Every finding on record at Providence Child Center

Based on observation, interview and record review it was determined the facility failed to ensure residents with limited range of motion received necessary equipment to prevent a further decrease in range of motion for 1 of 1 sampled resident (#3) reviewed for position and mobility. This placed residents at risk for worsening contractures. Findings include: Resident 3 was admitted to the facility in 2017 with diagnoses including contracture of multiple joints. Resident 3's 2/14/24 Quarterly MDS indicated the resident rarely/never made decisions, was dependent for all ADLs and experienced upper extremity impairment on both sides. A 3/6/24 Pediatric Physical Therapy Treatment Note indicated Resident 3 utilized hand splints. Resident 3's current HOB (Head of Bed) Care Plan directed the resident to wear hand splints when up in her/his wheelchair. Random observations of Resident 3 on 4/15/24 and 4/16/24 between 10:14 AM and 3:49 PM revealed the resident was up in her/his wheelchair without hand splints. The resident's fingers curled in towards the palm of her/his hands in the shape of a fist. On 4/17/24 at 11:12 AM Staff 3 (PT) stated Resident 3 was to wear hand splints when she/he was in her/his wheelchair and the splints were to be removed when the resident was in bed. On 4/17/24 at 11:27 AM and 3:49 PM Staff 4 (OT) stated Resident 3 was to wear hand splints when she/he was out of bed and in her/his wheelchair. Staff 4 further stated the hand splints were used for contracture prevention. On 4/17/24 at 12:22 PM Staff 5 (CNA) and at 12:24 PM Staff 6 (RN) indicated they found information about a resident's care needs in the resident's kardex (a tool that makes resident information accessible in a concise manner) or in the HOB care plan. Staff 5 and Staff 6 stated they had never seen Resident 3 wear hand splints and did not think the resident needed them. On 4/17/24 at 2:12 PM Staff 7 (RNCM) stated a resident's HOB care plan was the primary spot where direct care staff should go to find therapy-related information on residents, including the type of equipment used. Staff 7 reviewed Resident 3's HOB care plan and stated the resident should wear hand splints when she/he was up in her/his wheelchair. On 4/18/24 at 2:32 PM Staff 2 (DNS) and Staff 8 (Nurse Manager) acknowledged the findings of this investigation. Staff 2 confirmed information on resident equipment needs was found in the resident's HOB care plan and the types of equipment used by residents was determined by PT. Staff 8 stated she expected Resident 3 to wear hand splints when in her/his wheelchair.

Based on interview and record review it was determined the facility failed to put services in place to eliminate the risk of elopement for 1 of 1 sampled resident reviewed for elopement. Resident 1 was identified by the facility to have eloped from the building on 12/17/23 at approximately 4:00 PM and was not found until 9:00 PM. This failure was determined to be an immediate jeopardy situation because the facility failed to identify and put in place services to prevent Resident 1's elopement risk which placed residents at risk of harm or death. Immediate Jeopardy situation began on 12/19/23. Findings include: Resident 1 admitted to the facility on [DATE] with diagnosis of Dementia. Hospital discharge records dated 12/2/23 revealed Resident 1 had a history of severe cognitive impairment and history of wandering behaviors, risk of self-harm and required 24-hour care. The facility assessment dated [DATE] identified Resident 1 with wandering behaviors due to diagnosis of Dementia. On 12/17/23 a Facility Invesitigation Report identified Resident 1 had eloped from the facility at exactly 4:00 PM through an emergency exit door that [faced a busy intersection and highway]. The RN indicated she was unaware that Resident 1 had exited through the back exit as she was unaware the door was an emergency exit that led to the street. Further evidence indicated the emergency exit alarm chirped instead of alarming staff when the resident exited the facility. [Care staff failed to follow and understand protocols related resident elopement and failed to identify the sound of emergency exit alarm when sounded]. Resident 1 had a diagnosis of dementia and severe cognitive impairment and was missing for approximately five hours [in a dimly lit industrial area where it was 42 degrees outside]. A 12/18/23 Communication Note revealed Resident 1 was taken to the emergency room for observation before returning to the facility. On 12/19/23 at 10:52 AM Staff 5 (RN) indicated Resident 1 was located by family [between 8:30 PM and 9:00 PM inside a convenience store 2 miles away]. During interviews conducted on 12/19/23, Staff 4 (RN), Staff 5 (RN), Staff 6 (CNA) and Staff 7 (CNA) who were identified as the care staff involved in locating the resident during elopement on 12/17/23. Care staff stated they did not know Resident 1 her/his eloped from the emergency exit door. Furthermore, it was also determined care staff were unaware of the location and alarming system of an emergency exit door and were unaware of facility protocols when Resident 1 eloped from the facility. On 12/19/23 at 4:07 PM confirmed findings with Staff 1 (Administrator) and Staff 2 (DNS) and no additional information was provided. On 12/19/23 at 4:11 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 12/19/23 at 6:00 PM the facility submitted an acceptable immediacy removal plan. The immediacy removal plan included the following: Resident 1 is still a resident of this facility, facility to educate all ICF staff on alarm sound, use, rearming alarm, and response of emergency exit door on ICF, 2nd floor, North stairs. Education on all shifts by nursing leaders until all staff are training. Staff will be educated and trained at the beginning of their shift. Verbal and written competency trained and signed by staff. Educate staff on response to elopement of resident. Immediate action to account for all residents. Immediate notification if resident elopement is noted. Immediacy action for action for substantiated eloped resident. If the alarm sounds, all staff must respond immediately. One staff to go down the stairs and out the building to determine if resident left unit, one staff accounting for all residents if residents is missing, one staff calling 911 then security, one staff contacting administrator, one staff contacting family. On 12/19/23 at 6:33 PM observation, interview and record reviews were completed which verified the immediacy removal plan was fully implemented on 12/19/23.

Based on observation, interview and record review it was determined the facility failed to accurately document and display the DCSDR (Direct Care Staff Daily Report) in a prominent place readily accessible to residents and visitors for 33 of 33 days reviewed for staffing and for 2 of 2 units. This placed residents and visitors at risk for being uninformed of available staff and hours worked by facility staff. Findings include: Random observations from 1/23/23 through 1/26/23 revealed the DCSDR forms on the unit downstairs were posted in a hallway adjacent to the entrance not visible to the public and the form was sideways. The DCSDR forms were blank or inaccurate and missing census, current staff and hours worked. The upstairs unit had a DCSDR posted outside the medication storage room and the forms were inaccurate, dated incorrectly, missing daily census, number of working staff and hours worked. A review of the two separate DCSDR's, dated from 12/25/22 through 1/26/23 revealed 33 instances where the forms did not indicate the same information for both units and portions of the forms on each unit were inaccurate. The incomplete or inaccurate information included daily census number, signatures, number of working staff and hours worked by staff. On 1/24/23 at 9:21 AM and 1/26/23 at 3:15 PM Staff 2 (DNS) stated there was only one DCSDR which was completed and posted on the downstairs unit. Staff 2 was shown the forms from upstairs and indicated she would discuss with Staff 3 (DNS) in regard to the two separate DCSDR postings. Staff 2 acknowledged the DCSDR forms were not accurate or completed each shift and the DCSDR should be posted in a prominent area readily accessible to residents and visitors.

Based on interview it was determined the facility failed to ensure residents were provided with the opportunity to develop a Resident Council for 1 of 2 residential units (the adult unit) reviewed for Resident Council. This placed residents at risk for a lack of participation in group discussions regarding facility policies, procedures and resident rights. Findings include: The adult unit of the faciity had a census of eleven. Four of the eleven residents resided on the unit longer than 6 months. On 1/23/23 at 10:36 AM Staff 3 (DNS) stated the adult residential unit did not have a Resident Council. On 1/27/23 at 3:27 PM Staff 1 (Administrator) stated the adult unit did not have a Resident Council.

Based on observation, interview and record review it was determined the facility failed to ensure residents' personal information was not visible to the public for 1 of 2 resident care units. This placed residents at risk for unprotected personal heath information. Findings include: Observations from 1/23/23 to 1/27/23 revealed the presence of a large dry erase board in the main area of the adult care unit visible to all staff, residents and visitors. The board had documentation of room number and initials of each resident with care notes such as transfer status, appointments, hospice, dialysis, and behaviors. On 1/26/23 at 10:02 AM Staff 8 (RN) confirmed the facility utilized the white board as a means of communication for all staff and it was helpful when agency staff worked on the floor. Staff 8 stated it was easier than sifting through the electronic record to locate the care plan which was not easily accessible. On 1/27/23 at 9:17 AM Staff 6 (RN) indicated the facility had discussed options other than the white board for direct care communication but had not implemented an alternative process. On 1/30/23 at 10:32 AM Staff 3 (DNS) confirmed the facility was posting too much personal information on the white board by the nurses' station and the facility had plans to find other means to communicate resident care needs to direct care staff.

Based on interview and record review it was determined the facility failed to obtain therapy services for 1 of 1 sampled residents (#23) reviewed for therapy services. This placed residents at risk for a decline in functional abilities. Findings include: Resident 23 readmitted to the facility in 11/2022 with diagnoses including stroke and anxiety. A physician order on 12/29/22 directed staff to request an evaluation and treatment for OT and PT. A Communication Result Report (a fax document) dated 1/10/23 (12 days later) requested PT and OT from Staff 7 (Administrator Coordinator/Care Manager). On 1/23/23 at 12:15 PM Resident 23 stated she/he was frustrated because she/he was not working with therapy services. On 1/26/23 at 10:18 AM Staff 8 (RN) stated Resident 23 was upset because she/he was not provided PT or OT. Staff 8 stated he reported his concerns to Staff 7 and she thought it would be a good idea to initiate therapy services. On 1/26/23 at 11:04 AM Staff 7 acknowledged Resident 23 requested PT and OT in 12/2022 and the physician initiated the orders. Staff 7 stated the request was delayed due to the holidays and her being sick. Staff 7 further stated she sent a second fax on 1/26/23 for PT and OT for Resident 23. A Communication Result Report dated 1/26/23 (28 days later) requested PT and OT evaluation. On 1/30/23 at 8:27 AM Staff 3 (DNS) acknowledged the delay in therapy services for Resident 23.

Based on interview and record review it was determined the facility failed to have a contract with the dialysis provider for 1 of 1 sampled resident (#83) reviewed for dialysis services. This placed the resident at risk for unmet needs. Findings Include: Resident 83 was admitted to the facility in 1/2023 with diagnoses including end-stage renal disease requiring dialysis. Resident 83 received dialysis three days each week. On 1/27/23 at 3:27 PM Staff 1 (Administrator) confirmed the facility did not have a contract with the dialysis clinic that served Resident 83. She stated the facility had no contracts with any other dialysis facilities and would need to develop those for future needs.

Based on interview and record review it was determined the facility failed to thoroughly investigate falls for 1 of 2 sampled residents (#8) reviewed for accidents. This placed residents at risk for unmet needs. Findings include: Resident 8 admitted in 5/2022 with diagnoses including Alzheimer's disease and a history of falls. Fall investigations revealed the following: *Fall #1: -On 6/25/22 Staff 23 (Former LPN) heard a noise from Resident 8's room and found the resident with her/his back to the toilet in a seated position on the floor. Resident 8 had a skin tear to the right elbow. Staff 16 (CNA) last toileted Resident 8 at 5:30 AM and Staff 16 indicated he assisted her/him to the bathroom roughly six times throughout the night. The bed alarm was not on when Resident 8 was found on the floor with her/his back to the toilet. The investigation revealed Staff Resident 8 transferred herself/himself to the bathroom unassisted however, Staff 16 forgot to reset the bed alarm after taking Resident 8 to the bathroom at 5:30 AM. Resident 8 had no attempts to get out of bed prior to the incident. No indication of abuse. -The investigation did not include any witness statements or if Resident 8 had any signs or symptoms of impulsiveness prior to the 6/25/22 incident. -Records reviewed from 6/12/22 through 6/24/22 revealed Resident 8 was confusion, was impulsive, attempted to get up out of bed frequently to utilize the bathroom. Resident 8 did not complain of pain with urination, urine was yellow in color with no odor. -A progress note dated 6/26/22 revealed during a shower, staff discovered a bruise on the back of Resident 8's head and she/he confirmed hitting her/his head on the ground during the fall on 6/25/22. *Fall #2 On 12/15/22 Staff 8 (RN) heard Resident 8 yelling help, pee pee from the nurse's station. Staff 8 entered the room and found Resident 8 on the floor with her/his back against the bed and the bed alarm was not sounding. Resident 8 stated owie, my bottom, I fell . No sign of injury and she/he did not hit her/his head. Staff indicated Resident 8 was checked on 30 minutes prior to the incident by Staff 15 (CNA). -Staff 22 (Former RN) indicated Resident 8 was checked 30 minutes before she/he was found on the floor. Staff 15 indicated she thought she set the bed alarm but stated she must not have. The investigation revealed Resident 8 self-transferred, no injury, resident did not use call light and was impulsive. No indication of abuse. -A 12/15/22 progress note prior to Resident 8's fall indicated she/he had increased confusion was impulsive during the shift and her/his right hip was red hot to the touch and the redness was moving outside of the previous markers. Cream was applied to the area and Resident 8 was easily redirected. -The investigation did not include any additional witness statements or if Resident 8 had any signs or symptoms of impulsiveness or other potential concerns prior to the 12/15/22 incident. On 1/27/23 at 11:33 AM Staff 3 (DNS) stated she was unable to locate any documentation related to the witness statements for the 6/25/22 or 12/15/22 fall incidents. Staff 3 stated she would expect staff to initiate the investigation and include who, what, when, where, why, and an analysis of what the resident was doing prior or possible behaviors. Staff 3 further stated what they would implement after and if the care plan needed to be updated. On 1/30/23 at 10:04 AM Staff 11 (Former DNS) stated Staff 12 completed the investigations for the 6/2022 and 12/2022 falls vand would expect any person or resident who witnessed or had information related to the resident prior to be interviewed and their information incorporated into the incident report. Staff 11 stated she expected witness statements to be documented. On 1/30/23 at 12:26 PM Staff 12 (Former Assistant Care Manager/Certified Recreational therapist) stated she completed the investigations on 6/25/22 and 12/15/22. Staff 12 stated she would interview all staff in relation to the incident and residents. Staff 12 stated she would summarize her analysis of the incident to rule out abuse and neglect and witness statements should be documented. Refer to F689

Based on interview and record review it was determined the facility failed to assure a Level I PASARR (Preadmission Screening for Individuals with a Mental Disorder and Individuals with Intellectual Disability) was completed for 1 of 2 sampled residents (#10) reviewed for PASARR. This placed residents at risk for inappropriate placement in a nursing facility and a lack of needed services. Findings include: Resident 10 was admitted to the facility in 10/2020 with diagnoses including Lennox-Gastaut syndrome (a seizure disorder) and cerebral palsy. A review of the resident's electronic health record revealed Resident 10 was admitted for long term care in 10/2020 without the completion of a screening Level I PASARR. On 1/25/23 at 8:58 AM Staff 2 (DNS) stated an emergency suspension of PASARR's was in effect at the time of Resident 10's admission into long term care and was not required. On 1/25/23 at 3:57 PM Staff 5 (Administrative Assistant) stated the facility attempted to obtain a Level I PASARR for Resident 10 on 9/28/20. On 1/27/23 at 10:14 AM, Staff 3 (DNS) and Staff 5 confirmed Resident 10 did not have a screening for a Level I PASARR and provided no further information.

Based on and interview and record review it was determined the facility failed to ensure a bowel protocol was implemented for 1 of 5 sampled residents (#30) reviewed for medications. This placed residents at risk for constipation. Findings include: Resident 30 was admitted to the facility in 12/2022 with diagnoses including hydrocephalus (a brain disorder in which excess fluid accumulates in the non-fluid chambers of the brain), diabetes and schizoaffective disorder. Resident 30's 1/2023 physician orders instructed staff to administer the following: - polyethylene glycol (Miralax) powder for constipation daily as needed starting on 12/28/22; - senna (Senokot) tablet for constipation two times daily as needed starting on 12/28/22. Resident 30's 1/2023 bowel tracking revealed she/he had no bowel movement for four consecutive days (1/10, 1/11, 1/12 and 1/13/23). Resident 30 had a bowel movement on 1/14/23 and then no bowel movement for five consecutive days (1/15, 1/16, 1/17, 1/18 and 1/19/23). Resident 30's 1/2023 MAR revealed no medication was administered for constipation in 1/2023. There was no evidence Resident 30's physician was notified of the resident's lack of bowel movements and no clarification regarding the resident's bowel protocol. On 1/30/23 at 10:30 AM Staff 2 (DNS) stated bowel protocols were resident specific and she expected staff to administer medications as ordered. She stated the bowel medication orders for Resident 30 were to be administered as needed and they did not specify how many days to wait before they should be administered. Staff 2 confirmed Resident 30 did not have clear bowel care orders, was at risk for constipation due to the amount of time she/he did not have a bowel movement and was not administered medication for constipation. On 1/30/23 at 11:00 AM Staff 14 (CNA) Staff 24 (RN) and Staff 25 (RN) were present at the nursing station. Staff 14 reviewed Resident 30's bowel tracking with the state surveyor and confirmed she/he had no bowel movement from 1/10/23 through 1/13/23 and 1/15/23 through 1/19/23. Staff 24 and Staff 25 stated constipation medication would be administered to residents when a resident did not have a bowel movement for three days unless otherwise specified. Staff 25 stated bowel protocols were specific to each resident. Staff 24 and Staff 25 indicated the physician was to be called when orders were not clear. Staff 25 confirmed Resident 30 did not receive medication for constipation in 1/2023, her/his bowel orders were not clear.

Based on observation, interview and record review the facility failed to provide pharmaceutical service to ensure accurate acquiring, receiving and dispensing of medications for 2 of 5 sampled residents (#s 8 and 30) reviewed for medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 8 admitted to the facility in 11/2022 with diagnoses including Alzheimer's disease and a pelvic fracture. a. A physician order start date on 11/2/22 directed staff to administer Tylenol two tablets three times daily for pain. The 12/2022 MAR revealed the following: -12/31/22 at 9:22 AM and 2:06 PM Tylenol was not available. b. A physician order start date on 1/3/23, (a new order was placed approximately every seven days) 1/7/23, 1/14/23 and 1/21/23 directed staff to apply miconazole (antifungal medication) cream twice daily following perineal care. Ensure groin area was thoroughly dried prior to application of miconazole to her/his groin area bilaterally for Resident 8's rash. The 1/2023 MAR revealed the following: -1/3/23 at 9:25 AM indicated not administered at 8:26 PM miconazole was applied. -1/4/23 at 8:56 AM indicated not administered at 8:22 PM miconazole was applied. -1/6/23 at 9:30 AM miconazole was applied at 8:18 PM indicated not administered. -1/8/23 at 9:53 AM indicated not administered at 8:10 PM miconazole was applied. -1/14/23 at10:54 AM indicated not administered at 8:59 PM miconazole was applied. -1/21/23 at 10:25 AM and 8:23 PM indicated miconazole was not administered. -1/22/23 at 7:25 AM and 8:29 PM indicated miconazole was not administered. -1/23/23 at 9:43 AM indicated not administered at 8:04 PM miconazole was applied. On 1/26/23 at 10:02 AM Staff 8 (RN) stated on 12/31/22 he did not administer two doses of the resident's Tylenol because the medication was not available and needed to be reordered through the house stock. Staff 8 stated there were multiple days Resident 8's miconazole cream was not applied because the cream was not available. Staff 8 stated he re-ordered the miconazole cream through the pharmacy which was delayed for a couple of days (1/21/23 and 1/22/23) and Resident 8 did not get her/his miconazole cream applied. Staff 8 further stated at times it was difficult to receive or know if medication and creams were followed up on because the facility often utilized agency staff. On 1/26/23 at 2:59 PM Staff 9 (Pharmacist) stated Tylenol was typically on the unit and not something staff would have to order. The miconazole would be ordered through the pharmacy and if the facility was out on the unit staff could request stat which would be filled quickly and dispensed to the unit. In an interview and observation on 1/26/23 at 4:35 PM Staff 6 (RN) stated the facility had OTC (over the counter) Tylenol in the medication storage room and in the top drawer of the medication cart. Staff 6 showed the surveyor the medication room with the OTC medications and the medication cart which both included Tylenol. Staff 6 stated not all staff were aware of the medication room or what was stocked and available in the medication room. Staff 6 stated Resident 8's miconazole cream was applied twice daily and if the cream was almost out staff were expected to place an order through the pharmacy and follow-up on the order. Staff 8 further stated staff were not always good at following up on pharmacy orders because the facility utilized agency staff. On 1/27/23 at 11:33 AM Staff 3 (DNS) acknowledged the Tylenol not being administered on 12/31/22 and the miconazole cream not being applied when it was available. Staff 3 stated staff were expected to follow physician orders and if unsure on were to locate or order medication or creams staff were expected to ask for assistance. 38138 2. Resident 30 was admitted to the facility in 12/2022 with diagnoses including hydrocephalus (a brain disorder in which excess fluid accumulates in the non-fluid chambers of the brain), diabetes, tardive dyskinesia (a condition affecting the nervous system, often caused by long-term use of psychiatric medication) and schizoaffective disorder. a. A physician order with a start date of 12/27/22 directed staff to administer one drop of latanoprost eye solution to both eyes nightly. The 12/2022 MAR revealed on 12/27/22 at 8:03 PM the medication was not available. b. A physician order with a start date of 12/27/22 directed staff to administer one 40 mg capsule of valbenazine (a medication used to treat tardive dyskenisia) nightly. The 12/2022 and 1/2023 MAR revealed the following dates and times the medication was not available: - 12/27/22 at 8:03 PM - 12/28/22 at 8:17 PM - 12/29/22 at 8:06 PM - 12/30/22 at 8:53 PM - 12/31/22 at 8:16 PM - 1/1/23 at 9:23 PM c. A physician order with a start date of 12/28/22 directed staff to administer one CertaVite Senior tablet one time daily. The 12/2022 MAR revealed the medication was not available on: - 12/28/22 at 10:00 AM - 12/29/22 at 8:29 AM d. A physician order with a start date of 12/30/22 directed staff to administer one tablet of multivitamin with minerals one time daily. The 1/2023 MAR revealed the medication was not available on 1/3/23 at 9:25 AM. On 1/30/23 at 10:30 AM Staff 2 (DNS) stated she expected staff to administer medications as ordered. On 1/30/23 at 11:00 AM Staff 25 (RN) reviewed Resident 30's 12/2022 and 1/2023 MAR and confirmed Resident 30's medications were documented as not having been administered and were noted to have been unavailable. Staff 25 stated the facility utilized so many contracted staff and they did not always know where to go to obtain medications especially if the medications were house stock medications. Staff 25 stated Resident 30 should have received her/his medications as ordered. On 1/30/23 at 12:57 PM Staff 1 (Administrator) was informed of the findings of this investigation and stated Resident 30 should have received her/his medications as ordered.

Based on interview and record review it was determined the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless deemed appropriate by the attending physician for 1 of 5 sampled residents (#23) reviewed for medications. This placed residents at risk for receiving unnecessary medications and adverse side effects. Findings include: Resident 23 admitted to the facility in 11/2022 with diagnoses including stroke and anxiety. A physician order start date of 11/27/22 directed staff to administer prochlorperazine (anti-anxiety and used to control severe nausea and vomiting) PRN for nausea. A Pharmacist Consult Report dated 12/8/22 and 1/25/23 revealed prochlorperazine was an antipsychotic and required a 14-day review/renewal. The 12/23/22 MAR revealed Resident 23 was administered prochlorperazine for nausea. A review of Resident 23's revealed no written rationale or indication of ongoing use of the prochlorperazine by her/his physician after the 11/27/22 start date (58 days). On 1/26/23 at 03:05 PM Staff 9 (Pharmacist) stated he completed monthly chart reviews and made recommendations regarding 14-day PRN antipsychotic use. Staff 9 stated he was not sure why the requested recommendation was not reviewed or addressed by the physician. On 1/26/23 at 4:52 PM Staff 3 (DNS) acknowledged the 12/8/22 and 1/25/23 pharmacy recommendation was not addressed or followed up on regarding ongoing use of prochlorperazine.

Based on interview and record review it was determined the facility failed to ensure fall safety measures were in place for 1 of 2 sampled residents (#8) reviewed for accidents. This placed residents at risk for increased falls. Findings include: Resident 8 admitted in 5/2022 with diagnoses including Alzheimer's disease and a history of falls. Fall investigations revealed the following: *Fall #1 on 6/25/22: -Staff 23 (Former LPN) heard a noise from Resident 8's room and found her/his back to the toilet in a seated position on the floor. Resident 8 had a skin tear to the right elbow. Staff 16 (CNA) last toileted Resident 8 at 5:30 AM and Staff 16 indicated he assisted her/him to the bathroom roughly six times throughout the night. The bed alarm was not on when Resident 8 was found on the floor with her/his back to the toilet. The investigation revealed Resident 8 self-transferred herself/himself to the bathroom however Staff 16 forgot to reset the bed alarm after taking Resident 8 to the bathroom at 5:30 AM. Resident 8 had no attempts to get out of bed prior to the incident. No indication of abuse. *Fall #2 on 12/15/22: -Staff 8 (RN) heard Resident 8 yelling help, pee pee from the nurse's station. Staff 8 entered the room and found Resident 8 on the floor with her/his back against the bed and the bed alarm was not sounding. Resident 8 stated owie, my bottom, I fell . No sign of injury and Resident 8 did not hit her/his head. Staff indicated Resident 8 was checked on 30 minutes prior to the incident by Staff 15 (CNA). Staff 22 (Former RN) indicated Resident 8 was checked 30 minutes before she/he was found on the floor. Staff 15 indicated she thought she set the bed alarm but stated she must not have. The investigation revealed Resident 8 self-transferred, no injury, resident did not use call light and was impulsive. No indication of abuse. On 1/24/23 at 1:15 PM Staff 8 stated he was present on 12/15/22 and heard Resident 8 yelling, when he entered the room. Resident 8 was sitting on the ground, she/he had three side rails up and a table to block the other side of the fourth rail. Resident 8 pushed the bedside table away to exit the bed and the bed alarm did not sound and was not on. Staff 8 stated she/he had some minor bruising but no injuries. Staff 8 stated three staff assisted Resident 8 back into bed. On 1/24/23 at 1:25 PM Staff 15 (CNA) stated she was present on 12/15/22 but not in the room when Resident 8 swung her/his legs over the bed and was found on the floor by Staff 8. Staff 15 stated the bed alarm did not sound. Staff 15 stated Staff 8 heard the resident and entered the room and found her/him on the floor. Staff 15 indicated she had worked with Resident 8 prior to the fall and could not recall if she ensured the bed alarm was on or not. Staff 15 stated Resident 8 was often confused and impulsive. On 1/25/23 at 1:12 PM Staff 16 (CNA) stated Resident 8 was a fall risk, impulsive and attempted to get out of bed often. Staff 16 indicated on 6/25/22 when Resident 8 attempted to get out of her/his bed and her/his bed alarm did not sound and she/he did not use her/his call light. Staff 16 stated he forgot to turn the bed alarm back on after assisting with her/his ADL care needs prior to the fall. Staff 16 further stated he took Resident 8 to the bathroom multiple times on his shift that night. On 1/27/23 at 11:33 AM Staff 3 (DNS) acknowledged the bed alarm was not turned back on after ADL care was provided on 12/25/22 but she could not speak to the 6/2022 incident but would expect staff to follow and implement the care plan. On 1/30/23 at 10:04 AM Staff 11 (Former DNS) stated she recalled the incident with Resident 8 in 6/2022 and Staff 16 toileted the resident multiple times and forgot to ensure the bed alarm was turned back on. Staff 11 did not recall the 12/2022 incident but would expect staff to follow the care plan.

Based on interview and record review it was determined the facility failed to inform residents and their representatives and families by 5:00 PM the next calendar day following the occurrence of a suspected or confirmed COVID 19 infection, failed to include mitigating actions taken by the facility to prevent or reduce the risk of transmission and failed to provide cumulative updates to residents, their representatives and families regarding COVID 19 status in the facility for 1 of 2 units reviewed for COVID 19 infection notification. This placed residents, their representatives and families at risk for not being informed of the facility's COVID 19 infection status. Findings include: On 8/24/22, the facility was asked to provide documentation that residents, their representatives and families were notified of positive COVID 19 infections, what mitigating actions were taken and cumulative updates. No documentation was provided. (The facility's last COVID 19 positive infection was on 7/28/22). On 8/24/22 at 12:51 PM Staff 2 (DNS) stated residents were notified of positive COVID 19 infections within 24 hours and the resident representatives were notified if they came to the facility to visit. If the resident representative or family did not visit the facility, they were not notified of the facility's COVID 19 status. Staff 2 reported she was unaware of the specific reporting details regarding notification of residents, their representatives and families and the facility had no documentation to indicate the facility reported suspected or confirmed COVID 19 infections to residents, their representatives or families or provided cumulative weekly updates.

Based on interview and record review it was determined the facility failed to screen residents for appropriateness to receive COVID 19 vaccinations, failed to provide the resident or their representative education regarding the benefits, risks, and potential side effects associated with the COVID 19 vaccination and failed to provide the opportunity to accept or decline COVID 19 vaccinations for 4 of 5 sampled residents (#s 101, 104, 105 and 106) reviewed for immunizations. This placed residents at risk for making uninformed healthcare decisions and not being protected against the COVID 19 virus. Findings include: 1. Resident 101 was admitted to the facility in 5/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 101's electronic medical record and the facility's current Resident Vaccine Line list revealed the resident was not up-to-date with her/his COVID 19 vaccinations. On 8/25/22 at 9:58 AM Resident 101 stated she/he did not receive information regarding benefits, risks and potential side effects of the COVID 19 vaccination and was not offered a COVID 19 vaccination. The facility was unable to provide documentation Resident 101 was offered a COVID 19 vaccination or the resident or their representative received information regarding the benefits, risks and potential side effects related to the COVID 19 vaccine. On 8/25/22 at 12:25 PM Staff 2 (DNS) stated the facility did not currently screen residents to determine appropriateness to receive vaccinations, did not have a system in place to provide residents or their representatives information regarding the benefits, risks and potential side effects of the COVID 19 vaccination or to obtain consent or refusal of the vaccination and did not offer the COVID 19 vaccination to Resident 101. 2. Resident 104 was admitted to the facility in 5/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 104's electronic medical record and the facility's current Resident Vaccine Line list revealed the resident was unvaccinated for the COVID 19 virus. The facility was unable to provide documentation Resident 104 was offered a COVID 19 vaccination or the resident or their representative received information regarding the benefits, risks and potential side effects related to the COVID 19 vaccine. On 8/25/22 at 12:25 PM Staff 2 (DNS) stated the facility did not currently screen residents to determine appropriateness to receive vaccinations, did not have a system in place to provide residents or their representatives information regarding the benefits, risks and potential side effects of the COVID 19 vaccination or to obtain consent or refusal of the vaccination and did not offer the COVID 19 vaccination to Resident 104. 3. Resident 105 was admitted to the facility in 8/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 105's electronic medical record and the facility's current Resident Vaccine Line list revealed the resident was not up-to-date with her/his COVID 19 vaccinations. On 8/25/22 at 11:34 AM Witness 2 (Spouse) reported Resident 105 did not receive information regarding the benefits, risks and potential side effects of the COVID vaccination and was not offered the COVID 19 vaccination. Witness 2 stated Resident 105 was due for her/his next COVID 19 vaccination. The facility was unable to provide documentation Resident 105 was offered a COVID 19 vaccination or the resident or their representative received information regarding the benefits, risks and potential side effects related to the COVID 19 vaccine. On 8/25/22 at 12:25 PM Staff 2 (DNS) stated the facility did not currently screen residents to determine appropriateness to receive vaccinations, did not have a system in place to provide residents or their representatives information regarding the benefits, risks and potential side effects of the COVID 19 vaccination or to obtain consent or refusal of the vaccination and did not offer the COVID 19 vaccination to Resident 105. 4. Resident 106 was admitted to the facility 3/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 106's electronic medical record and the facility's current Resident Vaccine Line list revealed Resident 106 was not up-to-date with her/his COVID 19 vaccinations. On 8/25/22 at 11:37 AM Resident 106 stated she/he had been at the facility for several months and nobody provided her/him with information regarding benefits, risk and potential side effects of the COVID 19 vaccination and was not sure if she/he was offered the COVID 19 vaccination. The facility was unable to provide documentation Resident 105 was offered a COVID 19 vaccination or the resident or their representative received information regarding the benefits, risks and potential side effects related to the COVID 19 vaccine. On 8/25/22 at 12:25 PM Staff 2 (DNS) stated the facility did not currently screen residents to determine appropriateness to receive vaccinations, did not have a system in place to provide residents or their representatives information regarding the benefits, risks and potential side effects of the COVID 19 vaccination or to obtain consent or refusal of the vaccination and did not offer the COVID 19 vaccination to Resident 106. .

Based on interview and record review it was determined the facility failed to provide timely diagnostic services to meet resident needs for 1 of 3 sampled residents (#101) reviewed for diagnostic services. This placed residents at risk for undiagnosed needs. Findings include: Resident 101 was admitted to the facility in 5/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 6/23/22 Progress Note written by Staff 6 (RN) indicated Resident 101's PCP ordered a knee X-ray for the resident on 6/23/22 and the referral was to be sent to the outpatient radiology department by the morning of 6/24/22. The facility needed to make an appointment for Resident 101's knee X-ray on 6/24/22. On 8/24/22 at 10:46 AM and 8/25/22 at 10:01 AM Witness 1 (Complainant) reported Resident 101's PCP ordered an X-ray of the resident's knee on 6/23/22. Witness 1 reported the PCP's clinic staff contacted the facility on 6/23/22 and verified the facility received the order. Witness 1 stated, since 6/23/22, clinic staff followed up with the facility nursing staff on at least four different occasions to determine the status of Resident 101's knee X-ray and the knee X-ray was still not completed as of 8/24/22. On 8/24/22 at 11:10 AM Resident 101 stated her/his knee was painful and the knee X-ray was not yet completed. On 8/24/22 at 11:30 AM Staff 2 (DNS) reported Resident 101 had a knee X-ray order which was outstanding for some time. Staff 2 reported the resident went to the radiology department about ten days ago but the knee X-ray order was not entered correctly into the electronic medical record system so the knee X-ray was not completed. On 8/24/22 at 1:30 PM Staff 4 (RN) stated there was an ongoing issue with the facility's electronic medical record system which resulted in an inability for the nursing staff to put verbal or written orders into the system. She stated this issue caused a problem with Resident 101's knee X-ray being ordered and completed timely. On 8/25/22 at 2:20 PM Staff 6 (RN) stated on 6/23/22, Resident 101 shared her/his PCP appointment summary with her and she noted a knee X-ray order so she phoned the PCP clinic and verified the order with the front desk staff. Staff 6 stated the facility nursing staff dropped the ball and no one made the appointment for Resident 101's knee X-ray until the first week of August when the resident was taken to radiology for her/his knee X-ray but the order was no longer valid and the X-ray could not be completed. Staff 6 stated the facility recently changed medical providers and the current medical provider did not have access to the electronic medical record system to place a new order and needed to write a hand written order but the medical provider did not write the order so Resident 101's knee X-ray was further delayed. Staff 6 stated they were able to get the order in place and the X-ray completed on 8/25/22, nearly two months after the initial order.

Based on interview and record review it was determined the facility failed to screen residents for appropriateness to receive a pneumococcal vaccination, failed to provide the resident or their representative education regarding the benefits, risks and potential side effects of the pneumococcal vaccine and failed to provide the opportunity to accept or decline pneumococcal vaccinations for 2 of 5 sampled residents (#s 104 and 107) reviewed for immunizations. This placed residents at risk for making uninformed healthcare decisions and not being protected against pneumococcal disease. Findings include: 1. Resident 105 was admitted to the facility in 8/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/25/22 at 11:34 AM Witness 2 (Spouse) reported Resident 105 did not receive information regarding the benefits, risks and potential side effects of the pneumococcal vaccination and was not offered the pneumococcal vaccination. On 8/25/22, the facility was unable to provide documentation Resident 105 was offered a pneumococcal vaccination or the resident or their representative received information regarding the benefits, risks and potential side effects related to the pneumococcal vaccine. On 8/25/22 at 12:25 PM Staff 2 (DNS) stated the facility did not currently screen residents to determine appropriateness to receive vaccinations, did not have a system in place to provide residents or their representatives information regarding the benefits, risks and potential side effects of the pneumococcal vaccination or to obtain consent or refusal of vaccinations and did not offer the pneumococcal vaccination to Resident 105. 2. Resident 107 was admitted to the facility in 7/28/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/25/22, the facility was unable to provide documentation Resident 107 was offered a pneumococcal vaccination or the resident or their representative received information regarding the benefits, risks and potential side effects related to the pneumococcal vaccine. On 8/25/22 at 12:25 PM Staff 2 (DNS) stated the facility did not currently screen residents to determine appropriateness to receive vaccinations, did not have a system in place to provide residents or their representatives information regarding the benefits, risks and potential side effects of the pneumococcal vaccination or to obtain consent or refusal of vaccinations and did not offer the pneumococcal vaccination to Resident 107.

Based on observation, interview, and record review it was determined the facility failed to follow care planned interventions and thoroughly investigate incidents for 4 of 4 sampled residents (#s 1, 2, 3, & 4) reviewed for incidents. This placed residents at risk for potential injuries. Findings include: 1. Resident 1 was admitted to the facility in 4/2018 with [DIAGNOSES REDACTED]. The 4/13/18 Kardex Care Plan noted the resident was totally dependent for dressing and bathing and two person assistance with Arjo lift for transfers. PRN pain medication physician orders [REDACTED]. The 5/8/18 at 7:45 PM Progress Note disclosed the resident had emesis and crying. The resident was repositioned into bed with a heart rate elevated into 150s to 160s. The resident was treated with Ibuprophen and [MEDICATION NAME] (anti-nausea medication). Afterwards the resident rested comfortably with a heart rate in the 130s and was monitored. The 5/9/18 Progress Notes disclosed at 8:30 AM the resident had an alteration in comfort as evidenced by a FLACC (presence of pain exhibited by the resident's Face, Legs, Activity, Cry, and Consolability) score of 10 during and after incontinence care and repositioning and a heart rate in the 170s. The resident received Tylenol and [MEDICATION NAME]. At 10:30 AM the resident had a FLACC score of 5, she/he was transferred to a somatron (a vibroacoustic mattress) and given Ibuprophen. The resident was noted with increased heart rate and respirations and FLACC scores between 2-10 all shift. The resident had two emesis and continued with abnormal vitals and discomfort. Staff were in contact with Witness 3 (Physician) throughout the day. At around 11:30 AM the physician ordered labs and a chest x-ray then later sent the resident to the hospital. The resident left for the hospital via EMTs (Emergency Medical Technicians) at 2:55 PM. The 5/10/18 Pediatric Intensive Care Unit Admission History and Physical noted the resident had worsening respiratory distress. An outside chest x-ray incidentally revealed a right humerus fracture. There was no documented completed investigation of the fracture nor determination of abuse/neglect in the clinical record. The Addendum of Incident Self Report (provided with the facility's self report in complaint triage but not part of the resident's clinical record) noted on 5/8/18 the resident participated in a music therapy session and was positioned on the right side throughout the duration of the 45 minute session. During the session the resident was calm and showed no signs of discomfort. On 5/8/18 from 5:00 PM until the 5/9/18 afternoon hospital transfer the resident exhibited six documented pain events which were responsive to interventions. During that time the resident exhibited increased emesis and respiratory distress. Per the addendum there was no clear cause of the resident's increase in pain. The Addendum did not address how care was provided to the resident prior to the identification of the fracture nor was there a determination of abuse/neglect. In interviews on 7/12/18 at 1:05 pm and 1:35 PM, and 7/16/18 at 10:58 AM Staff 1 (DNS)stated the fracture was discovered when the x-ray related to respiratory distress was obtained. Regarding the lack of a documented, thorough investigation Staff 2 stated the information provided in the Addendum of Incident Self Report was not included in the resident's clinical record and there was no documentation of completed investigations in residents' clinical records. No other documentation was provided. Refer to F842, example 1. 2. Resident 2 was admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. The 5/16/18 at 12:13 PM Progress Note disclosed the resident had a bruise on the right arm and the top of the right hand from blood draws. The resident also had a 4 cm x 2 cm bruise on the top of the left foot caused by the resident rubbing/bumping her/his foot on the wheelchair footrest. The note indicated the resident refused to wear shoes and socks. Staff 2 (RN) documented in the 5/17/18 at 5:01 PM Progress Note the resident has been found on the floor, off of safety mat several times after being put to bed .currently has several bruises on body from rolling around off bed, on floor when left independently. The resident stated I am too wiggly when asked why she/he was not in the bed or on the mat. Staff 2 discussed the use of a posey bed (a bed with a canopy used to keep a resident in bed) as the best option for the resident. There was no documentation where the bruises were located on the resident's body. The 5/18/18 physician progress notes [REDACTED]. related .to this . and the resident's bed was changed to a posey bed. There was no documented investigation of how the resident got out of the bed and onto the floor, contributing factors such as furniture placement in the room, ensuring the mat was properly placed to minimize injury, nor if the 5/16/18 foot bruise was related to being on the floor rather than bumping the foot on the wheelchair footrest. In interview on 7/11/18 at 3:28 PM Staff 2 (RN) stated there was period of time when the resident sustained [REDACTED]. Resident 2 was in a hi-lo bed with a mat on the floor. There was a nightstand by the bed and space between the stand and the wall. The floor mat did not reach the wall due to the stand. The resident rolled herself/himself off of the bed which was approximately five inches to the mat then onto the linoleum. Staff 2 stated it was possible the resident hit the nightstand when on the floor. The resident was covered in bruises and Staff 2 spoke with the RNCM regarding the use of a posey bed to keep the resident safe. Staff 2 stated the resident sustained [REDACTED]. Per Staff 2 anytime the resident rolled off of the mat whatever body part was hit the resident sustained [REDACTED]. In interviews on 7/12/18 at 1:05 PM and 7/16/18 at 1:30 PM Staff 1 (DNS) stated the bruising noted by the physician on 5/18/18 referred to the bruising caused by lab draws. Staff 1 stated there was no further documentation regarding the resident's bruising in the clinical record. No documented investigation was provided. 3. Resident 3 was admitted to the facility with [DIAGNOSES REDACTED]. The 4/2018 CAAs noted the resident had active movement of her/his legs and kicked out and bounced when she/he was happy. The resident had a history of [REDACTED]. The 4/11/18 Care Plan noted the resident had chronic bruising on the knees and shins. The resident's skin was very sensitive and she/he was prone to bruising. Staff were to ensure padding was in place and surfaces were smooth and the use of heelbo's (padded protective equipment that protects from shear and friction) on her/his knees when in bed when movement is high. The 5/18/18 at 9:10 AM Progress Note documented the resident had a new abrasion on the left calf. Assumed to be from semi-involuntary movement while in wheelchair without protective pad. There was no documented investigation in the clinical record. A written summary was provided by Staff 1 (DNS) on 6/20/18 which was not in the clinical record. The summary noted the resident had frequent repetitive bicycling of her/his legs. It was noted the resident was in the swing during the previous evening. .It is unknown if pillow was placed under (Resident 3's) thigh as care plan directs. The bottom of the swing aligns with the abrasion and the fabric of the swing is not smooth. Most likely the swing is the cause. The Kardex/care plan was reflagged to ensure the resident has a smooth surface (rolled towel, pillow) under her/his legs and the resident's position was checked frequently as the padding could come loose during movement. The 5/28/18 at 10:29 AM Progress Note disclosed the resident had an 8 cm x 3 cm area of redness/bruising on the left shin. The resident often bicycled her/his legs in bed .and that is most likely the cause of the bruising .When in bed try to keep legs separated with a pillow. (Resident 3) wears knee pads while in bed d/t history of active legs and bruising. The 2:54 PM update noted a CNA reported the bruising might be from the foot strap on the wheelchair as the resident wiggled and rubbed her/his leg against the strap. There was no documented investigation of the redness/bruising including a determination of abuse/neglect. On 6/20/18 at 1:28 PM Resident 3 was observed in bed with no knee pads in place. The resident was observed moving her/his legs while in bed. On 6/20/18 at 1:47 PM Staff 15 (CNA) and Staff 18 (CNA) stated the resident kicked and bicycled her/his legs and was to have knee protectors in place when in bed. Staff 18 stated after providing the resident's incontinence care she removed the resident's soiled items from the room, got busy with other residents' care, and did not return to Resident 3's room and apply the knee pads. In interviews on 7/12/18 at 11:18 AM and 11:49 AM Staff 21 (RNCM) stated regarding the 5/18/18 abrasion, staff reported the pillow was initially in place when the resident was in the swing, however, when the resident was excited she/he kicked and the pillow could be dislodged. The abrasion lined up with the material of the swing. Regarding the 5/28/18 skin impairment Staff 21 stated it was a reddened area. A CNA reported the resident was particularly active that day and the ankle strap on the wheelchair lined up with the reddened area. When asked for a documented investigation of the incidents Staff 21 stated it was the facility's policy to not share the reports. The lack of following the care plan on 6/20/18 was shared with Staff 21, no additional information was provided. In interview on 7/12/18 at 1:35 PM Staff 1 (DNS) stated the written summary she provided on 6/20/18 regarding the 5/18/18 abrasion was not part of the resident's clinical record. No documented completed investigations were provided regarding the 5/18/18 and 5/28/18 incidents. Refer to F842, example 2. 4. Resident 4 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. The 7/2017 CAAs noted the resident was at risk for skin breakdown including self-inflected bruises, scratches, and abrasions. The injuries were not intentional but were a result of her/his independent movement. There was no care plan for 5/2018 in the clinical record. The 5/7/18 at 10:55 PM Progress note disclosed the resident sustained [REDACTED]. The 5/10/18 at 10:04 PM Progress Note disclosed the resident came home with a shallow abrasion on the right foot. There were no documented investigations of the 5/7/18 and 5/10/18 abrasions in the clinical record. In interview on 7/16/18 at 10:58 AM Staff 1 (DNS) stated there was no care plan available for the timeframe of the abrasions as the facility did not archive previous Kardex/care plans. No additional documentation regarding abrasion investigations was provided. Refer to F842, example 3

Based on interview and record review it was determined the facility failed to maintain a complete clinical record 3 of 4 sampled residents (#s 1, 3, & 4) reviewed for incidents. This placed residents at risk for unmet care needs. Findings include: The 11/2017 Revised Unusual Occurrence Reporting (UOR) Policy and Procedure included: Unusual occurrences will be reported in order to identify and establish a program of risk management. The purpose is to minimize exposure to undue risks for residents .An unusual occurrence is any event, which is not consistent with .routine care of a particular resident. It may be an accident, a situation that might result in bodily injury affecting residents .When an unusual occurrence is discovered, the individual involved in the incident and/or the individual discovering the incident will complete an electronic Unusual Occurrence Report (UOR) as soon as possible .No mention of the completion of the UOR is to be made in the medical record. However, the facts of the event should be documented in the electronic medical record if it has impact on resident care . 1. Resident 1 was admitted to the facility in 4/2018 with [DIAGNOSES REDACTED]. The 4/13/18 Kardex Care Plan noted the resident was totally dependent for dressing and bathing and two person assistance with Arjo lift for transfers. The 5/8/18 at 7:45 PM Progress Note disclosed the resident had emesis, crying, and an elevated heart rate. The 5/9/18 Progress Notes disclosed during the day shift the resident was noted with an increased heart rate and respirations, pain assessment scores between 2-10, and emesis. At around 11:30 AM the physician ordered labs and a chest x-ray and at 2:55 PM the resident was sent to the hospital. The 5/10/18 Pediatric Intensive Care Unit Admission History and Physical noted the resident had worsening respiratory distress. An outside chest x-ray incidentally revealed a right humerus fracture. There was no documented completed investigation of the fracture in the clinical record. The Addendum of Incident Self Report (provided with the facility's self report in complaint triage but not part of the resident's clinical record) noted on 5/8/18 from 5:00 PM until the 5/9/18 afternoon hospital transfer the resident exhibited six documented pain events which were responsive to interventions. During that time the resident exhibited increased emesis and respiratory distress. Per the addendum there was no clear cause of the resident's increase in pain. In interviews on 7/12/18 at 1:05 pm and 1:35 PM, and 7/16/18 at 10:58 AM Staff 1 (DNS) stated the fracture was discovered when the x-ray related to respiratory distress was obtained. Staff 1 stated once an incident was documented the nurse made a determination regarding the need for a UOR. The UOR was completed by the RNCM for follow up. Staff 1 could not provide the UOR and stated the Addendum of Incident Self Report was an excerpt from the UOR. Per Staff 1 the UOR was not part of the resident's clinical record and there was was no documentation of a completed investigation in the resident's clinical record. 2. Resident 3 was admitted to the facility with [DIAGNOSES REDACTED]. The 4/11/18 Care Plan noted the resident had chronic bruising on the knees and shins. The resident's skin was very sensitive and she/he was prone to bruising. Staff were to ensure padding was in place and surfaces were smooth and the use of heelbo's (padded protective equipment that protects from shear and friction) on her/his knees when in bed when movement is high. The 5/18/18 at 9:10 AM Progress Note documented the resident had a new abrasion on the left calf. Assumed to be from semi-involuntary movement while in wheelchair without protective pad. There was no documented investigation in the clinical record. A written summary was provided by Staff 1 (DNS) on 6/20/18 which was not in the clinical record. The summary noted the resident had frequent repetitive bicycling of her/his legs. It was noted the resident was in the swing during the previous evening. .It is unknown if pillow was placed under (Resident 3's) thigh as care plan directs. The bottom of the swing aligns with the abrasion and the fabric of the swing is not smooth. Most likely the swing is the cause. The Kardex/care plan was reflagged to ensure the resident has a smooth surface (rolled towel, pillow) under her/his legs and the resident's position was checked frequently as the padding could come loose during movement. The 5/28/18 at 10:29 AM Progress Note disclosed the resident had an 8 cm x 3 cm area of redness/bruising on the left shin. The resident often bicycled her/his legs in bed .and that is most likely the cause of the bruising .When in bed try to keep legs separated with a pillow. (Resident 3) wears knee pads while in bed d/t history of active legs and bruising. The 2:54 PM update noted a CNA reported the bruising might be from the foot strap on the wheelchair as the resident wiggled and rubbed her/his leg against the strap. In interviews on 7/12/18 at 11:18 AM and 11:49 AM Staff 21 (RNCM) stated it was the facility's policy to not share the investigative reports. In interview on 7/12/18 at 1:35 PM Staff 1 (DNS) stated the written summary she provided on 6/20/18 regarding the 5/18/18 abrasion was not part of the resident's clinical record. In interviews on 7/12/18 at 1:05 pm and 1:35 PM Staff 1 (DNS) stated she could not provide the UOR and the written summary provided on 6/20/18 was an excerpt from the UOR. Per Staff 1 the UOR was not part of the resident's clinical record and there was was no documentation of a completed investigation in the resident's clinical record. 3. Resident 4 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. The 7/2017 CAAs noted the resident was at risk for skin breakdown including self-inflected bruises, scratches, and abrasions. The injuries were not intentional but were a result of her/his independent movement. There was no care plan for 5/2018 in the clinical record. The 5/7/18 at 10:55 PM and 5/10/19 at 10:04 PM Progress Notes disclosed the resident sustained [REDACTED]. In interview on 7/16/18 at 10:58 AM Staff 1 (DNS) stated there was no care plan available for the timeframe of the abrasions as the facility did not archive previous Kardex/care plans.

Based on interview and record review it was determined facility staff failed to follow professional standards of practice regarding a feeding tube for 1 of 3 sampled residents (#1) reviewed for safety. Resident 1 was care planned for staff to remove all the extension tubing. The extension tubes were left in the feeding tube and during a transfer the feeding tube was pulled out which required hospitalization . The facility identified the noncompliance and initiated a plan of correction on 3/20/18, which resulted in increased staff awareness and no further incidents of feeding tubes becoming dislodged. This incident was identified as meeting the criteria for past noncompliance. Findings include: Resident 1 admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. 851-045-0040 Scope of Practice Standards for All Licensed Nurses (1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse: (a) Advocates for the client's right to receive appropriate care, including person-centered care and end-of-life care, considerate of the client's needs, choices and dignity; (b) Identifies client safety and environment concerns; takes action to correct those concerns and report as needed. On 3/20/18 Staff 1 (Chief Nurse Executive) notified the local state area on aging unit Resident 1 was was sent to the hospital to get her/his feeding tube replaced because the extensions were left on the tube and the tube was pulled out. Facility policy Tube Feedings: Nasogastric, Gastrostomy, Jejunostomy last approved on 2/2018 included: 17. Unless the resident's plan of care indicates otherwise, always remove extension set after feedings or medication administration to prevent tube dislodgement. The 8/18/17 care plan revealed the following: -Keep the tube hidden so the resident did not pull them out. -Ensure the feeding tube was out of reach as the resident tried to grab the tube. -Call the physician and admit Resident 1 to the hospital for [MEDICATION NAME] radiology (when imaging is used to diagnose or treat a condition) if there was a complication with the feeding tube. The 3/20/18 progress notes revealed Staff 5 (RN) noted Resident 1 had an alteration in nutrition and medication administration due to the feeding tube was pulled out. A different tube was placed temporarily to keep the stoma (opening in stomach) open. The resident was discharged to the hospital. The 3/21/18 hospital note revealed the feeding tube was replaced successfully and without complication. The resident had a large brown emesis after one hour of feeding. The resident missed one to two doses of acid blockers while her/his feeding tube was not functioning and had a strong history of being sensitive to missed dosages. Resident 1's acid blockers were restarted and she/he tolerated the tube feeding over night without issue or further emesis. The resident required another night of monitoring in the hospital due to the emesis. On 4/26/18 at 10:15 AM Staff 6 (RN) indicated two CNAs approached him after moving Resident 1 out of her/his chair. Staff 6 noticed the feeding tube was coming out and the extensions were still in, and the resident was sitting on the button that was detached from Resident 1's stomach. He indicated facility policy to take the extensions out after medication and feeding administration. On 4/26/18 at 10:21 AM Staff 5 (RN) indicated after disconnecting the feeding tube around 9:00 AM she left the extensions connected to the feeding tube because it was almost time for the resident's medications. Staff 5 tucked the extensions under the resident's binder (abdominal support) while the resident was in her/his chair. At 1:00 PM after an activity Staff 6 RN saw the tube was pulled out and the extensions were still in. The resident sat on the extensions and were somehow wrapped underneath the resident. Staff 5 placed another button in the stoma to hold the area open. She indicated the facility policy was to take the extensions out after administering medications and feedings, and the resident was not care planned to have the extensions left in. On 4/26/18 at 11:49 AM Staff 4 (CMA) indicated on 3/20/18 she worked as the CMA that day and normally didn't work with Resident 1. She indicated at 10:45 AM when she gave the resident [MEDICATION NAME] (anti-nausea and vomiting) both extensions were still attached to the feeding tube. She stated she made the mistake of assuming the resident would be eating soon so she left the extension attached to the feeding tube. Staff 4 indicated the facility policy was to take the extensions out after administering medications and feeding. On 4/26/18 at 12:00 PM Staff 1 (Chief Nurse Executive) indicated the policies and procedures were not followed regarding the extensions and the resident required a hospitalization for a new feeding tube. This situation met the criteria for past noncompliance as follows: 1. The incident indicated noncompliance at F693. 2. The noncompliance occurred since the exit date of the last standard recertification survey (3/16/18) and before the date of this complaint survey (5/1/18). 3. There was sufficient evidence that the facility corrected the noncompliance and is in substantial compliance with F693 as evidenced by: - No deficient practice found at F693 with additional sampled residents. - Evidence the deficient practice was identified by the facility, and a plan of correction was implemented on 3/20/18 to educate or reinforce education on facility policy regarding the management of feeding tube extensions. -Evidence there was a mandatory staff meeting where all the staff signed the policy. -RN, and CMA interviews all indicated knowledge and awareness of facility policy and expectations for when removing a feeding tube extensions set was required. For additional information refer to F693

Based on observation interview and record review, it was determined the facility failed to ensure the appropriate treatment of [REDACTED].#1) reviewed for feeding tube treatment. As a result, Resident 1's feeding tube was dislodged on 3/20/18. Resident 1 required admission to the hospital to have the feeding tube replaced under [MEDICATION NAME] radiology (guided by continuous X-ray imaging) and local anesthesia on 3/20/18. The facility identified the noncompliance and initiated a plan of correction on 3/20/18, which resulted in increased staff awareness and no further incidents of feeding tubes becoming dislodged. This incident was identified as meeting the criteria for past noncompliance. Findings include Resident 1 admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. Facility policy Tube Feedings: Nasogastric, Gastrostomy, Jejunostomy last approved on 2/2018 included: 17. Unless the resident's plan of care indicates otherwise, always remove extension set after feedings or medication administration to prevent tube dislodgement. Observations on 4/26/18 at 9:37 AM revealed Resident 1 was sitting in a wheelchair in the entrance of her/his room and was asleep. Staff 3 (RN) showed the surveyor the feeding tube and the tube was intact and there were no extensions attached to the feeding tube. The 3/7/18 Quarterly Pediatric Nutrition Assessment identified Resident 1 received all her/his nutrition through a feeding tube and did not eat or drink anything by mouth. The feedings were at 75 ml per hour for 15 hours starting at 4:00 PM and stopped when finished. The 8/18/17 care plan revealed the following: -Keep the tube hidden so the resident did not pull them out. -Ensure the feeding tube was out of reach as the resident tried to grab the tube. -Call the physician and admit Resident 1 to the hospital for [MEDICATION NAME] radiology (when imaging is used to diagnose or treat a condition) if there was a complication with the feeding tube. The 3/20/18 progress notes revealed Resident 1 had an alteration in nutrition and medication administration due to the feeding tube was pulled out. A different tube was placed temporarily to keep the stoma (opening in stomach) open. The resident was discharged to the hospital. On 3/20/18 Staff 1 (Chief Nurse Executive) completed a referral to the local state on agency unit to report two CNAs transferred Resident 1 from her/his wheelchair to the bed and after lifting the resident they noticed the feeding tube was almost out and there were extension tubes attached to the feeding tube. A different tube was placed temporarily and the physician was notified the resident required the tube to be replaced. Staff 1 revealed in (MONTH) (YEAR) Resident's 1 tube was pulled out during a transfer because the extension tubing was left in place. The 3/20/18 hospital note revealed Resident 1 presented after a GJ tube was removed early in the morning during shift change. Per staff it was unclear how the tube was extracted. The physician's replaced the feeding tube and Resident 1 received only a local anaesthetic. The 3/21/18 hospital note revealed the feeding tube was replaced successfully and without complication. The resident had a large brown emesis after one hour of feeding. The resident missed one to two doses of acid blockers while her/his feeding tube was not functioning and the resident had a strong history of being sensitive to missed dosages. Resident 1's acid blockers were restarted and she/he tolerated the tube feeding over night without issue or further emesis. On 4/26/18 at 10:15 AM Staff 6 (RN) indicated two CNAs approached him after moving the resident out of her/his chair. Staff 6 noticed the feeding tube was coming out and the extensions were still in, and the resident was sitting on the button that was detached from Resident 1's stomach. He indicated facility policy was to take the extensions out after medication and feeding administration. On 4/26/18 at 10:21 AM Staff 5 (RN) indicated after disconnecting the feeding tube around 9:00 AM she left the extensions connected to the feeding tube because it was almost time for the resident's medications. Staff 5 tucked the extensions under the resident's binder (abdominal support) while the resident was in her/his chair. At 1:00 PM after an activity Staff 6 RN saw the tube was pulled out and the extensions were still in. The resident sat on the extensions and were somehow wrapped underneath the resident. Staff 5 placed another button in the stoma to hold the area open. She indicated the facility policy was to take the extensions out after administering medications and feedings, and the resident was not care planned to have the extensions left in. On 4/26/18 at 11:49 AM Staff 4 (CMA) indicated on 3/20/18 she worked as the CMA that day and normally didn't work with Resident 1. She indicated at 10:45 AM when she gave the resident [MEDICATION NAME] (anti-nausea and vomiting) both extensions were still attached to the feeding tube. She stated she made the mistake of assuming the resident would be eating soon so she left the extension attached to the feeding tube. Staff 4 indicated the facility policy was to take the extensions out after administering medications and feeding. On 4/26/18 at 12:00 PM Staff 1 (Chief Nurse Executive) indicated she was notified immediately of the incident and contacted the physician, family and ombudsman and reported the incident to the local area on aging unit. On 3/20/18 Staff 1 provided an inservice on the policy of the extensions. She acknowledged the resident's extensions were left in and Resident 1 required hospitalization for a new tube to be inserted. This situation met the criteria for past noncompliance as follows: 1. The incident indicated noncompliance at F693. 2. The noncompliance occurred since the exit date of the last standard recertification survey (3/16/18) and before the date of this complaint survey (5/1/18). 3. There was sufficient evidence that the facility corrected the noncompliance and is in substantial compliance with F693 as evidenced by: - No deficient practice found at F693 with additional sampled residents. - Evidence the deficient practice was identified by the facility, and a plan of correction was implemented on 3/20/18 to educate or reinforce education on facility policy regarding the management of feeding tube extensions. -Evidence there was a mandatory staff meeting where all the staff signed the policy. -RN, and CMA interviews all indicated knowledge and awareness of facility policy and expectations for when removing a feeding tube extensions set was required.

Based on interview and record review, it was determined the facility failed to ensure the care of a feeding tube (a tube inserted into the digestive tract to provide nutrition when an individual is unable to take in sufficient nourishment by mouth) for 1 of 3 sampled residents (#1) reviewed for feeding tube care and management. As a result, Resident 1's feeding tube was dislodged on 4/28/17. Resident 1 required admission to the hospital to have the feeding tube replaced under fluoroscopy (guided by continuous X-ray imaging) and anesthesia on 4/29/17. The facility identified the noncompliance and initiated a plan of correction on 5/1/17, which resulted in increased staff awareness and no further incidents of feeding tubes becoming dislodged. This incident is identified as meeting the criteria for past noncompliance. Findings include: Facility policy Tube Feedings: Nasogastric, Gastrostomy, Jejunostomy last approved on 2/2017 included: 17. Unless the resident's plan of care indicates otherwise, always remove extension set after feedings or medication administration to prevent tube dislodgement. Resident 1 admitted to the facility in 1/2017 for respite care and with [DIAGNOSES REDACTED]. Resident 1 discharged from the facility in 5/2017. A 2/3/17 Initial Pediatric Nutrition Assessment identified Resident 1 received all nutrition through a feeding tube and did not eat or drink anything by mouth. Resident 1's care plan dated 4/20/17 directed staff to call the physician and admit Resident 1 to the hospital for [MEDICATION NAME] radiology (when imaging is used to diagnose or treat a condition) if a complication with the feeding tube occurred. The care plan did not indicate the extension tube was to remain in place during transfers. On 4/28/17, Staff 3 (CNA) was preparing Resident 1 to be transferred from the wheelchair into bed. Staff 3 was interrupted and left Resident 1 in the wheelchair to report a concern to the nurse. When Staff 3 returned, she transferred Resident 1 into bed without disconnecting the extension set. The extension set was caught on the wheelchair, which caused the feeding tube to be dislodged. The physician was notified and the resident was admitted to the hospital. A 4/30/17 Care Summary documented Resident 1 was admitted to the hospital on [DATE] for a feeding tube replacement and discharged back to the facility on [DATE]. A 5/3/17 Anesthesia Event documented on 4/29/17 Resident 1's anesthesia plan was TIVA with intravenous induction (a technique of general anesthesia using medications only given intravenously). Resident 1 received [MEDICATION NAME] (a local anaesthetic) and propofol (a medication that can be used for general anesthesia and procedural sedation) for a feeding tube replacement procedure. Resident 1 was unconscious and tolerated the procedure well. A 5/15/17 incident report sent to the State by Staff 2 (DNS) indicated this had been the fourth occurrence of this type for Resident 1 during 12 respite stays since 2014. All occurred because the extension set was left in place prior to transferring. On 5/16/17 at 2:30 pm, Staff 2 reported staff training had been done and changes were made to feeding practices to ensure resident safety. On 7/20/17, the facility identified 30 of 39 current residents had feeding tubes. On 7/20/17 at 12:15 pm and 7/21/17 at 11:01 am, Staff 1 (Chief Nurse Executive) confirmed Staff 3 was returning Resident 1 to bed, was interrupted, and returned. Staff 3 assumed she had disconnected the extension set, but had not. Staff 1 reported Resident 1 was admitted to the hospital after the event to have the feeding tube replaced under fluoroscopy. The situation was discussed daily each shift during the shift meeting for the following week, reinforcing the need to slow down, stop and validate what was done to ensure it was done. Staff 1 provided documentation to show the situation was addressed during the safety meetings starting conducted on each shift starting on 5/1/17 and emphasized extension sets must be disconnected when moving residents. On 7/20/17 at 1:52 am, Staff 4 (RN) reported the extension tubing must be removed when transferring a resident. This could be done by a RN, LPN, CMA, or CNA. The CNAs must report to the nurse or CMA when they disconnect the extension tube to coordinate care. On 7/20/17 at 3:48 pm, Staff 5 (CNA) stated CNAs are trained in what their responsibilities are in the care of a feeding tube and competencies are signed off by a nurse. Staff 5 stated the extension tubing must be removed before all transfers, unless it is specified in the care plan not to. Staff 5 recalled Resident 1 and the incident. He reported that Resident 1 was unique, because the feeding tube had to be surgically inserted by a doctor. On 7/20/17 at 3:31 pm, Staff 6 (CNA) reported only the nurses or the CMAs could connect the extension tubing, but the CNAs could disconnect them. She reported CNAs were to let the nurse know if they disconnected it. Staff 6 stated the extension tubing must always be disconnected when transferring residents (from wheelchair to bed, transfer to shower, etc.) and when doing movements like turning the resident in bed. On 7/20/17 at 3:42 pm, Staff 7 (RN) reported only nurses or CMAs could connect the extension tubing, but CNAs were able to disconnect. On 7/20/17 at 8:02 pm, Staff 3 (CNA) recalled preparing Resident 1 for bed when she noticed a possible rash on Resident 1's neck. She went to the nurse to tell her, returned, and proceeded to transfer the resident without disconnecting the extension tubing. Staff 3 stated she knew to take it off, it was part of training, but did not that day. Staff 3 knew there were certain residents who had it on the care plan to leave the tubing in place, but knew she should have disconnected the extension tubing before transferring Resident 1. On 7/21/17 at 10:15 am, Staff 8 (RNCM) confirmed the events leading to Resident 1's feeding tube becoming dislodged and subsequent hospitalization . Staff 8 reported they discussed the policy during safety meeting every shift and it was a catalyst to start a midshift safety meeting. Staff 8 was able to state the facility policy and reported that with the number of residents with feeding tubes at the facility, it was a constant topic. Everyone needed to be aware of where these tubes were. Staff 8 reported there were no further incidents of accidental feeding tube dislodgement since the 4/28/17 event. On 7/21/17 at 11:45 am, Staff 9 (RNCM) confirmed the events leading to Resident 1's feeding tube becoming dislodged and subsequent hospitalization . Staff 8 reported everyone met at the start of every shift and at mid shift to discuss any issues/situations. This incident was reviewed in the Medical Quality Assurance process and the [MEDICATION NAME] pediatrician developed a procedure for consistent practice if a tube was removed. She stated Staff 3 was aware of the policy to always disconnect the extension tubing, but that Staff 3 did not follow the policy. Staff 8 reported there were no further incidents of accidental feeding tube dislodgement since the 4/28/17 event. This situation met the criteria for past noncompliance as follows: 1. The incident indicated noncompliance at F322. 2. The noncompliance occurred since the exit date of the last standard recertification survey (2/10/17) and before the date of this complaint survey (7/20/17). 3. There is sufficient evidence that the facility corrected the noncompliance and is in substantial compliance with F322 as evidenced by: - No deficient practice found at F322 with additional sampled residents. - Evidence the deficient practice was identified by the facility, brought to quality assurance, and a plan of correction was implemented on 5/1/17 to educate or reinforce education on facility policy regarding the management of feeding tube extensions. - RNCM, RN, and CNA interviews all indicated knowledge and awareness of facility policy and expectations for when removing a feeding tube extensions set was required.

Based on interview and record review it was determined that the facility failed to identify and assess weight loss, act upon nutritional recommendations, and implement nutritional interventions in a timely manner to prevent weight loss for 1 of 5 sampled residents (#8) who experienced weight loss. Resident 8 experienced a severe unplanned weight and body mass index (BMI) loss due to the facility's failure to address the resident's caloric needs in a timely manner. Findings include: According to the Centers for Disease Control (CDC), BMI determines whether a weight is appropriate for a given height and is used to assess whether or not children are considered underweight, overweight or at risk for health related weight issues. The guidelines for children's BMI are as follows and include: *Underweight - BMI less than the 5th percentile *Healthy weight- BMI 5th percentile up to the 85th percentile Resident 8, an [AGE] year old child, had [DIAGNOSES REDACTED]. Resident 8 received nourishment through a gastrostomy feeding tube (a tube placed into the stomach through the abdomen). The child was assessed to be dependent on staff for administration of all nourishment through the gastrostomy tube (GT). According to Resident 8's medical record, from 7/15/09 to 6/23/10 the child had received four 500 ml GT meals a day. Two meals were blenderized [MEDICATION NAME] Pediatric Formula and pureed food, and the other two meals were Completa Pediatric Formula. On 1/14/10, Staff 5, Registered Dietitian, (RD) documented in a quarterly nutrition assessment that Resident 8 had a weight loss in the previous quarter and had grown an inch in height. It was further documented that the child's BMI had decreased from the 63rd percentile to the 27th percentile. The RD identified that increase in calories for energy needs and weight maintenance was necessary. A change in formula strength from 65% to 67% was recommended. There was no documented evidence that the recommendation had been acted upon or that the physician had been notified. A 4/16/10 quarterly nursing nutrition assessment identified Resident 8 had additional weight loss. "...is slightly below his desired weight...will consult with the Dietician re: increasing his calories..." There was no documented evidence that the RD had been notified of the additional weight loss. On 5/2/10 the resident's weight record identified that a 7.87% weight loss (severe) had occurred over the past month. There was no documented evidence that the severe weight loss was identified, that an assessment was done, or that the RD and physician had been notified. On 6/4/10 the child's weight record identified that an additional 1.92% weight loss had occurred over the past month. There was no documented evidence that the continued weight loss was identified, that an assessment was done, or that the RD and physician had been notified. A 6/17/10 lab report indicated a slightly low normal protein level. More than five months after the recommendation to increase calories to meet the child's nutritional needs, a 6/22/10 Nutrition Care Order signed by the RD directed the formula be changed to [MEDICATION NAME] (adult formula) at 50% strength "...calories increased to promote weight gain..." The change was directed to be implemented on 6/24/10. On 7/1/10, the child's weight record identified further weight loss of 0.14%. A 7/1/10 Nutrition Care order signed by the RD directed the formula strength be increased to 55% [MEDICATION NAME] formula, to increase calories to promote weight gain. According to the 7/8/10 RD assessment, the child had a significant weight loss of greater than 10% in the last 180 days. "...is now underweight...Inadequate caloric intake related to increased energy needs for growth as evidenced by gradual weight loss and BMI less than 1st percentile..." A 7/16/10 Social Service note, contained"... telephone call from Mom...especially concerned because the child is losing weight..." In interview on 8/24/10 at 2:03 pm, Staff 4, RNCM, confirmed that an unintended weight loss had occurred. Staff 4 further stated that the child had a growth spurt which contributed to the loss. Staff 4 reported that a weight gain had occurred since recent changes to the child's formula and with an addition of a 5th meal daily. The lack of identified severe weight loss, assessment of that loss, timely follow up, acting upon recommendations, and lack of timely interventions was discussed on 8/26/10 at 2:02 pm with Staff 5, Registered Dietician (RD). Staff 5 stated that a quarterly nutrition assessment should have been done in April and when the severe weight loss occurred in May. "...was missed...he fell through the cracks...even the mother noticed his weight loss and then we became aggressive..."