moderate to heavy yellow drainage. Post-debridement measurements: 4.5 x 2.8 x 4 cm. Wound #2: Coccyx: pre-debridement: 5 x 3 x 3.5 with partial eschar, minimal slough, heavy necrotic tissue, with odor and moderate to heavy yellow drainage. Post-debridement measurements: 5 x 3 x 3.5 cm. ... Assessment/Diagnosis: [REDACTED]. Wound / ulcer #2: Pressure ulcer of the coccyx, now stage 4 previously stage 3-improved. ...Wound Care as follows: #1, 2: Resume KCL Vac black foam 125 three times per week. Wet to dry with 1/4 strength Dakin's three times per day until VAC can be resumed..." A related encounter note from the resident's visit to the Wound Clinic on 4/17/13 documented, "... (Nursing Home) did not send the wound vac or the supplies. Both wounds are now clean and ready for wound vac to be placed back on. Called (Nursing Home) and spoke with the floor nurse, (LPN #5) and wound care nurse (RN #1) and orders were given to place wound vac on today and to start patient on oral [MEDICATION NAME] 500 mg TID (three times a day) for 10 days. Orders were faxed and sent with patient." A Physician Order dated 4/29/2013 documented, "Wet to dry drsg with dakins on coccyx / (right) gluteal bid (twice a day) until silver foam is here - twice daily everyday." j. The Wound Clinic visit notes dated 5/8/13 documented, "...Current treatment is: KCL Wound VAC with silver foam 125 three times per week. Previous treatment: Wet to dry with 1/4 strength Dakin's for right buttock, KCL wound VAC for coccyx wound. ...Wound #1 Right buttocks / ischium: Pre-debridement measurements: ...4 x 2.2 x 2.5 cm, partial eschar, small slough, no necrotic tissue, red granulation tissue, bone exposed, with odor and moderate to heavy yellow drainage. Post-debridement measurements: 4 x 2.2 x 2.5 cm. Wound #2: Coccyx: pre-debridement: 3.2 x 3.8 x 1.7 with partial eschar, minimal slough, heavy necrotic tissue, red granulation tissue, with bone visible, with odor and moderate to heavy yellow drainage. Post-debridement measurements: 3.2 x 3.8 x 1.7 cm. ...Resume: KCL VAC black foam 125 three times per week..." k. The wound clinic Related encounter Follow Up note dated 5/29/13 documented, "...Wound #1 right hip stage 4 (pressure ulcer)... Actual area debrided / post debridement... 4.9 cm x 4.1 cm x 1.4 cm... Status of wound post debridement - improved 4.9 cm x 4.1 cm x 1.5 cm... 3.4 cm undermining 9-1 o'clock 3.0 tunnel at 4 o'clock... Wound #2 Coccyx stage 4 (pressure ulcer)... Actual area debrided / post debridement... 4.0 cm x 1.3 cm x 2.5 cm. Status of wound post debridement - improved 4.0 x 1.3 x 2.6 cm (5 cm tunnel at 12 o'clock)... NPWT (negative pressure wound therapy) (with) silver foam applied (with) Y connector / [MEDICATION NAME] over exposed bone of coccyx wound... Findings - coccyx and (right) gluteal / hip stage 4 (pressure ulcers) with (positive) response, clean and with good granulation..." l. The Wound Clinic Related encounter notes dated 6/26/13 documented, "...#1 Right gluteal: Pre-debridement measurements: 4.2 cm x 3.5 cm x 1.0 cm Tunnel (at) 12 o'clock - 3.0 cm area ...Wound bed with small slough, [MEDICATION NAME] and Biofilm. no foul odor, moderate drainage, serosanguinous. There is exposed underlying bone- coccyx wound only periwound integrity: intact. ...Post-debridement measurements: 4.2 cm x 3.5 cm x 1.1. #2 Coccyx Pre-debridement measurements: 3.5 x 4.0 x 2.0 cm Tunnel at 12 o'clock 4.2 cm area ...Wound bed with small slough, [MEDICATION NAME], and Biofilm. Drainage, serosanguinous. No foul odor, moderate drainage. There is exposed underlying bone - coccyx wound only periwound integrity: intact. Post-debridement measurements: 3.5 cm x 4 cm x 2.1 cm. ...silver foam applied (with) Y connector / [MEDICATION NAME] over exposed bone of coccyx wound..." m. A letter dated 7/3/13 and received from Wound Clinic RN #1 on 10/3/13 documented, "Concerns about (Resident #1). Black foam was noted in wound instead of silver. Order specifically states silver foam. Please contact (wound vac company) and order larger silver foam kits. To adequately pack wound and bridge wound one small kits is not sufficient. Date on dressing was 6/30/13. I'm assuming it needed to be changed on Sunday instead of Monday due to broken seal but just want to make sure it will be changed again on Friday. My biggest concern is that when dressing removed it was noted that the black foam from the coccyx wound was not in contact with the bridge and therefore has not been getting any negative pressure to coccyx wound since that change on 6/30/13. The order states to use [MEDICATION NAME] over bone in coccyx wound and that continually is not found when we remove dressing. We did not receive updated med list which must be sent with patient for medication reconciliation to each wound clinic apt (appointment). We also need you to send both the dressing kit and canister to each appt. Luckily we had an extra canister here today but we will need you to send two next week to replace the one we used. I understand that (Resident #1) can communicate with us and that sending a staff member with her causes a hardship for your staffing but I do believe that having a staff member come with her to these visits is in the patient best interest as it provides better communication related to wound care, supplies and safety for the patient. We will not take direction from the transport staff about wound care. Thank you in advance for your cooperation." The letter was signed by the Clinical Coordinator of the Wound Clinic, (Wound Clinic RN #2). On 10/3/13 at 1:15 p.m., Wound Clinic RN #1 stated, "This is the only letter sent (to the Nursing Home) and it was sent with the transporter of the resident, who said he gave it to the Administrator. It was also faxed. I spoke with (RN #3), the DON who said she didn't get it." n. The Wound Clinic Related encounter notes dated 7/10/13 documented, "...Note: NH (Nursing Home) has not been applying [MEDICATION NAME] beneath vac, and inappropriately placed when seen here for evaluation, despite letter to their admin. (administrator), staff. Will hold NPWT for now ...#1 Right gluteal: ...Pre-debridement measurements: 3 cm x 4 cm x 1.0 cm ...Undermining (at) 12 = 2.7 cm ...Post-debridement measurements: 3 cm x 4 cm x 1.1 cm. ...#2 coccyx: Pre-debridement measurements: 2.5 cm x 2.5 cm x 2.7 cm ... Post-debridement measurements: 2.5 cm x 2.5 cm x 2.8 cm. Plan: ... Wound care as ordered - dakin's / kerlix, 3 (times) daily. ...Refer ...for consideration for surgical flap..." o. A related encounter note from the resident's visit to the Wound Clinic on 7/22/13 documented, "...KCL wound vac was in place but dressing was loose with no seal noted. Canister was completely full with alarm of blockage noted. No new canister was sent for this (patient) so I was not able to check the seal with the new dressing. Also noted that there was no [MEDICATION NAME] covering the bone on the coccyx bone. This has been an ongoing issue. We have called multiple times and sent several letters requesting [MEDICATION NAME] get placed over the bone, however, on every visit no [MEDICATION NAME] is noted. Will call again and give verbal orders over the phone as well as send a copy of the orders." p. The Wound Clinic visit notes dated 7/29/13 documented, "...Note: NH (Nursing Home) has not been applying [MEDICATION NAME] beneath vac, and inappropriately placed when seen here for evaluation, despite letter to their admin. (administrator), staff. ...Wound #1 Right gluteal: ...Pre-debridement measurements: 4.0 cm x 3.5 cm x 1.6 cm area = 14.0 cm sq (square) Undermining (at) 12 = 3.3 cm ...Post-debridement measurements: 4 cm x 3.5 cm x 1.7 cm. ...#2 coccyx: Pre-debridement measurements: 2.0 cm x 2.5 cm x 1.5 cm area = 5 cm sq ...Post-debridement measurements: 2.0 cm x 2.5 cm x 1.5 cm 5.0 sq cm. ... #3 L (left) gluteal ...Pre-debridement measurements: 3.0 x 3.5 x 1.6, with eschar, slough: large amt (amount) ...Post-debridement measurements: 3.0 x 3.5 x 1.6 cm. ...Imp (Impression): 1. Coccyx stage 4 pressure ulcers with pos (positive) culture and worse today. 2. right gluteal / hip stage 4 pressure with neg (negative) response to wound vac. 3. New (left) gluteal stage 3 ulcer that was necrotic..." Plan: ... Wound care as ordered - dakin's and 4 x 4 and hold wound vac. ...". A related encounter note from the resident's visit to the Wound Clinic on 7/29/13 documented, "...Wound vac did not have a seal and after vac dressing was removed it was noted that the coccyx wound did not have [MEDICATION NAME] placed over the bone. Also noted a new stage 3 pressure wound to her left gluteal area that was black and very soft and was only covered with wound vac tape. ...Wound vac dc (discontinued) at this time and all wounds dressed with 1/4 st dakins moist gauze and abd pad. New orders called to (LPN #6) at (Nursing Home) to stop the vac and verbal order for antibiotics were also given. Ordered with also sent with transport for copy to be given to nurse." The resident's July 2013 Treatment Administration Record (TAR) documented, "Cleanse wound site per protocol (and) provide wet to dry drsg. (Change) (with) Dakins solution, pack wound BID (twice a day)." There were no administration times documented on the TAR and no order date on the TAR. Nurses' initials on 7/12/13 and 7/14/13 documented the dressing change was administered. The resident's July 2013 Treatment Administration Record (TAR) documented, "Clean wound on coccyx with 1/4 St Dakins, cut silver foam to fit wound cover exposed bone with [MEDICATION NAME], apply transparent dressing connect to suction tubing (and) to Vac. Start date: 4/1/13 1x/day once daily every Mon Wed Fri." The TAR documented the treatment administration time as 9:00 a.m. There were no initials to document the resident's treatment was done on 7/1/13, 7/3/13, 7/5/13, 7/10/13 and 7/17/13. The TAR documented the order was changed on 7/29/13, but there was no 7/29/13 order documented on the TAR. The resident's July 2013 Treatment Administration Record (TAR) documented, "Clean wound on right hip with 1/4 st Dakins. Cut silver foam and pack wound, cover with clear transparent dressing connect suction tubing to wound VAC at 150 mm/hg cont. Start date: 4/1/13 1 (time) /day once daily every Mon, Wed, Fri." There were no initials to document the resident's treatment was done on 7/1/13, 7/3/13, 7/5/13, 7/10/13, 7/17/13 and 7/19/13. The TAR documented the order was changed on 7/29/13, but there was no 7/29/13 order documented on the TAR. A Physician order dated 7/30/13 documented, "(Change) drsg times to daily..." q. The Wound Clinic visit notes dated 8/12/13 documented, "...IMP (impression) - 1. Coccyx stage 4 Pressure ulcers with pos (positive) culture and improved today after hosp (hospital) stay. 2. Right gluteal/hip stage 4 Pressure ulcers with pos response 3. New (left) gluteal stage 3 ulcer that was necrotic, but improving. ...2. Wound Care as ordered - Dakins and 4 (by) 4 and hold [DEVICE]" r. The hospital After Visit Summary documented, "...8/26/2013 Admission... discharged ... 8/29/13... [DIAGNOSES REDACTED]. The hospital History and Physical dated 8/26/13 documented, "...Consultation... for evaluation and therapy of severe SSTI (skin and soft tissue infection) on buttocks... history of MS ([MEDICAL CONDITION]) for [AGE] years that has progressed until she is a functional quadriplegic. She has had problems with pressures ulcers in the past, but over the past year they have become very severe... recently admitted by (physician) for debridement and released. She was seen by (wound physician) at wound therapy where further debridement was performed, but noted progressive [MEDICAL CONDITION], and tissue open to the bone. She is on IV antibiotics at the NH where she resided... 2 very large buttock [MEDICAL CONDITION], distal lesion with some necrosis, neither with significant purulent drainage, she did have some surrounding [DIAGNOSES REDACTED] noted. Wounds both open to the level of bone... Plan: ...Severely handicapped MS patient with 2 very large decubitus on her buttocks, and in the sacral regions, extending to the bone... probably osteo[DIAGNOSES REDACTED]... check MRI (Magnetic resonance imaging)... begin [MEDICATION NAME] / [MEDICATION NAME] empirically." The Physician Discharge Summary dated 8/29/13 documented, "...Hospital Course: admitted with history of severely handicapped MS patient with 2 very large decubitus on her buttocks, and in the sacral regions, extending to the bone. Osteo[DIAGNOSES REDACTED] and [DIAGNOSES REDACTED] noted on MRI..." s. The nursing home admission orders [MEDICATION NAME] 1250 mg (milligrams) IV (intravenous) Q (every) 12 (hours). Diagnosis: [REDACTED]. On 10/3/13 at 4:50 p.m., the Director of Nursing (DON) stated, "There is no August TAR." t. The Wound Clinic visit notes dated 9/12/13 documented, "Patient here for follow up wound care. Patient reports her dressings are being changed, on average, every other day, and sometimes with longer times in between... RN also informed the charge nurse that the patients dressing changes were reportedly not being done daily as ordered. She states she was not aware of this and would report it to her DON. She confirmed that she had received the wound care orders faxed to them and faxed today." u. The Wound Clinic visit notes dated 9/16/13 documented, "...Wound #1: Right gluteal: ...Pre-debridement measurements: 5.0 x 3.5 x 0.3 cm. Post-debridement: 5.0 x 3.5 x 0.4 cm. ...#2: coccyx: ...Pre-debridement measurements: 2.5 x 2.2 x 0.9 cm. ...Post: 2.5 x 2.2 x 1.0 cm. ...#3 L gluteal: Pre-measurements: 3.5 x 1.8 x 1.0 cm. ...Post: ...3.5 x 1.8 x 1.1 cm. Imp: 1. Coccyx stage 4 Pressure ulcers with pos culture and improved today after hosp stay. 2. Right gluteal/hip stage 4 Pressure ulcers with pos response 3. New (left) gluteal stage 3 ulcer that was necrotic, but improving. ...2. Wound Care as ordered - Dakins and 4x4 and hold [DEVICE]" Further notes related to the visit on 9/16/13 at the Wound Clinic documented, "Patient seen today for follow up apt (appointment). Noted date on her wound dressings was dated 9/14/13, 1020 a.m. ...This was also noted last week which, at that time (Wound Clinic RN #3) called (Nursing Home) and spoke with the charge nurse and voiced her concerns about ...that her wound dressings have not been being changed three times per (Physician #1) orders. The nurse said she will look in to it and has been waiting on her DON. I called twice today, trying to speak with the DON, (RN #3), left two messages, (flagged urgent), with no call back. Per patient, she stated her wound dressings get changed every other day. This has been ongoing issue with this patient since her admission to (Wound Clinic) care. One nurse from this office calls (Nursing Home) each week due to orders not being followed. We have spoken to the DON, the Charge Nurses, the floor nurses, and the Administrator. I have spoken to the Medical Director over (Nursing Home), (Physician #2) regarding our concerns. (Physician #1) has also spoken with (Physician #2) last week regarding her care as well..." v. The Wound Clinic visit notes dated 9/23/13 documented, "...Wound #1: Right gluteal: ...Character of wound / ulcer pre-debridement: Improved, clean, bone exposed. Pre-debridement measurements: 4.8 x 3.5 x 0.6 cm. ...Character of wound / ulcer post debridement: improved, granulation tissue. ...Post-debridement: 4.8 x 3.5 x 0.7 cm. ...#2: coccyx: ...Character of wound / ulcer pre-debridement: Improved. Pre-debridement measurements: 2.0 x 1.7 x 1.0 cm. ...Character of wound / ulcer post debridement: Improved, granulation tissue. Post-debridement measurements: 2.0 x 1.7 x 1.1 cm. ...#3 (left) gluteal: Character of wound / ulcer pre-debridement: new. Pre-measurements: 3.5 x 2.7 x 1.2 cm. ...Post: ...3.5 x 2.7 x 1.4 cm. Imp: 1. Coccyx stage 4 ulcers with pos culture and improved today after hosp stay. 2. Right gluteal / hip stage 4 Pressure ulcers with pos response. 3. New (left) gluteal stage 3 ulcer that was necrotic, but improving. ...2. Wound Care as ordered - Dakins and 4 (by) 4 and hold [DEVICE]" A physician order dated 9/25/13 documented, "Clean wounds on (Right) ischial (hip area), (left) buttock and coccyx (with) 1/4 st (strength) Dakins, pack (with) Dakins moistened 4 (by) 4, Cover with Abd pad, then tape TID until healed..." w. The resident's September 2013 TAR documented, "Clean wounds on Ischial (hip area), left lower buttock (and) coccyx (with) 1/4 st Dakins, pack (with) Dakins moistened 4x4s - kerlix/gauze (and) cover (with) foam drsg ...until resolved or (changed) from WCC, 9/18/13." The TAR was initialed on the 7:00 a.m. to 3:00 p.m. shift on 9/18/13 through 9/23/13, on the 3:00 p.m. to 11:00 p.m. shift on 9/18/13 through 9/20/13 and from 9/23/13 through 9/24/13. There were no initials for the 11:00 p.m. to 7:00 a.m. shift. The order was discontinued on 9/24/13. The resident's September 2013 TAR documented, "Clean wounds (right) ischial (hip area), left lower buttock and coccyx (with) 1/4 st Dakins, pack (with) dakins moistened 4 (by) 4 gauze (and) cover (with) ABD pad, tape TID until healed." The treatment administration record documented the administration times as the 7:00 a.m. to 3:00 p.m. shift, the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift. There were no initials on the TAR on 9/25/13 for the 7:00 a.m. to 3:00 p.m. or 3:00 p.m. to 11:00 p.m. shift. There were no initials on 9/26/13 for the 11:00 p.m. to 7:00 a.m. shift. There were no initials on 9/29/13 and 9/30/13 for the 3:00 p.m. to 11:00 p.m. shift or for the 11:00 p.m. to 7:00 a.m. shift. x. On 10/3/13 at 3:04 p.m., Registered Nurse (RN) #1 set up supplies to perform wound dressing changes for the resident. The RN left the room to verify what solution to use. 1) At 3:35 p.m., RN #1 began the dressing changes. The dressings on the resident's right ischial area, the coccyx and the left ischial area were all dated 10/2/13 and had initials on them. The wound dressings were treated with the solutions and the supplies the doctor had ordered. All three of the wounds had granulation tissue, although the wound on the left gluteal area did have some slough also. 2) At 4:50 p.m., RN #1 was asked who had put the initials on the dressings she had removed, when she changed them at 3:35 p.m. She stated, "(RN #2); she worked last night." 3) At 6:52 p.m., RN #2 was asked if she had changed the resident's dressing at 9:00 p.m. last night (10/2/13). She stated, "Yes, but I didn't document it because the Treatment book was not on the treatment cart. I told (RN #1) this morning that I did. ...I changed the dressings (on the wounds) after 9:00 p.m. and before midnight last night." The RN was asked if she had changed the dressing this morning since her initials were on the dressings at 3:35 p.m. She stated, "No." y. On 10/3/13 at 4:15 p.m., the resident was sitting up in the bed. The resident was asked if the dressings on her wounds were changed as ordered. The resident stated, "Maybe twice a day sometimes." z. As of 10/3/13 at 4:50 p.m., the October 2013 TAR documented, "Clean Wounds on right ischeal (hip area) left lower buttocks and coccyx with 1/4 St Dakins, pack with Dakins Moistened 4x4 gauze and cover with ABD pad then tape, TID until resolved. Start date: 9/26/13, 3 (times) / day three times daily everyday." The dressing changes were documented by nurse's initials on 10/1/13 at 9:00 a.m. and 2:00 p.m. and on 10/2/13 at 9:00 a.m. and 2:00 p.m. There were no initials to document the resident's dressing changes were done on 10/1/13 at 9:00 p.m., on 10/2/13 at 9:00 p.m. and on 10/3/13 at 9:00 a.m. and 2:00 p.m. The October TAR further documented, "Clean open area on left groin with dakins 1/4 st, apply tao (Triple Antibiotic Ointment), cover abd, change q day until resolved. Start date: 10/2/13, 1 (time) / day once daily everyday." The TAR documented administration time for the resident's treatment as 9:00 a.m.; there were no nurse' initials to document the resident's dressing had been changed on 10/3/13.