Every finding on record at Reunion Plaza Healthcare & Rehabilitation

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #35 and Resident #25) of five residents, reviewed for infection control.1. The facility failed to ensure CNA A performed hand hygiene while bathing Resident #35. 2. The facility failed to ensure CNA B performed hand hygiene during incontinence care for Resident #25.These failures placed residents at risk for healthcare associated cross contamination and infections.Findings included: 1. Review of Resident #35's Quarterly MDS Assessment, dated 05/18/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Her BIMs score was 8 reflecting that her cognitive skills were moderately impaired. Her diagnoses included diabetes and Non-Alzheimer's Disease. The resident was always incontinent of bowel and bladder. The resident was dependent staff. An observation on 08/05/25 at 9:50 AM of Resident #35 revealed she was lying in bed. She said she was waiting to get a bath. CNA A put on gloves and gathered supplies. CNA A removed the resident's clothing and placed towels on the resident. CNA A removed the brief and threw it in the trash. CNA A changes his gloves but did not perform hand hygiene. CNA A cleaned the resident's arms, chest, abdomen, peri-area, and legs. CNA A changed gloves but did not perform hand hygiene. CNA A assisted the resident to roll to her right side. He cleaned her back, buttocks, legs, and cleaned bowel movement from the buttocks. CNA A grabbed a towel using the soiled gloves and dried the back of the resident's buttocks and back of thighs with the towel. CNA A removed his gloves and washed his hands. CNA A put on new gloves. CNA A did not wash the resident's feet. CNA A put a new brief on the resident and dressed her. An interview on 08/05/25 at 12:45 PM with CNA A revealed he had been trained/checked off to wash a resident's feet and peri-area with the vaginal folds during a bath. He said he also had been trained to perform hand hygiene between glove changes. He said he did not do those things because the resident had wounds and things on her feet. (The resident had a very small diabetic ulcer on the left first toe.) He also said the resident's peri-area was tight and he was not able to clean her. CNA A said the risk to the resident if her feet and vaginal folds were not washed was skin breakdown. CNA A said the risk to the resident if hand hygiene was not performed was infection.2. Review of Resident #25's Quarterly MDS Assessment, dated 07/16/25, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMs score was 15 reflecting that her cognitive skills were intact. The resident was always incontinent of bladder and bowel. Her diagnoses included heart disease and high blood pressure. The resident was dependent on staff for toileting/hygiene.Review of Resident #25's Care Plans reflected:11/03/24 Activities of daily living self-care performance deficit related to fatigue and limited mobility.Facility interventions included:Toilet use: incontinent of bowel and bladder. Check and change every two hours and as needed.An observation on 08/06/25 at 2:15 of Resident #25 revealed CNA B was preparing to perform incontinence care. CNA B folded the brief down and cleaned the peri-area. CNA B changed gloves but did not perform hand hygiene. The brief contained urine. The resident was assisted to turn to her right side and CNA B cleaned her buttocks. CNA B changed gloves but did not perform hand hygiene. CNA B placed the brief, applied cream, and assisted the resident to roll to her back. CNA B fastened the brief.An interview on 08/06/25 at 2:25 PM with CNA B revealed she had been trained to perform hand hygiene between glove changes. She said she did not do it this time because she was anxious. CNA B said the risk to the resident was infection.An interview on 08/06/25 at 2:30 PM with the ADON revealed staff were supposed to perform hand hygiene between glove changes during incontinence care. The ADON said the risk to the resident was urinary tract infections. The ADON said staff were supposed to wash resident's feet during a bath. The ADON said the risk to the resident was skin breakdown or fungal infections. She said it was not ok to use soiled gloves to grab a clean towel to dry a patient after cleaning them of bowel movement could cause urinary tract infections. An interview on 08/07/25 at 2:10 PM with the DON revealed staff were supposed to perform hand hygiene between glove changes and incontinence care. The DON said failure to do so could cause infection. The DON said staff were supposed to wash the resident's feet during a bath because staff were supposed to clean everyone's feet especially if they were diabetic. The DON said failure to clean the vagina properly could cause vaginal infection, urinary tract infections, and sores.Record review of the facility policy, Hand Hygiene, dated 06/13/24, reflected: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.Policy Explanation and Compliance Guidelines:Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.6. Additional considerations:a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on interviews and record review, the facility failed to complete a discharge summary that included but was not limited to, (i) A recapitulation of the resident's stay that includes, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; (ii) A final summary of the resident's status; (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for one (Resident #58) of four residents reviewed for discharge planning. 1. The facility failed to complete a discharge summary and a reconciliation of medications for Resident #58 for her unplanned discharge to the hospital on [DATE]. This could place residents at risk of a recapitulation of the stay being unavailable to help ensure continuity of care once they went back home and/or discharged from the facility. Findings included: Record Review of Resident #58's admission face sheet dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #58's active diagnoses included gastroesophageal reflux disease (GERD) without esophagitis (GERD is characterized by the backward flow of stomach acid into the esophagus, causing symptoms like heartburn and regurgitation. Esophagitis is a condition where the esophagus becomes inflamed due to this acid reflux), acute kidney failure (a sudden and rapid decrease in kidney function), dorsalgia (refers to pain in the dorsal spine, which is the mid-back region), hyperkalemia (a condition where there is a high level of potassium in the blood), hyperlipidemia (high cholesterol, is a condition where there are elevated levels of lipids (fats) in the blood), diabetes, and depression. Resident #58 was discharged from the facility to the hospital on [DATE]. Record review of Resident #58's Discharge MDS assessment dated [DATE], reflected that the BIMS assessment score was blank. Resident #58's BIMS score was not successfully completed due to being unable to complete the assessment because she had difficulty comprehending the instructions. In Section A - Identification Information - A0050. Type of Record, Section F., reflected Section F. Entry/Discharge reporting is coded 11, meaning Discharge assessment - return anticipated. In Section A0310 - Type of Assessment, Section G. Type of Discharge reflected that Resident #58 had an unplanned discharge. In Section Q - Participation in Assessment and Goal Setting section Q0400 - Discharge Plan, Question A. Is active discharge planning already occurring for the resident to return to the community? The entry code is 0, which means No. Record review of Resident #58's Care Plan dated [DATE] reflected, no information relating to her discharge from the facility. Record review of Resident #58's Clinical Records reflected no discharge summary. Record review of the facility's admission and Discharge Report for [DATE] reflected that Resident #58 was sent to the hospital and was discharged from the facility. An attempted telephone call to the facility's Ombudsman on [DATE] at 10:58 AM was unsuccessful. An attempted telephone call to Resident #58's RP on [DATE] at 1:09 PM was unsuccessful.[SP1] In an interview with the SW on [DATE] at 10:04 AM, she stated she could not locate a Discharge Summary for Resident #58. She reported that the DON was responsible for completing the Discharge Summaries for residents who discharge from the facility to the hospital. In an interview with the DON on [DATE] at 2:01 PM, she stated that she had been employed at the facility for 4 years. The DON acknowledged that discharge summaries were completed for each resident that discharges from the facility. The DON stated that she was responsible for completing the discharge summaries for residents who have discharged from the facility due to being hospitalized . She stated that there was not a discharge summary for Resident #58. She stated that the facility's Social Worker was responsible for completing the Discharge Summaries for residents. The DON stated there was a risk to residents being discharged from the facility without a discharge summary. She stated without a Discharge Summary, the discharge residents would not be able to meet with the staff to discuss their reconciliation of medications and their discharge plans such as home health and care responsibilities. The DON stated that there was not any harm to Resident #58 due to her discharging from the facility and not having a discharge summary in the clinical records. An attempted telephone call to Resident #58's RP on [DATE] at 2:14 PM was unsuccessful. [SP2] In an interview with the facility's Admissions Coordinator on [DATE] at 3:04 PM, he stated that he had been employed at the facility since [DATE]. He stated he did not make a telephone call to the hospital after Resident #58 was sent out to the hospital on [DATE]. He stated that he would only reach out to the family of the resident only after the Case Manager with the hospital reached out to him about the resident for a follow-up regarding the resident's discharge from the hospital to the facility. The Admissions Coordinator stated that he was unsure if there was any risks or harm associated with there not being a discharge summary completed for residents such as Resident #58 who were discharged from the facility due to being hospitalized . In an interview with the Administrator on [DATE] at 2:10 PM, he provided a copy of the facility's policy, Transfer and Discharge (including AMA), dated [DATE], reviewed and revised on [DATE]. The Administrator stated that he had been employed at the facility for 4 years. He stated that if a resident was sent to the hospital and does not have an anticipated return to the facility, the facility's policy stated that they did not have to complete a discharge summary for the resident. He stated that since he had been the Administrator at the facility, the staff had not completed any discharge summaries for residents that were sent to the hospital. He stated that if a resident was sent to the hospital, the Admissions Coordinator would follow-up with the hospital to verify if a resident will remain hospitalized or be discharged home or to the community. He stated that if a resident was hospitalized for an indeterminate time, the resident would be discharged from the facility and per the facility's policy and a discharge would not be completed. He stated that Resident #58 was discharged from the hospital and was later transferred to another facility and then passed away at the other facility. He stated that he spoke with Resident #58's RP and was informed that she was deceased . The Administrator acknowledged that discharge summaries should be completed for each resident that discharged from the facility. He stated the Social Worker was responsible for completing the Discharge Summaries for residents who discharged from the facility, except for hospitalizations. The Administrator stated he was not familiar with the Discharge Planning process and the Discharge Summary because the Social Worker did the process. He stated that if the resident was discharging home, the staff would speak with the family and a doctor to ensure the resident was being sent home with some instructions regarding the care that would be needed at home. The Administrator stated he did not know if there was any risk or harm that can be caused to a resident if they were discharged home without a discharge summary. The Administrator stated that he would have to check with his corporate office and do some research to possibly have the facility's policy revised relating to discharge summaries. He stated that in the 4 years he had been at the facility residents who were sent out to the hospital did not have any discharge summaries completed. Record review of the facility's policy titled, Transfer and Discharge (including AMA), dated [DATE], reviewed and revised on [DATE], reflected, Policy : It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source.Definitions: Anticipated Discharge is a discharge that is planned and not due to the resident's death or an emergency (e.g., hospitalization for an acute condition or emergency evacuation). Transfer and Discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical place or not. Transfer and discharge does not refer to movement of a resident to a bed within the same facility.Policy Explanation and Compliance Guidelines:1. The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs.2. Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions:a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .4.c. An immediate transfer or discharge is required by the resident's urgent medical needs.e. In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC ombudsman as soon as practicable before the transfer or discharge.5. The facility will maintain evidence that the notice was sent to the Ombudsman .h. Additional information, if any, outlined in the transfer agreement with the acute care provider.9. Emergency Transfers to Acute Carea. The facility will obtain a physician's order for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis.b. The facility will contact an ambulance service and provider hospital, or facility of resident's choice, when possible, for transportation and admission arrangements.c. For a transfer to another provider, ensure necessary information listed in #8 of this policy is provided along with, or as part of, the facility's transfer form.d. The original copies of the transfer form and Advance Directives will accompany the resident. Copies will be retained in the medical record.e. Provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form and manner that the resident can understand.f. Document assessment findings and other relevant information regarding the transfer in the medical record.g. Provide a notice of transfer and the facility's bed hold notice policy to the resident and representative as indicated.h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices.i. The resident will be permitted to return to the facility upon discharge from the acute care setting.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #35) of four residents reviewed for ADL care. 1. The facility failed to ensure CNA A thoroughly cleaned the vaginal area and feet of Resident #35 when he provided the resident with a bath on 08/05/25. This failure could place residents at risk for a skin breakdown and infection.Findings included: 1. Review of Resident #35's Quarterly MDS Assessment, dated 05/18/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Her BIMs score was 8 reflecting that her cognitive skills were moderately impaired. Her diagnoses included diabetes and Non-Alzheimer's Disease. The resident was always incontinent of bowel and bladder. The resident was dependent staff.Review of Resident #35's Care Plan, dated 08/25/23, reflected: The resident had an ADL self-care performance deficit related to impaired balance and mobility.Facility Interventions included: Bathing/Showering: requires (extensive assistance) by (2) staff on schedule shower days and as necessary.An observation on 08/05/25 at 9:50 AM of Resident #35 revealed she was lying in bed. She said she was waiting to get a bath. CNA A was in the room, wearing gloves, and preparing water. CNA A put on gloves and gathered supplies. CNA A removed the resident's clothing and placed towels on the resident. CNA A removed the brief and threw it in the trash. CNA A cleaned the resident's arms, chest, abdomen, peri-area, and legs. CNA A did not clean the vaginal folds. CNA A assisted the resident to roll to her right side. He cleaned her back, buttocks, legs, and cleaned bowel movement from the buttocks. CNA A did not wash the resident's feet. An interview on 08/05/25 at 12:45 PM with CNA A revealed he had been trained/checked off to wash a resident's feet and peri-area with the vaginal folds during a bath. He said he did not do those things because the resident had wounds and things on her feet. (The resident had a very small diabetic ulcer on the left first toe.) He also said the resident's peri-area was tight and he was not able to clean her. CNA A said the risk to the resident if her feet and vaginal folds were not washed was skin breakdown. An interview on 08/06/25 at 2:30 PM with the ADON revealed staff were supposed to wash the resident's feet during a bath. The ADON said the risk to the resident was skin breakdown or fungal infections. An interview on 08/07/25 at 2:10 PM with the DON revealed staff were supposed to wash the resident's feet during a bath because staff were supposed to clean everyone's feet especially if they were diabetic. The DON said failure to clean the vagina properly could cause vaginal infection, urinary tract infections, and sores.Record review of the facility policy, Perineal Care, dated 05/01/24, reflected: Policy:It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, decrease risk of infection to the extent possible, and to decrease risk of and assess for skin breakdown.7. Females:a. Assist resident in bending her knees slightly and spreading her legs.b. Wet washcloth and apply perineal cleanser. If using prepackaged product, open package and obtain the wet cloth.c. Separate the resident's labia with one hand, and cleanse perineum with the other hand by wiping in direction from front to back (from pubic area toward anus).d. Repeat on opposite side using separate section of washcloth or new disposable wipe.e. Clean urethral meatus and vaginal orifice using clean portion of washcloth or new disposable wipe with each stroke.Record review of the facility policy, Resident Showers, dated 04/15/24, reflected: Policy:It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice.Wash from head to toe.

Based on observation, interview and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented for 1 (Resident #7) of 5 residents reviewed for medical records. The facility failed to ensure Resident #7's medical records contained the results of the preadmission PASRR Level 1 screening and subsequent evaluations and determinations in accordance with accepted professional standards and practices. This failure could place the residents at risk of not achieving their person-centered plan of care objectives and goals. Findings included: Review of Resident #7's Face sheet, dated 08/07/2025, reflected he was a [AGE] year old male, who was admitted to the facility on [DATE], with diagnoses including end stage renal disease (the final stage of chronic kidney disease, characterized by the kidney's inability to filter waste and excess fluid from the blood), chronic respiratory failure with hypoxia (a condition where the lungs are unable to adequately oxygenate the blood and/or remove carbon dioxide), Type 2 Diabetes (the body does not produce enough insulin, leading to high blood sugar levels), dysphagia, oropharyngeal phase (difficulty swallowing) and chronic diastolic heart failure (a condition where the heart muscles is stiff, leading to increased pressure within the heart chambers). Review of the Resident #7's electronic medical record reflected there was not a PASRR Level 1 screening uploaded to the resident's medical record. During an interview with the MDS Coordinator on 08/07/2025 at 11:00 AM, the MDS Coordinator reviewed Resident #7's medical records and confirmed there was not a PASRR Level 1 uploaded to the resident's medical record. When asked how the PASRR Level 1 screening gets uploaded to the resident's medical record, the MDS Coordinator stated it was the responsibility of the MDS office to upload the PASRR Level 1 screening into the resident's medical record during admission, which they get from Simple, a software system used to manage the PASRR process in Texas. When asked what the risk is for the resident, the MDS Coordinator stated she did not think there was a risk in this instance because this was a discrepancy in charting. A review with the MDS Coordinator on 08/07/2025 at 11:05 AM revealed a PASRR Level 1 screening for Resident #7 had been completed on 05/19/2023 and was uploaded in Simple. The PASRR Level 1 screening was positive. Further review revealed a PASRR Level II evaluation was completed on 05/26/2023. An observation of the MDS Coordinator on 08/07/2025 at 11:10 AM reflected the MDS Coordinator uploaded the PASRR Level 1 screening and PASRR Level II evaluation to Resident #7's medical record. A review of the facility's Documentation in Medical Record policy, dated 02/01/2025, stated the following: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on observations, interviews, and record review, the facility failed to notify residents or their representatives on how to file a grievance in an anonymous manner, and the information of who the facility named as the Grievance Official for 2 residents (Resident #27 and Resident #43) out of 7 residents interviewed for grievances.1.The facility failed to notify Residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner. 2.The facility failed to follow their grievance policy by providing the correct information as to who the facility identified as the Grievance Official for Resident #27 and Resident #43. These failures could affect resident's ability to file a grievance without the fear of discrimination, reprisal, retribution, and their right to request a written decision regarding the resolution of their grievance. Findings Included:Review of Resident #27's MDS admission assessment, dated 08/07/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her BIMS score was 15. Her cognitive status was intact. Her diagnoses included Chronic Obstructive Pulmonary Disease (ongoing lung condition caused by damage to the lungs), GERD (a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach), Hypertension (a condition in which the force of the blood against the artery wall is too high), Major Depression Disorder (depressed mood or loss of interest in activities, causing significant impairment in daily live), Bipolar Disorder (mental condition marked by alternating periods of elation and depression) and Epilepsy (is a brain condition that causes recurring seizures).Review of Resident #43's MDS admission assessment, dated 08/07/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her BIMS score was 13. Her cognitive status was intact.In an interview with Resident #27 on 08/07/25 at 9:11 AM, she met with the Surveyor in the hallway, and she stated that she needed to speak with the Surveyor. Resident #27 reported that she had some issues with staff not assisting another resident (Resident #43) with her daily ADL's. Resident #27 stated that she did not know what a Grievance was and had not filed a grievance at the facility. Resident #27 stated that she did not know who the Grievance Official was at the facility. Resident #27 stated that she had never filed a grievance at the facility regarding any of her concerns because she did not know anything about filing grievances at the facility. In an interview with Resident #43 on 08/07/25 at 9:32 AM, she stated that there was an occasion when she had been left in her brief for about 10 hours. Resident #43 stated that she did not file a grievance with the facility because she was bedbound and unable to file leave her room to file a grievance. Resident #43 stated that she did not know who the Grievance Official was at the facility. Resident #43 stated that she had never filed a grievance at the facility regarding any of her concerns because she did not know how to file grievances at the facility.In an interview with the SW/GO 08/07/25 at 11:58 AM, she stated that the Grievance Forms were not available to residents, on the floor, but they were available at the Nurses Station. She stated that there was not any way for residents to complete a Grievance Form anonymously. She stated that she understood that residents needed a way to complete a Grievance Form anonymously. The SW stated that there was a risk of residents feeling concerned about retaliation if they go to the Nurses Station to fill out a Grievance Form. The SW stated that if someone completes a Grievance Form and it was turned into Management, they can feel like they were being retaliated against.In an interview with the ADON on 08/07/25 at 12:13 PM, she stated that the Grievance Forms were in a folder behind the Nurses Station. She stated that the Grievance Forms were also located inside of the Administrators Office. She stated that there was not any way for residents to complete a Grievance Form anonymously. She stated that there was a risk for residents not to feel safe, if they fill out a Grievance Form Observation on 08/07/25 at 12:20 PM, revealed that the Grievance Forms were in a folder behind the Nurses Station. Observation on 08/07/25 at 12:22 PM, revealed that the Grievance Forms were located on a side wall in front of the Administrator's Office. The Grievance Forms were on a wall with 2 wall pockets. There was not a sign indicating the location of the Grievances. Record Review of the facility's Grievance Log for January 2025 - July 2025 revealed that there were no grievances filed for Residents #27 and #43.Review of the facility's policy titled, Resident and Family Grievances dated February 2025 reflected: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC facility stay. Upon request, the facility will give a copy of this grievance policy to the resident. Information on how to file a grievance or complaint will be available to the resident.Review of the Resident's Rights subsection Grievances revealed, The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished; and the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to, and the facility must make prompt efforts by the facility to resolve grievances the resident may have.

Based on observation, interview and record review, the facility failed to ensure residents who had not used [CONDITION(S)] drugs were not given these drugs unless the medication was necessary to treat a condition as diagnosed and documented in the clinical record in an effort to discontinue these drugs for 1 (Resident #204) of 3 residents reviewed for [CONDITION(S)] medications. The facility failed to ensure there was a consent for Resident #204's trazadone ([CONDITION(S)] medication), [MEDICATION(S)] ([CONDITION(S)] medication), [MEDICATION(S)] ([CONDITION(S)] medication), and [MEDICATION(S)] (anti-depressant). These failures could place residents at risk for possible [CONDITION(S)] medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary [CONDITION(S)] medications. Findings included: A record review of Resident #204's face sheet dated 3/16/22 indicated the resident was admitted to the facility on [DATE] with the following diagnoses: [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)] disorder (psychiatric disorder), and aftercare of right hip replacement. A record review of Resident #204's physician orders dated 03/15/22 indicated the resident had an order for [MEDICATION(S)] 5mg 1 tab by mouth every bedtime, [MEDICATION(S)] 100mg 1 tab by mouth every day, [MEDICATION(S)] 300mg 1 tab by mouth every day, and trazadone 50mg 1 tab by mouth every bedtime for 14 days. A review of Resident #204's Medication Administration Record dated 03/01/22 through 03/31/22, indicated she received [MEDICATION(S)] 5mg 1 tab by mouth every bedtime [MEDICATION(S)] 300mg 1 tab by mouth every day, and trazadone 50mg 1 tab by mouth every bedtime daily from 03/15/22 through 03/22/22. A review of Resident #204's Medication Administration Record dated 03/01/22 through 03/31/22, indicated she received [MEDICATION(S)] 100mg 1 tab by mouth every day daily from 03/17/22 through 03/22/22. A review of Resident #204's Treatment Administration Record dated 03/01/22 through 03/31/22 indicated she was not monitored for possible [CONDITION(S)] medication side effects or adverse consequences. A review of Resident #204's clinical records revealed she did not have any [CONDITION(S)] consents. A review of Resident #204's baseline care plan report dated 03/15/22 completed by the MDS coordinator, LVN A, indicated she was on [CONDITION(S)] medications [MEDICATION(S)] ([MEDICATION(S)]) and [MEDICATION(S)] ([MEDICATION(S)]). A review of Resident #204's admission checklist dated 03/16/22 indicated the column indicating the psychoactive consent was completed and the behavior sheets filled out and placed in the medication administration record was not completed. During an observation and interview on 03/23/22 at 10:20 AM, Resident #204 was alert and oriented resting in her bed. She said she had bad [CONDITION(S)] disorder but said she did not recall what medications she was on for it and nobody had reviewed her medications or discussed them with her. During an interview and record review on 03/23/22 at 10:30 AM, LVN B said she was Resident #204's charge nurse. LVN B said when a resident was admitted , the charge nurse was responsible to review medications, including [CONDITION(S)] medications, with the physician and complete the psychoactive consents before they were administered and complete the behavior sheets and place them in the medication administration record. LVN B reviewed Resident #204's clinical records and said these were not completed appropriately. LVN B said she was not aware the admission checklist had not been completed but the ADON usually verified this was completed. During an interview and record review on 03/23/22 at 10:40 AM, the ADON said she and the DON was usually responsible to verify the admission checklist was completed but said she had not looked at Resident #204's clinical records but should have. The ADON reviewed Resident #204's clinical records and verified her psychoactive consents and behavior monitoring sheets were not completed. During an interview and record review on 03/23/22 at 10:45 AM, the MDS coordinator, LVN A, said she completed Resident #204's baseline care plan that included her prescribed psychoactive medications but did not complete the consents. LVN A said the DON and ADON were responsible to ensure Resident #204's psychoactive consents were obtained appropriately. During an interview on 03/23/22 at 10:50 AM, the DON said when a resident was admitted the charge nurse verified with the doctor to continue [CONDITION(S)] medications and ensure consents were obtained. The DON said the ADON was responsible to oversee this was completed and verified the admission checklist was completed. The DON reviewed Resident #204's clinical records and verified her psychoactive consents and behavior monitoring sheets were not completed. During an interview on 03/23/22 at 11:05 AM, the administrator said the DON and ADON were responsible to ensure the admission checklist was completed by the next interdisciplinary team meeting the next day but did not think this was appropriately reviewed resulting in Resident #204's psychoactive consents not obtained appropriately. The administrator said the DON and ADON had been on sick leave and were not aware it had not been completed prior to surveyor intervention. Resident #204's consent for the use of psychoactive medication therapy dated 03/23/22 after surveyor intervention indicated her [MEDICATION(S)] 5mg for diagnosis of [CONDITION(S)] disorder had clinical side effects or risks associated with the medication included cholesterol increased, confusion, constipation, [CONDITION(S)], movement disorder/extrapyramidal effects, [CONDITION(S)], tardive dyskinesia, tremors, [CONDITION(S)], and weight gain. Resident #204's consent for the use of psychoactive medication therapy dated 03/23/22 after surveyor intervention indicated her [MEDICATION(S)] 100mg for diagnosis of depression had clinical side effects or risks associated with the medication included anxiety, constipation, diarrhea, [CONDITION(S)], [CONDITION(S)], nausea/vomiting, [CONDITION(S)], tremors and weight loss/gain. Resident #204's consent for the use of psychoactive medication therapy dated 03/23/22 after surveyor intervention indicated her trazadone 50mg for diagnosis of depression had clinical side effects or risks associated with the medication included anxiety, constipation, diarrhea, [CONDITION(S)], [CONDITION(S)], nausea/vomiting, [CONDITION(S)], tremors and weight loss/gain. Resident #204's consent for the use of psychoactive medication therapy dated 03/23/22 after surveyor intervention indicated her [MEDICATION(S)] 300mg for diagnosis of [CONDITION(S)] disorder had clinical side effects or risks associated with the medication included abdominal pain, ataxia, frequent urination, nausea/vomiting, thirst, tremors and weight loss/gain. A review of the facility's Antipsychotic Medication Use policy revised December 2016 indicated the attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. The nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician.

Based on observation, interview, and record review, the facility failed to maintain a safe environment for residents, staff, and the public for 1 0f 1 dumpsters observed. The facility did not ensure the dumpster was closed and the surrounding area was free of debris. This failure could place residents, staff and the public at risk for an unsafe environment. Findings included: During an observation on 12/16/20 at 12:00 PM, the facility dumpster revealed 4 bags of trash on the ground, used PPE overflowing from top of the receptacle, bin door was open and debris, including used ppe and soiled brief, was on the ground around the dumpster. During an interview on 12/16/20 at 03:04 PM the housekeeping supervisor said the dumpster was the sole receptacle for the facility and the trash service emptied it on Mondays, Wednesday, and Fridays. She said the door to the bin was supposed to be kept closed and there was no excuse for the trash all over the ground. A facility waste disposal policy revised January 2012 indicated all infectious and regulated waste shall be handled and disposed of in a safe and appropriate manner.

Based on observation, interview, and record review, the facility failed to ensure nurse aides demonstrated competency in techniques to care for 2 of 3 residents reviewed for incontinent care . (Resident #s 29 and 11). CNA A and B did not use correct technique when providing incontinent care for Resident #29. CNA D failed to use correct technique when providing incontinent care for Resident #11. This failure could place residents at risk of being provided care by staff who have not been trained to provide appropriate resident care. Findings included: 1. During an observation on12/16/20 at 09:15 AM CNA A was assisted by CNA B to provide incontinent care for Resident #29. Both CNAs washed their hands. CNA A laid her supplies on a clean towel on the overbed table including opening 2 small packets of barrier cream. Both CNAs donned gloves. CNA A opened the brief and CNA A turned the resident on her left side so CNA A could check for bowel movement. She cleaned the resident's anal area using one wipe which returned with feces. She changed her gloves because she had soiled them. She pulled fresh wipes from the package and cleansed the anal area again. Using the same soiled gloves, the CNAs turned the resident to her back. CNA A wiped across the lower abdomen and down both groin areas with the same wipe. She did not turn or fold the wipe. She took another wipe and cleansed the inner labia. Using the same soiled gloves, CNA A took the clean brief from the table, opened it, and placed it on the bed. Using the same soiled gloves, she pulled more wipes from the package and turned the resident onto her left side and cleansed the resident's right buttock. She took more wipes and cleaned the buttock area two more times. The left buttock was only partially cleansed. The resident was not turned to her other side and the left buttock thoroughly cleansed. Using the same soiled gloves, CNA A placed the fresh brief under the resident and turned her onto her back. Both CNAs pulled the brief through her legs and fastened the tabs. CNA A removed her gloves. The resident was pulled up in bed and made comfortable. During an interview on 12/16/2020 at 09:25 AM CNA A said the resident did not need any barrier cream placed on her because she had no red spots on her bottom. She said she would usually change her gloves if they were visibly soiled, like she did after the first wipe. She said she should have changed her gloves before touching clean items. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated the resident was to have [MEDICATION(S)] ointment applied to buttocks and peri-area daily and as needed for excoriation. The most recent MDS dated [DATE] for Resident #29 indicated the resident required extensive assistance of 2 staff with bed mobility, transfers, dressing, toileting and personal hygiene. She required limited assistance of one staff with eating. She was incontinent of bladder and incontinent of bowel. A care plan last revised on 10/14/2020 indicated Resident #29 required extensive assistance from staff with ADLs to remain clean, dry, odor free, and well-groomed. The care plan indicated she had urinary incontinence related to impaired mobility and was at risk for urinary tract infection or skin breakdown. The care plan indicated the resident was at risk for skin breakdown and was to be kept clean and dry as possible and incontinence care was to be provided after each episode. The care plan indicated the resident was at risk for pressure ulcers and incontinence care was to be provided after each episode. 2. During an observation on 12/16/20 at 4:00 PM, CNA D performed incontinent care on Resident #11. CNA D cleaned the peri area, turned Resident #11 on her right side and cleaned only her left buttocks. With gloves on, CNA D removed the soiled brief and placed it in the plastic bag. Using the same soiled gloves, she then picked up the clean brief and placed it under Resident #11's buttocks. During an interview on 12/16/20 at 4:09 PM, CNA D said the only thing she would have done differently was the set up. She said she usually does not set everything up separately, she just brings in her bags with her supplies. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS, dated [DATE], indicated Resident #11 was always incontinent of bowel and bladder and needed extensive assistance with ADLs. A care plan last revised on 08/12/20 indicated Resident #11 was total care for incontinence management and she does not participate in the process. She required extensive assistance. A Perineal Care Policy ,revised October 2010, indicated .Wash labia .continue to wash downward and outward including the thighs .do not reuse same washcloth .turn resident on her side .wash rectal area thoroughly, wiping from the base of the labia extending over the buttocks .remove gloves and discard .wash and dry hands .reposition bed covers and make resident comfortable . A Personal Protective Equipment-Using Gloves Policy, revised September 2010, indicated .gloves are used to prevent the spread of infection .gloves primarily prevent the contamination of the employee's hands when providing treatment or services to the patient . According to the World Health Organization's Glove Use Information Leaflet revised August 2009 The efficacy of gloves in preventing contamination of health-care workers' hands and helping to reduce transmission of pathogens in health care has been confirmed in several clinical studies. Nevertheless, health-care workers should be informed that gloves do not provide complete protection against hand contamination. Pathogens may gain access to the caregivers' hands via small defects in gloves or by contamination of the hands during glove removal. Hand hygiene by rubbing or washing remains the basic to guarantee hand decontamination after glove removal

Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 8 of 24 residents reviewed for infection control. (Residents #9, 11, 29, 33, 36, 37, 47 & 55). room [ROOM NUMBER] bathroom, used by two residents (Residents #36 & 55) had an unlabeled basin and bedpan stored unbagged in the corner under the sink In the bathroom for room [ROOM NUMBER] Resident #9's urinal had feces smeared on it and his personal items were not labeled or stored appropriately. Personal use items were improperly stored in the bathroom used by Residents #8 & 37. LVN O & LVN P contaminated clean areas while performing incontinent care on Resident #37. CNA A contaminated clean areas and did not thoroughly clean Resident #29 when providing incontinent care. CNA D touched clean items with soiled gloves while performing incontinent care on Resident #11 MA M did not maintain infection control procedures while separating medication capsules for Resident #33. MA N did not maintain infection control procedures while separating medication capsules for Resident #47. These failure could place residents who required assistance with incontinent care at risk for discomfort, skin breakdown, cross contamination, and infections. Findings included: During an observation on 12/14/20 at 09:40 AM, the room [ROOM NUMBER] bathroom, used by two residents (Residents #36 & 55) had an unlabeled basin and bedpan stored unbagged in the corner under the sink. During an observation on 12/14/20 at 09:48 AM, the room [ROOM NUMBER] bathroom, used by Resident #9, had a urinal with feces smeared on the handle thrown in the bathroom floor and unlabeled toothbrush laying on a tube of toothpaste openly touching sink and faucet. During an observation on 12/14/20 at 10:04 AM, the room [ROOM NUMBER] bathroom, shared by two residents (Residents #8 & 37), had an unbagged and unlabeled basin with an unlabeled bedpan in it and unlabeled jug with soap-consistency contents in it. During an interview on 12/14/20 at 10:20 AM, CNA A said CNAs were responsible for bagging and labeling residents' personal items and there should not be any cleaning chemicals or dirty items left in the bathrooms. During an observation and interview on 12/15/20 09:10 AM, the urinal with feces on the handle was still on floor in room [ROOM NUMBER] and the toothbrushes were still open sink. Resident #9 said he used the bathroom but did not know why his urinal was left on the floor. He said no one assisted him to label or store his personal items. During an observation on 12/15/20 at 09:14 AM, LVN O was assisted by LVN P to provide incontinent care for Resident #37. Both LVNs did not wash or sanitize their hands before donning gloves. LVN O did not sanitize her hands or change gloves after she removed the wet brief and wiped feces. LVN O handed the soiled brief to LVN P and he dropped the wet brief onto the floor. LVN O touched items on the overbed tray, top sheet, bottom sheet, resident's gown and body with contaminated gloves while repositioning her. After the care was completed, LVN O removed her gloves and used hand sanitizer on her hands. During an interview on 12/15/20 at 9:25 AM, LVN O said she should have changed her gloves and not cross contaminated between clean and dirty during the care, but she was nervous. During an interview on 12/15/20 at 9:27 AM, LVN P said they should have washed their hands before the care and between handling the dirty and clean items because they cross contaminated the resident. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS dated [DATE] for Resident #37 indicated the resident required extensive assistance of 2 staff with bed mobility, transfers, dressing, toileting and personal hygiene. She required limited assistance of one staff with eating. She was incontinent of bladder and incontinent of bowel. A care plan last revised on 11/06/2020 indicated Resident #37 required extensive assistance from staff with ADLs to remain clean, dry, odor free, and well-groomed. The care plan indicated she had urinary incontinence related to impaired mobility and was at risk for urinary tract infection or skin breakdown. The care plan indicated the resident was at risk for skin breakdown and was to be kept clean and dry as possible and incontinence care was to be provided after each episode. The care plan indicated the resident was at risk for pressure ulcers and incontinence care was to be provided after each episode. During an observation and interview on 12/15/20 at 01:16 PM LVN C said CNAs were responsible for making sure resident items were labeled and bagged appropriately and no personal items or corrosive chemicals or cleaners were left unsecured in resident areas. LVN C said she in-serviced staff a few months ago regarding this protocol and was responsible to oversee that it was done. LVN C observed the cleaning fluids in the room [ROOM NUMBER] bathroom and said they were definitely not supposed to be there. She said both residents (Residents 36 & 55) used the bathroom with assistance and Resident 55's bedpan and basin should be labeled and bagged. She observed the room [ROOM NUMBER] bathroom and said it looked and smelled like poopie on the urinal on the floor and should have been cleaned up and Resident 9's toothbrush and paste should be bagged and labeled because it was not hygienic to be left out on the sink. During an interview on 12/15/20 at 2:40 PM the MDS Nurse said she was responsible for making daily room rounds in the morning on 400 hall, which included checking on the resident's well-being and comfort and check the room and bathroom environment for cleanliness and prohibited items, such as cleansers or unlabeled or dirty items. She said she checked 400 hall both yesterday and today and did not identify any issues. She said they were supposed to document this on a daily log to be turned in to the administrator, but she had worked there for 7 years and had the log memorized. During an observation on 12/16/20 at 09:15 AM CNA A was assisted by CNA B to provide incontinent care for Resident #29. Both CNAs washed their hands. CNA A laid her supplies on a clean towel on the overbed table including opening 2 small packets of barrier cream. Both CNAs donned gloves. CNA A opened the brief and CNA A turned the resident on her left side so CNA A could check for bowel movement. She cleaned the resident's anal area using one wipe which returned with feces. She changed her gloves because she had soiled them. She pulled fresh wipes from the package and cleansed the anal area again. Using the same soiled gloves, the CNAs turned the resident to her back. CNA A wiped across the lower abdomen and down both groin areas with the same wipe. She did not turn or fold the wipe. She took another wipe and cleansed the inner labia. Using the same soiled gloves, CNA A took the clean brief from the table, opened it, and placed it on the bed. Using the same soiled gloves, she pulled more wipes from the package and turned the resident onto her left side and cleansed the resident's right buttock. She took more wipes and cleaned the buttock area two more times. The left buttock was only partially cleansed. The resident was not turned to her other side and the left buttock thoroughly cleansed. Using the same soiled gloves, CNA A placed the fresh brief under the resident and turned her onto her back. Both CNAs pulled the brief through her legs and fastened the tabs. CNA A removed her gloves. The resident was pulled up in bed and made comfortable. During an interview on 12/16/2020 at 09:25 AM CNA A said the resident did not need any barrier cream placed on her because she had no red spots on her bottom. She said she would usually change her gloves if they were visibly soiled, like she did after the first wipe. She said she should have changed her gloves before touching clean items. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated the resident was to have zinc ointment applied to buttocks and peri-area daily and as needed for excoriation. The most recent MDS dated [DATE] for Resident #29 indicated the resident required extensive assistance of 2 staff with bed mobility, transfers, dressing, toileting and personal hygiene. She required limited assistance of one staff with eating. She was incontinent of bladder and incontinent of bowel. A care plan last revised on 10/14/2020 indicated Resident #29 required extensive assistance from staff with ADLs to remain clean, dry, odor free, and well-groomed. The care plan indicated she had urinary incontinence related to impaired mobility and was at risk for urinary tract infection or skin breakdown. The care plan indicated the resident was at risk for skin breakdown and was to be kept clean and dry as possible and incontinence care was to be provided after each episode. The care plan indicated the resident was at risk for pressure ulcers and incontinence care was to be provided after each episode. During an observation on 12/16/20 at 4:00 PM, CNA D performed incontinent care on Resident #11. CNA D cleaned the peri area, turned Resident #11 on her right side and cleaned only her left buttocks. With gloves on, CNA D removed the soiled brief and placed it in the plastic bag. She then picked up the clean brief, with the same gloves, and placed it under Resident #11's buttocks. During an interview on 12/16/20 at 4:09 PM, CNA D said the only thing she would have done differently was the set up. She said she usually does not set everything up separately, she just brings in her bags with her supplies. During an observation on 12/15/20 at 8:15 AM, MA M went to remove a medication from the cup of 4 medications for Resident #33 and he used his bare hands, not sanitized, to remove the medication from the cup. During an observation on 12/15/20 at 9:15 AM, MA N was taking Resident 47's medication out of a bubble pack when it bounced out of the cup and fell on the top of the medication cart. She then picked up the medication from the top of the medication cart with her bare hand and put the medication back into the cup, then administered the cup of medications to Resident #47. An infection control policy revised July 2014 indicated this facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Infection control program goals and indicators for 2020 included .d. routine surveillance rounds including: the environment, hand hygiene practices, compliance with personal protective equipment, best clinical practice and provision of feedback to departments. A Perineal Care Policy ,revised October 2010, indicated .Wash labia .continue to wash downward and outward including the thighs .do not reuse same washcloth .turn resident on her side .wash rectal area thoroughly, wiping from the base of the labia extending over the buttocks .remove gloves and discard .wash and dry hands .reposition bed covers and make resident comfortable . A Personal Protective Equipment-Using Gloves Policy, revised September 2010, indicated .gloves are used to prevent the spread of infection .gloves primarily prevent the contamination of the employee's hands when providing treatment or services to the patient . According to the World Health Organization's Glove Use Information Leaflet revised August 2009 The efficacy of gloves in preventing contamination of health-care workers' hands and helping to reduce transmission of pathogens in health care has been confirmed in several clinical studies. Nevertheless, health-care workers should be informed that gloves do not provide complete protection against hand contamination. Pathogens may gain access to the caregivers' hands via small defects in gloves or by contamination of the hands during glove removal. Hand hygiene by rubbing or washing remains the basic to guarantee hand decontamination after glove removal An Administering Medications policy dated revised December 2012, indicated .22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications . An undated facility statement of services & charges for residents indicated the facility was responsible to provide maintenance service to provide a safe, comfortable environment.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering and securing of medications for 2 of 3 nurse medication carts (hall 1 and hall 4) (Residents # 28, 57 and 59)and 1 of 4 Residents during medication pass, reviewed for pharmacy services. (Residents # 28). CMA N administered Resident #28 an inaccurate dose of [MEDICATION(S)]. Hall 1 nurse medication cart contained Resident #57's opened vial of insulin, with no opened date. Hall 4 nurse medication cart contained Resident #28's expired [MEDICATION(S)] 3 mg (blood thinner). Hall 4 nurse medication cart contained Resident #59's bottle of [MEDICATION(S)]/APAP ,d+[DATE] mg uncapped in locked drawer. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: 1.During an observation on [DATE] at 9:30 AM CMA N administered Resident #28 her [MEDICATION(S)] 400 mcg one tablet by mouth. Physician orders dated [DATE] indicated Resident #28 was to receive Folvite ([MEDICATION(S)]) 1 gm by mouth daily. This order was written on [DATE]. During an interview on [DATE] at 11:48 AM the ADON C said CMA N gave 400 mcg, one tablet by mouth. Since it is supposed to be 1 gm she would write an order and send it to the pharmacy. 2. During an observation on [DATE] at 10:15 AM hall 1 nurse medication cart contained Resident #57's opened vial of Novolog, with no opened date documented. During an interview on [DATE] at 10:20 AM the ADON C said I just went through these carts yesterday. Last night when I checked them this vial was not in here. It was done over night to this time. It should have had a date on the insulin when opened. 3. During an observation on [DATE] at 10:25 AM hall 4 nurse medication cart contained Resident #28's [MEDICATION(S)] 3 mg (blood thinner), expired on [DATE]. During an interview on [DATE] at 10:29 AM ADON C said she (Resident #28) does not even take this anymore, I don't know why it is on the cart. 4. During an observation on [DATE] at 10:25 AM hall 4 nurse medication cart contained Resident #59's bottle of [MEDICATION(S)]/APAP ,d+[DATE] mg. The bottle was sitting uncapped in the narcotic drawer. During an interview on [DATE] at 10:30 AM LVN F said that should not be that way. A record review of the facility's Administering Medications Policy dated revised [DATE] indicated .3. Medications must be administered in accordance with the orders, including any required time frame .9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container . A record review of the facility's storage of medications policy dated revised [DATE], indicated .1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent accidents was provided for 1 of 15 residents reviewed for accident hazards. (Resident #1) The facility did not implement interventions to prevent Resident # 1 from leaving the building without staff knowledge. Resident #1 was at risk for elopement. Resident #1 told staff he wanted to leave the facility and he packed his belongings to leave the facility. The facility did not have a wanderguard (system that sends an alert or locks the door) in place for Resident #1 and the alarms on the doors to alert staff of the door opening were turned off on halls 200, 300, and 400. Resident #1 was found outside approximately ,[DATE] feet from the exit door of hall 200 on the ground by a visitor on [DATE]. An Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at isolated incident with a potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of corrective systems. This failure could place residents with unsafe wandering behaviors at risk of severe injury or death. Findings included: A face sheet dated [DATE] indicated Resident #1 was [AGE] years old, admitted on [DATE], and died in the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #1 received hospice services. Physician orders [REDACTED].#1 included continuous oxygen at 3 liters via nasal cannula. An elopement risk assessment dated [DATE] indicated Resident #1 was at risk for elopement. The assessment did not include elopement interventions. A baseline care plan dated [DATE] indicated Resident #1 was confused, had a history of [REDACTED]. The care plan did not address Resident #1's elopement risk or his need for continuous oxygen. A care plan conference summary dated [DATE] indicated Resident #1 continued hospice services. The summary indicated Resident #1 was a very jovial person with no psychological problems noted. The care plan conference summary did not address Resident #1's elopement risk. Resident #1 signed the care plan conference summary. There were no other care plans for Resident #1. A nursing note dated [DATE] indicated Resident #1 was in the hall in his wheelchair and was asking to call his daughter, because he said he was leaving the facility that evening. Resident #1's oxygen was off, and the resident was confused. Resident #1's daughter was called, and daughter requested that the resident receive something to settle him down. The note indicated a new order was obtained from hospice for [MEDICATION NAME] 50 mg twice a day. A nursing note dated [DATE] at 7:47 a.m. indicated Resident #1 was found on the floor in the main lobby and had a laceration to the back of his head. Resident #1 said he was walking, and he fell . Resident #1 was hard to keep awake and was transferred to the local hospital for evaluation. Vital signs indicated Resident #1's blood pressure was ,[DATE], pulse 73, respirations 16, and oxygen saturation at 87% on 3 liters of oxygen. Resident #1 returned to the facility at 1:20 p.m. with staple repair to back of his head and a fracture to his T7 vertebrae. A Minimum (MDS) data set [DATE] indicated Resident #1 had moderately impaired cognition and usually made his needs known and usually understood others. He required extensive assistance with ADLs and used a wheelchair for mobility. He was continent of bowel and occasionally incontinent of bladder. Resident #1 required oxygen therapy. A nursing note dated [DATE] at 1:48 p.m. for Resident #1 indicated he was found walking behind his wheelchair with his belongings packed in the wheelchair. Resident #1 was educated that he lived at the facility. Resident #1 said okay and the resident's belongings were returned to his room. Resident #1 sat in his wheelchair and propelled himself throughout the facility. During an interview on [DATE] at 8:54 a.m., a family member of another resident said on the evening of [DATE] she saw a male resident standing in the grass and he looked like he was going to fall. She said he slid down to the ground and she noticed the resident was not wearing shoes. She said she entered the facility and notified staff about the resident. She said she was not sure of the time, but it was evening time and beginning to get dark. An incident report dated [DATE] indicated at 8:10 p.m., Resident #1 was found outside in the grass lying on his left side in the mud. Resident denied pain and was alert to self. Resident #1 was assessed, and neurological checks were initiated. No injuries were noted. Resident #1 was assisted to his wheelchair. Resident #1's blood pressure was ,[DATE], pulse was 111, and respirations were 16 breaths a minute. Interventions included a wander guard. During an interview on [DATE] at 4:50 p.m., RN K said she was the on-call hospice nurse that assessed Resident #1 on [DATE] after he was found outside. She said she arrived at the facility sometime between 9:00 p.m. and 10:00 p.m. on [DATE]. She said Resident #1 was clean and propelling himself up and down the hallways. She said Resident #1 told her that he was ready to go home. She said Resident #1 was alert to himself. She said she assessed Resident #1 and his vital signs were normal. She said staff told her that Resident #1 walked out the exit door earlier that evening and he said he was going home. She said staff said he was always agitated, and she received an order for [REDACTED].#1 did not have a wander guard on when she assessed him on [DATE] after he was found outside. Nursing notes dated [DATE] for Resident #1 indicated the following: *8:10 p.m.- Resident #1 was found outside lying on his left side on the ground in the mud. Resident #1 was without his oxygen. Resident #1's vital signs were assessed, neurological checks initiated, and the resident denied pain. Resident #1 was assisted to his wheelchair. Resident #1's family, hospice, and veteran's affairs were notified; *8:20 p.m.- Resident #1 was found in another room and redirected to his room. Resident #1 was given a shower; *8:30 p.m.- hospice RN assessed Resident #1, new order for Trazadone 50 mg (antidepressant) and [MEDICATION NAME] 1 mg; 9:00 p.m.- Trazadone 50 mg and [MEDICATION NAME] 1 mg given, resident in bed and continued to take off oxygen, resident redirected and reapplied oxygen. During an interview on [DATE] at 1:13 p.m., Resident #1's daughter said she was aware that her dad wanted to come home. She said staff told her when her dad admitted that he was a flight risk. She said she was notified that her dad went out the exit door at the end of hall 200 and fell in a muddy hole. She said one of the nurses told her Resident #1 was wearing a wanderguard but ripped it off before the incident. Resident #1's daughter said she would not reveal which nurse reported that to her. She said she came to visit Resident #1 on [DATE] and he was unresponsive. She said Resident #1 died on [DATE]. A provider investigation report dated [DATE] indicated Resident #1's daughter alleged the facility neglected Resident #1 when he was found outside of the facility in the grass. The report indicated Resident #1 did not exhibit any wandering or exit seeking behaviors and did not meet the criteria for a wander guard before the incident on [DATE]. Resident #1 was assessed and had no complaints of pain after being found on the ground outside of the facility on [DATE]. Resident #1 began actively dying on [DATE] and Resident #1's daughter believed the unwitnessed fall outside of the facility on [DATE] caused his change of condition. A wander guard was placed on Resident #1 after the incident on [DATE] and staff were in-serviced on elopements, wandering, and unsafe residents. The facility will conduct elopement drills on each shift and ensure the elopement book was up to date. During an interview on [DATE] at 2:45 p.m., RN J said she was Resident #1's hospice nurse. She said she saw Resident #1 on [DATE] after he fell and received a laceration to the back of his head and a fracture to his back. She said Resident #1 was alert on [DATE] and when she was leaving, Resident #1 said he wanted to go with her because he wanted to go home. RN J said she saw Resident #1 again on [DATE]. She said Resident #1 was unresponsive except when she performed a sternal rub. She said when she listened to his heart and lungs, he had so much fluid on his lungs, she could not hear his heart. RN J said Resident #1's respirations were 31 breaths a minute (normal respiration rate ,[DATE] breaths a minute). She said she discussed Resident #1's change of condition with his family and they decided to discontinue all scheduled medications at that time but continued comfort medications. Nursing notes dated [DATE] at 9:36 p.m. for Resident #1 indicated hospice pronounced Resident #1 deceased . During an interview on [DATE] at 8:10 p.m., LVN A said she was Resident #1's charge nurse on [DATE] when he exited the facility. She said days before the incident, Resident #1 was restless and confused. She said Resident #1 sun downed in the evenings and refused to rest. She said Resident #1 began wanting to eat his evening meals in his room for several days before the incident. She said Resident #1 would propel himself in his wheelchair throughout the facility but had no history of exit seeking behaviors. LVN A said Resident #1 packed his belongings a few times and said he was going home. She said Resident #1 was not combative and was redirected easily. She said on [DATE], the last time she saw Resident #1 before he was found outside, was before dinner. She said that afternoon, Resident #1 propelled himself to the nursing station and wanted to talk to his daughter. LVN A said she called Resident #1's daughter and handed the resident the phone. She said Resident #1 told his daughter he was leaving the facility and was going home. She said around 8:00 p.m., she was notified Resident #1 was outside. LVN A said she thought Resident #1 used the exit door at the end of hall 200. She said Resident #1 left his wheelchair and oxygen in the middle of hall 200 and walked out the exit door. LVN A said it had rained earlier and Resident #1 was lying in a puddle of water in a grassy area on the other side of the driveway. She said Resident #1 was alert to himself but confused. She said Resident #1 said he wanted to go home. She said she assessed Resident #1 and he had no injuries and did not complain of pain. She said neurological checks were initiated. She said Resident #1 was muddy and LVN [NAME] assisted the resident to his wheelchair. LVN A said he was wearing shorts and shoes but no shirt. She said LVN F and CNA [NAME] also came outside to assist. LVN A said they took Resident #1 back into the facility and CNA C took him to the shower. She said Resident #1 was restless that night and later he was found in another resident's room, LVN A kept him at the nursing station with her until the hospice nurse came to assess Resident #1 later that evening. LVN A said she did not hear any exit door alarms sound that evening. She said Resident #1 had not attempted to leave the facility before the incident on [DATE]. During an interview on [DATE] at 5:21 p.m., MA B said she worked on [DATE] and administered Resident #1's evening medications. She said she was not sure of the time, but she usually started her medication pass on Resident #1's hall at 6:30 p.m. She said Resident #1 was in his room and took his medications with no issues. She said Resident #1 had no history of trying to leave the facility. During an interview on [DATE] at 2:40 p.m., CNA [NAME] said he worked [DATE] and sometime after dinner, a daughter of another resident notified him that a man was outside lying in the grass and screaming for help. He said he went outside along with LVN D, LVN F, and LVN A. CNA [NAME] said Resident #1 was lying in puddles of water in the grass. He said the side of Resident #1's face was wet, and he was muddy. CNA [NAME] said Resident #1 was helped up and into his wheelchair. He said the resident said he was not hurt but he was scared, and the resident thanked everyone that helped him. He said he did not hear any exit doors alarm. He said he had not worked with Resident #1 before the incident on [DATE]. During an interview on [DATE] at 2:15 p.m., LVN D said he worked the evening of [DATE]. He said another resident's daughter notified staff about a resident being outside. LVN D said Resident #1 was lying on his right side in the grass. He said there were puddles of water in the grass because it rained earlier. LVN D said Resident #1 had his arm up and he acted like he was fine. He said Resident #1 was confused. He said LVN A assessed the resident and the resident had no complaints of pain. He said CNA C went to find Resident #1's wheelchair and brought it outside. He said he assisted the resident to stand and helped him to his wheelchair. He said Resident #1 was muddy. LVN D said his own socks were wet after assisting Resident #1 up to his wheelchair. He said he did not hear any exit door alarms sound that night. He said Resident #1 had not tried to leave the facility before the incident on [DATE]. During an interview on [DATE] at 3:34 p.m., CNA C said she worked [DATE]. She said she was walking from the laundry area back to the facility and saw LVN D, LVN A, and LVN F assisting Resident #1 back into the facility in his wheelchair. She said Resident #1 was muddy from head to toe and had ants on him. She said she took Resident #1 to the shower and cleaned him up. She said Resident #1 was talking after the incident, but she could tell it took the breath out of him. She said after the shower, she attempted to assist Resident #1 to his bed, but he continued to get up and go into other residents' rooms. CNA C said Resident #1 had no history of leaving the facility, but he would pack up his things and say he was leaving. She said Resident #1 would say he needed to go outside and work on something. CNA C said she thought Resident #1 ate dinner in his room on [DATE] and she probably brought his meal to him but could not remember the last time she saw him before he exited the facility. She said Resident #1 had not tried to leave the facility before and was easily redirected when he said he wanted to go outside. During an interview on [DATE] at 3:43 p.m., LVN F said she worked the evening of [DATE]. She said one of the CNAs reported that Resident #1 was on the ground outside. She said she, LVN D, and LVN A went outside and assisted Resident #1. She said Resident #1 was lying in a puddle in the grass on the other side of the driveway. She said Resident #1 denied any pain or injuries, but he was wet and muddy. She said they assisted Resident #1 to his wheelchair and brought him inside the facility. She said Resident #1 had no history of attempting to exit the facility. During an interview on [DATE] at 12:02 p.m., RN G said Resident #1 followed her every time she worked. She said Resident #1 once gathered some of his belongings and put them in the seat of his wheelchair. She said Resident #1 would walk behind his wheelchair and say he wanted to go home. She said she redirected him and told him that he lived in the facility and he understood. She said she was told that Resident #1 would wander in the facility looking for her when she was not working. She said Resident #1 was alert during the day but became more confused in the evening. She said Resident #1 had no history of trying to leave the facility and was easily redirected when he said he wanted to go home. During an interview on [DATE] at 12:13 p.m., CNA H said Resident #1 packed up his belongings daily and said he was going home. CNA H said he was not aware of Resident #1 having a history of physically attempting to leave the facility. During an interview on [DATE] at 3:28 p.m., Resident #4 said she was aware that Resident #1 went outside and fell . She said Resident #1 would always say let's go outside. She said she did not go outside with Resident #1. During an observation on [DATE] at 2:17 p.m., LVN D walked the surveyor outside to where Resident #1 was found lying in the grass approximately ,[DATE] feet from the exit door at the end of hall 200. The area where Resident #1 was found on the grass was wet, had uneven terrain, and was on the other side of the facility's driveway. During an observation on [DATE] at 3:03 p.m., the alarm on the exit door at the end of hall 200 was turned off. The exit door was also equipped with a wanderguard alarm. The surveyor opened the exit door and the alarm did not sound. There was a sign posted on the exit door that read .do not turn off the door alarm! For the safety of our residents who wander, the alarm must remain on . During an interview on [DATE] at 3:05 p.m., the activity director said the alarms on the exit doors were to be on at all times. During an observation and interview on [DATE] at 3:20 p.m., the exit door at the end of hall 400 was open but was not alarming. The door [MEDICATION NAME] was loose and prevented the door from closing. The exit door was also equipped with a wanderguard alarm. MA B moved the door [MEDICATION NAME] and closed the exit door. MA B re-opened the exit door and the alarm did not sound. The exit door alarm was turned off. MA B said the exit door alarms were to be on at all times. There was a sign posted on the exit door that read .do not turn off the door alarm! For the safety of our residents who wander, the alarm must remain on . During an observation on [DATE] at 3:23 p.m., the exit door in the middle of hall 300 did not alarm when the door was opened. The alarm on the exit door was turned off. The exit door was also equipped with a wanderguard alarm. There was a sign posted on the exit door that read .do not turn off the door alarm! For the safety of our residents who wander, the alarm must remain on . During an interview on [DATE] at 5:06 p.m., the administrator said the facility was not required to have exit door alarms. He said the facility had wander guard alarms on all the exit doors for residents that wore wander guards. The surveyor asked the administrator about the signs on the exit doors that indicated the door alarms must remain on. The administrator said the exit door alarms were supposed to be on at all times. The administrator said currently no residents were exhibiting exit seeking behaviors. The administrator said he came to the facility on the night of [DATE] after Resident #1 attempted to elope and placed a wander guard on Resident #1. During an interview on [DATE] at 12:21 p.m., the administrator said new exit door alarms were ordered before the surveyor re-entered on [DATE], that required a key to be turned off. He said they had problems in the past with family members turning off the exit door alarms. He said residents could go outside. He said a few residents were assessed to safely go outside without supervision, but most residents required supervision. He said residents were expected to notify staff if they planned to go outside. He said Resident #1 had no history of attempting to leave the facility before the incident on [DATE]. During an observation on [DATE] at 3:15 p.m., Resident #2 wore a wander guard. LVN D pushed Resident #2 in her wheelchair near the exit doors to ensure the wander guard worked properly. The exit door at the end of hall 400 did not alarm or lock when Resident #2 was pushed near the door. During an interview on [DATE] at 5:45 p.m., the maintenance supervisor said he performed monthly checks on the wander guard system, by carrying a wander guard bracelet, while he walked around the doors. He said he tested 9 doors with wander guard alarms and the alarms were in working order. He said he last tested the wander guard system on [DATE]. The maintenance supervisor said before the incident on [DATE], they had no system in place to check the exit door alarms. He said he changed the exit door alarms and the new alarms required a key to turn off the alarm. He said he would begin checking the exit door alarms monthly to ensure they worked properly. The facility's unsafe wandering policy last revised (MONTH) 2014 indicated .staff will identify residents who are at risk for harm because of unsafe wandering (including elopement); staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering; the resident's care plan will indicate the resident is at risk for elopement or other safety issues; interventions to try to maintain safety, such as a detailed monitoring plan will be included . The administrator was notified on [DATE] at 12:25 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The Immediate Jeopardy template was provided to the administrator on [DATE] at 12:39 p.m. via email, and conformation of receipt of the email was received from the administrator at 12:44 p.m. The facility's Plan of Removal was accepted on [DATE] at 8:50 p.m., and included: 1. Resident #1 no longer resides in the facility. 2. Facility active residents will have updated Elopement Risk Assessments completed by Reunion nursing staff. Initiated 1:20pm [DATE]. Completed at 5:30pm [DATE]. 3. Residents' Elopement Risk Assessment scores will be reviewed and evaluated for elopement interventions as indicated by Nursing Management and/or Regional Nurse. Initiated 1:20pm [DATE]. Completed 6:00pm [DATE]. 4. Residents requiring elopement interventions will have care plans reviewed and updated as appropriate by Nursing Management. Initiated 6:15pm [DATE]. Completed 8:00pm [DATE]. 5. Facility Elopement Binder will be reviewed and updated as indicated from Elopement Risk Assessment scores. 6. Exit door signage regarding door alarm procedures and confirming with charge nurse, prior to assisting Resident to an exit, will be posted on all facility exit doors. Initiated [DATE] at 2:50 pm. Completed 3:20pm [DATE]. 7. Education: A. Licensed Nursing Staff will be provided education on (MONTH) 3, 2019 beginning at 1:45 pm on [DATE]. The staff that the facility was not able to in-service on [DATE] will be in-serviced before the start of their next shift [DATE] 6am. 1. Elopement Risk Assessment Procedures and location of Elopement Binder (Elopement Binder is kept in the facility Med Room. 2. Use of wanderguard devices 3. Door alarm monitoring and documentation procedures. B. Facility Staff will be provided education on (MONTH) ,[DATE] beginning at 1:45 pm on [DATE]. The staff that the facility was not able to in-service on [DATE] will be in-serviced before the start of their next shift [DATE] 6am. 1. Signs / behaviors of wandering / elopement. 2. Notification procedures to DON / Administrator when signs / behaviors of wandering / elopement are noted. The Elopement Binder will be monitored and updated by the DON and/or designee. The Elopement Binder will be kept the facility Med Room. 3. Monitoring procedures for Residents when signs of wandering / elopement behaviors are noted. Frequency of monitoring can be Resident specific. 4. Exit door alarms should be on at all times. 8. Compliance to be monitored by: A. Review of Elopement Risk Assessments / scores and implementation of interventions through chart audits by Nursing Management during clinical meetings with corrective actions taken for identified concerns. B. Review of Accident / Incident Reports by Nursing Management for events that may indicate additional actions indicated for specific residents. Licensed Nursing staff will review door alarm function every shift and document on the alarm log. Began 2pm [DATE]. The rest of the staff will be in-serviced before the start of their next shift. Completed 6am [DATE]. C. Administrator and / or DON will monitor door alarms / alarm logs for compliance 5 days a week and prn with corrective actions taken for identified concerns. E. Facility QAPI Committee will review Accident /Incidents on a monthly basis for additional actions if indicated. F. The administrator in-serviced the Maintenance Director on [DATE] regarding his responsibility of the monthly monitoring of the wanderguard system through TELS. Initiated 6:39pm [DATE]. Completed 6:40 pm [DATE]. 9. The staff that the facility was not able to in-service on [DATE] will be in-serviced before the start of their next shift. On [DATE], the surveyor confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: Reviewed updated resident elopement assessments of residents at risk of elopement. Elopement assessments were placed in the elopement binder. The elopement binder included a face sheet, a picture of the resident, resident elopement assessments, and updated care plans that included the resident's risk of elopement and appropriate interventions. Observed exit door signage that read .family members and visitors: please don't help anyone outside unless you've cleared it with the charge nurse. Staff: please ensure that the alarms remain on at all times . New exit door alarms were installed on exit doors and functioned properly. During an interview on [DATE] at 8:31 p.m., the administrator said staff ensured residents' wander guards were functioning properly. Observed staff taking residents with wander guards to exit doors to ensure the wander guard was alarming the doors. During an interview on [DATE] at 10:35 p.m., the DON said she in-serviced staff on signs of wandering and elopement behaviors, notification procedures regarding residents with wandering/elopement behaviors, location of the elopement binder, who monitors and updates the elopement binder, monitoring procedures for residents with wandering/elopement behaviors, and exit door alarms should be on at all times. She said she licensed nursing staff also received training on elopement risk assessment procedures, the use of wander guard devices, and exit door alarm monitoring and documentation procedures. She said she reviewed the in-services with staff and they were able to answer all questions correctly. During interviews on [DATE] from 8:52 p.m. to 10:34 p.m., 8 nurses (2 from day shift, 3 from evening shift, and 3 from night shift), 1 MA (evening shift), 12 CNAs (4 from day shift, 5 from evening shift, and 2 from night shift), and the social worker were interviewed and said they received training on signs of wandering and elopement behaviors, notification procedures regarding residents with wandering/elopement behaviors, location of the elopement binder, who monitors and updates the elopement binder, monitoring procedures for residents with wandering/elopement behaviors, and exit door alarms should be on at all times. Staff said they if a resident showed signs of unsafe wandering or eloping, they would stay with the resident and notify their charge nurse, DON, and administrator. Staff said an elopement assessment would be completed, the physician and family would be notified, a wander guard order would be received, and a wander guard would be applied to the resident. Licensed nursing staff said they also received training on elopement risk assessment procedures, the use of wander guard devices, and exit door alarm monitoring and documentation procedures. Licensed nursing staff said they were responsible for checking all exit doors every shift to ensure the alarms were on and documenting on the exit door logs every shift. During an interview on [DATE] at 9:41 p.m., the maintenance supervisor said he completed training on his responsibility of ensuring monthly monitoring of the wander guard system and the exit door alarms. On [DATE] at 10:36 p.m., the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at an isolated incident with potential for more than mimimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure staff attended resident council meetings by invitation only, act promptly upon grievances, and demonstrate a response and rationale for resident council concerns and requests, for 4 of 6 residents reviewed for resident council. (Resident #'s 21, 47, 69, 76, ). The AD attended all resident council meetings without invitation. The facility did not promptly respond to grievances made at the resident council meeting when Resident #21 and Resident #76 reported their beds were broken. This failure could place residents who attended resident council meetings at risk of frustration, decreased confidence with administration and decreased resident rights. Findings included: During a group meeting on 06/04/19 at 09:29 a.m.: * Resident #47 (President) and Resident #76 (Vice President) said they were told when Resident #69 (former President) asked in (MONTH) 2019 that the AD had to be at the Resident Council meetings. * Resident #69 indicated he was the previous resident council president and the activity director told him she must be present during their resident council meeting. Resident #69 said the resident council was not able to meet without the AD present. * Resident #47 and Resident #76 said they did not know the results of grievances voiced by the Resident Council; and * Resident #76 said she and Resident #21 had complained about the bed being broken to the during resident council with the AD present for a few months now and hers had not been fixed. She said she was made to sleep on a broken bed. Resident council minutes dated (MONTH) 11, 2019 indicated as old business Resident #'s 21 and 76 needed their bed fixed. Resident council minutes dated (MONTH) 09, 2019 indicated as old business Resident #'s 21 and 76 needed their bed fixed. The annual grievance book for 2019 indicated there were no grievance forms related to resident council. A written maintenance log for 2019 indicated there were no entries regarding Resident #'s 21 and 76 beds. A computer printout of the maintenance information dated 06/05/19 indicated there were no entries regarding Resident #'s 21 and 76 beds. During an interview on 06/04/19 at 02:37 p.m. Resident #21 said his bed was still broken. He said it was reported in the resident council meeting a couple of months ago but nothing had been done. During an interview and observation on 06/06/19 at 11:15 a.m., the AD said she did not complete a grievance form about Resident #'s 21 and 76 beds. An observation of Resident #21's bed indicated the controller to move the head, foot, and whole bed was not working properly. The AD said she checked the bed on 6/5/19 with the MD and it was working fine. During an interview on 06/04/19 at 12:10 p.m., the AD said she thought she had to attend the resident council meetings. She said she did not realize they had to invite her. She said she filled out a Resident/Family Concern form at the resident council meetings and gave them to the SW for her to investigate because the SW was the grievance officer. During an interview on 06/05/19 at 01:45 p.m. the SW said she usually filled out the grievance forms. She said she did not receive any information from the resident council. During an interview on 06/04/19 at 02:40 p.m. the MD said if he was told about a bed not working then he would fix it. He said he sometimes forgot to put things in the log or computer but did fix them. He said he had fixed Resident #76's bed but did not know about Resident #21's bed. During an interview on 06/04/19 at 11:35 a.m., the administrator said the AD received grievances during resident council and they went to the appropriate department. He said each department addressed their own related issues. He said the grievances were discussed in the next resident council meeting as old business. He said the SW was the designated grievance officer. A Grievances/Complaints, Recording, and Investigating Policy revised (MONTH) (YEAR) indicated Policy Interpretation and Implementation: 1. The Administrator has assigned the responsibility of investigating grievances and complaints to the Grievance Officer 7. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within ______ working days of filing of the grievance or complaint 10. Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident.

Based on interview and record review the facility failed to ensure residents had the right to personal privacy during personal care and received mail promptly for 1 of 7 residents reviewed for privacy and 6 of 6 residents reviewed for mail delivery (Resident #'s 332, 5,12,47,53,69 and 76) The facility did not maintain privacy while providing personal care for Resident #332. The facility did not provide for mail delivery on Saturdays. This failure could place residents at risk of being exposed and a decreased quality of life. Findings included: 1. Physician orders [REDACTED].#332 was an [AGE] year old female admitted to the facility on [DATE]. A baseline care plan dated 05/29/19 indicated Resident #332 was alert and cognitively intact, required assistance of one staff with transferring and toileting, and was continent of bowel and bladder. A resident ability assessment dated [DATE] indicated Resident #332 required occasional assistance with transferring; occasional, but not constant assistance with toileting and was able to maintain balance while on the toilet. During an interview on 06/03/19 at 08:52 AM, Resident #332 said she was admitted to the facility on Wednesday. She said one night around 11 or 12 an aide assisted her to the bathroom. She said the aide left the hall door open and the bathroom door open. Resident #332 said the aide was by the hall door getting some gloves and she asked her if she could close the door and the aide told her it didn't need closing. The resident said she knew it was night and probably no one would come by, but said she felt exposed and felt like she should have been afforded some privacy. She said she could not identify the staff member. During an interview on 06/06/19 at 11:05 AM, the DON said when staff assisted a resident to the bathroom the door to the hallway should always be closed and the door to the bathroom may need to be left open a little so they could monitor the resident. She said the staff member could block the line of sight of any other persons entering the room with the bathroom door slightly open. She said if a resident was cognizant and aware of their surroundings the bathroom door could be closed. She said the privacy and dignity of the resident should always be observed. 2. During a group interview on 06/04/19 at 09:29 a.m.: * Resident #'s 5, 12, 47, 53, 69, and 76 said they did not receive any mail on Saturdays; * Resident #53 said she passed mail out to residents but was not told to pass out mail on Saturdays; and * Resident #69 complained of not getting mail on Saturday when he was expecting it. During an interview on 06/05/19 at 02:32 p.m. HR said she got the mail and gav it to the BOM who would sort the mail according to the facility and resident mail. She said the BOM gave the resident mail to Resident #53 who would pass it to residents on the weekdays. She said she and the BOM were not at the facility on Saturdays to give the mail out to Resident #53 or to the residents. An undated Admission Packet provided on entrance indicated under Services We Provide on page 31 What about mail? Mail is delivered daily A Quality of Life-Dignity policy, revised (MONTH) 2009, indicated .10. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care . An Assisting a Resident to Walk to the Bathroom policy, revised (MONTH) 2010, indicated .9. Assist the resident to the bathroom. Close the bathroom door.

Based on observation, interview, and record review, the facility failed to secure medications for 2 of 3 nurse medication carts. * LVN A left the medication cart unlocked/unsecured and out of the line of sight during medication administration. * LVN B left the medication cart unlocked/unsecured and out of the line of sight during medication administration. This failure could place residents at risk for drug diversion and decreased quality of life. Findings included: During an observation on 06/04/19 at 11:30 a.m., LVN B walked away from the medication cart back to the medication room. The medication cart was left unlocked, out of the line of the nurse's sight, and with the doors and drawers facing the hallway. During an observation on 06/04/19 at 11:45 a.m., LVN A walked away from the medication cart to administer insulin to a resident. The medication cart was left unlocked, out of the line of the nurse's sight, and with the doors and drawers facing the hallway. During an interview on 06/06/19 at 08:15 a.m., LVN B said she should have locked the medication cart to secure the meds for safety reasons. During an interview on 06/06/19 at 08:20 a.m., LVN A said she should have locked the medication cart to secure the meds for residents' safety. She said she had been warned about leaving the cart unlocked. During an interview on 06/06/19 at 09:40 a.m., the DON said she had talked to LVN A before about leaving the medication cart unlocked. She said the medication carts should be locked according to policy. A Security of Medication Cart Policy Statement revised (MONTH) 2007 indicated Policy Statement: The medication cart shall be secured during medication passes. Policy Interpretation and Implementation. 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. 3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out of the nurse's view.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and the transmission of disease and infection for 2 of 4 residents observed for incontinent care (Residents #51 and70). CNA D did not change gloves, sanitize or wash her hands and touched the resident a clean brief, pillows, and the bed control with soiled gloves while providing incontinent care for Resident #51. CNA C did not sanitize or wash hands between glove changes and touched clean wipes with soiled gloves while providing incontinent care for Resident #70. This failure could place residents who require incontinent care at risk for cross contamination and infections. Findings included: 1. During an observation on 6/5/19 at 10:25 AM, CNA D provided incontinent care for Resident #51. CNA D cleaned the peri area and the wipes had visible stool on them and turned Resident #51 on her side and cleaned the buttocks. CNA D rolled the soiled brief and pad under Resident #51 and placed the clean brief and pad under her. CNA D rolled the resident to her back and pulled out the soiled brief and pad. CNA D secured the brief, repositioned Resident #51 and placed pillows between her contracted legs and under her lower legs, picked up the bed control and put the bed to low position and raised the head of the bed without changing gloves and sanitizing hands. CNA D did not change gloves and sanitize her hands during incontinent care and prior to touching clean items linens and items in the resident's room. 2. During an observation on 06/03/19 at 10:28 a.m., incontinent care was performed for Resident #70 by CNA C. CNA C changed gloves only one time and did so without washing or sanitizing her hands. Resident #70 had feces in her brief, some of which stuck to the glove of the hand with which CNA C was wiping. CNA C used the same soiled gloved hand to grab clean wipes. During an interview on 6/5/19 at 10:41 AM CNA D said she should have been better prepared and changed her gloves and washed her hands between cleaning the front and back. During an interview on 06/03/19 at 10:35 a.m., CNA C said she would not have completed incontinent care any differently. During an interview on 06/05/19 at 10:05 a.m., the DON said infection control is very important during incontinent care. She said the staff should wash or sanitize their hands when they changed their gloves, especially if the gloves are soiled. A Handwashing/Hand Hygiene policy statement revised (MONTH) (YEAR) indicated .7.Use an alcohol-based hand rub containing at least 62% alcohol; or, alternately, soap (antimicrobial of non-antimicrobial) and water for the following situations: h. Before moving from a contaminated body site to a clean body site during resident care; .j. After contact with blood or bodily fluids; .m. After removing gloves .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident for accurate administration of medication for 1 of 3 residents observed receiving insulin during medication pass (Resident #63). The facility did not ensure Resident #63 received the accurate administration of medication as ordered by the physician during the medication pass. LVN A did not administer the correct dose of insulin as ordered by the physician to Resident #63. This failure could place residents receiving insulin at risk for not receiving the intended therapeutic benefit of the medication and for unintended side effects of the medication received. Findings included: Physician orders [REDACTED].#63 was a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED].#63 was to receive an additional 5 units of [MEDICATION NAME]in addition to the 6 units per sliding scale for a blood sugar of 301-350. During an observation and interview on 06/04/19 at 11:41 a.m., LVN A checked Resident #63's blood sugar and obtained a reading of 315. LVN A indicated Resident #64 would receive 13 units of insulin. During an observation on 06/04/19 at 11:45 a.m., LVN A administered 13 units of [MEDICATION NAME]to Resident #63. During an interview on 06/05/19 at 10:36 a.m., LVN said she made an error. She said she gave Resident #63 13 units of [MEDICATION NAME]and she should have received 11 units. LVN A said she said she was nervous about being watched and gave 2 units too much. During an interview on 06/06/19 at 08:50 a.m., the DON said medications were to be administered correctly per the physician order. An insulin administration policy, revised 2014, indicated: Steps in the Procedure (Insulin Injections via Syringe) .8.Check the order for the amount of insulin 12 Double check the order for the amount of insulin .15 Re-check that the amount of insulin drawn into the syringe matches the amount of insulin ordered .

Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse for 1 of 2 residents reviewed for abuse. (Resident # 1) The facility did not suspend an employee after he was identified in an allegation of abuse by Resident #1. The identified employee participated in the investigation of the allegation. This failure could place residents at risk for abuse. Findings included: Physician orders [REDACTED].# 1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident # 1 usually understands others and was usually understood by others. The MDS indicated Resident # 1 required extensive assist and 1 staff for bed mobility, transfer, dressing and personal care. The MDS indicated Resident #1 was frequently incontinent of bowel and bladder. A revised care plan dated 5/20/19 indicated Resident # 1 was accusatory towards staff at times with an approach to provide redirection addressing specific accusation, social worker to visit as needed and provide 2 staff to assist at times. The care plan indicated Resident #1 displayed socially inappropriate behavior (groping and asking male CNA's to sleep with her). The approach indicated activities to provide diversion and to talk to her in a calm voice when her behavior is disruptive. A facility investigation report dated 5/20/19 indicated an incident occurred on 5/15/19 at 10:25 a.m. involving Resident #1. The report description of the allegation indicated Resident #1 reported that a white male who works the morning shift had forced her into a sexual situation. When the charge nurse asked the resident whom the white male was she indicated it was the administrator. A statement on the facility investigation report entered by the DON stated, even though the allegation was made against the administrator, the administrator continued to interview all the other white males in the building. During an interview on 5/23/19 at 8:30 a.m., the administrator said on 5/15/19 the speech therapist came to him and reported that Resident #1 had complained that someone was being mean to her. The administrator said he went to the resident and asked her if anything was bothering her and she said a white guy was making her perform oral sex. The administrator said he asked the charge nurse to speak with the resident and perform an assessment. He said the charge nurse asked her who the male employee was, and the resident said the man that just spoke to me, indicating the administrator. The administrator said he conducted an interview with Resident #1's roommate and interviews with the male staff. The administrator said he did not leave the facility. He said he stayed in the DON's office away from the residents. During an interview on 5/23/19 at 2:44 p.m., the DON said she conducted the investigation and the administrator assisted with interviews. She said the administrator remained in her office until after lunch. The DON said the administrator did not leave the facility during the investigation. During an interview on 5/23/19 at 4:03 p.m., the administrator indicated he assisted with interviews during the investigation of the allegation made by Resident #1. He indicated he did not know he should have left the facility during the investigation. A Policy titled Abuse Prohibition Guideline (YEAR) indicated . on page 7. Investigations; 3. (b) Procedure for the investigation will include but is not limited to . protection of the resident including, if identification of suspect is made, immediate suspension of person or persons accused of the abuse allegation . Page 8. Protection; 2. (a). the employee is to immediately leave the area, badge out and exit the property. (b). the employee is not to return until requested to do so

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse for 1 of 2 residents reviewed for abuse. (Resident # 1) The facility did not follow their policy and suspend an employee after Resident #1 identified the employee in an allegation of abuse. This failure could place residents at risk for abuse. Findings included: A Policy titled Abuse Prohibition Guideline (YEAR) indicated . on page 7. Investigations; 3. (b) Procedure for the investigation will include but is not limited to . protection of the resident including, if identification of suspect is made, immediate suspension of person or persons accused of the abuse allegation . Page 8. Protection; 2. (a). the employee is to immediately leave the area, badge out and exit the property. (b). the employee is not to return until requested to do so Physician orders [REDACTED].# 1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident # 1 usually understands others and was usually understood by others. The MDS indicated Resident # 1 required extensive assist and 1 staff for bed mobility, transfer, dressing and personal care. The MDS indicated Resident #1 was frequently incontinent of bowel and bladder. A revised care plan dated 5/20/19 indicated Resident # 1 was accusatory towards staff at times with an approach to provide redirection addressing specific accusation, social worker to visit as needed and provide 2 staff to assist at times. The care plan indicated Resident #1 displayed socially inappropriate behavior (groping and asking male CNA's to sleep with her). The approach indicated activities to provide diversion and to talk to her in a calm voice when her behavior is disruptive. A facility investigation report dated 5/20/19 indicated an incident occurred on 5/15/19 at 10:25 a.m. involving Resident #1. The report description of the allegation indicated Resident #1 reported that a white male who works the morning shift had forced her into a sexual situation. When the charge nurse asked the resident whom the white male was she indicated it was the administrator. A statement on the facility investigation report entered by the DON stated, even though the allegation was made against the administrator, the administrator continued to interview all the other white males in the building. During an interview on 5/23/19 at 8:30 a.m., the administrator said on 5/15/19 the speech therapist came to him and reported that Resident #1 had complained that someone was being mean to her. The administrator said he went to the resident and asked her if anything was bothering her and she said a white guy was making her perform oral sex. The administrator said he asked the charge nurse to speak with the resident and perform an assessment. He said the charge nurse asked her who the male employee was, and the resident said the man that just spoke to me, indicating the administrator. The administrator said he conducted an interview with Resident #1's roommate and interviews with the male staff. The administrator said he did not leave the facility. He said he stayed in the DON's office away from the residents. During an interview on 5/23/19 at 2:44 p.m., the DON said she conducted the investigation and the administrator assisted with interviews. She said the administrator remained in her office until after lunch. The DON said the administrator did not leave the facility during the investigation. During an interview on 5/23/19 at 4:03 p.m., the administrator indicated he assisted with interviews during the investigation of the allegation made by Resident #1. He indicated he did not know he should have left the facility during the investigation.

Based on interview and record review, the facility failed to report an injury of unknown source to the state agency for 1 of 4 residents. (Resident #1) The facility did not report Resident #1's unwitnessed fall that a caused a right [MEDICAL CONDITION]. This failure could place residents at risk for abuse, neglect, and significant harm. Findings included: The facility's abuse policy dated (YEAR) indicated . an injury should be classified as an injury of unknown source when both of the following conditions are met: 1. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and 2. The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incident of injuries over time .the health care center will thoroughly investigate all alleged violations and take appropriate actions. No later than 2 hours if the allegation involves abuse or results in serious bodily injury, and no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury .the health care center will report allegations to the state agency in accordance with state law (note timeframe requirement) . A face sheet dated 04/10/19 indicated Resident #1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. A care plan dated 01/09/19 indicated Resident #1 had a history of [REDACTED]. Interventions included to position the bed in the lowest position, keep call light in reach, keep resident's room clean, and anticipate when the resident might need something. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was sometimes able to make his needs known and sometimes understood others. He required extensive assistance with ADLs. He was frequently incontinent of bowel and bladder. An incident report dated 12/31/18 at 8:20 p.m. indicated Resident #1 was found on the floor in his room by CNA B. The report indicated that after getting vital signs and checking him over, Resident #1 was assisted to his feet, he grabbed his right hip and said ouch. The nurse asked Resident #1 if he was hurting and the resident did not reply. The nurse practitioner was notified and ordered a STAT x-ray of the right hip. Resident #1's pain scale was 7 (out of 0/10 pain scale). A right hip x-ray dated 12/31/18 indicated Resident #1 had a non-displaced femoral neck fracture. During an observation and interview on 04/10/19 at 4:49 p.m., Resident #1 was sitting in a wheelchair in his room and his wife was visiting. Resident #1 was unable to answer any questions or tell how he fell due to his cognition. Resident #1's wife said she received a call on 12/31/18 after 8:00 p.m. and was notified that Resident #1 fell in his room. She said they ordered an x-ray and the x-ray showed a right [MEDICAL CONDITION]. She said Resident #1 was transported to the hospital and had surgery. She said Resident #1 was in the hospital for 5 days. During an interview on 04/10/19 at 1:42 p.m., LVN A said she worked with Resident #1 on 12/31/18. She said CNA B notified her that Resident #1 fell in his room. She said when she got to the room, she asked Resident #1 what happened and Resident #1 said y'all busted me. She said Resident #1 was unable to explain how he fell , she said she assessed Resident #1 and then assisted Resident #1 from the floor. She said Resident #1 grabbed at his right hip and said ouch. She said his bed was in the lowest position and it appeared that he tried to sit in a high back chair that his wife had brought to his room. She said Resident #1 did not understand how to use the call light due to his cognition. LVN A said Resident #1 was the only resident in the room. She said she called the nurse practitioner and received an order for [REDACTED].#1 was sent to the hospital for further evaluation. She said Resident #1 had surgery repair to his right hip and he returned to the facility. During an interview on 04/10/19 at 2:55 p.m., CNA B said he worked with Resident #1 on 12/31/18, he said he checked on Resident #1 about an hour before he was found on the floor. CNA B said Resident #1 was in his bed and was semi-sleeping. He said Resident #1's bed was about 3 feet off the ground. He said he was making his rounds an hour later and saw Resident #1 on the floor in his room. CNA B said he stuck his head out of the door and called for LVN A. He said LVN A came to Resident #1's room and assessed him. He said they assisted Resident #1 to his feet and Resident #1 grabbed at his hip. He said LVN A thought Resident #1 may have a fracture and called the nurse practitioner. During an interview on 04/10/19 at 1:17 p.m., the administrator said he was notified about Resident #1's fall and [MEDICAL CONDITION] that occurred on 12/31/18. He said there was enough evidence to show that Resident #1's fall was not an injury of unknown origin. He said CNA B was in the room before the fall and saw Resident #1 in the bed. The administrator said Resident #1 was then seen on the floor. He said they knew he had a fall and the fall caused the fracture. He said Resident #1 was not able to explain how he fell . An unsigned and undated note was provided by the administrator as the investigation of Resident #1's fall on 12/31/18. The note indicated .on 12/31/18 at approximately 8:00 p.m. the administrator was notified that Resident #1 had a fracture. Upon investigation, the administrator found out that Resident #1 had been laid down in his bed for the night by CNA B. CNA B checked back by the room during rounds and found Resident #1 on the floor laying on his back facing the window in his room. Upon assessment from LVN A, Resident #1 did not verbalize any pain, and nothing looked out of place. LVN A and CNA B got Resident #1 up onto his feet at which point Resident #1 said ow. From there, Resident #1 was put back in bed, LVN A contacted Resident #1's physician and got an x-ray to check on Resident #1's leg. An x-ray was obtained and revealed that Resident #1 had a fractured leg. From there, Resident #1 was sent to the emergency room . The facility did not report this fall because the facility was able to determine how the injury occurred. Resident #1 was witnessed to be in bed and was then found on the floor. In a skilled nursing facility, when there is an unwitnessed change in plane, this is considered a fall. Based off this definition, Resident #1 had a fall. Resident #1 did not have a fracture before the fall, but he did have a fracture after the fall. The fall caused the fracture, and based off these findings, the facility did not consider this a reportable incident .

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 15 of 15 rooms on the 400 Hall reviewed for environmental conditions. (Rooms 402, 403, 404, 405, 406, 407, 408, 409, 410, 411, 412, 413, 414, 415, and 417) The facility did not maintain safe and comfortable water temperatures in the 15 resident rooms on the 400 hall. The findings included: During observations on 09/20/18, the hand sink water temperatures were conducted in the following residents' rooms with the administrator. The administrator used a facility digital thermometer. Temperature finding were: *room [ROOM NUMBER] at 1:20 p.m. 121.6 degrees Fahrenheit *room [ROOM NUMBER] at 1:23 p.m. 124.9 degrees Fahrenheit *room [ROOM NUMBER] at 1:28 p.m. 124.4 degrees Fahrenheit *room [ROOM NUMBER] at 1:31 p.m. 121.6 degrees Fahrenheit *room [ROOM NUMBER] at 1:34 p.m. 124.0 degrees Fahrenheit *room [ROOM NUMBER] at 1:38 p.m. 121.6 degrees Fahrenheit *room [ROOM NUMBER] at 1:42 p.m. 123.6 degrees Fahrenheit *room [ROOM NUMBER] at 1:45 p.m. 122.2 degrees Fahrenheit *room [ROOM NUMBER] at 1:49 p.m. 123.8 degrees Fahrenheit *room [ROOM NUMBER] at 1:51 p.m. 122.4 degrees Fahrenheit *room [ROOM NUMBER] at 1:54 p.m. 123.3 degrees Fahrenheit *room [ROOM NUMBER] at 1:56 p.m. 122.4 degrees Fahrenheit *room [ROOM NUMBER] at 1:59 p.m. 122.5 degrees Fahrenheit *room [ROOM NUMBER] at 2:03 p.m. 122.4 degrees Fahrenheit *room [ROOM NUMBER] at 2:06 p.m. 122.2 degrees Fahrenheit During an interview on 09/20/18 at 1:01 p.m., the administrator said the facility's maintenance supervisor was responsible for conducting water temperatures weekly. The administrator said the facility did not currently have a maintenance supervisor and he was responsible for conducting weekly temperature checks. The administrator said the facility did not have a policy related to water temperatures or checks. He said the facility used an online safety compliance database system that indicated weekly water temperature checks were to be conducted weekly. The administrator said water temperatures should be between 100 degrees Fahrenheit and 110 degrees Fahrenheit. The administrator said temperature logs were kept in the life safety book and the facility had not conducted a weekly water temperature check since 08/20/18. The facility's life safety book reviewed on 09/20/18 at 1:05 p.m. indicated the last water temperature check on hall 400 was conducted on 08/20/18 in room [ROOM NUMBER] with a temperature of 106 degrees Fahrenheit. The American Burn Association Scald Injury Prevention Educator's Guide on 09/20/18 provided the following information. The basis of the information is from research conducted by Moritz, AR, Henriques, F.C. Jr. (1947). Studies of thermal injuries: II The Relative Importance of Time and Surface temperature in the Causation of Cutaneous Burns. M J Pathology 1947; 23:695-720 and Stone, M, Ahmed J, Evans J. The continuing risk of domestic hot water scalds to the elderly.[MEDICAL CONDITION]; 26:347-350.: Water was a safe temperature for bathing at 100 degrees Fahrenheit. Water at 120 degrees Fahrenheit would cause a third-degree burn (full thickness burn) in 5 minutes. Water at 124 degrees Fahrenheit would cause a third-degree burn in 3 minutes.

Based on observation, interview, and record review, the facility failed to promptly notify the physician of laboratory (lab) results that fell outside of clinical reference ranges for 1 of 4 residents reviewed for lab results. (Resident #2) Resident #2's white blood cell count (WBC) was increasing and the physician was not notified for 4 days ([DATE]-[DATE]). Resident #2 was admitted to the hospital with [REDACTED]. This failure could place 23 residents who resided on Hall 100 that received lab work at risk of not receiving prompt care and medical intervention. Findings included: Physician orders [REDACTED].#2 was [AGE] years old, admitted on [DATE], and discharged to a local hospital on [DATE]. His [DIAGNOSES REDACTED]. A physician order [REDACTED]. An MDS dated [DATE] indicated Resident #2 understood others and made his needs known. He required extensive assistance with activities of daily living (ADLs). The MDS indicated Resident #2 did not have any verbal or physical behaviors. A care plan dated [DATE] indicated Resident #2 was at risk for frequent infections due to diabetes. Interventions included monitoring labs and notifying physician of abnormalities. Resident #2 was at risk for complications due to high blood pressure and interventions included to monitor labs and to report any abnormalities to the physician. A lab result dated [DATE] indicated Resident #2's WBC (white blood count) was abnormally high at 12.8 (reference range normal 4XXX,[DATE].0). During an interview on [DATE] at 12:58 p.m., LVN C said he worked [DATE]. He said he called the NP and notified her of Resident #2's critical hemoglobin level of 7.3 (normal 13XXX,[DATE].5). He said he received an order to send Resident #2 to the emergency room . He said he was not sure if he notified the NP of Resident #2's elevated WBC. A nursing note dated [DATE] at 11:56 a.m. indicated the NP was notified of Resident #2's critically low hemoglobin level by phone. The nursing note did not address Resident #2's elevated WBC level. Resident #2's vital signs were blood pressure ,[DATE], pulse 114, temperature 99.4, and oxygen saturation 95%. Hospital records dated [DATE] indicated Resident #2 received a blood transfusion at the hospital and his WBC (white blood count) was 15.5 (normal 4XXX,[DATE].0). Resident #2 was sent back to the facility on [DATE] after his blood transfusion. During an interview on [DATE] at 9:50 a.m., the wound care physician said he saw Resident #2 on [DATE] at the facility and started Resident #2 on antibiotics for his sacral pressure injury because it looked infected. A lab result dated [DATE] at 11:53 a.m. indicated Resident #2's WBC was abnormally high at 20.8 (reference range normal 4XXX,[DATE].0). At the bottom of the lab result sheet was an undated note that indicated the NP was notified that Resident #2 had a new order for antibiotics from the wound treatment physician. A nursing note dated [DATE] at 12:43 a.m. indicated Resident #2's vital signs were blood pressure ,[DATE], pulse 107, temperature 98.2, and oxygen saturation 95%. There was no indicated the MD was notified of the elevated pulse. A nursing note dated [DATE] at 6:30 p.m. indicated Resident #2 was mildly lethargic, blood pressure ,[DATE], heart rate 120, temperature 100.2, and oxygen saturation 92%. Resident #2 was placed on oxygen and oxygen saturation increased to 98%. LVN C notified the NP of the resident's change of condition. During an interview on [DATE] at 12:58 p.m., LVN C said he worked on [DATE]. He said Resident #2 was lethargic, had low blood pressure, high heart rate, and a fever. He said he called the NP and received an order to send Resident #2 to the emergency room . A transfer form dated [DATE] indicated Resident #2 was transferred to the ER because of low blood pressure of ,[DATE], heart rate of 120, and temperature of 100.2. The transfer form indicated Resident #2 had a stage 4 coccyx wound infection. During an interview on [DATE] at 1:44 p.m., the NP said she did not remember if the facility contacted her about Resident #2's elevated WBC. Hospital records dated [DATE] indicated Resident #2 had a urinary tract infection and urosepsis upon admission. Resident #2's WBC was 20.9 on [DATE]. Resident #2 had [MEDICAL CONDITION] on [DATE] and died in the hospital on [DATE]. An undated resident roster indicated 23 residents resided on Hall 100 and received lab work.

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services were provided based on the comprehensive assessment to promote healing and prevent new pressure injuries (ulcers) from developing for 1 of 5 residents reviewed for pressure injuries. (Resident #1) The facility did not prevent the development of 4 stage 2 pressure injuries and multiple shearing pressure injuries for Resident #1. Resident #1 was admitted with a pressure injury and was at risk for developing more pressure injuries. Resident #1's indwelling urinary catheter tubing was left beneath her buttocks and she was left lying on an incontinent pad for extended periods of time. This failure could place 5 residents who had pressure injuries at risk for developing new or the worsening of existing pressure injuries. Findings included: Physician orders [REDACTED].#1 was 86 and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1 had orders for daily wound care to her left ischium (near the gluteal fold) pressure injury. An MDS dated [DATE] indicated Resident #1 understood others and made her needs known. She required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. She was incontinent of bowel and had an indwelling urinary catheter. The MDS indicated Resident #1 was at risk for developing pressure injuries and was admitted with a pressure injury. A care plan dated 01/17/17 indicated Resident #1 had a pressure injury on her left ischium and was at risk for skin breakdown. Interventions included performing ordered treatment and report any skin breakdown to physician. A TAR for March 2017 indicated Resident #1 did not receive wound care on her left ischium on 03/04/17, 03/05/17, 03/11/17, 03/12/17, or 03/18/17. A wound assessment report dated 03/23/17 indicated Resident #1 had a stage 3 pressure injury to her left ischium (buttock) area that measured 2.0 cm x 1.8 cm x 0.60 cm. The assessment indicated Resident #1's surrounding skin was normal. The assessment did not address any other skin issues. A weekly skin assessment dated [DATE] indicated Resident #1's skin was not intact. During an observation and interview on 03/28/17 at 10:05 a.m., the treatment nurse provided Resident #1 with wound care. Resident #1's urinary catheter tubing was underneath Resident #1's legs. Resident #1 had a stage 3 pressure injury on her left buttock. Resident #1 had multiple reddened, opened areas on her right and left buttocks. The wound care nurse said the reddened areas were due to the urinary catheter being under her the resident's legs and from the folds in the incontinent pad under the resident's legs and buttocks for an extended amount of time. She said the reddened areas had been on Resident #1 and staff was applying barrier cream. She said they were not wounds, but were shearing. She did not measure the shearing and said they were not stageable because they were shearing. During and observation and interview on 03/29/17 at 1:23 p.m., Resident #1 said RN A (weekend supervisor) had already performed her daily wound care. The dressing on the resident's left ischium was dated 03/28/17. Resident #1's buttocks was lightly covered with a white substance. Resident #1 had multiple, reddened, open areas on her buttocks. There were also four stage 2 pressure injures that were open and undressed near her right gluteal fold. During an interview on 03/29/17 at 2:57 p.m., RN A said he performed daily wound care on Resident #1 on 03/29/17. He said he must have incorrectly dated the dressing on Resident #1 left buttock. He said he was the weekend supervisor and typically did not perform wound care on residents. He said he was so focused on Resident #1's wound on her left ischium, that he did not pay any attention to the other open areas to Resident #1's right buttocks. He said no staff notified him of any new opened areas on Resident #1. During an observation and interview on 03/29/17 at 2:40 p.m., the wound treatment nurse and the ADON observed Resident #1's right buttocks area. The wound treatment nurse said one area on Resident #1's right buttock worsened from the day before. The wound treatment nurse said the worsened area to Resident #1's right buttock was not a stage 2 pressure injury. She said staff did not notify her of Resident #1's change in skin. The wound care nurse measured the stage 2 pressure injury on the resident's right buttock and said it was 2.2 cm x 1.0 cm. She said it was probably caused by Resident #1's urinary catheter tubing pressing against her skin. The wound treatment nurse said the other reddened, open areas on her buttocks were shearing and not pressure injuries. There was a dressing on Resident #1's left buttock dated 03/28/17. The facility's pressure injury policy dated September 2013 indicated staff would perform routine skin inspections with daily care and immediately and report any signs of a developing pressure ulcer to the supervisor. Pressure can come from bed linen. Risk factors for shears included catheters under residents' legs. According to www.npuap.com, accessed 04/03/17, .Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel . The CMS 672 dated 03/28/17 indicated 5 residents had pressure injuries.

Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 6 residents reviewed for medications. (Resident #1) Resident # 1 received multiple psychoactive medications including [MEDICATION NAME] as needed. On 6/8/14, she received 3 doses of [MEDICATION NAME]. The following day Resident #1 was unresponsive with a change in her heart rate and was sent to the hospital where she was found to be overmedicated. The facility did not evaluate her medications to determine if the medication should be discontinued or reduced. This failure could place the 29 residents receiving psychoactive medications at risk for over sedation and decreased quality of life. Findings included: Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. *[MEDICATION NAME] Sodium ([MEDICATION NAME]) 500 milligrams (mg.) 1 tab twice daily (anticonvulsant) *[MEDICATION NAME] 25 mg. 1 tab twice daily (antipsychotic) *[MEDICATION NAME] 30 mg. 1 tab once daily, (antidepressant) Physician orders [REDACTED]. tablet three times a day as needed. The most recent MDS assessment dated [DATE] indicated Resident #1 required extensive total care for all of her ADLs. Nursing notes for Resident #1 included the following: * 05/15/14 [MEDICATION NAME] given at 6:00 a.m. for increased agitation, resident continues to yell for help at nursing station * 5/15/14 at 7:40 p.m. No adverse reaction to [MEDICATION NAME], resident refuses/unable to sit up in wheelchair. *5/16/14 No adverse reaction to [MEDICATION NAME]. *5/16/14 at 8:40 p.m.- Resident seems lethargic Medication administration records for Resident #1 indicated she received [MEDICATION NAME] twice a day, [MEDICATION NAME] twice a day, and [MEDICATION NAME] daily from June 1st - June 8th. Medication count sheets for May and June 2014 indicated Resident #1 was administered [MEDICATION NAME] on 5/15/14 at 6:00 a.m. and on 06/08/14 at 7:00 a.m., 2:00 p.m., and 7:00 p.m. Physician orders [REDACTED].#1 was ordered to be sent out for evaluation at the local hospital. Hospital discharge physician orders [REDACTED].#1 was discharged from the local hospital back to the facility with a [DIAGNOSES REDACTED]. The hospital discharge orders indicated to consult with the facility physician to have medications adjusted to prevent overmedication. During an interview on 06/12/14 at 10:00 a.m. LVN C said Resident #1 recently had a change of condition and became lethargic due to possible overmedication. He said she was prescribed [MEDICATION NAME] and [MEDICATION NAME] but the medications had too much of an effect on Resident #1. He said she was in and out of lethargic states either yelling for help or asleep. LVN C said he did not think to notify the physician about the resident's lethargy from the medication. During an interview on 06/12/14 at 9:00 a.m., CNAs A and B said Resident #1's energy levels drifted in and out recently. She said when Resident #1 was alert she was able to assist with her own care; however, on days the resident seemed sleepy, she would be totally dependent on staff for care. During an interview on 06/12/14 at 12:30 p.m. the DON and Administrator said on 06/09/14 Resident #1 was administered [MEDICATION NAME] to comfort her due to her yelling out "help me". They said later that day, Resident #1 was found unresponsive with a change in her heart rate. The DON said Resident #1 was sent to a local hospital where she was assumed to be overmedicated. The DON said Resident #1 had been experiencing episodes of lethargy. According to the website, <http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=8620>, accessed 6/25/14, the following was noted: " ...The mean half-life of [MEDICATION NAME] in human plasma is about 12 hours and for its major metabolite, [MEDICATION NAME] glucuronide, about 18 hours ... ...Elderly or debilitated patients may be more susceptible to the sedative effects of [MEDICATION NAME]. Therefore, these patients should be monitored frequently and have their dosage adjusted carefully according to patient response; the initial dosage should not exceed 2 mg .... ...The benzodiazepines, including [MEDICATION NAME] ([MEDICATION NAME]), produce increased CNS-depressant effects when administered with other CNS depressants such as antipsychotics, sedative/hypnotics, anticonvulsants ....The incidence of sedation and unsteadiness was observed to increase with age ... ...For elderly or debilitated patients, an initial dosage of 1 to 2 mg/day in divided doses is recommended, to be adjusted as needed and tolerated ... " The CMS-672 dated 06/12/14 indicated 29 residents received psychoactive medications.

Based on observation, interview and record review, the facility failed to provide treatment and services to prevent the development of a pressure ulcer for 1 of 2 residents sampled with pressure ulcers. (Resident #1) Resident #1 was admitted [DATE] with 4 Stage II pressure ulcers to her buttocks and coccyx, and an unstageable pressure ulcer to her left heel. The facility did not assess, obtain treatment orders or care plan interventions for the pressure ulcers until 3/21/11. Resident #1 developed an unstageable pressure ulcer on her right heel. This failure could place 27 residents who received preventative skin care at risk for developing new pressure ulcers and worsening of existing pressure ulcers. Findings included: Resident #1's admission physician order [REDACTED]. Resident #1's nursing notes documented that she was admitted into the facility on [DATE] at 6:30 p.m. Resident #1's Discharge Post Acute Care sheet dated 3/18/11 documented she was a [AGE] year old female and had a past history of [MEDICAL CONDITION], insulin dependent type two diabetes, [MEDICAL CONDITION], chronic venous stasis to lower extremities, obesity, hypertension, [MEDICAL CONDITIONS], chronic back pain, and severe debilitation. The form noted Resident #1 was cooperative and had no cognitive impairment. The hospital discharge form noted: *cleanse buttocks twice a day and as needed with No Rinse cleanser and pat dry. Apply a thin layer of Critic-Aid Clear. Use air flow pad under resident. Tilt off back as much as possible. *keep heels off the bed at all times During an observation with the ADON and LVN A on 3/21/11 at 11:24 a.m., the following was noted regarding Resident #1: *She was lying in bed on a Hill-Rom PrimeAire Pressure Relief Mattress, and her heels were not off loaded. *Her heels were positioned on the mattress directly on unstageable ulcers on her left and right heels. The ADON and LVN A raised Resident #1's legs and she had hard dark brown unstageable pressure ulcers on the left and right heels. There was a purplish brown deep tissue injury surrounding the unstageable pressure ulcer on the left heel. *She had 4 Stage II pressure ulcers on her right and left lower buttocks, sacrum, and the left side of her sacrum. There were no dressings or ointments on the pressure ulcers. The wound bed and surrounding skin of the pressure ulcers were pink in color without drainage. During observations on 3/22/11 at 9:10 a.m., 9:47 a.m. and 12:00 noon, Resident #1's heels were not off loaded and her unstageable ulcers were positioned directly on the mattress. During an interview on 3/21/11 at 11:24 p.m., Resident #1 said she was admitted Friday (3/18/11) and no one had treated her pressure ulcers since she was admitted . The resident said she was not able to move, turn, or reposition herself in the bed. Resident #1's facility admission orders [REDACTED]'s wounds. Resident #1's Admission Skin assessment dated [DATE] documented no assessment of the wounds except for the following: *left inner buttock - 0.5 cm x 1 cm *middle of coccyx - 1.5 cm x 0.5 cm *upper left buttock - 0.3 cm x 1 cm *right inner buttock - 1 cm x 2 cm *bottom of left heel with black necrosis that measured 5 cm x 3.5 cm. There was no documented assessment of her right heel on the Admission Skin assessment dated [DATE]. During an interview on 3/21/11 at 3:40 p.m., LVN B said she admitted Resident #1 on 3/18/11. She assessed the resident's buttocks and she had several "Stage III" pressure ulcers. LVN B said she assessed Resident #1's heels and there was a hard brown necrotic area to the resident's left heel. There was no pressure ulcer on Resident #1's right heel. She said she sent the physician a text message to inform him that the resident had several wounds and no treatment orders. She said she received a text message from the physician that noted, "Ok" so she, "just left it at that." During an interview on 3/22/11 at 8:30 a.m., LVN C said she was the nurse who took care of Resident #1 on 3/19/11 and 3/20/11 from 6:00 a.m. to 10:00 p.m. She said the admitting nurse was responsible for contacting the physician and obtaining treatment orders. LVN C said she was unsure of what skin concerns Resident #1 had because she did not assess or observe her skin on 3/19/11 or 3/20/11. During an interview on 3/22/11 at 8:45 a.m., LVN D said she was the nurse who took care of Resident #1 on 3/19/11 and 3/20/11 from 10:00 p.m. to 6:00 a.m. She said that she did not assess or look at Resident #1's skin. During an interview on 3/21/11 at 10:00 a.m., LVN A said that on 3/21/11 after the surveyor observed Resident #1's skin, she (LVN A) was made aware that the resident did not have any treatment orders for the pressure ulcers. She said that on 3/21/11 (3 days after admission), she contacted the physician and obtained a treatment order. A physician telephone order dated 3/21/10 noted staff were to: *cleanse ulcers to coccyx area with [MEDICATION NAME] and apply after each incontinent care and as needed, and *keep resident off her back and off-load her heels. During an observation and interview with the DON on 3/22/11 at 9:10 a.m., the DON said she would describe Resident #1's ulcers on both heels as unstageable. She said they were hard and dark brown in color. During an interview on 3/22/11 at 9:26 a.m., the DON said there was no care plan for interventions related to Resident #1's pressure ulcers or for the resident being at risk for skin break down. She said the nurses were to initiate a care plan upon admission, but they failed to do so. She said they did not thoroughly assess Resident #1 and obtain treatment orders when she was admitted . The facility Pressure Ulcer policy and procedure dated 3/5/08 documented the following: * Pressure ulcers were any [MEDICAL CONDITION] caused by unrelieved pressure that results in damage to the underlying tissue. * Risk factors were decreased mobility, diabetes mellitus, and impaired diffuse or localized blood flow/arterial insufficiency., * An evaluation was to be completed on admission to help identify the resident at risk of developing a pressure ulcer and the existing pressure ulcers or areas of skin that are at risk for breakdown. Initial care approaches are identified and implemented promptly to attempt to prevent pressure ulcers. * For the resident at risk for developing or who has pressure ulcers, the facility was to develop an individualized care plan that addresses prevention, care, and treatment of [REDACTED]. * The nurse was to document the location and staging of the ulcer, size, depth, drainage, and a description of the wound bed, wound edges and of the surrounding skin. * An arterial ulcer is an ulcer that occurred as the result of arterial occlusive disease when non-pressure related disruption of blockage of the arterial blood flow to an area causes tissue necrosis. * A [MEDICAL CONDITION] ulcer previously known as stasis ulcer is an open lesion of the skin and subcutaneous tissue of the lower leg. The Agency for Healthcare Policy and Research, Number 15 for treatment of [REDACTED]. Individuals who were in bed should not be positioned on the pressure ulcer. The National Pressure Ulcer Advisory Panel website, http://www.npuap.org/pr2.htm, accessed on 03/28/11 indicated the following: Pressure Ulcer DefinitionA pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidate. Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The CMS-672 dated 3/21/11 indicated 27 residents received preventative skin care.