Every finding on record at Protection Valley Manor

The facility reported a census of 41 residents with one resident sampled for accident hazards. Based on observation, interview, and record review, the facility failed to ensure operational door locks, alarms, and supervision for cognitively impaired Resident (R) 1, a resident at high risk for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) to prevent an elopement. On 06/04/25 at 07:29 PM, R1 exited the facility without staff knowledge or supervision through an unlocked front door. The door was typically locked but the door lock override was implemented, leaving the door unsecured and the alarm disabled. An off-duty staff member observed R1 walking outside, approximately two blocks away from the facility. Staff assisted R1 into the staff member's car and returned the resident to the facility at 07:42 PM. R1 was uninjured. The facility's failure to ensure door locks and alarms were implemented and failure to provide supervision to prevent R1 from eloping through an unlocked door, placed R1 in immediate jeopardy. Findings included: - A review of the Electronic Health Record (EHR) documented R1 had diagnoses that included dementia (a progressive mental disorder characterized by failing memory and confusion) with psychotic (a gross impairment perception) disturbance. R1's 06/03/25 Entry Minimum Data Set (MDS) documented R1 admitted to the facility from her home on [DATE]. R1's 06/09/25 Admission MDS documented a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. The assessment documented R1 had hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) with wandering behavior one-to-three days during the seven-day observation period. The MDS documented R1 was independent with locomotion and was not at risk for falls. The 06/09/25 Behavioral Symptoms Care Area Assessment (CAA) documented R1 was at high risk for elopement and would often have her belongings packed. R1's paper Elopement Risk Assessment dated 06/03/25 at 03:00 PM recorded a score of 22 which indicated R1 was at high risk for elopement. R1's initial Care Plan lacked interventions related to her high risk for elopement on 06/04/25. On 06/05/25 (after the incident) R1's Care Plan was updated to reflect R1's elopement risk related to impaired safety awareness. The following interventions were initiated on 06/05/25 and revised on 06/06/25: Staff would assess R1 for fall risk. Staff would distract R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Staff would identify patterns of R1's wandering and intervene as appropriate. Staff would monitor R1 for fatigue and weakness. Staff would monitor R1's location with visual checks every 30 minutes and document wandering and attempted diversions in the behavior log. Staff would provide structured activities such as toileting, walking inside and outside, utilize orientation strategies such as signs, pictures, and memory boxes. R1 had a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) placed on her right ankle (revised 06/09/25). R1's EHR documented under the Progress Note tab documented the following: On 06/05/25 at 11:52 AM, Administrative Nurse D documented a late entry for 06/03/25 at 03:15 PM, which recorded staff placed a WanderGuard on R1's right wrist as she declined to have the device placed around her ankle. On 06/03/25 at 03:26 PM, Administrative Nurse D documented R1 was admitted to the facility from a private residence where she had lived for the last five years. R1 was accompanied by family and her family reported R1 had been leaving her apartment to go looking for jobs, find family members, and purchase items but R1 had difficulty remembering where businesses were and would ask for directions from other local businesses. On 06/03/25 at 09:10 PM, Licensed Nurse (LN) H documented R1 had not exhibited exit-seeking behaviors. On 06/04/25 at 10:00 PM, LN H documented that on 06/04/25 at approximately 07:45 PM, an (unnamed) off-duty staff member called the facility to report R1 was walking down the road. The note documented the staff member returned R1 to the facility. LN H assessed R1 who was without injury; R1 was not wearing a WanderGuard. The note documented LN H placed a new WanderGuard on R1's ankle and initiated 30-minute visual checks. LN H's Witness Statement dated 06/06/25 documented on 06/04/25 at approximately 07:45 PM, an (unnamed) off-duty staff member called the facility to report a resident was walking along the road to the west of the facility. The staff member brought R1 back to the facility and R1 was not wearing the WanderGuard. R1 was dressed appropriately for the weather. R1 was without injury and a new WanderGuard was secured to R1's ankle. Certified Nurse Aide (CNA) M's Witness Statement dated 06/06/25 documented LN G came back with an (unnamed) resident at approximately 06:45 PM and the front door alarm sounded. LN H went to the front door and shut off the door alarm. CNA M noted she set up her snack cart for the evening snack rounds and offered R1 a snack between 07:15 PM and 07:20 PM. CNA M documented she finished snack rounds at approximately 07:45 PM and was in the office when the phone rang and then LN H asked CNA M to go check on R1. R1 was not located in her room or bathroom and CNA M alerted LN H. CNA M noted she then went and checked the front door, and the keypad light was green (which indicated the door was unlocked and unsecured). CNA M noted she entered the override code to lock the door, and the keypad light turned red (which indicated the door was locked and secured) and sometime after that, a staff member brought R1 back to the facility. Dietary BB's Witness Statement dated 06/06/25 documented on 06/04/25 at 07:42 PM she was driving in the community with her children and noticed someone walking along the road who looked like a resident in the facility. Dietary BB documented the individual was wearing a red long-sleeve shirt with jeans. Dietary BB was able to positively identify the individual as R1 and initiated contact with the resident. R1 told Dietary BB that she was unsure how she left the facility other than she just walked out. Dietary BB asked R1 to accompany her back to the facility and Dietary BB drove R1 back to the facility in her private vehicle. R1 and Dietary BB were greeted by the facility staff at approximately 07:50 PM. During an observation on 07/01/25 at 08:15 AM, R1 sat in a recliner in her room and appeared to be reading a book. Further observation revealed a WanderGuard on R1's right ankle. During an observation on 07/01/25 at 11:35 AM, R1 walked independently in the hallway. She wore a WanderGuard on her right ankle. On 07/01/25 at 09:33 AM, Administrative Nurse F said that upon admission, the facility initiates the care plan but does not use the baseline care plan template. Administrative Nurse F said the full care plan was initiated within the first 48 hours and included the required basic items; the full care plan was completed within 14 days of when the admission MDS was completed. Administrative Nurse F confirmed R1's Care Plan lacked interventions related to elopement risk until 06/05/25. Administrative Nurse F confirmed that on 06/03/25 at approximately 03:00 PM, staff completed an elopement risk assessment on R1, who scored 22, which indicated a high elopement risk. Administrative Nurse F stated the facility's elopement book at the nursing station was updated at that time and Administrative Nurse D put a WanderGuard on R1's right wrist. Administrative Nurse F said somehow R1 was able to remove the WanderGuard from her wrist and staff later discovered it under R1's bed. On 07/01/25 at 11:32 AM, CNA M confirmed the information documented in her Witness Statement and stated on 06/04/25 at approximately 07:45 PM she checked the front door, and the keypad light was green (which indicated the door was unlocked and unsecured). CNA M noted she entered the override code to lock the door, and the keypad light turned red (which indicated the door was locked and secured) and sometime after that, a staff member brought R1 back to the facility. CNA M said that prior to R1's elopement on 06/04/25, she was unaware of the facility processes in place to check for WanderGuard placement. CNA M confirmed since R1's elopement on 06/04/25, education has been provided related to elopement prevention and revealed staff visually check on R1 every 30 minutes which included visually checking the placement of the WanderGuard on R1's ankle and documenting in the log. On 07/01/25 at 11:37 AM, Certified Medication Aide (CMA) S revealed she was working on 06/04/25, the day that R1 eloped, but she was not in the building at the time of the elopement because the incident occurred after her shift had ended. CMA S said that she was unaware of any facility processes in place to check for WanderGuard placement, prior to the elopement. CMA S confirmed since the incident, staff visually checked the resident's location every 30 minutes, checked the placement of the WanderGuard on R1's ankle and documented it in the log. During an interview on 07/01/25 at 11:45 AM, Dietary BB said she had nothing to add to the Witness Statement and confirmed since R1's elopement on 06/04/25, education was provided related to elopement prevention and steps to follow in the event of an elopement. On 07/01/25 at 11:57 AM, Administrative Nurse D revealed she placed a WanderGuard on R1's wrist on 06/03/25 at approximately 03:15 PM but it was not tight enough on her wrist as she was able to remove it sometime during the day on 06/04/25. R1 was the first resident in a long time to have an elopement risk high enough to warrant WanderGuard placement/use. Administrative Nurse D revealed prior to the elopement on 06/04/25 Administrative Nurse D or Administrative Nurse E checked the placement and function of the WanderGuard system on the doors once per month. Administrative Nurse D or Administrative Nurse E checked the function of the WanderGuard device worn by the resident(s) every morning, and this process was performed by the day shift charge nurse on the weekends or whenever administrative nurses were not in the facility. Administrative Nurse D said on the morning of 06/04/25, she checked the placement and function of R1's WanderGuard and it was in place and functioning appropriately. Administrative Nurse D stated the biggest factor that allowed R1's elopement to occur was the door override code (to disable the door locks) was known by all staff, and a staff member had inadvertently left the front doors unlocked and unsecured. On 07/01/25 at 12:00 PM, Administrative Staff A stated the facility's investigation revealed one of the contributing factors that allowed R1 to elope on 06/04/25 was that a staff member had entered the door override code and did not reset the lock before leaving the area. This allowed R1 to leave the building without the permission, knowledge, or supervision of staff. Administrative Staff A said this was an unacceptable risk, and the door override code had been changed and provided only to Administrative Staff A, Administrative Nurse D, and Maintenance W. The facility's Elopement Risk Policy policy, dated 04/06/17 documented the facility would provide a safe environment for residents at risk for wandering. Every newly admitted resident would be assessed by a licensed nurse to determine the risk for wandering. Residents identified at risk for wandering/elopement must have an individualized plan of care. The policy documented alarmed doors would not be disengaged except for repair or emergency evacuation and required continual and constant observation by a staff member. On 07/01/25 at 02:30 pm, Administrative Staff A and Administrative Nurse D received a copy of the Immediate Jeopardy [IJ] Template and were informed of the IJ for R1. The facility's corrective measures, fully completed on 06/10/25, included the following, which were verified by the surveyor on-site during the investigation. 1. On 06/05/25 at approximately 07:45 PM, a WanderGuard was placed on R1's right ankle and staff implemented visual checks of R1 and R1's WanderGuard every 30 minutes and documented checks in a log. 2. On 06/04/25 at 08:00 PM, a new override code procedure was implemented, and the override code was changed, the only staff who know the override code are Administrative Staff A, Administrative Nurse D, and Maintenance W. The new override code was placed in a sealed bright pink envelope with the emergency evacuation log in the nurses' station. 3. On 06/04/25 at an unknown time, all facility staff were educated related to elopement prevention and procedures to follow in the event of an elopement, completed on 06/10/25. 4. On 06/06/25 an ad hoc Quality Assurance Process Improvement meeting was held. 5. On 06/06/25 the Wander Guard System and Elopement Risk . policies were updated All corrections were completed prior to the onsite survey; therefore, the deficient practice was cited as past noncompliance at a scope and severity of J.

The facility reported a census of 40 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility. Findings included: - On 03/03/25 at 10:44 AM during an initial tour of the main kitchen, refrigerator and dry food storage areas with Dietary Manager DD, the following areas of concern were observed: One unsealed/open box of outshine popsicles with an expiration date of 5/31/24 in snack freezer. One ten pound-bag of hamburger dethawing dated 2/23/24 in walk in freezer. On 03/03/25 at 10:36 AM, an interview with Dietary Manager DD revealed she expected staff to label, and date opened food items. Dietary Manager DD confrimed the concerns. The facility policy For Snack Refrigerator dated 06/12/2023 revealed Resident's personal items will be properly labeled and dated, will be monitored and disposed of as need be. The facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility.

The facility identified a census of 40 residents. The sample included 12 residents. The facility identified residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure the EBP residents were identified for staff and visitors. Further the facility failed to ensure staff used appropriate hand hygiene between glove changes and to follow infections for trends. These deficient practices placed the residents at risk for infectious diseases. Findings included: - On 03/03/25 at 11:02 AM, observation of Certified Nurse Aide (CNA) M and CNA O provided care for Resident (R) 8. CNA M changed gloves from dirty to clean and did not perform hand hygiene. CNA O changed gloves following cares with no hand hygiene between. On 03/03/25 at 11:17 AM, CNA M revealed she should have performed hand hygiene between glove change. CNA M confirmed she had not performed hand hygiene when changed her gloves from dirty to clean. On 03/05/24 at 09:03 AM, CNA O revealed she should have performed hand hygiene with glove change. CNA O confirmed she had not performed hand hygiene between change of gloves. On 03/05/25 at 08:10 AM, tour of the facility revealed three residents on EBP with no signs on their doors. On 03/05/25 at 09:03 AM, CNA O revealed the residents on EBP would have a sign on their door and there was a list in the breakroom on the bulletin board. On 03/05/25 at 09:05 AM CNA P shows that there was a list of residents with EBP in the breakroom on the bulletin board, she confirmed there would also be a sign on their doors. On 03/05/25 at 09:45 AM, Licensed Nurse (LN) I confirmed each resident with EBP should have a sign on their door and supplies in their rooms. LN I revealed there was a list of EBP residents in the breakroom. On 03/05/25 at 08:27 AM, Administrative Nurse D revealed every resident with EBP should have a sign on their door and supplies in their room. She confirmed some residents without signs on their doors that were on the EBP list. The facility's Enhanced Barrier Precautions (EBP) policy dated 10/04/24 documented that the policy of the facility was to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms, that employ targeted gown and glove use during high contact resident care activities. The facility failed to ensure staff followed infection prevention protocols and place signs on EBP resident room doors to advise staff and visitors of precautions. This deficient practice placed the residents at risk for infection.

The facility reported a census of 42 residents. Based on observation, interview, and record review, the facility failed to provide sanitary food preparation, storage and serving to prevent the spread of food borne illness to the residents of the facility. Findings included: - The initial environmental tour of the kitchen, on [DATE] at 08:02 AM with Dietary Staff BB, revealed the following items/areas of concerns: 1. The ice machine lacked a two-inch air gap between the drainpipe and the municipal discharge drain. 2. There were 12 stacks of dishes, each approximately 16 inches high, stored on the bottom shelf of a wire rack, approximately eight to 10 inches from the floor, with eating surfaces exposed. The stacks of dishes lacked a covering to protect them from dust or other contamination. 3. There were 14 bowls of assorted dry breakfast cereals portioned out for the next breakfast service, stacked on top of each other, however, the bowls lacked barriers between the food and the bowls. 4. A box of breakfast cereal, open to air with an open date of [DATE]. 5. A box of breakfast cereal with an open date of [DATE]. The initial environmental tour of the dry storage, on [DATE] at 08:02 AM with Dietary Staff BB revealed a box of minute tapioca, open to air with an open date of [DATE]. On [DATE] at 08:02 AM, Dietary Staff BB stated that dry breakfast cereals that have been opened have a two-week expiration date per policy. Additionally stated that all opened items should be resealed or placed in an air-tight container/packaging. The facility's [DATE] Policy & Procedure For Expired Foods documented that expired foods will not be served to residents or staff and all expired foods will be disposed of. Further documents that all dietary staff were responsible to look at food items expiration dates and discard if necessary. The facility's [DATE] Food Storage Policy/Procedure documents that plastic containers with tight-fitting covers must be used for storing cereals. The facility failed to store, prepare, and serve food under sanitary conditions for the residents in the facility. This created the potential for the spread of food borne illnesses to the residents of the facility.

The facility census totaled 42 residents with 12 residents in the sample that included three for falls. Based on observation, interview, and record review, the facility failed to review and revise the care plans for three residents, Resident (R)7, R 22, and R 32 related to fall prevention interventions. Findings included: - R7's Electronic Health Record (EHR) documented diagnoses that included psychosis (any major mental disorder characterized by a gross impairment in reality testing) and major depressive disorder (major mood disorder). The 12/27/22 Annual Minimum Data Set (MDS) documented R7 had a Brief Interview for Mental Status (BIMS) of 12, indicating moderately impaired cognition. R7 had two or more non-injury falls, and one minor injury fall since the prior assessment. The 01/24/23, the Significant Change MDS documented a BIMS score of six, indicating severe cognitive impairment. R7 had two of more non-injury falls since the prior assessment. The 01/24/23 Falls Care Area Assessment (CAA), documented R7 had several falls in the last couple of months. R7 experienced increased weakness and cognitive changes that contributed to the falls. The 02/10/23 Care Plan documented R7 was at risk for injuries related to multiple falls and lacked an updated intervention related to the falls experienced by R7 on 12/11/22 and 01/08/23. Review of Nurse Notes dated 12/11/22, documented R7 had a fall due to weakness, R7 stated her knees had become weak, she lowered herself to the floor, and denied hitting her head. Review of the Fall Investigation for fall on 12/11/22, documented R7 had fallen, and the intervention was to remind R7 (who had moderate cognitive impairment) to use her call light and wait for staff to arrive. Review of the Nurse Notes dated 01/08/23, documented R7 had a fall and she had stated she did not hit her head. Review of the Fall Investigation for fall on 01/08/23, documented R7 had a fall, and the intervention was for staff to ambulate with R7, when she was walking alone. On 03/15/23 at 09:04 AM, R7 sat in her wheelchair, that was being propelled by staff. R 7 stated she was unable to walk by herself anymore. On 03/16/23 at 09:54 AM, Certified Nurse Aide (CNA) E reported R7 had falls, but had not received any injuries, as far as he knew. CNA E stated he had worked there long enough he knew the residents care very well. On 03/16/23 at 10:28 AM, Licensed Nurse (LN) D revealed the care plan should be updated whenever there was an incident. On 02/02/23 at 09:55 AM, Administrative Nurse B revealed that staff should change/revise the care plan with each fall. All the nurses and administration staff could change the resident's care plans. Administrative Nurse B stated the interdisciplinary team (IDT brings together knowledge from different health care disciplines) team met weekly for care plan interventions. She confirmed R7's falls on 12/11/22 and 01/08/23 lacked interventions to prevent further falls on the care plan. The facilities undated Care Plan Revisions policy, documented staff were to revise the care plan after every fall. To include specific instructions based on the causal factors identified at the time of the occurrence and during the fall investigatory process to prevent or reduce the possibility for recurrence of a fall. The facility failed to revise the care plan with interventions after this resident fell on [DATE] and 01/08/23, to prevent further possible falls. - R22's Electronic Health Record (EHR) documented diagnoses that included hallucinations (sensing things while awake that appear to be real, but the mind created) and legal blindness. The 03/25/22 Admission Minimum Data Set (MDS) documented R22 had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R22 had one minor injury fall since the prior assessment. The 12/26/22, the Quarterly MDS documented a BIMS score of 12, indicating moderate cognitive impairment. R22 had two or more non-injury falls, and one minor injury fall since the prior assessment. The 03/25/22 Falls Care Area Assessment (CAA), documented R22 had a history of falls at her previous home. R22 felt that her low blood glucose may contribute to her falls. The 01/25/23 Care Plan documented R22 was at risk for falls due to her blindness and lacked an updated intervention related to the fall experienced by R22 on 12/09/22. Review of the Nurse Notes dated 12/09/22, documented R22 had a fall and she had stated she did not hit her head. Review of the Fall Investigation for fall on 12/09/22, documented R22 had a fall, and the intervention was to educate family to inform staff when leaving the resident alone. On 03/15/23 at 08:21 AM, R22 sat in her recliner, had a blanket over her legs, and the call light was within reach. On 03/15/23 at 01:03 PM, Certified Nurse Aide (CNA) F reported R22 had falls, but had not received any injuries, as far as he knew. CNA F stated he believed R22 just had needed time to get acquainted with the facility, and using the call light, she had falls at the beginning of her stay but not recently. On 03/16/23 at 10:28 AM, Licensed Nurse (LN) D revealed the care plan should be updated whenever there was an incident. On 02/02/23 at 09:55 AM, Administrative Nurse B revealed that staff should change/revise the care plan with each fall. All the nurses and administration staff could change the resident's care plans. Administrative Nurse B stated the interdisciplinary team (IDT brings together knowledge from different health care disciplines) team met weekly for care plan interventions. She confirmed R7's falls on 12/11/22 and 01/08/23 lacked interventions to prevent further falls on the care plan. The facilities undated Care Plan Revisions policy, documented staff were to revise the care plan after every fall. To include specific instructions based on the causal factors identified at the time of the occurrence and during the fall investigatory process to prevent or reduce the possibility for recurrence of a fall. The facility failed to revise the care plan with interventions after this resident fell on [DATE], to prevent further possible falls. 46960 - Review of R32's diagnoses from the Electronic Health Record (EHR) documented schizophrenia (a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), tremor (a neurological disorder where fine motor control has degraded which causes shaking movements in one or more parts of the body, most often the arms/legs) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). Review of R32's annual Minimum Data Set (MDS), dated [DATE], documented a brief interview for mental status (BIMS) of 14, indicating intact cognition. R32 was independent with ambulation (walking) and transfers. R32 had no falls during the lookback period. Review of R32's quarterly MDS, dated [DATE], documented a BIMS of 15, indicating intact cognition. R32 was independent with ambulation and transfers. R32 had one fall with minor injury. Review of the Falls Care Area Assessment (CAA) dated 08/10/22, revealed that the resident was at increased risk for falls and injury due to medication he was taking, recent fall was due to tripping, and had not been affected by environmental factors. Review of the resident's assessments revealed fall risk screenings, dated: On 02/04/22, with a score of 65, indicating the resident was a high risk for falling. On 05/08/22, with a score of 55, indicating the resident was a high risk for falling. On 11/07/22, with a score of 55, indicating the resident was a high risk for falling. On 02/06/23, with a score of 65, indicating the resident was a high risk for falling. Review of fall reports revealed the following: R32 had a witnessed fall on 07/20/22. The root cause analysis determined that the resident tripped on the wheel of the front wheeled walker (FWW). The immediate intervention was to encourage the resident to remain seated but lacked an intervention on the care plan. R32 had an unwitnessed fall on 09/29/22. The root cause analysis determined that the resident attempted to go to the bathroom without utilizing the call light system to ask for help. The immediate intervention was to instruct the resident to use the call light for assistance, but the care plan lacked an intervention, On 03/15/23 at 04:00 PM, Licensed Nurse (LN) C reported that after a fall, the nurse on duty would come up with an intervention related to that fall to prevent future falls. The IDT (interdisciplinary team) would later update the care plan. On 03/16/23 at 09:14 AM, Administrative Nurse B reported the licensed nurse on duty at the time of a fall would implement an immediate intervention until the IDT could meet to create a permanent intervention and update the resident's care plan to prevent further falls. IDT should meet weekly. The facility's undated Care Plan Revisions policy, documented staff were to revise the care plan after every fall, and to include specific instructions based on the causal factors identified at the time of the occurrence and during the fall investigatory process to prevent or reduce the possibility for recurrence of a fall. The facility failed to review and revise this resident's care plan related to falls.

The facility census totaled 39 residents. Based on observation, interview, and record review the facility failed to provide residents with a safe environment by the failure to secure dangerous chemicals in a locked place, inaccessible to the eight cognitively impaired, independently mobile residents living in the facility. Findings included: - Observation on 08/24/21 at 01:59 PM of the unlocked and open public bathroom, accessible to all residents, revealed a container on the counter identified as Di-Cide Ultra Wipes. Upon closer inspection, the Di-Cide Ultra Wipes container label noted to Keep Out of Reach of Children with warnings the wipes could cause severe eye injury. The online literature regarding Di-Cide Ultra Wipes noted Di-Cide Ultra is a hospital-level, one-step, ready-to-use quaternary ammonium, intermediate high-level alcohol-based disinfectant. The online Safety Data Sheet (SDS, a fact sheet developed by manufacturers describing the chemical properties of a product. Material Safety Data Sheets include brand-specific information such as physical data (solid, liquid, color, melting point, flash point, etc.), health effects, first aid, reactivity, storage, handling, disposal, personal protection and spill/leak procedures) regarding Di-Cide Ultra Towelettes noted the signs and symptoms of exposure as: Mild irritation of the eyes, nose and throat. Drowsiness, headache and incoordination may also occur. Swallowing isopropyl alcohol may cause drowsiness, unconsciousness and death. The SDS also noted the precautions in safe handling and use to Keep closed, do not handle or store near flame, heat or strong oxidants. Adequate ventilation required. Do not contaminate water, food or feed by storage and disposal. Interview on 08/24/21 at 02:05 PM Administrative Nurse A removed the chemicals and acknowledged they should not have been in the public bathroom where residents could have gotten to them. Review of the undated facility policy Control of Hazardous Chemicals revealed all substances with warning labels including keep out of reach of children will always be locked and inaccessible. The facility failed to provide residents with a safe environment by the failure to secure dangerous chemicals in a locked place, inaccessible to the eight cognitively impaired, independently mobile residents.

The facility census totaled 39 residents with 13 included in the sample. Based on interview and record review the facility failed to provide Resident (R) 6 or her representative with a bed-hold policy upon transfer to a hospital. Findings included: - Review of R6's signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The resident required extensive assistance with activities of daily living (ADL) and was non-ambulatory. The resident received as needed (PRN) pain medication for pain rated eight out of ten, and received Insulin injections antipsychotic, antidepressant and diuretic medications daily in the seven-day observation period. Review of the ADL Care Area Assessment (CAA) dated 01/05/21 revealed R6 required extensive staff assistance with her ADL. She has limitations in mobility as she is obese. She experiences episodes of pain that limit her ability to perform some ADL's. She is very fearful that she is going to fall during her transfers. Has struggled to regain strength since Covid-19. Review of the Care Plan dated 07/28/21 revealed the resident required extensive assistance with all daily cares. Review of the Nurses Progress Notes dated 06/30/21 revealed the resident's physician called this nurse to report she would be admitting the resident to the local hospital from her office for intravenous antibiotics for [CONDITION(S)]. Review of the physician visit dated 08/26/21 revealed the resident had good improvement on her left pinky finger. Res has been stable since returning from hospitalization . Review of the Electronic Health Record (EMR) dated 06/30/21 lacked evidence of a bed hold policy upon transfer to the hospital. During an interview on 08/25/21 at 11:25 AM CNA F reported the resident was recently in the hospital with an infection in her little finger on her left hand. During an interview on 08/25/21 at 03:45 PM Licensed Nurse C reported the resident was in the hospital on intravenous (IV) antibiotics for [CONDITION(S)] in her finger. The nurse reported she never sent a bed hold with a resident to the hospital, as she thought that was part of the admission stuff and did not know a bed-hold policy should be given to the responsible party when the resident went to the hospital. During an interview on 08/25/21 at0 4:00 PM Social Service staff D reported she did not know another bed hold policy was required upon hospitalization transfers, since the resident received one at the time of admission. SS D stated she had note sent any bed hold policies out with hospitalization transfers. Interview on 08/25/21 at 04:15 PM revealed Administrative Nurse A did not know the facility should give a bed hold policy to the resident or responsible party for hospitalization transfers of residents. Review of the undated facility policy Bed-Hold Policy revealed that before the facility transfers a resident to the hospital or the resident goes on therapeutic leave, the facility will provide written information to the resident and/or his representative that specifies: the duration of the state bed-hold policy during which the resident is permitted to return and resume residency in the facility: the reserve bed payment policy in the state plan; the facilities policies regarding bed-hold period, which are consistent with the law permitting the resident return. The facility failed to provide R6 or her guardian with a bed-hold policy upon transfer to a hospital.

The facility census totaled 39 residents with 13 sampled for review and all sampled residents reviewed for Minimum Data Set (MDS) completion. Based on record review and interview the facility failed to complete the required Death in The Facility MDS in a timely manner for Resident (R) 30. Findings included: - Review of the Electronic Medical Record (EMR) for R30 on [DATE] at 04:00 PM revealed R30 died on [DATE] at 09:59 AM. The MDS assessments lacked a completed Death in The Facility MDS assessment for R30. During an interview on [DATE] at 04:10 PM Administrative Nurse B reported she forgot to complete the Death in the Facility MDS assessment. Review of the RAI Manual dated [DATE] revealed when a resident death in the facility occured the facility should complete a Death in the Facility MDS within seven days of the death occurring, and transmitted no later than 14-days after the resident death. The facility failed to complete the required Death in The Facility MDS in a timely manner for R30.

The facility reported a census of 39 residents, with 13 sampled. Based on observation, interview, and record review the facility failed to update three resident's care plans in a timely manner, regarding fall interventions for Resident (R) 4 and R8, and skin issues and antibiotic use for R15. Findings Include: - Review of R4's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident was independent with no set up needed for all activities of daily living (ADL) except dressing, toilet use, and personal hygiene which required extensive assistance of one staff. R4 experienced one fall since the last assessment with no injuries or skin issues noted. The 04/13/21 Quarterly MDS documented a BIMS of 10, indicating moderately impaired cognition. R4 had two falls with no injury since the last assessment. Review of R4's Falls Care Area Assessment (CAA) dated 07/13/21 documented when R4 had a temper tantrum he would walk swiftly down the hallway looking down, without care for his safety. This put him at risk for falls. R4 slept very deeply in the chairs in the dayroom, which would put him at risk to fall out of the chair if the chair did not have arms. The 04/08/21 Care Plan for R4 documented interventions for actual falls with dates of falls to include: 04/09/21, changed out the swivel rocker in R4's room 06/27/21, ensure nonskid socks in place 07/22/21, toilet riser removed from R4's bathroom The Care Plan lacked an intervention for R4's 08/20/21 fall. Review of the EHR documented R4 fell on [DATE]. On 08/25/21 at 09:48 AM R4 sat in a chair in his doorway with staff set up to play bingo, R4 allowed and encouraged to place chips on numbers called. R4 smiled and visited with staff during the game. On 08/30/21 at 10:20 AM Certified Medication Aide (CMA) F revealed at the time of a fall whoever saw the resident first got the nurse or Director of Nursing (DON) and then went to the resident to assist in any way they could. The nurse performed the assessment and obtained vital signs (VS) and then instructed the staff of the next steps. The nurse would also perform any wound care needed. On 08/30/21 at 09:24 AM Licensed Nurse (LN) C revealed it was the nurse on duty at the time of the fall who updated intervention on the care plan. On 08/30/21 at 10:07 AM Administrative Nurse A revealed she expected the care plan to be updated timely and accurately. The undated facility Care Plan Revisions policy documented that changes in a resident's condition often require changes to the care plan . the care plan will be revised after every fall to include specific instructions to staff based on the causal factors identified at the time of the occurrence and during the fall investigatory process to prevent or reduce the possibility for recurrence of a fall. The facility failed to update R4's care plan with fall interventions after the 08/20/21 fall. - Review of R8's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was independent with no set up help needed for all activities of daily living (ADL). R8 experienced no falls since the last assessment. The 06/26/21 Quarterly MDS documented a BIMS of 10, indicating moderately impaired cognition. R8 had no falls since the last assessment. Review of R8's Falls Care Area Assessment (CAA) dated 12/26/20 documented R8 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She no longer used a walker with ambulation. She walked with a steady gait and at a safe pace at that time. The 04/15/21 Care Plan for R8 documented interventions for falls with date of fall to include: An undated intervention for staff to encourage R8 to participate in activities that promote exercise, and physical activity for strengthening and improved mobility 11/15/19, encourage R8 to rise slowly from sitting The Care Plan lacked an intervention for R8's 08/23/21 fall. Review of the EHR documented R8 fell on [DATE]. The 08/23/21 Fall Investigation Report documented R8 needed staff assistance when ambulating outside. On 08/26/21 at 09:12 AM R8 sat in her room in the recliner in a dress and a pair of nonskid socks. R8 was alert and awake and stated she was doing well. On 08/30/21 at 10:20 AM Certified Medication Aide (CMA) F revealed at the time of a fall whoever saw the resident first got the nurse or director of nursing (DON) and then went to the resident to assist in any way they could. The nurse performed the assessment and obtained vital signs (VS) and then instructed the staff of the next steps. The nurse would also perform any wound care needed. On 08/30/21 at 09:24 AM Licensed Nurse (LN) C revealed it was the nurse on duty at the time of the fall who updated interventions on the care plan. On 08/30/21 at 10:07 AM Administrative Nurse A revealed she expected the care plan to be updated timely and accurately. The undated facility Care Plan Revisions policy documented that changes in a resident's condition often require changes to the care plan . the care plan will be revised after every fall to include specific instructions to staff based on the causal factors identified at the time of the occurrence and during the fall investigatory process to prevent or reduce the possibility for recurrence of a fall. The facility failed to update R8's care plan with fall interventions after the 08/23/21 fall. - Review of R15's signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident had delusions and verbal behaviors towards staff and rejection of care identified on 1-3 days of the look back period. The resident was independent with activities of daily living (ADLs). She weighed 225 pounds with no weight change. Medications included antipsychotic antidepressant and diuretic medications received daily in the 7-day observation period. Review of the Quarterly MDS dated [DATE] revealed the resident would not answer questions to complete the BIMS. Staff answered questions with no changes noted in R15's cognition. The resident had delusions and rejection of care. She weighed 210 pounds. Medications remain the same with physician determining reduction would be clinically contraindicated on 04/22/21 Review of the Nutrition Care Area Assessment (CAA) dated 09/09/20 revealed the resident consumed 75-100% of all meals offered. She could make her own choices of what she liked at meals. She has no issues with chewing or swallowing and received diuretic (medication to promote the formation and excretion of urine) medications. She was overweight and had intakes of excessive amounts of fluid and retains fluid. She frequently refused medication. The staff were to assist her to and from meals on level of health at that mealtime. The CAA noted, at times, she will walk with the walker and other times she needed assistance with transfers into the wheelchair and locomotion to the dining table, by staff. Review of the Care Plan dated 05/15/16 revealed no current nutritional problems to include her protein drinks or weight loss. Review of the resident weights revealed: On 06/04/2021, the resident weighed 210 pounds. On 07/29/2021, the resident weighed 196.4 pounds, which is a -6.48% loss from 06/04/21. Review of the Dietary Progress Notes dated 08/26/21 revealed-Food intake/weight: The resident refused to be weighed this month. Last month her weight was 214 pounds. The resident continued to battle [CONDITION(S)] in lower extremities. Depending on her mood, she might or might not have refused to take her medication to help keep the [CONDITION(S)] off. When she refused, she had difficulty breathing. During that time, she usually asked for a protein shake for her meals. We tried to avoid her drinking a shake when she also ate the meal. She loved her high sodium foods that we tried to get her to avoid as well. Observation on 08/25/21 at 11:50 AM revealed the resident had not eaten her lunch but was drinking a protein drink. Observation on 08/30/21 at 07:50 AM revealed the resident sat in her recliner with her plate of uneaten food, on the table beside the resident Observation revealed no protein drink visible. During an interview on 08/25/21 at 11:35 AM Certified Nursing Assistant (CNA) F reported the residents percent of meal consumed, depended on her mood but when she did not eat, she usually took a protein drink. During an interview on 08/26/21 at 12:15 PM CNA G reported she took the residents lunch tray from her room. She stated the resident consumed 25% of her meal, maybe at the most. and no other nourishment During an interview on 08/25/21 at 03:54 PM Licensed Nurse C reported the resident did not like to eat and wanted protein drinks instead for meals and snacks. When she was told how expensive those were, she then just drank them for her meals. Staff offered the meal served but most of the time the resident will only take a protein drink. The resident is encouraged to eat but would not allow staff to assist her. During an interview on 08/30/21 at 03:00 PM Administrative Nurse B acknowledged she should have updated the current care plan to reflect the resident's nutritional status. During an interview on 08/26/21 at 12:00 PM Administrative Nurse A reported the care plan should have been updated. The resident was very resistive of all care but liked her food and ate well. Administrative Nurse A reported she was aware the care plans needed to be updated. Review of the undated facility policy named Care Plan Revisions revealed the care plan would be revised whenever the resident experienced a change in eating/drinking patterns or a change in documented weight. The facility failed to revise the current Comprehensive Care Plan to reflect the change in eating and drinking patterns and the weight change for R 15.

The facility reported a census of 39 residents with 13 sampled. Based on observation, interview, and record review the facility failed to provide treatment and care in accordance with professional standards of practice by not completing dressing changes as ordered for Resident (R) 4 and did not accurately complete skin assessments for R8. Findings Include: - Review of R4's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident was independent with no set up needed for all activities of daily living (ADL) except dressing, toilet use, and personal hygiene which required extensive assistance of one staff. The 04/13/21 Quarterly MDS documented a BIMS of 10, indicating moderately impaired cognition. The 04/08/21 Care Plan for R4 documented staff where to monitor, document, and report any new skin issues. Review of the EHR documented R4 fell on [DATE] and obtained a skin tear to his left shin. The Orders in the EHR documented on 08/20/21 staff were to cleanse R4's minor skin tears with normal saline then apply Antibiotic ointment and dressing daily until healed, and to notify provider at first sign of infection. Review of the August 2021 Treatment Administration Record (TAR) documented the dressing applied on 08/20/21 and lacked documentation of daily dressing changes or a change in the order for leave open to air on 08/30/21. On 08/25/21 at 09:48 AM R4 sat in a chair in his doorway and had a dressing on his right shin dated 08/20/21 (five days past the date it was placed). On 08/30/21 at 12:13 PM R4 sat in his room on the bed with no covering to the skin tear on his right shin. The skin tear showed no observable signs of infection. On 08/30/21 at 10:20 AM Certified Medication Aide (CMA) F revealed at the time of a fall whoever saw the resident first got the nurse or director of nursing (DON) and then went to the resident to assist in any way they could. The nurse performed the assessment and obtained vital signs (VS) and then instructed the staff of the next steps. The nurse would also perform any wound care needed. On 08/30/21 at 09:24 AM Licensed Nurse (LN) C revealed it was the nurse on duty at the time of the fall who would initiate any standing orders for minor skin issues or obtain new orders as needed (PRN) for anything more serious. LN C confirmed the order had been entered as PRN instead of scheduled as it should have been. LN C stated that oncoming nurses would not know of the dressing as it would not pop up to be completed when entered as PRN. On 08/30/21 at 10:07 AM Administrative Nurse A revealed she expected the orders in the resident's records to be followed completely and accurately for R4. The facility Routine Orders signed by facility medical director on 05/26/21 documented the staff were to cleanse minor skin tears with normal saline and approximate with steri-strips as needed, apply triple antibiotic ointment and dressing daily until healed, and to notify provider at the first sign of infection. The facility failed to provide R4 with care and treatment in accordance with professional standards of practice by not changing the dressing to his injury as ordered. - Review of R8's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was independent with no set up help needed for all activities of daily living (ADL). The 06/26/21 Quarterly MDS documented a BIMS of 10, indicating moderate cognitive impairment. The 04/15/21 Care Plan for R8 documented staff were to monitor, document, and report any new skin issues. Review of the EHR documented R4 fell on [DATE] and had abrasions noted to the left inner ankle and right knee. The 08/23/21 Fall Investigation Report documented R8 had abrasions to left inner ankle and right knee from the fall. The Skin Observation Tool dated 08/26/21 (three days after the fall) documented R8 had scratches to her left outer ankle and a cut to her second toe, but lacked documentation of any right knee abrasion On 08/26/21 at 09:12 AM R8 sat in her room in the recliner in a dress and a pair of nonskid socks. R8 showed the surveyor the scratches to her left inner ankle and right knee, from her fall. On 08/30/21 at 10:20 AM Certified Medication Aide (CMA) F revealed at the time of a fall whoever saw the resident first would get the nurse or director of nursing (DON) and then went to the resident to provide assistance. The nurse performed the assessments, obtained vital signs (VS), and then instructed the staff of the next steps. The nurse would also perform any wound care needed. On 08/30/21 at 09:24 AM Licensed Nurse (LN) C revealed it was the nurse on duty at the time of the fall who would document the assessment of the resident's injuries, if there were any. Any nurse completing the weekly skin assessment should document the injuries noted until they are healed. LN C confirmed the injuries for R8's fall were on her left inner ankle and right knee, and stated she had not heard anything regarding a cut to R8's toes. On 08/30/21 at 10:07 AM Administrative Nurse A revealed she expected the skin assessments for R8 to be accurately documented. The facility did not provide a policy regarding skin assessments as requested on 08/30/21 at 02:44 PM. The facility failed to provide accurate skin assessments of R8's injuries from her 08/23/21 fall.

The facility reported a census of 42 residents. Based on observation, interview, and record review the facility failed to promptly review screenings of staff and visitors for COVID-19 signs and symptoms before gaining full entrance into the facility and access to residents. The facility further failed to ensure staff wore protective face coverings inside the facility and around residents. These failures placed all 42 residents in the facility in immediate jeopardy. Findings included: - Observation on 06/16/20 at 11:30 AM revealed Administrative Staff A in the foyer with the surveyors onsite and Administrative Staff A explained why the surveyors needed to screen themselves. Administrative Staff A did not wear a protective face mask. Observation on 06/16/20 at 11:35 AM revealed Administrative Staff A in the commons area of the facility and continued to not wear a protective face mask. Observation on 06/16/20 at 11:36 AM revealed three unidentified staff did not wear protective face masks while in the commons area of the facility. Observation on 06/16/20 at 12:00 PM revealed Certified Medication Aide (CMA) M and CMA N stood at a medication cart in the hallway of the facility, and neither wore a protective face mask while working. Observation on 06/16/20 at 01:00 PM revealed Certified Nurse Aide (CNA) O propelled an unidentified resident in her wheelchair. CNA O did not wear a mask in the presence of the resident, and he bent over and talked to the resident. During an interview on 06/16/20 at 12:05 PM, CMA M stated she sanitized her hands with gel, filled out the screening form, and took her temperature first thing when she arrived at work. CNA M reported she then put the form in a box by the time clock and went to work. CNA M reported the staff were not required to wear protective face masks. During an interview on 06/16/20 at 12:08 PM CMA N reported no staff wore protective face masks when they worked, as they were not required. CNA N also reported she did her own screening in the morning when she came in to work and put the form in that box (pointing to the box by the Director of Nursing (DON) office). During an interview on 06/16/20 at 01:00 PM CNA O reported he had his own protective face mask he carried in his pocket, but he did not have to wear it at this facility. CNA O did not know for sure who reviewed the screening sheets staff put in the DON box every day. During an interview on 06/16/20 at 12:30 PM Administrative Nurse B reported she tried to check the screening forms every day that she worked. Administrative Nurse B said the facility always had a registered nurse working and she attempted to have the nurse look at the screening sheets on their shift and hoped it was getting done. During an interview on 06/16/20 at 11:35 AM Administrative Staff A and Administrative Nurse B reported the staff in the facility do not wear face masks as it caused behaviors and anxiety with the residents who had a mental illness diagnosis. Administrative Staff A and Administrative Nurse B reported a meeting with the medical director who agreed for staff to not wear masks. Administrative Staff A said employees were responsible to screen themselves prior to entering the facility, by sanitizing hands, taking their own temperatures, and stated the employees also had to answer questions on symptoms and travel. Administrative Staff A stated no one person was responsible to screen employees as they came in to work and said Administrative Nurse B or the nurse reviewed the screening sheets sometime during that day. During an interview on 06/16/20 at 03:23 PM Physician JJ reported he just went along with the facility suggestion not to wear masks when they approached him about it. Review of a Centers for Medicare and Medicaid Services (CMS) guidance, dated 04/02/20, entitled COVID-19 Long-Term Care Facility Guidance, revealed long term care facilities were to implement symptom screening on every individual entering a long-term care facility to mitigate the spread of COVID19. The guidance further noted for the duration of the state of emergency in their State, all long-term care facility personnel should wear a facemask while they are in the facility. The facility failed to ensure prompt review of screening of staff and visitors for COVID-19 symptoms before entering the facility, which allowed full access to residents and their environment, and failed to ensure staff wore face protective masks while in the facility. These failures put all residents in immediate jeopardy. On 06/16/20 at 05:00 PM the surveyor provided Administrative Staff A and Administrative Nurse B with the IJ template and notified that the facility failure to ensure all staff and visitor screenings were promptly reviewed for COVID-19 symptoms and the failure of facility staff to wear protective masks while in the facility constituted immediate jeopardy at F880, with the potential to affect all residents in the facility. The facility presented an acceptable plan of removal of the immediate jeopardy on 06/16/20 at 06:41 PM, which included in-servicing of staff regarding COVID-19 screenings for all visitors and staff and included all staff to wear protective face masks while in the facility. The survey team validated the immediate jeopardy removal on 06/17/20 at 07:55 AM following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a scope and severity of an F.

The facility reported a census of 41 residents. Based on record review and interview the facility failed to provide mail to residents on the day of delivery, which included Saturday. Findings included: - During a resident council meeting on 12/03/19 at 01:45 PM the members in attendance stated the facility did not deliver mail to residents on Saturdays. (Resident (R) 36, R9, R19, R31, R30, R27, R2, R6, R22, and R20) On 12/04/19 at 01:31 PM Certified Nurse Aide (CNA) M stated Administrative Staff L or Administrative Nurse A delivered mail to the residents and she did not believe they delivered the mail on weekends. On 12/04/19 at 01:39 PM Administrative Nurse Staff A confirmed staff picked up the facility mail from post office on Monday through Friday twice a day, but not on Saturdays. Review of the facilities undated policy Right to Send and Receive Mail revealed if the facility had mail delivered to a post office box, the facility would arrange for mail pick-up on the day the mail was delivered to the post office box. The facility failed to provide the residents with timely mail delivery, which included Saturdays.

The facility census totaled 41 with 12 residents sampled. Based on observations and interviews the facility failed to display staffing information in a prominent place accessible to residents and visitors when the facilty posted staffing hours inside of the nurse's office and were not legible from the hallway and/or nurse's station window. Findings included: - Observations by surveyors on 12/01/19 and 12/02/19 lacked evidence of visible posted staffing hours. Observations on 12/02/19 through 12/05/19 revealed staffing hours posted inside of the nurse's station, which was often locked and not accessible to the residents and/or the public. The posted staffing hours document was not legible from the hallway and/or nurse's station window. An interview on 12/05/19 at 03:02 PM with Administrative Nurse A stated the licensed nurses posted the hours and those were kept inside the nurse's office. Administrative Nurse A reported the staff took the document down for anyone who asked to see it. Administrative Nurse A agreed the posted hours were not legible from the hallway and/or nurse's window and moved the document to a prominent place where it could be view by anyone. The facility's undated policy titled Posted Daily Nurse Staffing Form documented the posted staffing hours were posted at the nursing station and were accessible to residents, family members, and others in the public. The facility failed to display staffing information in a prominent place accessible to residents and visitors when the facility posted staffing hours inside of the nurse's office and were not legible from the hallway and/or nurse's station window.

The facility reported a census of 41 residents. Based on observation, interview, and record review the facility failed to provide a safe, sanitary, and comfortable environment for the residents of the facility when staff failed to sanitize a glucometer according to the manufacturer's recommendation between resident uses and failed to ensure staff followed proper hand hygiene prior to administration of medications. (Resident (R) 27) Findings Included: - On 12/04/19 at 11:01 AM Licensed Nurse (LN) K obtained a blood glucose reading and failed to properly clean and sanitize the glucometer according to the manufacturer's recommendation. During an interview on 12/04/19 at 11:27 AM Administrative Staff L confirmed the LN had manufacturer literature on glucometer care and would follow the instructions to clean the machine properly. During an interview on 12/04/19 at 11:46 AM Administrative Nurse A stated the facility policy instructed staff to use disinfecting wipes to clean the glucometer between each resident use. During an interview on 12/04/19 at 12:52 PM LN K revealed she cleaned glucometers with an alcohol wipe between each resident and stated she always did it that way and she was trained to do it. Review of the facility Blood Glucose Monitoring policy revised on 04/03/17 instructed staff to thoroughly clean all equipment used per manufacture recommendation and return to the appropriate storage area. Review of the Manufactures Guide for Medline Even Care ProView blood glucose monitoring system stated staff would use a Caviwipe towelette or other registered disinfecting wipe. Staff would allow the cleaned area to remain wet for two minutes and for other registered disinfecting wipes the staff would allow the surface of the meter to remain wet for the contact time listed on the disinfecting wipes instructions for use. The facility failed to ensure staff cleaned the facility blood glucose monitor according to manufacturer recommendations. - An observation on 12/02/19 at 11:18 AM revealed Certified Medication Aide (CMA) H broke a potassium chloride tablet with his bare hands before giving it to Resident (R) 27 without using hand sanitizer or gloves. An observation on 12/03/19 at 11:40 AM revealed CMA H broke a potassium chloride tablet with his bare hands before giving it to R27 without using hand sanitizer or gloves. CMA H also touched other pills while popping them out of the medication cards. During an interview on 12/04/19 at 01:52 PM, CMA H stated he did not use gloves unless he spoon fed medications to residents. CMA H stated he never thought about the fact that he broke up medications with his ungloved hands. During an interview on 12/04/19 at 03:22 PM, Administrative Nurse A stated she expected staff to wear gloves if they handled medications. Administrative Nurse A stated if a resident requested a pill and it needed to be cut in half, staff should wear gloves prior to snapping the pill in half. Review of the undated Hand Hygiene policy revealed, If hands are not visibly soiled, an alcohol-based hand rub may be used for routinely decontaminating hands .before and after medication administration. The facility failed to ensure staff followed proper hand hygiene prior to administering medications to R27.

The facility reported a census of 41 residents with one sampled for activities. Based on interview, observation, and record review the facility failed to provide an ongoing activity program for the residents of the facility, which included weekends. Findings Included: - Observation on 12/02/19 at 02:30 PM revealed the displayed activity calendar for the facility had no activities listed on the weekends of the month of (MONTH) 2019. Review of calendars in the resident's rooms revealed the same printed calendar with no activities listed on the weekends. On 12/03/19 at 11:15 AM Certified Nurse Aid (CNA) I stated the activities on the weekends were the resident's choice and a resident would generally take charge and pick an activity to do such as a watch a movie, play a board game, or do some coloring or drawing. On 12/03/19 at 11:25 AM Social Services Staff C revealed she knew they had games available and the nurses turned on a movie for the residents on the weekends for the activity. On 12/04/19 at 10:58 AM Activity Staff F revealed she only conducted activities Monday through Friday. On 12/04/19 at 11:39 AM Activity Staff B revealed she left a key for the nurses and let them decide what activity to do on the weekends. On 12/05/19 at 01:45 PM Administrative Nursing Staff A revealed weekend activities were at the request of the residents. Review of the facilities undated Life Enhancement and Activity Programming policy revealed it was the responsibility of all staff to create opportunities for each resident to experience pleasures of their choice each day. Residents who were unable to verbally respond to the question were offered daily pleasures known to the staff members by observation and through information provided by family. The facility failed to provide an ongoing activity program for the residents of the facility, which included weekends.

The facility census totaled 41 residents. Based on observation, interview, and record review the facility failed to date opened insulin pens for two residents who received insulin. The facility further failed to ensure staff did not pre-pop medications from medication cards ahead of medication administration times for 34 residents. (Resident (R) 31, R34) Findings included: - An observation of the facility Treatment Cart on 12/01/19 at 05:00 PM revealed a [MEDICATION NAME] (insulin) for R31 opened but not dated, a [MEDICATION NAME] pen (insulin) for R34 opened but not dated, and a [MEDICATION NAME] (insulin) for R34 opened but not dated. An observation of the facility Medication Cart on 12/01/19 at 05:09 PM revealed medications for 34 residents, which were pre-popped from medication cards and stored in small, clear plastic medication cups with resident initials. During an interview on 12/01/19 at 05:09 PM Certified Medication Aide (CMA) N stated she pre-popped medications for administration to residents later in the evening. During an interview on 12/04/19 at 03:27 PM Administrative Nurse A stated she expected concurrent documentation and concurrent popping of pills out of medication cards. Administrative Nurse A further stated medications were not to be placed in plastic cups for future administration. Administrative Nurse A expected all medications to be dated when opened. Review of the undated Medication Labeling, Storage and Administration policy revealed nothing specific to the above situations. The facility failed to ensure opened medications were properly dated and failed to ensure staff did not pre-pop and store resident medications prior to administration of medications.

The facility census totaled 41 with 12 residents sampled. Based on observations and interviews the facility failed to ensure a safe environment free from potential accident hazards for residents when facility staff left the service hall door unlocked/unalarmed and an unlocked/unattended maintenance cart included several hazardous items left open and unsecured. Findings included: - An observation on 12/01/19 at 05:24 PM revealed the service hall did not alarm or alert staff when surveyors entered through the doorway without entering a code to the door. In the hallway, there was an opened bag of cat litter on the floor and an unopened bag of Instasalt ice melt. An unlocked maintenance cart contained several opened chemicals which included: 1. Two cans of WD40 2. Two opened tubes of liquid nails 3. One opened tube of silicone 4. Two opened containers of multipurpose cement 5. One container of FlexSeal 6. Multi-purpose floor adhesive 7. Bottle of cologne 8. Maintenance Staff (MS) E's prescription for a non-steroid anti-[MEDICAL CONDITION] medication 9. One can of paint on top of the maintenance cart 10. One large bucket of paint, open with the lid loosely positioned over bucket 11. One lighter 12. Hand saw 13. Box knife 14. Fire ant bait An observation on 12/01/19 at approximately 05:30 PM of the unsecured service hall revealed open doors to the laundry room which contained several unsecured chemicals, which included: 1. Clorox wipes 2. Carb choke/Gumout 3. Two aerosol cans of break down odor eliminator 4. Two containers of Comet cleaner with bleach 5. One container of Comet disinfecting cleaner with bleach 6. One aerosol can of glass cleaner 7. One can of hospital [MEDICATION NAME] (carbolic acid) disinfectant 8. One jug of bleach under the sink in the laundry room 9. One jug of laundry bleach next to the sink 10. One large jug, opened with no lid, of auto-chlor next to the sink An interview on 12/01/19 at 06:13 PM with Administrative Staff L stated the door to the service hallway was supposed to alarm but it did not. Administrative Staff L reported one resident at risk for wandering stated the door would remain locked until fixed. An interview on 12/05/19 at 02:15 PM with Licensed Nurse (LN) J stated the alarm to the service hall had always been loud enough for her to hear and she never had any problems with the security code function and/or alarm for the entrance door of the service hall. LN J reported residents never entered the hall without a staff member and the facility did not have a history of residents or visitors who entered the hall without staff present. An interview on 12/05/19 at 10:45 AM with MS [NAME] stated he was painting the walls in the service hall on Sunday and confirmed he left his cart out and opened in the hall. MS [NAME] reported he normally locked his cart and kept it in his workshop on grounds outside of the facility. The facility did not provide a policy for maintaining security of the service hall and/or maintenance cart. The facility failed to ensure a safe environment free from potential accident hazards for residents when facility staff left the service hall door unlocked/unalarmed and an unlocked/unattended maintenance cart included several hazardous items left open and unsecured.

The facility census totaled 41 residents. Based on interview and record review the facility failed to complete 12 hours of Certified Nurse Aide (CNA) in-service training per year for five of five CNA's reviewed. Findings included: - Review of the nurse aide training documentation provided by the facility revealed: 1. CNA I completed 11 hours out of the 12 hours of training required. 2. CNA O completed two hours out of the 12 hours of training required. 3. CNA P completed three hours out of the 12 hours of training required. 4. CNA Q completed eight hours out of the 12 hours of training required. 5. CNA R completed five hours out of the 12 hours of training required. An interview on 12/05/19 at 10:30 AM with Administrative Nurse A revealed she began her position in (MONTH) 2019 and reported the training was done on paper and not electronically. Administrative Nurse A provided staff sign-in sheets for in-service training and/or proof of any nurse aide training she found regarding the annual 12 hours of CNA in-service training to the surveyor. Administrative Nurse A checked with Administrative Staff L and confirmed there were no other sign-in sheets for nurse aide education/training available. Upon request for a policy, Administrative Staff L confirmed the facility did not have a policy for nurse aide training. The facility failed to complete the required 12 hours of in-service training per year.

The facility census totaled 41 residents with 12 residents reviewed for care plans. Based on interview, observation, and record review the facility failed to revise the care plan to include specific targeted behaviors related to the use of [MEDICATION NAME] (antipsychotic medication) and [MEDICATION NAME] (antipsychotic medication) for Resident (R)3. Findings included: - Review of the (MONTH) 2019 Physician order [REDACTED]., guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score could not be obtained. R3 had both short-term and long-term memory problems, continuously present behaviors which did not fluctuate, and difficulty focusing attention. R3 had a total mood severity score of 21 indicating severe depression and exhibited rejection of evaluation or care on a daily basis. R3 received an antipsychotic and an antidepressant medication daily during the seven-day observation period. Review of the quarterly MDS dated [DATE] revealed a BIMS score could not be obtained as R3 was rarely/never understood. R3 continued with both short-term and long-term memory problems, continuously present behaviors which did not fluctuate, and difficulty of focusing attention. R3 had a total mood severity score of 17 indicating moderately severe depression. R3 received an antipsychotic and an antidepressant medication daily during the seven-day observation period. Review of the Mood State Care Area Assessment (CAA) dated 02/17/19 revealed R3 was resistive to all cares and he did not acknowledge the presence of others. He would bob his head up and down when staff attempted to feed him at meals/snack and he tried to force himself to the ground during transfers. R3 forced his weight against staff and grabbed at staff when staff changed him in bed. Review of the Behavioral Symptoms CAA dated 02/17/19 revealed R3 had little to no safety awareness. Review of the Care Plan dated 03/10/15 revealed R3 depended on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits. When R3 was not asleep, he sat in his chair bobbing his head back and forth and did this violently at times. R3 also rubbed his hands over his face. Review of the 06/01/15 Physician order [REDACTED]. Review of the 04/25/15 Physician order [REDACTED]. Review of the 05/01/15 Physician order [REDACTED]. Review of the Behavior's Notebook revealed documentation between (MONTH) 2019 through (MONTH) 2019 for head banging, uncooperativeness, and undressing. (The care plan did not include head banging and undressing as behaviors to be monitored.) An observation on 12/03/19 at 08:19 AM revealed R3 sat in a recliner in the living room with other residents. R3 sat covered with a white blanket and his eyes were closed. R3 did not exhibit any negative behaviors, and remained calm and quiet. During an interview on 12/04/19 at 01:35 PM Certified Nurse Aide (CNA) I stated R3 fought staff during cares, mainly when staff got him dressed. CNA I stated for the most part R3 did not exhibit any negative behaviors. During an interview on 12/04/19 at 02:13 PM Licensed Nurse (LN) K stated R3 would at times remove his shirt and make a coughing sound, possibly to communicate that he did not want to eat. R3 remained non-verbal most of the time and rarely spoke although he could speak. LN K stated R3 decided when he would let staff help him or not. LN K stated staff documented behavior monitoring in a behavior notebook which included head banging, uncooperativeness, and undressing. During an interview on 12/05/19 at 12:49 PM, Administrative Nurse D stated behaviors to monitor for do not really have a correlation to the care plan. Administrative Nurse D stated she did not see anything about R3 taking his shirt off included in the care plan. Administrative Nurse D stated she really did not review the care plan with behaviors monitored for or updates and stated the nurses could, and were encouraged to, update the care plans. During an interview on 12/05/19 at 01:23 PM Administrative Nurse A stated she expected monitored behaviors to correlate to the behaviors mentioned in the care plan. The facility failed to provide a policy for care plans. The facility failed to revise the care plan to include specific targeted behaviors to monitor for the use of [MEDICATION NAME] and [MEDICATION NAME] for R3.

The facility census totaled 41 residents with five residents reviewed for unnecessary medications. Based on interview, observation, and record review the facility failed to ensure one of five residents did not receive unnecessary medications due to the failure to monitor for specific targeted behaviors related to the use of [MEDICATION NAME] (antipsychotic medication) and [MEDICATION NAME] (antipsychotic medication) for Resident (R)3. Findings included: - Review of the (MONTH) 2019 Physician order [REDACTED]., guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score could not be obtained. R3 had both short-term and long-term memory problems, continuously present behaviors which did not fluctuate, and difficulty focusing attention. R3 had a total mood severity score of 21 indicating severe depression and exhibited rejection of evaluation or care on a daily basis. R3 received an antipsychotic and an antidepressant medication daily during the seven-day observation period. Review of the quarterly MDS dated [DATE] revealed a BIMS score could not be obtained as R3 was rarely/never understood. R3 continued with both short-term and long-term memory problems, continuously present behaviors which did not fluctuate, and difficulty of focusing attention. R3 had a total mood severity score of 17 indicating moderately severe depression. R3 received an antipsychotic and an antidepressant medication daily during the seven-day observation period. Review of the Mood State Care Area Assessment (CAA) dated 02/17/19 revealed: R3 was resistive to all cares and he did not acknowledge the presence of others. He will bob his head up and down when staff attempt to feed him at meals/snack and he would try to force himself to the ground during transfers. R3 would force his weight against staff and grab at staff when staff changed him in bed. Review of the Behavioral Symptoms CAA dated 02/17/19 revealed R3 had little to no safety awareness. Review of the Care Plan dated 03/10/15 revealed R3 was dependent on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits. When R3 was not asleep he sat in his chair bobbing his head back and forth and would do this violently at times. R3 also rubbed his hands over his face. Review of the 06/01/15 Physician order [REDACTED]. Review of the 04/25/15 Physician order [REDACTED]. Review of the 05/01/15 Physician order [REDACTED]. Review of the Behavior's Notebook revealed documentation between (MONTH) 2019 through (MONTH) 2019 for R3's head banging, uncooperativeness, and undressing. An observation on 12/03/19 at 08:19 AM revealed R3 sat in a recliner in the living room with other residents. R3 sat covered with a white blanket and his eyes were closed. R3 did not exhibit any negative behaviors, and remained calm and quiet. During an interview on 12/04/19 at 01:35 PM Certified Nurse Aide (CNA) I stated R3 fought staff during cares, mainly when staff got him dressed. CNA I stated for the most part he did not exhibit any negative behaviors. During an interview on 12/04/19 at 02:13 PM Licensed Nurse (LN) K stated R3 would remove his shirt and make a coughing sound possibly to communicate that he did not want to eat. R3 was non-verbal most of the time and rarely spoke although he could speak. LN K stated R3 decided when he would let staff help him or not. LN K stated staff documented behavior monitoring in a behavior notebook which included head banging, uncooperativeness, and undressing. During an interview on 12/05/19 at 01:23 PM Administrative Nurse A stated R3 used to run up and down the halls and intentionally bump into things or people. He also used to bang his head on anything around and wore a helmet for safety, but he would constantly try to take it off. Administrative Nurse A stated she expected monitored behaviors to correlate to the behaviors mentioned in the care plan. The facility failed to provide a policy for behavior monitoring or unnecessary medications. The facility failed to ensure R3 did not receive unnecessary medications by the failure of staff to monitor behaviors identified specifically for the use of [MEDICATION NAME] and [MEDICATION NAME].

The facility census totaled 42 residents with 12 residents sampled and 6 reviewed for accidents. Based on observation, interview and record review the facility failed to provide adequate supervision when they failed to develop and implement appropriate interventions for residents assessed at risk for elopement for 3 of 6 sampled residents. Resident #24 left the facility for a walk, although staff assessed him/her at risk for elopement, for a walk on [DATE] and never returned as of [DATE]. This deficient practice placed the resident in immediate jeopardy. Staff found resident #44, also assessed at risk for elopement, over a mile away from the facility when he/she went for a walk unsupervised. This deficient practice placed this resident in immediate jeopardy. Staff also allowed resident #37, who staff identified at risk for elopement, to go for walks downtown unsupervised. The facility also failed to adequately investigate falls for causal factors and implement appropriate interventions after falls for 3 of 3 residents. (#27, #34, #8) The facility also failed to ensure residents remained free of accidents related to bed rails by their failure to assess bed rails for excessive gaps that could lead to resident entrapment in the rails. This had the potential to affect 18 residents on hall 1 and 17 residents on hall 2 (total of 35 out of 42 residents in the facility affected). Findings included: - Review of resident #24's signed medication administration record (MAR) dated [DATE] included the following Diagnoses: [REDACTED]. appearance). Review of the admission minimum data set assessment ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating the resident had no cognitive impairment. The resident had no delirium, disorganized thinking and no alteration in level of consciousness. The resident had a mood score of 14 indicating moderate depression. The resident had no behaviors and no wandering. The assessment documented it was very important to the resident to go outside to get fresh air when the weather was good. The resident was independent in all activities of daily living (ADLs) and did not use an assistive device for mobility. The resident had no falls and received antipsychotic, antianxiety, and antidepressant medications daily for 7 days of the observation period. The resident also had severe pain for which he/she received scheduled and as needed (PRN) pain medications as well as non-medication interventions for pain management. Review of the quarterly MDS dated [DATE] revealed a mood score of 10 which indicated moderate depression and the resident also had inappropriate behavior symptoms not directed towards others (hitting/scratching self, yelling, or disruptive sounds) ,[DATE] days out of the 7 day observation period. Otherwise, there were no changes from the [DATE] MDS. Review of Care Area Assessments (CAAs) dated [DATE] revealed the following: Review of the Mood state CAA revealed the resident was very anxious at all times and suspicious of others often. He/she wanted staff to look at him/her and tell him/her if he/she looked bad. The resident consumed him/herself with worry about health problems that he/she did not have. Review of the Falls CAA revealed the resident had no noted issues and walked as he/she desired without assistive devices. Review of the Pain CAA revealed the resident had chronic back pain and saw a specialty pain physician with no relief of the pain. The resident had a high level of anxiety and was also overweight. Review of the Psychosocial Well-Being CAA revealed the resident had a high level of anxiety, enjoyed being around others, visiting with staff and doing devotions. The resident had depression and relied on staff to help him/her ease his/her worries at times. Review of the Psychotropic drug use CAA revealed the resident's medication regimen included psychotropic medications (medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing). Review of the Wander risk/elopement risk assessments dated [DATE], [DATE], [DATE] and [DATE] revealed the resident was at moderate risk for wandering/elopement. Review of the care plan reviewed on [DATE] revealed the following interventions: [DATE]- staff needed to provide the resident with a program of activities that was meaningful and of interest, including performing morning devotions. The resident also wanted to be the next resident council president. Staff needed to encourage and provide opportunities for exercise and physical activity. The resident needed time to talk and express his/her feelings when he/she felt anxious. The resident enjoyed going out of the facility on Sunday for church services and walked to the local library to research and read books. He/she knew to inform the charge nurse before he/she left and upon returning. The care plan lacked evidence that the resident was a moderate risk for elopement as identified on the wandering/elopement risk assessment, and lacked interventions to prevent elopement. Review of the timed progress notes included the following: [DATE]- The resident continued with constant health issues and concerns including, Do I look OK?, I am so tired, You are not going to send me to (the stated mental hospital) are you? , and Please help me I'm so tired. [DATE] at 8:57 AM - Over the past 3 weeks the resident talked to social services staff T several times throughout the day while at the facility and numerous private messages through a social media website. The resident complained of how bad he/she felt, about his/her pain and how he/she just could not go on this way. The resident thought the pain came from his/her chair or the way he/she slept and the next day he/she would have a different excuse. Sometimes he/she cried and said he/she just cannot do this. Staff T asked the resident if he/she had suicidal thoughts and the resident denied it because suicide would be a sin. The resident used to write spiritual reflections for friends and he/she had stopped doing that but staff convinced him/her to write one today. Staff T assured the resident he/she could come to staff T any time as they remained friends for many years. The increase in visiting and complaints of pain started when the resident found out his/her family member had cancer. During this time the facility also had to be evacuated because of the prairie wild fires, all of which upset the resident. [DATE] at 8:45 AM- The resident almost beat social services staff T into his/her office today. The resident walked right behind staff T and kept talking about how he/she could not go on like this. He/she kept interrupting other residents and everything was about him/her. The resident continued to be very depressed and had paranoid feelings that 3 other residents were talking about him/her. The resident did not go to church the past 3 weeks and already stated he/she could not go this Sunday. [DATE] at 5:46 PM- The resident received a call stating his/her family member passed away. The resident became distraught and wanted to stay in his/her room. [DATE] at 8:38 AM- Social services staff T visited with the resident about going to his/her family member's funeral and the resident stated he/she could not go. Staff T visited with the resident for an hour and the resident remained firm that he/she could not go to the service. The resident cried a lot during the visit and staff told him/her if he/she changed his/her mind, he/she could go with staff T. Staff T and the resident often communicated through private messenger and the resident had contacted staff T and seemed better than the day before. Staff T gave the resident the memorial card and he/she only focused on him/herself. The resident wanted to leave the facility because he/she felt people thought he/she was crazy, made fun of him/her and did not like him/her. Staff T provided reassurance and the resident stated he/she just wanted to go to the state mental health hospital. The resident had stopped writing religious reflections when he/she became more depressed. The resident's pain continued to be an issue for him/her even though the resident went to a pain specialist and chiropractors. [DATE] at 1:47 PM- The resident went to the physician's office for a medication review and the resident thought the physician would change his/her medications or make him/her leave the facility. Staff provided reassurance. The resident offered to do a dance at the Senior Olympics. When it was time to practice the resident initially did not want to, but when the music started and he/she had the hat, the resident got right up and showed everyone how to do the dance. Later in the afternoon the resident stated the only place that wanted him/her was the state mental health hospital and staff provided the resident assurance he/she did not qualify for the hospital because he/she did not pose a danger to him/herself or others. The resident continued to talk about his/her pain and staff explained what they are doing for his/her pain and that he/she had gone to a specialist. [DATE] at 1:29 PM- The resident had no changes in his/her behaviors and still asked, Do I look good? and Are you sending me away? [DATE] at 8:25 AM- The resident met staff T at the door and looked very unkempt, unshaven, eyes red, hair uncombed and very flat affect (A severe reduction in emotional expressiveness). The resident stated the facility started the paperwork to send him/her to the state mental health hospital. Staff T again explained he/she would have to have an evaluation first and would have to prove he/she posed danger to him/herself or others. Staff explained he/she did well at the Senior Olympics and he/she did not agree. The resident stayed with staff T most of the day but did not complain much. The facility failed to reassess the resident's risk of wandering/elopement, and failed to provide increased supervision after staff noted these changes with the resident. [DATE] at 2:16 PM- Staff T spoke with the resident's guardian to get consent to send the resident to the behavioral health unit (BHU). Staff T assured the resident's guardian that the resident would be able to return to the facility after discharge from the BHU. Staff explained to the guardian the resident really wanted to go to the state mental hospital but he/she needed to go to the behavior unit first and could not promise him/her the resident would not get upset when he/she arrived at the BHU. Arrangements were made with the BHU and the facility planned to take the resident that afternoon. On [DATE] per late entry posted on [DATE] at 2:30 PM- The resident was out of the facility for a walk to calm down due to going to the BHU that afternoon. Another late entry revealed on [DATE] at 3:28 PM- The resident had not returned to the facility and staff went out looking for the resident. Another late entry revealed on [DATE] at 4:30 PM- social service staff U had told the resident he/she had been accepted to go to the BHU. Staff U explained to the resident he/she needed to pack and the resident said he/she would get ready. About 15 minutes later staff went to check on the resident and administrative staff A reported the resident went for a walk. Staff A stated he/she asked the resident to stay in the parking lot since he/she would be leaving soon for the BHU. Staff U went outside and the resident was not in the parking lot. Staff checked inside the facility and could not find him/her and then multiple staff left the facility to drive around town and could not find the resident. Staff searched for about an hour and 20 minutes and then staff contacted the resident's guardian and assured him/her staff would keep him/her updated on the situation. Administrative staff A then contacted the police to file a missing person report. Staff continued to search the facility and areas around town and could not find the resident. On [DATE] at 1:31 PM (late entry) - The resident spoke with social services staff T several times on [DATE] and staff assured the resident the facility would get him/her help as soon as a bed was available. The resident was very stressed and nervous. Administrative staff A had asked the resident to walk in the parking lot and when facility staff went to take the resident to the BHU he/she was not in the parking lot area. Staff immediately started looking for the resident as well as other towns' people began a search. The sheriff's department started a search and rescue and looked until around midnight. It was cold and rainy and staff/friends were extremely worried. He/she had not done this in years, but unknown to the facility he/she had a history of [REDACTED]. Observation on [DATE] at 10:05 AM revealed an approximate distance from the front porch of the facility to the main road leading into the town measured ,[DATE] yards looking west. The main street was wide, paved and had sidewalks on both sides of the street. The speed limit was 30 miles per hour (mph) then reduced to 20 mph headed into town residential areas then turning into a small downtown area with businesses. The distance from the facility parking lot to the local community center and library was 0.6 miles one way to the north of the facility. A major highway measured 0.3 miles south of the facility which led west to a neighboring town. The highway did not have a shoulder but had wide ditches and a speed limit of 65 mph. The surrounding area to the south and west consisted of open farmland. During an interview on [DATE] at 10:22 AM administrative staff A reported the resident had a routine of going outside and walking around the community and had a normal pattern he/she walked for about an hour. On the morning of [DATE], the resident came to staff A said he/she wanted to go to state mental hospital because of his/her high anxiety. Staff A explained the resident could not go to the state mental hospital without an assessment, so staff would see if they could arrange for him/her to go to the BHU. Administrative staff A stated staff made arrangements for the resident to go to the BHU and social services staff T told the resident he/she would take him/her to the BHU later that day. Administrative staff A reported at around 2 PM, the resident came and said he/she was going on a walk (per his/her usual) and he/she told the resident not to be gone for very long because he/she was going to be leaving for the BHU soon. The resident agreed. At about 2:30 PM, the resident still had not returned, but administrative staff A figured the resident would be back any minute. At 2:45 PM, the resident still had not returned and staff started looking for him/her in the facility and out in the community. Staff did not find him/her, so they notified law enforcement (LE) after looking for the resident for about an hour and a half. LE came to the facility within 10 minutes and began looking for the resident with the help of volunteer firefighters and others in the community. They looked everywhere, on porches, behind bushes, and made a sweep of the whole town and did not find him/her. At the time of this interview, the resident still had not been found. Through the process of trying to find him/her, staff asked the resident's family members who said he/she did this all through his/her life (running away/hiding). Staff A reported the facility did not know of this previous behavior prior to this incident. During an interview on [DATE] at 11:14 AM the resident's guardian reported once in 2004, the resident eloped from a hospital but had not done it since. The representative stated the resident had not expressed a desire to leave the facility. The resident had lived in many other facilities including the State mental hospital and had not attempted to leave those facilities. During an interview on [DATE] at 8:33 AM housekeeping staff R stated he/she knew the resident went out for walks on his/her own but did not know where he/she walked to. On [DATE] at 10:20 AM direct care staff L reported he/she had worked at the facility for about a year and he/she believed the resident knew the code to the door and would go on walks frequently unaccompanied, especially during nice weather. Staff L said the resident would walk to the park and usually came back after about 30 minutes. The resident had not mentioned to staff L he/she planned to leave the facility or that he/she wanted to go somewhere else. Staff L also stated the resident did not act any differently that morning than he/she did on any other day. On [DATE] at 10:51 AM direct care staff H reported he/she knew the resident before he/she lived at the facility. The resident was anxious a lot but seemed to be content living in the facility. The resident had never verbalized he/she wished to go somewhere else or had plans to leave the facility. Staff H stated the resident went outside by him/herself probably every other day and would walk to the local library and stay out ,[DATE] minutes. Staff H stated the resident made his/her own decisions and was very active with activities and lead devotions. During an interview on [DATE] at 2:41 PM social service staff T reported prior to Monday, the day the resident left the facility, the resident learned his/her family member had cancer and went to see him/her. The facility had the fire evacuations and then his/her family member died . The resident had done well until he/she found out about his/her family member's cancer. When the resident had increased anxiety he/she would talk to staff T and seemed to calm down. The resident participated in the activities and would laugh as usual but when the activity was over he/she asked if he/she looked OK which was his/her usual behavior. On Friday, [DATE] the resident did not initially want to participate in the Senior Olympics, but he/she did. When the resident returned from Senior Olympics he/she showed a little more depression than normal. On Monday the 3rd, the resident said he/she wanted to go to the state mental health hospital as he/she had in the past. Staff T visited with the resident and talked about how much he/she hated it when he/she went there before. When the resident would talk about going to state mental health hospital he/she would seem better and sometimes go for a walk and then did not mention it again. However, on Monday the resident was adamant about it and staff T assured the resident the facility would get him/her somewhere today. Staff T visited with the resident about suicide because his/her other family member committed suicide and the resident said he/she would never do that because he/she would not go to heaven. Staff T said the resident knew he/she was going to the BHU later that day. Staff T left work at 2:00 PM and said the resident seemed fine and said the facility was sending him/her somewhere today. Staff T explained that was because he/she had asked to go. Staff T said the facility contacted him/her sometime after 3:00 PM and reported the resident did not return from his/her walks so staff T went to mutual friends and the churches and did not find the resident. Staff T stated the resident had always come back from his/her walks and followed the rules because he/she did not want to upset anyone. During an interview on [DATE] at 8:45 AM administrative nursing staff C reported when a resident came to the facility he/she reviewed the discharge summary from where the resident came from and if it identified a history of wandering or elopement he/she would include that in the elopement assessment. Staff C stated he/she did not inquire with the resident's guardian if the resident had any previous attempts of wandering or eloping from his/her prior residence. During an interview on [DATE] at 9:06 AM administrative nursing staff B reported the residents that knew the exit code to the front door were not a high risk for elopement and needed to tell staff when he/she went out to sit on the front porch swing. Staff B stated administrative staff A started allowing residents to go for walks started a few months ago and he/she and other staff were surprised when the residents were allowed to go on walks. Staff B reported administrative staff A said he/she trusted the residents and as long as they told him/her they were going for a walk he/she thought it would be OK. During an interview on [DATE] at 1:57 PM administrative staff A reported the residents that knew the door codes at this time knew them prior to him/her coming to the facility. None of them have left the facility grounds without telling him/her first. Staff A stated he/she had not checked the resident's elopement risk assessment prior to giving him/her permission to go for walks because he/she had already seen the resident out of the facility and assumed he/she had gone on walks before. Staff A stated the resident would check with him/her before going on a walk and that was part of his/her anxiety therapy. During an interview on [DATE] at 10:26 AM administrative nursing staff C reported the elopement assessment triggered most all of the residents at a moderate risk just because of their diagnoses. Staff C stated if the resident was an elopement he/she would put interventions in the care plan. The elopement risk assessment used by the facility had [DIAGNOSES REDACTED]. However, the assessment did not take into account the residents need for total assistance with all cares including mobility which made the resident not at risk for elopement. Staff C thought he/she had made a note in the clinical record to show the resident was not an elopement risk but could not find it. During an interview on [DATE] at 10:40 AM administrative staff B reported he/she felt the facility elopement assessment needed to be revamped because most of the residents triggered for a moderate risk of elopement even though he/she did not think they were a risk. Staff B stated if the resident was at risk for elopement there would be interventions in the care plan but if they were not a risk staff did not go back and verify on the assessment why the facility did not think the resident was an elopement risk. Review of the undated Elopement policy revealed an immediate jeopardy elopement check list was done on admission. The plan of care would be specific with interventions to identify the residents risk for elopement. The policy did not include that the assessment would include changes in resident cognition/behaviors or if the resident verbalized the desire to leave the facility. The facility failed to provide adequate supervision for resident #28 identified at moderate risk for elopement, who was allowed to go out on walks unsupervised and did not return after a walk on [DATE]. The facility also failed to reassess the resident or develop and implement any additional interventions after the resident displayed changes and verbalizations of desire to go to the state hospital for treatment of [REDACTED]. This failure put resident #28 in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] by implementation of the following corrective actions: The facility changed the front exit door code and staff were the only ones to know the exit code. Development of a policy and procedure related to elopement risk for residents which include an interdisciplinary review of each resident's elopement risk score to determine whether or not the score was appropriate. The facility held inservice training for all staff regarding the new elopement policy and the new exit door codes. After abatement, the deficient practice remained at a scope/severity of a G. - Review of resident #44's signed physician orders [REDACTED].), and psychosis (any major mental disorder characterized by a gross impairment in reality testing). Review of the quarterly minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 0, indicating severe cognitive deficit. The resident had fluctuating problems with difficulty focusing attention and being easily distracted. The resident had a mood score of 17 indicating moderate/severe depression. The resident had hallucinations, rejection of care and wandering 1 to 3 days out of the 7 day observation period. The resident performed all activities of daily living (ADLs) independently and had no limitations in functional range of motion. The resident received antipsychotic (medication used to treat psychosis) medications daily for the 7 day observation period. Review of the annual MDS dated [DATE] revealed a BIMS score of 7, indicating severe cognitive impairment. The resident had a mood score of 10, indicating moderate depression. The resident experienced hallucinations and delusions wandered daily and exhibited verbal aggression toward others. The assessment documented it was very important to the resident to get fresh air when the weather was good. The resident remained independent in ADLs and received an antipsychotic and daily for the 7 day observation period. Review of the cognitive loss care area assessment (CAA) dated [DATE] revealed the resident was oriented to time, person, and place but refused to answer review questions. The resident also had episodes of hallucinations at least daily. The resident refused medications at times and did not believe he/she needed to live in the facility. Review of the behavior symptoms CAA dated [DATE] revealed the resident made poor eye contact with others, threw his/her medicine cups and water at times when he/she refused to take medications. The resident also did not speak when spoken to on most occasions. Review of the psychotropic medication CAA dated [DATE] revealed the resident received antipsychotic medications. Review of the resident's elopement risk assessment dated [DATE] revealed the resident had a [DIAGNOSES REDACTED]. The resident had no history of wandering without regard to safety or from previous placement elsewhere. The resident had an elopement risk score of 9, which indicated moderate risk for elopement. Review of the care plan dated revised on [DATE] recorded the resident liked to go on walks around town after breakfast. The care plan also identified the resident was independent in walking without direction from staff. The care plan lacked any interventions related to the resident being at moderate risk for elopement from the facility. Review of the progress notes revealed the following: [DATE]-1:32 AM The resident frequently went outside to smoke but did not wander from the facility. [DATE]- 3:36 AM The resident wandered the halls the entire time this nurse has been on shift and had not slept. The resident went into other resident rooms and staff redirected the resident to leave the rooms. [DATE]-10:39 PM The resident sometimes did things he/she knew were not appropriate but was easily corrected. The resident remained awake and wandering halls most nights. [DATE] at 11:48 AM the resident left the facility to go for a walk. [DATE] at 12:43 PM Staff found the resident approximately 1 mile outside of the city limits. Staff picked up the resident and explained that distance was too far to go on his/her walks. Resident stated he/she planned to go to a friend's house and staff informed the resident his/her friend's house was too far out of town and it was not safe for him/her to walk that far. The resident voiced understanding and returned to the facility. An observation on [DATE] at 11:03 AM revealed the resident returned from the outside courtyard after smoking a cigarette. The resident walked with a steady, swift gait and went to his/her room. The resident did not inform anyone that he/she had gone out to smoke or that he/she had returned. An observation on [DATE] at 11:44 AM revealed the resident went out the back door to the fenced in courtyard. The resident put the code in the door and went outside without difficulty. At 11:52 AM the resident returned to the facility. An observation on [DATE] at 5:28 PM revealed the resident met resident #37 to get a lighter and then went out the front door putting the code into the key pad to open the door. The resident did not tell administrative staff A or any other staff member that he/she went out the front door. The resident sat on the bench outside and then paced around the front of the building smoking. The resident came back into the facility, did not tell anyone that he/she had returned, and returned the lighter to the other resident. During an interview on [DATE] at 11:17 AM direct care staff L reported sometimes the resident went out front to smoke if there was another resident out front. Otherwise, he/she went outside the back of the facility to smoke. Staff L stated the resident knew the code to all of the doors and as far as he/she knew the resident had not left the facility grounds unaccompanied. During an interview on [DATE] at 12:55 PM direct care staff N reported the resident knew the code to the front door (which led to an area that was not fenced in). Staff N stated the resident went with a friend to different social events and he/she had not seen the resident leave facility property without being accompanied with someone. During an interview on [DATE] at 1:06 PM social services staff U reported the resident went out the front door for a walk, but always told staff when he/she left and when he/she returned. Staff U stated the resident went out a couple of times a week and had a bright hoodie to wear for visibility. Staff U stated the resident just started leaving the facility grounds the past couple of months and administrative staff A decided the resident could leave the facility grounds to go for walks as long as he/she checked in and out with administrative staff A. During an interview on [DATE] at 1:20 PM administrative nursing staff C reported he/she did not know how the resident knew the code to the front door and he/she did not make the decision on which resident could to out alone and for walks. Staff C reported the facility staff talked about residents at risk for elopement during the morning meetings and about which residents were allowed off campus. Staff C stated back in January the resident had walked too far, planned to go to a friend's house and thought it was OK since he/she had told the nurse he/she was going for a walk. During an interview on [DATE] at 1:58 PM administrative staff A reported the residents that knew the exit code to the front door obtained it prior to him/her working at the facility. Staff A stated the first time he/she let the resident go for a walk there were a lot of staff that came to his/her office and questions why the resident could leave the facility campus. Staff A said the facility did not have a plan in place to determine which residents could go off campus in the past. Staff A said the resident stuck his/her head in the office and said he/she was going out. Staff got the resident a hoodie so the towns' people would recognize the resident. Staff A assumed the residents were allowed to go off-campus because he/she saw them outside the

The facility census totaled 44 residents with 3 sampled for supervision to prevent accidents. The facility identified 32 residents as independently mobile with or without assistive devices. Based on observation, interview and record review the facility failed to assess residents at risk and failed to provide adequate supervision to prevent accidental burns from hot liquids delivered by a commercial coffee and hot water dispensing machine for 1 of 3 residents (#1). On 9/18/16, resident #1 attempted to get a beverage from the commercial coffee machine, spilling it on him/herself and resulting in first and second degree burns (burns which only affect the superficial skin layers are first degree, when injuries extends into some of the underlying skin layer it is a second degree burn). This placed resident #1 as well as the 31 other independently mobile residents in immediate jeopardy when the facility failed to secure the commercial coffee machine to prevent further accidents. Findings included: - Review of resident #1's admission orders [REDACTED]. Review of the admission MDS (minimum data set) for resident #1 dated 8/12/16 revealed a BIMS (brief interview for mental status) score of 6, indicating severe cognitive impairment. The resident required extensive assist with all ADLs (activities of daily living) except eating which required supervision. Review of the cognition CAA (care area assessment) dated 8/15/16 revealed the resident was oriented to person only. Review of the ADL CAA dated 8/15/16 revealed the resident required extensive assist with ADLs with the exception of locomotion while in the wheelchair and eating. Review of the nursing admission/history screening dated 8/7/16 indicated the resident had unsteady gait and poor balance with short and long-term memory problems. He/she required assistance with bed mobility, transfers, dressing and toilet use and ate independently. Review of the nutritional risk assessment dated [DATE] revealed no assessment regarding safety with hot beverages. The assessment section of the resident's record lacked a nursing assessment for hot beverages. Review of the care plan dated 8/26/16 revealed the resident had impaired cognitive function and required staff to cue, re-orient and supervise him/her as needed. The resident could make his/her own way throughout the facility in his/her wheelchair. The care plan indicated the resident had an ADL self-care deficit related to inability to maintain standing position without staff assistance. Staff were to provide assistance to the resident with dressing and extensive assistance by 2 staff for transfers to the wheelchair. He/she could propel the wheelchair independently to the dining room and ate independently. The care plan included the resident had limited physical mobility related to his/her inability to ambulate. The resident could independently move while in his/her wheelchair. The staff added the following to the care plan on 9/27/16: The resident had actual impairment to skin integrity of the right thigh related to a burn caused by obtaining hot water from the coffee machine. Interventions included: educate resident/family/caregivers of causative factors and measures to prevent skin injury. Identify/document potential causative factors and eliminate/resolve where possible. Staff educated the resident on the danger of the coffee machine. Staff were to closely monitor the resident while he/she was in the dining room and redirect him/her as needed. Staff were to place lids on the resident ' s hot fluids. Review of the physician's orders [REDACTED]. Change dressing daily until healed. Review of the September 2016 treatment administration record revealed staff administered Vaseline gel to blisters on right inner leg topically at bedtime every day between 9/20/16 until marked healed and discontinued on 9/26/16. Review of the nurses' notes revealed on 9/18/16 at 10:50 AM a nurse recorded the following; at approximately 9:40 AM dietary staff alerted this nurse the resident burned himself/herself with hot water from the coffee pot. The nurse made a skin assessment which revealed a large burned area to the front of the right middle inner thigh. The area was slightly warm to touch, no blistering at this time and light red/pink in color. Staff placed a call to the physician on call with no new orders. The note lacked any information regarding first aid provided such as rinsing the area with cool water. Review of the nurse ' s notes revealed an entry dated 9/19/16 at 2:11 PM: measurements of the resident's burn he/she received were as follows; approximately 7 cm (centimeters) in diameter with jagged sides and 4 blisters sizing from 1 cm to 1.5 cm. At 4:35 PM a nurse wrote the resident had an appointment to see the physician the next day. The physician ' s notes dated 9/20/16 revealed the physician saw the resident on 9/20/16 related to burns from a coffee spill 2 days prior. The physical exam revealed about halfway down the right inner thigh was a kind of waterfall of redness over 4 inches in length which started as about half an inch wide and widened to about 2 inches. In 3 areas on the periphery (the outer limits or edge of an area or object) of the widened area are clear fluid filled blisters, the largest being about 3/8 inch in diameter and the other two being 1/4 inch and flatter. The rest of the area was just red. The physician noted; 1st and 2nd degree burns from coffee on the inside right thigh. Review of the facility's investigation of the incident dated 9/18/16 at 9:40 AM revealed no evidence of a root cause analysis regarding why or how the resident had unsupervised access to the coffee/hot water machine. The investigation included a water temperature of 163 degrees but did not specify what water or when staff obtained the temperature. The corrective action taken by the facility included staff to shut off the coffee/hot water machine they closed the kitchen. Staff were to monitor coffee temperatures monthly, and ensure the coffee/hot water machine to remained visible by kitchen staff when in use. The facility did not provide evidence of temperature monitoring on the coffee/hot water machine either before the incident or after the incident as requested. Review of a sheet provided by the kitchen titled, Residents at risk for hot liquid burns dated 7/14/16 included all residents at the assisted table, 2 residents names typed and 4 names hand written. One of the names included resident #1 added on 9/19/16. On 9/27/16 at 8:50 AM observation with the supervisory dietary staff B revealed a coffee/hot water dispensing machine accessible to residents. The coffee/hot water dispensing machine sat on a counter in the dining room adjacent to the kitchen. The kitchen staff could visualize the coffee machine from the kitchen when staff opened the serving window. The machine delivered 6 types of coffee and the center button dispensed hot water. Dietary staff B checked the temperature of the coffee which measured 156.7 degrees F (Fahrenheit) as dispensed into a cup. The hot water measured 158.7 degrees F. On 9/27/16 at 10:15 AM observation revealed the resident sat in a wheelchair at the front doors where he/she remained until the resident propelled him/herself to the dining room table. He/she had a glass of water on the table already; he/she picked it up and drank without difficulty. At 11:17 AM dietary staff C prepared a cup of coffee for the resident. He/she added 2 ice cubes and covered the cup with a plastic lid. Once served the resident removed the lid, licked the coffee from it, set the lid down on the table and set the cup aside. Staff did not intervene to put the lid back on or explain the purpose to the resident. At 11:19 AM the resident picked up the coffee cup with both hands and drank the coffee without a lid. On 9/27/16 at 12:50 PM observation revealed direct care staff D and direct care staff E assisted the resident to toilet. Observation revealed on the resident ' s right lower inner thigh were 3 reddish/tan areas of skin discoloration and 1 small darker area that staff identified as a healing blister. He/she said the resident had a blister there a couple days ago. On 9/27/16 at 2:35 PM observation revealed the large serving window to the adjacent dining room was closed. Dietary staff F was in the kitchen by the stove and could not visualize the coffee/hot water machine. At this time the surveyor obtained a Styrofoam cup next to the machine and pushed the button to dispense coffee and hot water. On 9/27/16 at 2:49 PM observation revealed resident #3 walked up to the coffee machine and obtained coffee with the kitchen serving window still closed. At 3:03 PM the window remained closed. Dietary staff F confirmed the coffee/hot water machine remained on. Temperatures taken at that time with two separate thermometers revealed the coffee registered 158.1 degrees F and the hot water registered 167.3 degrees F. Dietary staff F reported he/she closed the window during the bingo activity which ended around 2:30 PM. On 9/27/16 at 12:30 PM direct care staff D reported he/she did not work on 9/18/16 but saw the burn and blisters on 9/19/16. He/she had not seen the resident attempt to get coffee from the machine. Usually the staff brought it to the resident. He/she reported not knowing of any changes to the care plan since the incident. He/she said the staff had discussed it and started adding ice and putting a lid on the cup. He/she said would find out about changes in shift to shift report and the care plan. On 9/27/16 at 2:49 PM direct care staff G reported he/she had not seen the resident attempt to get coffee from the machine. He/she said normally the resident asked staff for coffee with 2 creamers. Since the incident staff were to put a lid on the coffee before serving the resident. On 9/27/16 at 8:50 AM supervisory dietary staff B reported he/she had not taken routine temperatures of the coffee/hot water prior to the incident but had taken some random ones since the incident but did not write it down on a log. On 9/27/16 at 9:00 AM dietary staff H reported he/she was in the kitchen preparing food on 9/18/16 at the time of the incident when a resident came to the kitchen and said the resident had spilled coffee on him/her self. He/she could not remember if the window was open all the way or part way. He/she usually opened the window about 6:00 AM when he/she started the coffee. He/she reported he/she did not see the resident in the area or accessing the machine. He/she reported there was water on the floor, the resident's pants were wet and the resident had a Styrofoam cup in his/her had with some hot water in it. Dietary staff H said he/she reported it to the nurse. Dietary staff H reported the changes made since the incident included educating the residents to ask for help. He/she thought the company had turned the temperature down on the coffee machine, but he/she did not know for sure. He/she reported the temperatures were monitored by supervisory dietary staff B. On 9/27/16 at 9:48 AM supervisory dietary staff B reported the facility had no information from the manufacturer about the machine or what the temperature should be. He/she said the company representative who serviced the machine reported most machines were set to have an inlet temperature of 196 degrees F. Supervisory dietary staff B said coffee brewed in the kitchen was served at 140 degrees F. He/she reported since the incident the serving window should be open once staff started the coffee to allow for visualization. When the kitchen closed, staff were expected to remove the coffee cartons and lock out the water. At this time he/she demonstrated opening the machine cabinet (which was not locked) and pushing a button labeled lock. He/she reported the staff had a list of residents were to have ice added to hot beverages and a lid on the cup. Review of the list revealed the resident ' s name added on 9/20/16. On 9/27/16 at 1:18 PM licensed nurse J reported prior to the incident dietary staff served the resident his/her coffee when he/she came to the table. He/she reported the resident usually asked for coffee or would hold his/her cup up. He/she did not know of any changes to the procedures since the incident. On 9/28/16 at 12:46 PM licensed nurse K said he/she circulated around during the meals to monitor for safety and the staff knew the residents that cannot be left alone in the dining room. He/she did not know of any changes since the incident. He/she would find out in report or on the care plan. On 9/27/16 at 1:20 PM administrative nurse M confirmed the care plan lacked revision following the incident. On 9/27/16 at 3:11 PM administrative nurse L confirmed the resident had not been assessed for safety with hot beverages prior to the incident but staff put him/her on the watch list for the kitchen now. He/she confirmed he/she worked as the floor nurse when resident #1 burned him/herself. He/she did not report administering first aid at the time when explaining the incident. When asked if he/she provided first aid, he/she replied he/she had applied a cool wet cloth. After he/she talked with the physician he/she did not do anything further. He/she said the facility did not have information on first aid for burns and the staff were expected to call the physician and follow those orders/directions. He/she reported he/she had not looked at other residents for risk as part of the investigation or at any time since the incident. He/she believed the increased supervision would fix the problem. The policy/procedure titled, Residents at risk for hot burns from beverages dated 7/19/16 directed staff preventive measures will be taken for all residents at risk for hot burns due to shaking, poor motor skills or those who may not be cognitive to make proper decision with hot liquids. Residents will be monitored for signs or symptoms that put them at risk for getting burned with hot liquids by nursing or dietary. The hot liquids for at risk residents would be cooled before served by placement of 2 ice cubes in the hot liquid and the cups would have lids. Nursing would monitor to make sure these residents kept the lids on the cups and remind the residents of the reason why there is a lid on their hot beverages. The facility failed to assess resident #1 for risks with hot liquids and failed to provide adequate supervision to prevent accidental burns from hot liquids delivered by a coffee and hot water dispensing machine. On 9/18/16, resident #1 attempted to get a beverage from the commercial coffee machine, spilling it on him/herself and resulting in first and second degree burns (burns which only affect the superficial skin layers are first degree, when injuries extends into some of the underlying skin layer it is a second degree burn). This placed resident #1 as well as the 31 other independently mobile residents in immediate jeopardy when the facility failed to secure the commercial coffee machine to prevent further accidents. On 9/28/16 the facility abated the immediate jeopardy when they implemented removal of the commercial coffee machine from the dining room; implemented a new system to ensure residents would receive hot beverages from the facility kitchen with lidded cups; and educated all staff on all shifts regarding the new system for hot beverages. This deficient practice remains at the scope and severity of a G.

The facility reported a census of 39 residents with 19 residents sampled and 10 of the 19 sampled for review of unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure that one of ten sampled residents medication regimen remained free of unnecessary medications. (#36) The facility failed to monitor the resident for possible undesired side effects of the medications, failed to ensure that staff administered medications in accordance with the manufacturer's guidelines and failed to follow up on recommendations from the consulting pharmacist regarding the increased potential for a [MEDICAL CONDITION]. Resident #36 experienced a [MEDICAL CONDITION]. Findings included: - The 4/22/11 Significant Change MDS (minimum data set assessment) post-discharge from a Geriatric Psychiatric Unit, revealed resident #36 with severe cognitive impairment and totally dependent on two persons for Activities of Daily Living. This assessment also documented the resident with verbal and physical behavior difficulties. The dated 4/22/11 Care Area Assessment Summary for Behavior revealed the resident remained calm through the day, but became restless, loud, yelled and became difficult to redirect and calm down. The 5/6/11 Care Plan revealed the resident's inability to participate in activities related to the loss of physical function and loss of cognitive function. During multiple random observations on 10/19, 10/20, 10/24, 10/25, and 10/26/11, survey staff observed a lethargic individual that would respond to verbal and tactile stimuli, but spent most of the time sleeping in the wheelchair or in the recliner in his/her room. During observation of the resident during an activity on 10/24/11 at 10:30 a.m., Activity Staff Q placed a bean bag in the resident's hand and after approximately 4 minutes of coaxing, the resident released the bean bag into the container. Resident #36's medical record included a Behavior Monitoring Sheet. An interview with Licensed Nursing Staff G on 10/24/11 at 9:45 a.m. confirmed staff documented on the form for psychoactive and antidepressant medication side effects. The Behavior Monitoring Sheets for Resident #36 directed staff to record resident behaviors of hitting staff, yelling at staff, and signs of depression. The behavior monitoring sheet for the month of July 2011 included two behavior episodes, one when the resident refused a bath and the other when the resident refused to go to the bathroom. During the Month of August 2011, staff identified no episodes of this type of behavior. The September 2011 behavior sheet included 2 behavior episodes that included repetitive speech. The October behavior monitoring sheet indicated no behaviors for the month as of 10/24/11. The physician order [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] ? [MEDICATION NAME] 0.25 mg (milligrams) daily at bedtime for anxiety (an antianxiety medication) since 2/24/11 ? [MEDICATION NAME] 2 [MEDICATION NAME](Oral Disintegrating Tablet) one tablet in mouth daily at 1600 (4 p.m.) for behavior disturbances (an atypical antipsychotic) since 12/22/10 ? [MEDICATION NAME] 0.5 mg every morning for behavior disorder since 4/27/11 ? [MEDICATION NAME] 1 mg every day at bedtime since 6/24/11 ? Trazadone 100 mg at bedtime for depression (antidepressant medication) since 3/21/11 ? [MEDICATION NAME] 60 mg each morning for depression (antidepressant medication) since 8/20/11 ? [MEDICATION NAME] 15 mg daily for depression (antidepressant medication) since 4/27/11 ? [MEDICATION NAME] 10 mg twice daily for Alzheimer Dementia since 8/11/11 ? Donepezil 10 mg at bedtime for Dementia since admission 12/22/10 ? [MEDICATION NAME] daily [MEDICAL CONDITION] (prevents blood clots from forming) since admission 12/22/10 ? [MEDICATION NAME] 150 mg twice daily (0800, 1800) [MEDICAL CONDITION](gastro [MEDICAL CONDITION] reflux disease) since 12/22/10 ? [MEDICATION NAME] Suspension 1 gm (gram) at 0800, 1200, 1800 and 2000 since 9/10/11 as twice daily; increased to four times daily since 10/4/11 ? [MEDICATION NAME] 400 mg daily for arthritis pain since 4/27/11 (discontinued 9/10/11). The Table 1 in the State Operations Manual at F329 CFR 483.25(I)states: " The use of an antipsychotic must meet the criteria and applicable requirement below: A. The symptoms are identified as being due [MEDICAL CONDITIONS] or B. The behavior symptoms present a danger to the resident or others or C. The symptoms are significant enough that the resident is experiencing one or more of the following: Inconsolable or persistent distress (e.g. fear, continuously yelling, screaming). . . " Resident #36 received 3.5 mg of Risperdone daily. The Lexi-Comp 2011 Drug Handbook included a black box warning for the drug [MEDICATION NAME] that read: "Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotics are at an increased risk for death compared to placebo. " The Lexi-Comp 2011 Drug Handbook also states that the use of the drug [MEDICATION NAME] is contraindicated with active pathological bleeding such as [MEDICAL CONDITION] ulcer disease. The Lexi-Comp 2011 Drug Handbook indicates that [MEDICATION NAME] should be given for no more than 8 weeks to heal [MEDICAL CONDITION] ulceration. The medication should be administered 1 hour before meals or 2 hours after meals. According to the October 2011 MAR, the resident received [MEDICATION NAME] 45 minutes after breakfast, 45 minutes after lunch, and 45 minutes after the evening meal. The Lexi-Comp 2011 Drug Handbook indicates the medication [MEDICATION NAME] ([MEDICATION NAME]) should be administered 30 minutes before meals. According to the October 2011 MAR, the resident received [MEDICATION NAME] 45 minutes after breakfast and 45 minutes after the evening meal. The 5/11/11 pharmacy review revealed the [MEDICATION NAME] dose increased, and also noted that [MEDICATION NAME] may increase confusion in elderly - also GI (gastrointestinal) problems. The 7/11/11 pharmacy review notified staff of the risk of increased bleeding with the use of [MEDICATION NAME] and [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]). The 8/11/11 pharmacy review notified the staff of significant problems with [MEDICATION NAME] and [MEDICATION NAME] in patients [MEDICAL CONDITION] history of bleeding. The review also noted, "the patient is on 3 antidepressants." The nurses' notes dated 9/6/11 at 0600, revealed the resident had a large bowel movement full of blood clots. Staff transported resident #36 to the hospital with a [MEDICAL CONDITION]. The resident returned from the hospital on [DATE]. The 9/10/11 physician admission orders [REDACTED]. The 9/11/11 pharmacy review noted the discontinuing of [MEDICATION NAME] and increase of the [MEDICATION NAME] ([MEDICATION NAME]) dose, added [MEDICATION NAME] suspension, and the same bleeding warning. Discontinued one but added [MEDICATION NAME] so monitor patient. Psy (sic) last done May 11 but multiple changes since then. According to the nurses' notes on 10/4/11 at 2000, "Resident has been very lethargic and drowsy this evening, will not answer questions . . . " Interview of consultant T on 10/26/11 at 3:30 p.m. confirmed that the monthly pharmacy reports included warnings to staff regarding the medication regimen for resident #36. On 10/25/11 at 3:15 PM Direct care staff R and S stated that the resident had been pretty lethargic especially the past few weeks. During an interview on 10/26/11 at 8:30 a.m., Social Service Staff D stated, " The resident has not been good since the resident returned from the hospital following a [MEDICAL CONDITION] bleed about a month ago. We thought the resident was going to do it again this week." During an interview on 10/26/11 at 3:00 p.m., with Physician's Assistant U, responsible for the residents care, confirmed that reducing some of the resident's medications would be indicated with the resident's present level of consciousness, he/she also agreed that the [MEDICATION NAME] should be administered 1 hour before meals or two hours after, and also confirmed receipt of the recommendations from the pharmacist. Resident #36 received unnecessary medications. An unnecessary medication is any medication given without adequate indication, without adequate monitoring, or in the presence of side effects. The pharmacy reviews alerted staff to significant concerns with the medication regimen that increased the risk of [MEDICAL CONDITION] with no action or risk benefit statement from the physician to continue the medication. Resident # 36 experienced a [MEDICAL CONDITION]. The resident continued to receive antipsychotic medications without the evidence of aggressive behaviors that would indicate the need for continued use of the medication. The resident continued to receive the antianxiety medication [MEDICATION NAME] when the resident displayed symptoms of over sedation.

The facility reported a census of 38 residents with three sampled for review. Based on observation, interview and record review, the facility failed to provide thorough assessments of existing pressure ulcers and implementation physician orders [REDACTED].#2) and failed to provide timely position changes and pressure reduction devices/techniques to prevent pressure ulcers for 3 of 3 residents identified as at risk for pressure ulcers. (#1, #2, #3) Findings included: - A 1/6/11 Quarterly MDS (minimum data set) identified resident #2 usually understood, had long and short term memory loss with severely impaired decision-making skills. The resident required extensive to total assistance with transfers and bed mobility. The resident had no skin issues but had a risk for pressure ulcers. The record showed the resident returned from a hospital stay on 2/21/11. Discharge instructions from that date stated to notify the physician of redness or swelling around a wound, or foul drainage from the wound and to keep pressure off the resident ' s right heel. Neither the discharge instructions nor the admission nursing notes showed any evidence of an assessment of a wound for the resident. Nursing notes from 2/22/11 at 10:30 am stated, " Has purple area 3 cm (centimeters) round on right heel. Dressing applied for protection use heel protector when down in bed. " The record lacked evidence of physician orders [REDACTED]. On 2/24/11 at 7 pm, nursing staff noted the resident right heel had a " bluish area. " The record lacked a complete assessment of the area which included the size of the discoloration. The record lacked evidence of any further assessments of the wound until 3/4/11, 8 days later. A 3/4/11 assessment showed the resident had a " blackened area, unopened " to the right foot. The record lacked evidence staff notified the physician of the changes in the resident ' s wound. Assessments on 3/10/11, 3/17/11, 3/24/11 and 3/28/11 stated the resident had a black area to the right heel. The assessments lacked the size of the blackened area and whether the area contained intact skin over the black area or if the black area was eschar (a black, scab-like substance indicating deep wounds). The record lacked evidence staff notified the physician of the changes in the heel following any of the above four assessments. A 4/5/11 Significant Change MDS assessment identified that the resident continued to have both long and short term memory deficits and continued to require extensive to total assistance of 1 - 2 persons for assistance with all ADLS, including transfers and bed mobility. It identified the resident had one unstageable pressure ulcer with necrotic tissue that was present on reentry and did not have a dressing or treatment. On 4/6/11, the physician assessed the wound during routine rounds. The physician progress notes [REDACTED]. ... large black eschar painful dry. " The physician left orders for staff to apply heel protectors at all times and to refer to a skin and wound specialist for the resident ' s heel ulcer. On 6/14/11 at 1 pm, social services staff C reported she had attempted to contact the wound specialist but could not get the resident into the specialist due to vacations. She stated the specialist had offices in three different locations and, although the facility did take residents to two of the three locations, she had not attempted to get an appointment for the resident in the soonest time possible, instead opting to make an appointment one month later on 5/6/10. Administrative nursing staff B reported on 6/14/11 at 1 pm that the staff did not make the physician aware of the one month delay in seeing the specialist. A 4/19/11 care plan identified the resident as at risk for pressure ulcers with a goal of " will not have any pressure sores for 90 days " and included the following interventions: o " Skin assessment weekly. o Pressure risk quarterly. o Turn q (every) 2 hours while in bed and reposition while in chair. o Pad in chair. o Follow dietary protocol for decubitus as needed. o Heel protectors at all times with heels floating while in bed with boots, or pillows. o Continue to monitor heel. o Do not remove eschar unless instructed by MD to do so. The record contained two wound assessments by two different nurses on 4/14/11. The notes indicated a wound measuring 7.5 cm x 7.5 cm with a blackened area to the right heel and a wound assessment form showed a 4 x 6 cm wound with necrotic eshcar to the right heel; a significant difference in size. Wound assessment and Care records from 4/20/11 - 5/4/11 showed the staff assessed the residents wound at 5 cm x 4.5 cm with necrotic eschar and no drainage. Assessments from 4/30/11 - 5/4/11 showed the resident had " other " tissue type at the wound site but did not specify the " other " tissue type. Wound assessments on 5/4/11 and 5/5/11, nursing staff noted drainage from the wound but no foul odor or purulence at the site. The record lacked evidence staff notified the physician of the changes in the wound. On 5/6/11, one month following the physician recommendation for the specialist, the wound care specialist assessed the wound. The progress notes stated, " Cool foot, necrotic wound posterior heel with purulence on edge, positive for malodor, pulses faintly palpable. " Administrative nursing staff B, on 6/14/11 at 1 pm, confirmed the wound had worsened during the month between the order for the referral and the appointment. Although nursing notes indicated the physician debrided (removed some of the necrotic tissue) the ulcer on 5/6/11, none of the assessments from 5/6/11 - 6/13/11 showed evidence of an accurate assessment of the depth of the wound or any assessment of the wound bed. Wound assessment records lacked a standardized system for accurate measurements of the wound. Although staff traced the wound onto a measurement guide, some staff centered the guide on the wound, other staff placed the center of the guide on the edge of the wound, and other tracings showed the guide off-center of the wound. On 6/14/11 at 12:25 pm, nursing staff E, F and G assisted the resident to bed. The resident had an intact dressing to the right heel and a pressure reducing boot on the right foot. After staff laid the resident in bed, staff did not elevate the resident ' s heels or place any device onto the left foot to prevent pressure ulcers on that foot. Observations of the wound on 6/14/11 at 3:20 pm showed a stage III ulcer to the right heel. The ulcer measured 0.7 cm in depth, had a beefy red center with flecks of white in the wound base. The edges of the wound appeared pale with a discolored, bruise-like area noted approximately 1 cm away from the wound at the 10 o ' clock area. The resident also had two small scabbed areas on the back of the ankle along the Achilles tendon. After licensed nurse D changed the resident ' s dressing, staff placed the pressure reduction boot on the resident ' s right heel, covered the resident and left the room. Staff again did not elevate the resident ' s feed nor place any pressure reduction devices to the resident ' s left heel to prevent further ulcers. Licensed nurse D stated at 3:20 pm during the dressing change that she did not know about the two wounds on the back of the ankle. Medication aide E reported at 3:10 pm that the medication aides usually performed dressing changes to the wound and the licensed nurses just assessed the wound. She stated she had placed a [MEDICATION NAME] dressing to the areas on the back of the ankle to help with healing. The record lacked evidence of physician notification of the two new wounds or a physician's order [REDACTED]. Administrative nursing staff B reported on 6/14/11 at 1 pm the facility lacked a system to ensure timely and accurate assessments of pressure ulcers. The National Pressure Ulcer Advisory Panel 2009 Pressure Ulcer Prevention and Treatment Clinical Practice Guidelines, provided by the facility stated, " Assess the pressure ulcer initially and re-assess at least weekly, documenting findings. " The guidelines further stated to " Assess and accurately document physical characteristics such as location, category/Stage, size, tissue type(s), would bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudates, necrotic tissue, odor, presence/absence of granulation tissue, and [MEDICATION NAME]. " In summary, the facility failed to initiate physician's order [REDACTED]. The pressure ulcer for resident #2 worsened within that month. The facility also failed to have a system in place to ensure accurate and complete wound assessments, timely physician notification for changes in a wound, and to implement pressure reduction techniques to prevent further pressure ulcers. -A 5/10/11 Annual MDS (minimum data set) assessment showed resident #1 had unclear speech with slurred or mumbled words and sometimes understood communication with staff. The resident had both long and short term memory impairments with severely impaired decision making abilities and required total assistance of 1 -2 persons with transfers, bed mobility and toileting. The resident had no pressure ulcers s but was identified as at risk for pressure ulcers and had a healed stage 2 pressure ulcer. An undated Pressure ulcer CAA (care area assessment) stated, " Potential for pressure ulcers because resident cannot move ...or change position. Allergy to gel pad if skin to pad contact, sheepskin in chair and on back of chair so skin doesn ' t touch gel pad, elevate heels while in bed with pillows turn and reposition every 2 hours and good nutrition " A 5/24/11 care plan included a problem for altered skin integrity related to the inability to move independently. Interventions included: o A skin assessment weekly. o Out of bed daily for all meals. o Turn every 2 hours at night, o Monitor nutritional status, o Provide supplemental protein to promote healing o Keep bed as flat as possible to reduce friction, o Clean well after urinary incontinence to ensure no odor or skin breakdown, o Place a blanket or pillow between knees when in bed. o Pillow under legs to keep heels off of bed. On 6/14/11 10:30 am the resident sat in wheelchair in living area with no pressure reduction device between the resident and the chair. At 11:24 am on the same date, the resident sat in the dining room eating lunch, again with no pressure reduction under resident. Frequent observations of the resident between 10:30 am and 1:10 pm showed the resident sat in the wheelchair without a pressure reduction surface (a period of 2 hours and 40 minutes) At 1:10 pm, nursing staff H, E and J assisted the resident to the toilet. Nursing staff J confirmed the resident did not have a pressure relief pad to the wheelchair. She stated, " (the resident) is supposed to have a gel pad to the chair. " Staff J also stated the resident had an alternating air flow mattress on the bed. When checked by staff J, she noted the air mattress did not function. She stated she did not know how long the mattress had not functioned. In summary, although identified as at risk for pressure ulcers, the facility failed to provide timely position changes and pressure reduction surfaces for resident #1. - An annual 5/17/11 MDS assessment showed resident #3 had short and long term memory loss and severely impaired cognitive skills. ? The assessment showed the resident required total staff assistance of 1-2 staff for bed mobility, transfer and toilet use. The assessment showed the resident as at risk for ulcers. The 5/31/11 care plan included a problem of potential for pressure ulcers related to the inability to move per self. Interventions included: o Staff to turn or reposition resident every 2 hours at night and wile in the chair. o Pressure assessment quarterly and skin assessed weekly. o To watch for red areas and report to nurse. o Gel pad in wheelchair. Frequent observations between 12:10 pm and 3:20 pm showed the resident sat in a recliner in the room (a total of 3 hours and 10 minutes) without a position change. In summary, the facility failed to provide timely position changes for resident #3 identified as at risk for pressure ulcers.