Every finding on record at River Ridge Rehabilitation and Care Center

Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure sufficient staffing to meet the residents' needs as evidenced by not following the facility assessment staffing guidelines for 74 of 87 shifts reviewed from 03/01/2025 day shift through 03/31/2025 night shift. The findings include: A review of a facility policy titled, Facility Assessment, dated 12/13/2024, indicated the facility had an average daily census of 74. Common diagnoses of the facility's residents included psychiatric/mood/substance use disorders, heart/circulatory system disorders, neurological system disorders, intellectual disabilities, musculoskeletal system disorders, cancers, respiratory disorders, genitourinary disorders, blood diseases, skin conditions, and infectious diseases. fractures and arthritis. The facility assessed acuity affecting licensed nurses were 16% residents on an altered diet and 4% residents with swallowing disorder, 51.4% with Psychiatric/Mood Disorders, 87.5% with Heart/Circulatory, 2% with Major Joint replacement or Spinal Surgery, 47% Non-Orthopedic Surgery and Acute Neurologic, 32% Other Orthopedic, 19% Medical Management, 11% Extensive services, 62% Special Care High, 11% Special Care Low, 9% Clinically Complex, 7% Reduced Physical Functioning. Acuity Affecting Nurse Aides revealed 7 residents were dependent upon staff for dressing, 16 for bathing, 16 for transfers, 6 for eating, 7 for toileting, 5 for oral hygiene, 11 for mobility, 3 for bed mobility. The facility assessed their coverage needs to adequately met the residents' daily needs per shift as: Day Shift: 1-Director of Nursing (RN), 3-4 Registered Nurse (RN), 1-Infection Preventionist, 2-Licensed Practical Nurses (LPNs), 6-7 Certified Nurse Assistants (CNAs), 1 Restorative Aide, 1 Med Techs. Evening Shift: 0 RNs, 2 LPNs, 4-6 CNAs, 1 Med Tech. Night Shift: 1 RN, 1 LPNs, 4 CNAs. A review of the facility's Resident Matrix printed 6/2/2025 revealed that 11 out of 64 facility residents had suffered a fall, two of which resulted in a major injury, 27 had a diagnosis of Alzheimer's/Dementia, one was on transmission based precautions (isolation requiring a personal protective equipment), four were on hospice care, nine were being treated for an infection, three had a pressure injury, three had a urinary catheter in place, and eight required tube feedings. A review of the documents Detailed Hours, for March 2025 daily staffing was reviewed from the employee's time clock punch reports starting with the day shift on 3/1/2025 through the end of the night shift on 3/31/2025. Using staffing guidelines defined by the facility in their 12/13/2024 Facility Assessment, the bedside staff coverage was found lacking coverage by either a partial or complete open shift on 74 of 84 shifts between the dates of 03/01/2025 and 03/31/2025. A review of a document titled, Incident by Incident Type, reviewed for a date range from 3/1/2025 to 3/31/2025, revealed two witnessed falls, five unwitnessed falls, and two falls during staff assist incidents. Review of an Medication Administration Record for the month of March indicated Resident #37 ha a physician ' s order for two types of insulin, including a long acting form of insulin ordered to be administered twice daily at 8:00 AM and 8:00 PM, and a fast acting form of insulin ordered to be administered via sliding scale at 7:30 AM, 11:30 AM, 4:30 PM, and 8:00 PM. A review of a document titled Medication Admin Audit Report reviewed for a date range from 3/1/25 to 3/31/25, revealed Resident #37 had received the ordered doses at least one hour, and up to four hours late, on 16 occasions in the month of March. During an interview on 6/6/2025 at 9:10 AM Director of Nursing (DON) stated the facility does not use temporary or contract staff. The DON stated the low staffing issue that was identified on the Payroll Based Journal that was submitted for the 1st quarter of 2025 was addressed by implementing a weekend option so that the facility would have 8 certified nurse assistants that work from on Saturday and Sunday from 6AM-6PM. When asked about Resident #37 receiving ordered insulin late, the DON confirmed that the time frame for medication to be administered, is 1 hour before and after dose was scheduled, with a concern of the resident developing hyperglycemia if the schedule is not followed. During an interview on 6/6/2025 at 2:10 PM, Certified Nurse Assistant (CNA) #5 stated that they have noticed that the facility did not have enough staff, especially during the last six months. They continued by stating that they have observed on the first shift, the facility not having enough staff to meet residents' needs, resulting in residents waiting a long time for someone to help them. CNA #5 reported that sometimes beds are left unmade and rooms messy on the weekend. During an interview on 6/6/2025 at 2:40 PM, CNA #6 stated that they have noticed, sometimes, that the facility does not have enough staff, especially during the last six months. CNA #6 stated that they sometimes observed the facility not having enough staff to meet residents' needs, such as residents waiting a long time for someone to help them. CNA #6 also reported that beds are left unmade and rooms are messy on the weekend, and there are times when there are not enough staff to take care of the residents. During an interview on 6/7/2025 at 9:30 AM, Dietary Aide #8 stated that they hear the residents complain about their food getting cold while they wait to be assisted by nursing staff. Dietary Aide #8 stated that food trays come back untouched, which might indicate short nursing staff. Dietary Aide #8 stated that residents might be absent from the dining room because nursing staff are not available to assist them to the dining room.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure the medication error rate was not 5 % or greater for one of one medication administration pass reviewed for medication errors. Four (Residents #9, #24, #49, and #32) of seven residents observed during medication administration. Eleven medication errors were observed during 42 observed medication administration opportunities. This resulted in a medication error rate of 26.19 %. The findings include: During a medication administration observation on 06/04/2025 at 7:15 AM, Licensed Practical Nurse (LPN) #1 administered medications to residents on D hall. The following errors were observed: At 7:33 AM, LPN #1 failed to administer the ordered dose of antihistamine to Resident #49. At 7:36 AM, LPN #1 failed to administer the ordered dose of antihistamine to Resident #32. At 7:40 AM, LPN #1 failed to administer the ordered dose of antihistamine, laxative solution, and eye drops to Resident #9. At 7:47 AM, LPN #1 failed to administer the ordered doses of vitamin C, ferrous sulfate elixir, multivitamin, protein oral liquid, zinc, and a laxative to Resident #24. When LPN #1 indicated the medication pass was completed, this surveyor asked if anything was omitted or not administered as ordered. LPN #1 stated, No. A review of Resident #49 ' s Medication Administration Record (MAR) and Clinical Physician Orders revealed an antihistamine tablet 10 milligrams (mg), was ordered on 12/10/2024, to be given at 8:00 AM daily. A review of Resident #32 ' s MAR and Clinical Physician Orders revealed an antihistamine oral tablet 10 mg was ordered on 04/23/2025, to be given at 8:00 AM daily. A review of Resident #9 ' s MAR and Clinical Physician Orders revealed eye drops, 1 drop in both eyes, was ordered on 05/30/2025; an antihistamine tablet 10 mg was ordered on 06/26/2024; and laxative solution 17 grams/scoop was ordered on 03/01/2024; all were ordered to be given at 7:30 AM daily. A review of Resident #24 ' s MAR and Clinical Physician Orders revealed a multivitamin-minerals oral tablet was ordered on 08/10/2024; a ferrous sulfate elixir 220 mg, was ordered on 08/10/2024; zinc sulfate 50 mg, was ordered on 08/10/2024; laxative 100 mg, was ordered on 08/09/2024; vitamin C 500 mg was ordered on 08/10/2024; and protein oral liquid 30 milliliters was ordered on 08/09/2024; all were ordered to be given at 8:00 AM daily. A review of the Medication Administration training and nurse competencies for 23 nurses revealed LPN #1's training was complete and up to date. During an interview on 06/04/2025 at 8:15 AM, LPN #1 confirmed all medications that were due were given to the residents during the observation. LPN #1 was asked to review the MAR for the observed residents. When asked if she administered the medications listed above to the four residents listed above, she stated, No I didn't. LPN #1 stated, I didn't scroll over there to see those. A review of the Medication Administration Audit Report revealed the medications that were observed to not be given to the four residents, were marked as given by LPN #1. When asked, why the medications were marked as given, LPN #1 stated I'm not sure. During an interview on 06/04/2025 at 9:30 AM, the Administrator confirmed the nursing staff were expected to administer medications, according to the physician's orders, and per the Medication Administration policy. A review of the Medication Administration policy revealed, Medications are administered in accordance with good nursing. Medications are administered in accordance with written orders of the prescriber, following the rights of medication administration principles and practices and only by person legally authorized to administer medications do so only after they have been properly oriented, to the facility's medication distribution system.

Based on observation, interview, and facility policy review, the facility failed to ensure food stored in the dry storage area was covered and sealed, dented cans were removed from stock, and expired food items were discarded on or before the expiration or use- by date for 1 of 1 kitchen observed. The findings include: On 06/02/2025 at 11:20 AM, the following observations were made on the shelves in two food storage areas during a tour of the kitchen and pantries, accompanied by the Dietary Manager (DM). 1. Eight dented cans of various food items were observed on the shelving used to store food intended to be served to the residents. The Dietary Manager (DM) was asked what was done with dented cans, and stated, They are trashed because metal shavings can get inside. 2. A opened bottle of lemon flavor sweet tea. The DM stated, It should have been refrigerated once opened. 3. One opened bag of rice. The bag was not sealed and was open to air. 4. Two bags of corn chips, also stored in an area used to store food intended to be served to residents, had a use-by date of 04/08/2025. On 06/02/2025 at 12:15 PM, the following observations were made on the shelf in the kitchen area: 1. Two seasoning/spice bottles with a use-by date of 04/03/2025. 2. One bottle of steak sauce with a use-by date of 02/02/2025. 3. Three grated cheese containers with a use-by date of 05/24/2025. A review of the facility policy titled, Diet, Sanitation and Menu revealed that the nursing facility will store, prepare, distribute, and serve food under sanitary conditions.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to dress a resident in their preferred attire for one (Resident #19) of one resident reviewed for dignity. The findings include: A review of Resident #19 ' s Medical Diagnosis, indicated the resident had diagnoses which included hemiplegia and hemiparesis, following cerebral infarction, affecting right dominant side. A review of Resident #19 ' s quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 05/12/2025, revealed the resident had a Staff Assessment for Mental Status score of 3, which indicated the resident was severely impaired in daily decision making. The MDS also revealed Resident #19 required substantial/maximum assistance with dressing upper body. A review of Resident #19's Care plan, initiated on 05/29/2025, indicated due to cognitive impairment, cerebral vascular accident, Resident #19 required assistance with activities of daily living. Interventions specified Resident #19 required assistance from staff for dressing, and the resident preferred to have a white T-shirt on, at all times. During an observation on 06/02/2025 at 11:25 AM, Resident #19 was lying in bed, with a hospital gown on. During an observation on 06/03/2015 at 9:28 AM, Resident #19 was lying in bed, with a hospital gown on. During an interview on 06/03/2025 at 2:34 PM, with Resident #19 ' s representative, the representative reported Resident #19 was always in a hospital gown when they visited. The representative also revealed that Resident #19 did have clothes at the facility. During an interview with the Director of Nursing (DON) on 06/05/2025 at 10:40 AM, the DON reported Resident #19 should not have been in a hospital gown and should have had regular clothes on. The DON also reported Resident #19 ' s care plan stated to put Resident #19 into a white t-shirt, every day. The DON looked in Resident #19 ' s drawers and found clothes. During an interview with the DON on 06/06/2025 at 8:45 AM, the DON reported that the resident ' s dignity was not being honored, and dignity was part of the resident ' s rights. During an interview with the Administrator on 06/06/2025 at 8:51 AM, the Administrator reported that a resident's pride could be affected if dignity was not honored. The Administrator reported that dignity was part of a resident's rights. During an interview with Licensed Practical Nurse (LPN) #2 on 06/04/2025 at 2:55 PM, LPN #2 reported that being in a hospital gown was against a resident's rights. A facility policy review of Resident Rights revealed, The nursing facility protects and promotes the rights of each Resident/Elder admitted in order to provide a dignified existence, self-determination and communication with and access to persons and services inside and outside the nursing facility. The nursing facility will protect and promote the rights of each Resident/Elder.

Based on observations, interviews, record review, and facility document review, the facility failed to ensure the comprehensive person-centered care plan was developed and implemented to include ordered care for one (Resident #6) of one sampled resident. The findings include: During a hall observation, in front of Resident #6 ' s room on 06/04/2025 at 10:23 AM, this surveyor heard the resident request Certified Nursing Assistant (CNA) #10 to get them up to a chair. CNA #10 told the resident they would go get help and get the resident up. CNA #10 exited the room at 10:25 AM. During a continuous hall observation, outside of Resident #6 ' s room on 06/04/2025 from 10:23 AM through 12:40 PM, no staff entered the room to get the resident up to a chair. During an observation, outside of Resident #6 ' s room on 06/04/25 at 11:09 AM, the Social Services Director (SSD) was observed putting on personal protective equipment to enter the resident ' s room. CNA #10 approached the SSD and stated Resident #6 wanted to get up to a chair. CNA #10 turned and walked away, without providing assistance the Resident # 6. A review of Resident #6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/07/2025, revealed Resident #6 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also revealed the resident required maximum assistance for toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, and lying to sitting on side of bed. Resident #6 was dependent for chair/bed-to-chair transfer and tub/shower transfer. A review of a Physician Order, dated 01/15/2025, indicated the Medical Director ordered Resident #6 to be up in their wheelchair, three times a week during day shift, on Monday, Wednesday, and Friday. A review of Resident #6's Comprehensive Care Plan dated 04/22/2025, indicated the resident required extensive assistance with personal hygiene and two-person assistance with mechanical lift for all transfers, using an extra-large blue poly lift pad. No documentation or intervention to transfer Resident #6 to their wheelchair, during day shift, every Monday, Wednesday, and Friday was revealed. A review of Patient Care Team Nursing Home Progress Note dated 01/15/2025, indicated the Nurse Practitioner documented a plan of order to prevent muscle weakness to get Resident #6 up in chair, three times a week, and to document refusal. A review of a Faxed Note of Access Medical Clinic, dated 01/20/2025, revealed the document was sent to the facility, showing the ordered notation of Resident #6 to be up to a chair, three times a week. A review of a Nursing Progress Note dated 01/15/2025, indicated staff decided the resident would get up to a chair on Sundays, with resident choice of the other two days. A review of Resident #6 ' s Kardex dated 06/05/2025, indicated the resident was a two-person assistance, with mechanical lift for all transfers, and to use an extra-large blue poly lift pad. There was no documentation noted for the resident to get up to a chair, three days a week. During an interview on 06/04/2025 at 9:43 AM, a family member of Resident #6 stated that the resident was supposed to get up to a chair three days a week, but that did not happen. The family member indicated they had to call the facility to tell them the resident better be up to a chair when they get there, and we shouldn't have to do that. The family member indicated Resident #6 was always on their back, in the bed, and they had never seen the resident turned on their side. During an interview with the Assistant Director of Nursing (ADON) on 06/05/2025 at 2:30 PM, the ADON stated a care plan was what the MDS Coordinator put in as part of a residents' chart, and any interventions that went with the care plan were placed on the Kardex. The ADON stated an employee would look at the care plan, or Kardex, to know what should have been done with the resident. Staff would use the care plan to determine if the resident required assistance if the resident could get up to a chair. During an interview on 06/03/2025 at 1:09 PM, CNA #10, stated the employees had to look at the Kardex or care plan to find out what to do with the resident, such as assistance with bath, total care, lifts, or anything to do specifically, with that resident. CNA #10 verified they had not received training on repositioning residents, although training had been received on reading care plans. We reposition residents every two hours, and if the resident refused, the charge nurse was notified. If the resident refused, the staff would go back to try again after a few minutes. If a resident stayed in one position for too long, they could get pressure sores. The Kardex or care plan was looked at for interventions.

Based on observation, interviews, record review, and facility document review, the facility failed to implement a physician ' s order to get a resident up to a chair, for one (Resident #6) of one sampled resident, reviewed for quality of care. The findings include: During an observation on 06/04/2025 at 10:18 AM, Resident #6 pressed the call light, with this surveyor in the room, to request to be gotten up to a chair. During a hall observation in front of Resident #6 ' s room, on 06/04/2025 at 10:23 AM, this surveyor heard the resident request Certified Nurse Assistant (CNA) #10 to get them up to a chair. CNA #10 told the resident they would go get help, to get the resident up. CNA #10 exited the room at 10:25 AM. During a continuous hall observation outside of Resident #6's room, on 06/04/2025 from 10:23 AM through 12:40 PM, no staff entered Resident #6 ' s room or offered assistance to get the resident up to a chair. During an observation outside of Resident #6's room, on 06/04/2025 at 11:09 AM, the Social Services Director (SSD) was putting on personal protective equipment to enter the resident's room. CNA #10 approached the SSD and stated the resident wanted to get up to a chair. CNA #10 walked away, without providing assistance to the resident. During a concurrent observation and interview with Resident #6 on 06/04/25 at 12:35 PM, the resident was still lying on their back, in the bed. When asked what CNA #10 said when the call light was pressed, the resident stated, [CNA #10] had to go get some help to get up to the chair and would be back, but they have not returned. A review of Resident #6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/07/2025, indicated Resident #6 had a Brief Interview for Mental Status score 15, which indicated the resident was cognitively intact. The MDS also revealed Resident #6 required maximum assistance for toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, and lying to sitting on side of bed. Resident #6 was dependent for chair/bed-to-chair transfer and tub/shower transfer. A record review of Physician Order dated 01/15/2025, indicated the Medical Director ordered Resident #6 to be up in the wheelchair, three times a week during day shift, on Monday, Wednesday, and Friday. A review of Resident #6's Comprehensive Care Plan, dated 04/22/2025, indicated the resident required extensive assistance with personal hygiene and two-person assistance with mechanical lift for all transfers using an extra-large blue poly lift pad. No documentation of intervention to transfer Resident #6 to a chair during the day every Monday, Wednesday, and Friday. Th Care Plan also revealed that Resident #6 was at risk for impaired skin integrity related to immobility and incontinence. A review of Patient Care Team Nursing Home Progress Note dated 01/15/2025, indicated the Nurse Practitioner plan of order to prevent muscle weakness was to get Resident #6 up in chair, three times a week, and to document refusal. A record review of Faxed Note of Access Medical Clinic dated 01/20/2025, revealed the document was sent to the facility, showing the ordered notation of Resident #6 to be up to a chair, three times a week. A record review of Nursing Progress Note dated 01/15/2025, indicated staff decided the resident would get up to a chair on Sundays, with resident choice of the other two days. A review of a facility document titled Kardex dated 06/05/2025, indicated Resident #6 was a two-person assistance with mechanical lift for all transfers and to use an extra-large blue poly lift pad. No documentation was included for Resident #6 getting up to a chair three days a week. During an interview on 06/04/2025 at 9:43 AM, a family member of Resident #6 stated the resident was supposed to get up to a chair three days a week, but that did not happen. The family member indicated they had to call the facility to tell them Resident #6 better be up to a chair when they get there, and we shouldn't have to do that. The family member indicated the resident was always on their back, in the bed, and they had never seen the resident turned on the side. During an interview on 06/03/2025 1:09 PM, CNA #10 stated the employees had to look at the Kardex or care plan to find out what to do with the resident, such as assistance with bath, total care, or anything to do specifically, with that resident. CNA #10 verified they had not received training on repositioning residents. CNA #10 stated, We reposition residents every two hours, and if the resident refused, the charge nurse was notified. If the resident refused, the staff would go back to try again after a few minutes. If a resident stayed in one position for too long, they would get pressure sores. The Kardex or care plan was looked at for interventions. During an interview with the Director of Nursing (DON) on 06/05/2025 at 8:42 AM, she stated during day shift on 06/04/2025 the facility had nine CNAs, three Licensed Practical Nurses (LPNs), and three Registered Nurses (RNs). The DON stated residents should be turned every two hours and not left lying on their back for hours and hours. When residents lay on their backs for long periods of time, they could obtain pressure ulcers. Every resident should get up to a chair daily, even the residents that are a two-person assist. The DON stated that when a resident had asked to be gotten up to a chair, the employee should have gotten them up. During an interview with CNA #10 on 06/05/2025 1:12 PM, CNA #10 stated if a resident could not move their arms or legs, staff should perform range of motion to the residents. When CNA #10 was asked where they documented every two-hour position changes of the residents, she stated the stop and watch notes. If a resident did not get up to a chair, the resident could get pressure sores. CNA #10 stated they had plenty of staff to assist when getting dependent residents up. Residents should be helped up any time they want, and Resident #6 had not been up to a chair since being moved to that hall last Friday 05/30/2025, because the resident had not asked to be up. During an interview with the MDS Coordinator on 06/05/2025 at 2:24 PM, she stated the staff did not document residents being turned every two hours, it was a standard of care. Therefore, there was no documentation of Resident #6 being repositioned. During an interview with the Assistant Director of Nursing (ADON) on 06/05/2025 at 2:30 PM, she stated residents should be turned every two hours, and the ADON was unsure if the staff documented it. She indicated, it is not good for a resident to lay in one position for hours, and a negative outcome would be skin breakdown or infections. The ADON revealed the resident(s) determined if they got up, if they required a two person assist, they would use the mechanical lift. If a resident requested to be gotten up to a chair, staff should do it. During an interview with the Administrator and the DON on 06/05/2025 at 3:10 PM, they revealed the facility did not have a policy on standard of care. The Administrator defined the standard of care as, the resident should be turned every two hours or as needed. The DON stated, the resident should be turned every two hours, as needed or when asked. A review of an undated facility policy titled Positioning Immobility, indicated the goal of frequent position changes was to prevent pressure sores. Changed positions several times a day prevented changes in the cardiovascular system. The recommendation was to change body position every two hours and more frequently in patients who had no spontaneous movement. A review of an undated facility policy titled Pressure Ulcer indicated pressure ulcers were the most common result from prolonged periods of bed rest which can develop within hours. Repositioning every two hours, using cushion devices on bony areas, and provided activity and ambulation as much as possible prevented pressure ulcers.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to provide supplemental oxygen per physician orders for 1 (Resident #49) of 1 resident reviewed for respiratory care. The findings include: During an observation on 06/02/2025 at 11:38 AM, Resident #49 was observed in their room receiving oxygen from an oxygen concentrator, at four liters per minute, via nasal cannula. During an observation on 06/03/2025 at 8:25 AM, Resident #49 was observed in their room, receiving oxygen from an oxygen concentrator, at four liters per minute, via nasal cannula. During an observation on 06/03/25 at 2:29 PM, Resident #49 ' s was observed in their room receiving oxygen from an oxygen concentrator, at five liters per minute, via nasal cannula. A review of the Medical Diagnosis portion of Resident #49 ' s electronic health record revealed diagnoses which included chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. A review of Resident #49 ' s quarterly Minimum Data Set, with an Assessment Reference Date of 03/03/2025, revealed the resident had a Brief Interview for Mental Status score of 13, which indicated the resident was cognitively intact. A review of Resident #49 Care Plan, initiated on 10/24/2024 and revised on 05/30/2025, revealed the resident had COPD and chronic respiratory failure. Interventions instructed staff to check oxygen settings, provide oxygen as ordered, and to see physician orders. A review of Clinical Physician Orders, revealed Resident #49 may have oxygen at two liters, via nasal cannula, as needed. On 06/03/2025 at 2:50 PM, the Director of Nursing (DON) accompanied the surveyor to Resident #49 ' s room, to look at the resident ' s oxygen concentrator. The DON reported Resident #49 ' s oxygen concentrator was set at five liters per minute. The DON reported, after reviewing Resident #49 ' s orders, the resident ' s oxygen was to be set at two liters per minute. During an interview on 06/06/2025 at 8:31 AM, the DON stated a resident that received a high dosage of oxygen, with a diagnosis of COPD, could develop carbon dioxide poisoning. The DON reported Resident #49 was not able to the turn knob on their oxygen concentrator, due to not being able to move their right side or get out of the bed. The DON indicated Resident #49 ' s oxygen concentrator was situated behind the resident. During an interview) on 06/06/2025 at 9:10 AM, the Assistant Director of Nursing (ADON) reported if a resident with a diagnosis of COPD received a high dosage of oxygen, the resident could develop decreased respirations and carbon dioxide poisoning. The ADON reported Resident #49 could not reach their oxygen concentrator to adjust the flow rate themselves due to not being able to get out of bed. A review of a facility policy titled, Oxygen Administration, indicated, Check physician's order for liter flow and method of administration. Set the flow meter to the rate ordered by the physician.

Based on observation and interview, the facility failed to ensure (1) that the kitchen floor, wall and ceiling tiles were cleaned and free of stains, chipped, grease and paint peeling to provide a sanitary environment for food preparation, (2) food items stored in the refrigerator, freezer, and storage area were covered or sealed, (3) expired dressing were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of 2 kitchen, (4) the ice machine was maintained in clean and sanitary condition, and (5) dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 63 residents who received meals from the kitchen. The findings are: 1. On [DATE] at 10:15 AM, the following observations were made in the kitchen. a. At the entrance door to the kitchen area, the floor between the ice machine and air vent had rust stains. b. The floor between the oven and deep fryer had grease build up and the body of the deep fryer and oven had grease build up. c. Inside the deep fryer, the shelf had an accumulation of loose, greasy, dark brown, food crumbs covering the whole surface. d. The corners inside the food preparation sink had sage color settled on them. e. The wall above the food preparation sink was discolored a rust color and cracked. f. The window above the food preparation sink was cracked and there were gnats flying around the window. g. The wall between the food preparation counter to the handwashing sink was cracked and discolored with rust-colored stains around it. h. The ceiling tile between the milk refrigerator and dry goods rack was chipped, exposing the cement and concrete and the area was sage color. i. Wall inside the janitor's closet was cracked, discolored sage color around the area. j. The door leading to the walk-in refrigerator had rust stains. k. The wall above the fire extinguisher had paint peeling, exposing the brown colored fiber board. l. The wall behind the water hose in the dish machine had red, black and sage color stains. m. The floor where the metal bar was attached to the steam table had thick brownish rust on it. n. The floor area around the 2 poles attached to the steam table had rust. 2. On [DATE] at 10:17 AM, there were loose tea and coffee filters on top of a box, below the food counter where the tea and coffee machines are kept. Dietary Cook (DC) #1 was asked what those are used for. DC #1 stated, The big ones are for the tea and the small ones are for the coffee. 3. On [DATE] at 10:24 AM, Dietary Aide #2 used a water hose to spray left over food particles out of the dishes, then placed the dishes on the rack and pushed it inside the dish machine. Without washing his hands, he picked up the plates with his bare hand and dried them with a rag and sat on a cart to be used in portioning food items to be served to the residents for lunch. This Surveyor immediately asked Dietary Aide #2, What should you have done after touching dirty objects and before handling clean equipment? Dietary Aide #2 stated, I should have washed my hands. 4. On [DATE] at 10:26 AM, the following observations were made in the walk-in refrigerator: a. An open box of sausage was on the shelf in the walk-in refrigerator, the box was not covered or sealed. b. An open box of bacon was on the shelf in the walk-in refrigerator, the box was not covered or sealed. 5. On [DATE] at 10:28 AM, an open box of garlic bread was on a shelf in the walk-in freezer, the box was not covered or sealed. 6. On [DATE] at 10:30 AM, Dietary Aide #2 used a water hose to spray left over food particles out of the dishes, then placed the dishes on the rack and pushed it inside the dish machine without washing their hands. After the machine stopped Dietary Aide #2 moved to the clean area, and without washing his hands picked up the glasses at the rim that touches the mouth, stacked them on the tray to be used for the residents during the noon meal. 7. On [DATE] at 10:37 AM, the seams of the milk refrigerator had white, black, and brown residue on them. At 1:28 PM, the Activity Director was asked to wipe the residue observed on the seams of the milk refrigerator. The Activity Director wiped the seams and a white, black, brown residue easily transferred to the tissue. The Activity Director was asked to describe what was found. The Activity Director stated, It is mildew. 8. On. [DATE] at 11:03 AM, the following observations were made in the dry storage room: a. An open container of parmesan cheese was on a shelf in the dry storage room. There was no received or open date on the container to ensure first in and first out. There were two additional open containers of parmesan cheese that did not have an open date. b. There was an open bottle of Hershey, with an open date of [DATE], the manufacturer specification documented Refrigerate after opening. c. A box that contained 45 individual packages of gluten free, thousand island dressing, was on a shelf and had an expiration date of [DATE]. 9. On [DATE] at 11:36 AM, Dietary Cook #1 pushed the blender motor toward the edge of the food preparation counter. Without washing her hands, she picked up the blade and attached it to the base of the blender to be used in pureeing items to be served to 1 resident on puree diet. As she was about to pour lima bean into a blender the Surveyor immediately stopped her and asked, What should you have done after touching dirty objects and before handling clean equipment? Dietary Cook #1 stated, I should have washed my hands.- 10. On [DATE] at 11:57 AM, Dietary Aide #2 turned on the food prep sink faucet by the drink area and obtained water in a pitcher and placed it on the counter. She then used her bare hand to turn off the faucet contaminating them. Without washing her hands, she picked the glasses by their rims and placed them on the trays to be used in serving beverages to the residents for lunch. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, I should have washed my hands. 11. On [DATE] at 12:50 PM, Dietary Cook #1 who was on the tray line serving noon meal picked up the tray cards and placed them on a shelf above the steam table. Without washing her hands, she picked up the plates to be used in portioning food items to serve the residents with her fingers inside of the plates. She picked up the hot dog bun and separated it with her bare hands, before placing hot dog between the bun to be served to the resident who requested for it. 12. On [DATE] at 12:30 PM, the top panel of the ice machine had wet black residue on it. The Surveyor asked the Activity Director to wipe off the black/rusty residue on the panel with a paper towel. She did so, and the black/substance easily transferred to the paper towel. The Activity Director stated, It had black/brown residue. The surveyor asked, Who used the ice from the Ice Machine and how often do you clean the ice machine. The Dietary Supervisor stated, That's the ice the CNAs use for the water pitchers in the residents' rooms, I don't know who is responsible to clean it. 13. A facility policy titled Hand Washing documented, Before starting work: Always wash hands before beginning any food-related tasks. After touching anything else, such as dirty equipment, work surfaces, or cloths: Regularly clean hands to prevent cross-contamination.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu, and recipes were followed to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 15 residents who received mechanical soft diets and 21 residents who received enhanced diets from 1 of 1 kitchen. The findings are: 1. The menu for lunch documented the residents on mechanical soft diets were to receive 4 ounces of meat loaf and residents on pureed diets were to receive 2 ounces of gravy with mashed potatoes. a. On 05/28/2024 at 12:01 PM, Dietary Cook (DC) #1 placed 6 servings of meatloaf into a blender, ground and poured into a pan. DC #1 added 2 more servings of meat loaf, ground and poured in the same pan for a total of 8 servings, instead of 15 servings required per list the provided by the Social Director on 05/29/2024 at 08:56 AM. b. On 05/29/2024 at 11:01 AM, the Surveyor asked DC #1 how many mechanical soft diets there were in the facility. DC#1 stated, 15. Only 8 servings were prepared. The Surveyor asked if they should be short on their portions. DC #1 stated, No. We should not have any left over. The Surveyor asked DC #1, If the scoop was filled up, should you have any left over? DC #1 stated, No. c. On 05/28/2024 at 12:35 PM, a resident on puree diet was not served gravy with her noon meal. The menu indicated for the resident on puree was to receive 2 ounces of gravy with mashed potatoes. d. On 05/29/2024 at 11:01 PM, the Surveyor asked DC #1 the reason the resident on a puree diet did not receive gravy on the mashed potatoes. DC #1 stated, I did not see that. 2. The menu for breakfast revealed the residents on super calorie diets were to receive one cup of super cereal. a. On 05/29/2024 at 08:10 AM, all residents on super calorie diets were served a single portion of super cereal, instead of one cup as specified on the menu. b. On 05/29/2024 at 11:17 AM, the Surveyor asked DC #4 what scoop size she used to serve super cereal oatmeal. DC#4 stated, The (gray scoop #8) 1/2 cup to serve one serving each. 3. The Surveyor asked DC #1 how much water was used when pureeing meatloaf, lima beans, and bread. DC #1 stated she used one cup each. Cook #1 was asked what the best liquid to utilize to maintain nutrient use when pureeing food items. Cook #1 stated, Milk and broth off the meat. Cook #1 was asked how the food tastes when you use water. Cook #1 stated, It would not taste as good as it should be.

Based on observation, record review, and interview, the facility failed to ensure the meals were served in a method that conserved nutritive value and maintained appearance, that cold product was stored at 41 degrees Fahrenheit or below, and hot food items were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 9 residents who receive meal trays in their rooms on the A-Hall, 7 residents who receive meal trays in their room on the B-Hall, 9 residents who receive meal trays on the C-Hall, and 10 residents who receive meal trays in their room on the D-Hall. The findings are: 1. A review of the Order Summary Report, indicated Resident #34 had diagnoses that included chronic obstructive pulmonary disease and essential hypertension. a. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/20/2024 revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. b. On 05/28/2024 at 10:50 AM, the Surveyor asked Resident #34, Do you eat in your room all the time? Resident #34 stated, Yes. The Surveyor then asked, Is the hot food hot when you get your tray from the kitchen? Resident #34 stated, The food is always cold when it gets to my room. 2. The facility recipe for lima beans documented to use 1/2 cup plus 2 tablespoons stock chicken/soup base in preparation. On 05/28/2024 at 11:39 AM, Dietary Cook (DC) #1 used a 4 ounce (oz) spoon to put two servings of lima beans into a blender, then used the 4 oz spoon to add tap water, twice, to the beans and puree. 3. The facility recipe for meatloaf documented to use 1/2 cup plus 2 tablespoons (TBSP) water or stock in preparation. a. On 05/28/2024 at 11:44 AM, DC #1 placed two servings of meatloaf into the blender, then used 4 ounces (1/2 cup) spoon to add tap water, twice, for a total of 1 cup of tap water and pureed. b. At 05/28/2024 at 01:28 PM, the Surveyor asked the Activity Director to taste meatloaf served to the resident on puree diet. She did so and stated the meatloaf did not taste salty and required more salt, it is bland. 4. A review of the Order Summary Report, indicated Resident #13 had a diagnosis of diabetes mellitus. a. A Quarterly MDS with an ARD of 03/08/2024 documented a BIMS score of 9 (08-12 indicates moderately impaired). b. On 05/28/2024 at 11:51 AM, Resident #13 confirmed that eating their meals in their room, and that meals arrived cold. 5. The recipe for the puree dinner roll indicated 1/2 cup plus 2 TBSP of water or milk to be used in preparation. To thicken the dinner, roll 1 TBSP plus 3/4 teaspoon to be used in preparation. a. On 05/28/2024 at 12:09 PM, DC #1 placed 2 slices of white bread into a blender, used a 4 ounce spoon to add 2 servings of tap water on the bread, then added 2 tablespoons of thickener and pureed. b. On 05/28/2024 at 1:28 PM, the Activity Director stated the meatloaf did not taste salty and required more salt. 6. On 05/29/2024 at 11:01 AM, the Surveyor asked DC #1, how much water was used when pureeing meatloaf, lima beans, and bread, and what would be the best way to maintain the nutritive value when pureeing food items? DC #1 stated, I used one cup of water each. Milk and broth off the meat. DC #1 was asked how the food tastes when using water to puree. DC #1 stated, It would not taste as good as it should be. 7. On 05/29/2024 at 7:27 AM, an unheated cart that contained 9 breakfast trays was delivered to the A- hall by Certified Nursing Assistant (CNA) #5. At 07:36 AM, immediately after the last resident received tray in their room on A Hall, the temperature of test food items on the tray were checked and read by the CNA #5 with the following results: a. Scrambled eggs - 105 degrees Fahrenheit. b. Ground sausage with gravy - 104 degrees Fahrenheit. 8. On 05/29/2024 at 07:40 AM, an unheated cart that contained 16 breakfast trays for both B and C halls, was delivered to B hall by CNA #6. On 05/29/2024 at 07:50 AM, the food cart was then delivered to the C Hall by CNA #6. At 07:56, immediately after the last resident received their tray in their room on the C Hall, the temperature of food items on the test tray from the cart were checked and read by CNA #6 with the following results: a. Milk - 55 degrees Fahrenheit. b. Sausage - 91 degrees Fahrenheit. c. Scrambled eggs - 105 degrees Fahrenheit. d. Ground sausage with gravy - 103 degrees Fahrenheit. 9. On 05/29/2024 at 07:52 AM, an unheated cart that contained 10 breakfast trays was delivered to the D Hall. At 08:02 AM, immediately after the last resident received their tray in their room on D Hall, the temperature of food items on the test tray from the cart were checked and read by CNA #6. The temperatures were: a. Milk - 52 degrees Fahrenheit. b. Sausage - 95 degrees Fahrenheit. c. Scrambled eggs - 96 degrees Fahrenheit.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 1 resident who received a pureed diet. The findings are: 1. On 05/28/2024 at 11:44 AM, Dietary Cook (DC) #1 placed two servings of meatloaf into the blender, then used a 4 ounce spoon to add tap water twice and pureed. DC #1 poured the pureed meatloaf into a pan and placed it on the steam the steam. The consistency of the pureed meat loaf was lumpy and was not smooth. At 01:26 PM the surveyor asked the Activity Director to describe the consistency of the pureed meatloaf served to the resident on a puree diet. She stated, It looks chunky. 2. On 05/29/2024 at 12:49 PM, puree cubed steak, served to the resident on a pureed at lunch, contained clumps. The cabbage was not smooth and contained clumps. The surveyor asked the Activity Director to describe the consistency of the pureed food items served to the resident on puree diet. She stirred the cubed steak and stated, It is thick and stringy. 3. On 05/29/2024 at 12:50 PM, the surveyor asked Certified Nursing Assistant (CNA) #8 to describe the consistency of the meat and cabbage. CNA #8 stated, It is thick and gritty.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to perform proper incontinent care for 1 (Resident #9) of 1 resident reviewed for incontinent care. Findings include: A review of the Order Summary Report, indicated the facility admitted Resident #9 with diagnoses that included morbid (severe) obesity due to excess calories, dysuria, urinary tract Infection. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/2024 revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The MDS indicated the resident was substantial/maximal assistance with toileting hygiene. A review of Resident #9's Care Plan, revised 04/19/2024, revealed the resident is at risk for impaired skin integrity r/t (related to) incontinence, impaired mobility, obesity, circulatory issues associated with atherosclerotic heart disease, scoliosis, and DM (diabetes mellitus). Interventions included provide incontinent/peri-care after each incontinent episode and as needed dated 07/09/2019. During an observation on 05/31/2024 at 11:32 AM, Certified Nursing Assistant (CNA) #12 assisted CNA #7 in rolling the resident to a left side lying position. CNA #12 used disposable wipes to clean an incontinent episode from the base of the buttocks near the anus and cleansed upwards. After pausing to ensure all stool was removed CNA #12 noted solid waste below the resident's buttocks, cleansed the area with disposable wipes, and applied barrier cream to the sacrum. A clean brief was placed behind the resident, the resident was rolled onto their back and CNA #12 and #7 secured the brief, repositioned resident, and exited the room. Licensed Practical Nurse (LPN) #10 was present in the room but never advised the CNAs otherwise. Resident #9 was noted to have been incontinent of solid waste, and neither the CNAs or the LPN cleaned the perineal area. During an interview on 05/31/2024 at 01:56 PM, CNA #12 confirmed only the backside was cleaned during the incontinence episode task and the front should have been cleaned as well. CNA #12 said to the Surveyor that by not cleaning the perineal area there was a potential to cause yeast infections or urinary tract infections. During an interview on 05/31/2024 at 02:30 PM, LPN #10 confirmed incontinent care was only performed from the anus to the rear, and that the front should have been cleaned as well. LPN #10 added that by not cleaning the perineal area the resident was at risk for skin breakdown and urinary tract infections. During an interview on 05/31/2024 at 02:40 PM, the Director of Nursing (DON) stated that incontinent care with stool involved should include cleaning from the top of the buttocks to the thighs, between the thighs, and the front. The DON added this is to ensure that the resident does not endure any skin breakdown or a urinary tract infection from stool entering the urinary tract. A review of a facility policy titled, Perineal Care, dated 2017, indicated, .Using gentle downward strokes, clean from the front to the back of the perineum to prevent intestinal organisms from contaminating [perineal area]. Turn the patient on his/her side to the [left side, left hip and lower extremity straight, and right hip and knee bent] position, if possible, to expose the anal area. Clean, rinse, and dry the anal area, .wiping from front to back. After cleaning the perineum, apply a moisture-barrier skin protectant as needed.

Based on observation, interviews, and record review, the facility failed to ensure assistance in positioning/repositioning were provided for 1 (Resident #26) of 1 sampled resident who required assistance. Findings include: 1. A review of the Order Summary indicated Resident # 26 had diagnoses of cerebral infarction, retention of urine, and obstructive and reflux uropathy. a. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/15/2024 indicated a Brief Interview for Mental Status (BIMS) score of 9 (8-12 indicated moderately impaired). b. The Care Plan dated 03/24/2024 included, Bed Mobility: Substantial/maximal assistance - Helper does MORE THAN HALF the effort. The helper lifts or holds trunk or limbs and provides more than half the effort. c. On 05/29/2024 at 12:49 PM, a lunch tray was provided for Resident #26. Resident #26 was lying with the head of the bed elevated and was not positioned high enough in the bed to be able to reach the meal tray. The meal tray was on the bedside table to the left side of the resident's bed, not across the bed. Resident #26 was observed trying to eat and struggling to reach the tray. d. On 05/29/2024 at 1:00 PM, Certified Nursing Assistant (CNA) # 8 was asked if the resident was positioned correctly to feed themselves. CNA #8 said Resident #26 should be positioned higher in the bed and the bedside table should be across the bed and not on the side of the bed. e. On 05/29/2024 at 1:00 PM, CNA #11 was asked if Resident #26 was positioned correctly in bed in order to feed themself. CNA #11 said Resident #26 should be positioned higher in the bed and the bedside table should be across the bed and not on the side of the bed. f. On 05/31/2024 at 8:47AM, Licensed Practical Nurse (LPN) #10 was asked how a resident who required assistance in positioning should be positioned in the bed to feed themselves, and where should the meal tray be placed. LPN #10 said the resident should be positioned up in bed with the head of the bed elevated and the bedside table with the lunch tray on it should be across the bed. g. On 05/31/2024 at 8:47AM, the Director of Nursing (DON) was asked how a resident who required assistance in positioning should be positioned in the bed to feed themselves, and where should the meal tray be placed. The DON said the resident should be positioned up in bed with the head of the bed elevated and the bedside table with the lunch tray across the bed. h. On 05/31/2024 at 9:12 AM, the Administrator stated that the facility had no policy on positioning residents in bed.

Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to perform wound care treatments as ordered by the physician to prevent worsening of an identified pressure ulcer for 1 (Resident #465) of 1 resident reviewed for pressure ulcers. Findings include: A review of the Order Summary Report indicated Resident #465 had diagnoses that included immunodeficiency, extended spectrum beta lactamase (ESBL) resistance, peripheral vascular disease, pressure ulcer of sacral region, stage 4, local infection of the skin and subcutaneous tissue, unspecified, pain, unspecified, type 2 diabetes mellitus without complications, and elevated white blood cell count. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/16/2024, revealed Resident #465 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact, and had one stage 4 pressure ulcer present at time of assessment (Stage 4 pressure ulcers involve full-thickness skin loss that extends through the fascia with considerable tissue loss. There may be muscle, bone, tendon, or joint involvement). A review of Resident #465's Care Plan, revised 03/20/2024, revealed the resident has a pressure ulcer or potential for pressure ulcer development r/t (related to) impairment in mobility, foley catheter tubing, bowel incontinence, anorexia, and protein-calorie malnutrition. Interventions included administering treatments as ordered and observe for effectiveness, dated 11/30/2023. A review of the Order Summary Report, revealed Resident #465 had a physician's order with a start date of 04/16/2024 which stated, Cleanse sacrum with wound cleanser. Pat dry. Apply primary dressing of [named brand of mesh gauze] to the exposed bone. Apply secondary dressing of saline moistened gauze to wound bed. Apply tertiary dressing of 2 ABD (abdominal pad) pads secured with tape daily and PRN (as needed) soiling/saturation every day and evening shift for wound healing. This order was discontinued on 05/07/2024. A review of Treatment Administration Record (TAR) 04/01/2024- 04/30/2024, revealed Resident #465 had wound care treatments scheduled every day and evening shift starting on 04/16/2024 which according to the TAR the treatments were not completed on 04/16/2024 evening shift, 04/19/2024 both day and evening shift, 04/22/2024 evening shift, 04/24/2024 both day and evening shift, 04/26/2024 both day and evening shift, 04/29/2024 evening shift, 04/30/2024 evening shift. This was a total of 10 treatments missed. A review of Treatment Administration Record (TAR), revealed Resident #465 had wound care treatments scheduled every day and evening shift continued into the month of May. According to the TAR ordered treatments were not completed on 05/02/2024 day shift, 05/06/2024 both day and evening shift. This was a total of 3 treatments missed for the month of May. A review of [Facility named] Wound Healing Center Progress Note Details, revealed Resident #465 had an encounter in the center on 04/29/2024 during which current measurements at that time were 8.7 cm (centimeter) length, 10.8 cm width, and 6 cm depth and noted the wound is deteriorating. A review of Progress Notes revealed Resident #465 had a progress note documented on 05/06/2024 at 21:00 (09:00 PM) which stated, Resident observed diaphoretic and barely responding. No output observed in catheter throughout 8 hour shift. Vital signs taken BP [blood pressure] 108/46, HR [heart rate] 113, O2 [oxygen] 95%. Assess medical contacted, stated to irrigate catheter, 1000 cc (cubic centimeters) of urine returned, UA [urinalysis] obtained, unable to get blood due to being a hard stick, urine sent to [hospital name] lab. [provider name] notified via access medical. A review of Progress Notes revealed Resident #465 had a progress note documented on 05/07/2024 at 04:17 which stated, attempted to draw blood twice in right ac [antecubital], and right hand. Minimum blood return. Attempts unsuccessful. A review of Progress Notes revealed Resident #465 had a progress note documented on 05/07/2024 at 08:35 which stated, Current vital signs 101/46, 103.2 axillary, 56 [heart reat], 16 [respirations], notified [provider name] order to send to [hospital name] for evaluation and treatment, resident is lethargic and slow to respond to verbal stimuli, notified EMS [Emergency Medical Services] to transport, report called to [nurse's name] at [hospital name], notified [name] who is resident caseworker and guardian she verbalized understanding. A review of [Hospital] Critical Care History and Physical, revealed Resident #465 had been admitted to Intensive Care Unit with sepsis, UTI (urinary tract infection) and sacral decubitus. The Certified Nurse Practitioner (CNP) documented the sacral wound was pink with pale yellow slough, foul odor, and undermining. The sacral wound measured approximately 6 inches by 5 inches by 2 inches (This translates to 15.24 cm by 12.7 cm by 5.08 cm). This note was from 05/07/2024 at 19:23 (07:23 PM). A review of [Hospital] Imaging Services, revealed Resident #465 had an MRI (Magnetic Resonance Imaging) of the pelvis on 05/10/2024 which was compared to the last MRI on 07/16/2022. The current impression is large sacral decubitus ulcer with osteomyelitis of most of the remaining sacrum and the posterior left iliac bone. Findings are worse than on the 2022 study. During an interview on 05/31/2024 at 01:29 PM, the Director of Nursing (DON) said wound treatments would be documented in the Treatment Administration Record (TAR). The DON clarified that the wound center was implemented as an intervention to assist with the sacral wound healing. During an interview on 05/31/2024 at 05:24 PM, Registered Nurse (RN) #13 stated that there is currently no wound care nurse in the facility and so all nurses are responsible for wound treatments ordered by the physician. RN #13 added treatments ordered by the physician is the responsibility of the nurse who is assigned to the resident to complete, to ensure optimal care in the facility for each individual resident. During an interview on 05/31/2024 at 05:32 PM, the Director of Nursing (DON) said floor nurses are responsible for treatments ordered by the physician. The DON confirmed on the TAR empty boxes mean the treatment was not signed off and the DON added, If it's not signed off its not completed. The DON emphasized that the importance of wound care as ordered is to ensure continuity of care and to make sure that physician orders are followed. A review of a facility policy titled, Pressure Ulcer- Injury Prevention and Management, dated 2022, indicated, The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection, and the development of additional pressure ulcers/injuries. Interventions for prevention and to promote healing. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions.

Based on observations, interviews, and record review, the facility failed to ensure a leg strap was in place to prevent trauma from the indwelling catheter for 1 (Resident #26) of 2 (Resident #26 and #54) sampled residents who were dependent on staff for indwelling catheter care. The findings are: 1. Resident #26 had diagnoses of retention of urine and reflux uropathy. a. An Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/15/2024 indicated a Brief Interview for Mental Status (BIMS) score of 9 (8-12 indicated moderately impaired) and Resident #26 was admitted with an indwelling catheter. b. A review of the Physician Orders (dated, 05/23/24) revealed Resident #26 had an indwelling catheter, which was inserted through the urethra and left in the bladder to drain urine. c. A review of Resident #26's Care Plan with a revision date of 04/18/2024 revealed .The resident has foley catheter related to DX [diagnosis] of obstructive uropathy .position catheter bag and tubing below the level of the bladder, secure catheter tubing to leg with applicable device. d. On 05/29/2024 at 12:48 PM, Resident #26 was being repositioned in the bed by Certified Nursing Assistant (CNA) #8 and #11. The indwelling catheter was not secured to Resident #26's leg with a leg strap. e. On 05/29/2024 at 12:50 PM, CNA #8 was asked if the resident had anything to secure the tubing to the resident's leg to prevent pulling or tugging. CNA #8 said there was nothing to secure it. f. On 05/29/2024 at 12:51 PM, CNA #11 was asked if there should be something in place to prevent the catheter tubing from pulling or tugging and she said it should have something, but it does not. g. On 05/29/2024 at 08:45 AM, Licensed Practical Nurse (LPN) #10 was interviewed and asked if a resident who has an indwelling catheter should have a supportive device to keep it from pulling or tugging. LPN #10 said there should always be a leg strap or some type of secure device in place. LPN #10 was asked who would be responsible for ensuring it was in place and she said everyone should. h. On 05/29/2024 at 8:47 AM, the Director of Nursing (DON) was asked to explain the process for staff to follow to make sure the catheter tubing is stable or secured. The DON said the catheter tubing should be held in place by placing a leg band or something to secure the tubing on the resident. The DON was asked who should be responsible for ensuring the leg strap was in place and the DON said everyone should. i. On 05/29/2024 at 9:12 AM, the Administrator said the facility had no policy on indwelling catheter care.

Through observation, record review, and interview, the facility failed to ensure expired medications were removed and placed into an area for destruction to prevent potential administration to residents. The findings are: 1. On 05/30/2024 at 1:40 PM, the following medicines or equipment were found expired in an area of the medication storage room used to store medications and supplies in active use: a. One hypodermic needle, 22-gauge x 1, expired on 03/31/2022. b. One 16 fluid ounce liquid multivitamin/mineral supplement expired 04/2024. c. 30 syringes - 1 milligram (mg) per 0.5 mL (milliliter) Lorazepam (Ativan) Intensol (benzodiazepines), expired on 05/04/2024. 2. On 05/30/2024 at 1:53 PM, Licensed Practical Nurse (LPN) #9 confirmed the expiration dates and stated neither the hypodermic needle nor the liquid multivitamin/mineral supplement should have been on the shelves. LPN #9 placed the items in the medication discard box. 3. On 05/30/2024 at 1:57 PM, LPN #10 confirmed the expiration date and the number of expired unused benzodiazepine oral syringes. LPN #9 and LPN #10 gave the benzodiazepine oral syringes to the Director of Nursing (DON). The DON confirmed the oral syringes were expired as of 05/02/2024.

Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to perform hand hygiene during resident care to prevent the spread of bacteria for 1 (Resident #9) of 1 resident reviewed for incontinent care. Findings include: A review of the Order Summary Report, indicated Resident #9 had diagnoses that included morbid (severe) obesity due to excess calories, dysuria, and urinary tract infection. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/2024 revealed Resident #9 had a Brief Interview of Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The MDS indicated the resident was substantial/maximal assistance with toileting hygiene. A review of Resident #9's Care Plan, revised 04/19/2024, revealed the resident is at risk for impaired skin integrity r/t (related to) incontinence, impaired mobility, obesity, circulatory issues associated with atherosclerotic heart disease, scoliosis, and DM (diabetes mellitus). Interventions included provide incontinent/peri-care after each incontinent episode and as needed dated 07/09/2019. During an observation on 05/31/2024 at 11:32 AM, Certified Nursing Assistant (CNA) #12 was performing incontinence care for Resident #9. CNA #12 entered and immediately applied gloves; hand hygiene was not observed by the Surveyor. The brief was loosened, and the resident was positioned to the resident's left side. The incontinent stool was removed by CNA #12 with disposable wipes. Licensed Practical Nurse (LPN) #10 instructed the CNA to change gloves. CNA #12 changed gloves; hand hygiene was not performed. CNA #12 noted more stool, cleansed with disposable wipes. LPN #10 instructed CNA #12 to change gloves; hand hygiene was not performed with glove change. CNA #12 removed barrier cream from bedside nightstand and applied to sacrum. Placed brief on resident and repositioned resident. Removed gloves when finished placed in trash bag and took bag down the hallway and disposed of the trash. This Surveyor never observed CNA #12 perform hand hygiene before going down a different hall. During an interview on 05/31/2024 at 01:56 PM, the CNA #12 confirmed to the surveyor that hand hygiene was not performed during incontinent care and that hand hygiene should have been performed with each glove change, prior to gloves applied, and once the gloves were removed. CNA #12 added hand hygiene should have been performed to prevent the spread of germs from resident to resident. During an interview on 05/31/2024 at 02:30 PM, the LPN #10 confirmed no hand hygiene was performed during incontinent care and staff should perform hand hygiene when hands become soiled, and when switching from clean to dirty. LPN #10 stated hand hygiene is performed to prevent the spread of germs. During an interview on 05/31/2024 at 02:40 PM, the Director of Nursing (DON) stated gloves should be changed once in contact with a soiled surface and hand hygiene is to be performed between glove changes. The DON added hand hygiene is the first line of infection prevention and prevents the spread of infection. A review of the facility's undated policy titled, Hand Hygiene, indicated, Hand hygiene is any method that removes or destroys microorganisms on hands that includes handwashing and alcohol-based hand rubs. Perform hand hygiene when: 1. Before having direct contact with patients. 2. After contact with blood, body fluids, or excretions, mucous membranes, non-intact skin, or wound dressings. 3. After contact with patient's intact skin. 4. If hands will be moving from a contaminated-body site to clean-body site during patient care. 5. After contact with inanimate objects in immediate vicinity of the patient. 6. After removing gloves.

Based on record review and interview, the facility failed to ensure the antibiotic stewardship program was consistently implemented as evidenced by a resident was prescribed an antibiotic for a suspected urinary tract infection (UTI) that did not meet selected criteria for 1 (Resident #26) of 1 sampled resident reviewed for a UTI. The findings are: Per an Order Summary Report, Resident #26 had a diagnosis of urinary retention. The Infection Surveillance Monthly Report for April 2024 showed Resident #26 had a symptom of weakness that started on 04/13/2024 and was prescribed Macrobid for a UTI on 04/14/2024. The [name] Criteria showed two of the following must be met for a resident with an indwelling catheter: fever, new flank, or suprapubic pain/tenderness, change in character of urine, or worsening of mental or functional status. An Advance Practice Registered Nurse (APRN) documented on an encounter note that Resident #26's appointment date and time was 04/11/2024 at 8:39 AM, and the resident was alert and resting in bed. The APRN documented Resident #26 had a [brand name] catheter present and reported no fever or abdominal pain. For mental status, the APRN documented resident #26 was oriented to time, place, and person. An Administration Note dated 04/13/2024 at 2:00 PM showed, .UA [urinalysis] send to [name] .UA sent to [local hospital] .d/t [due to] [name] not running on weekends . A Laboratory Report dated 04/13/2024 showed the test was a urine source with a result of [brand name] cath (catheter) and there was 1+ (plus) bacteria in the urine with a reference of 0-trace. On the bottom lower right of the report, the following information was written, 4-14-24 Macrobid 100 mg 1/1 PO [by mouth] BID [twice a day] x [times]10 days. [prescribing physician] A Physician's Order dated 04/14/2024 documented, Macrobid Oral Capsule 100 MG (milligrams) .give 1 capsule by mouth two times a day for UTI for 10 days . (Macrobid is an antibiotic.) On 05/31/2024 at 4:15 PM, the Nurses Notes were reviewed for 04/04/2024 to 04/12/2024 and there was no documentation of flank or suprapubic pain or tenderness, fever, change in urine, or worsening of mental or functional status. On 05/31/2024 at 4:27 PM, Resident #26's temperature summary was reviewed in the electronic health record and there were no elevated temperatures documented for the time period between 03/28/2024 to 04/16/2024. On 05/31/2024 at 4:54 PM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP), was interviewed and asked what does she do to ensure a resident who has been prescribed an antibiotic needs it. She stated there was an antibiotic stewardship form. She confirmed this form was done for Resident #26 for an antibiotic prescribed in April of 2024. She was asked if the pharmacist made any recommendations on this form, and she stated no. She was asked if she fills out the [name] criteria form when a resident is placed on an antibiotic and she confirmed she did and added, I did do this and I documented no, that it did not meet criteria. I spoke with the doctor, but he documented the urine was cloudy and a diagnosis of urinary retention and that's all. She was asked to look at the form under the information needed under a UTI with a catheter. She confirmed that a diagnosis of urinary retention was not listed under the criteria. On 05/31/2024 at 5:07 PM, the ADON/IP provided a copy of a Pharmacy MRR (Medication Regimen Review) Antibiotic Stewardship form that only included the data from section B. The IP documented no culture and sensitivity was ordered and that this was not a true infection. She documented the urinalysis was reviewed by the medical doctor with an antibiotic prescription given due to the urine appearance was cloudy and a diagnosis of urinary retention. The Infection Prevention and Control Program policy provided by the administrator on 05/28/2024 with a copyright date of 2022 documented, .Antibiotic Stewardship: Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program . An Antibiotic Stewardship policy with no date documented, .Staff will utilize the [name] Criteria when considering initiation of antibiotics and for determination of suspected infections in residents .

Based on observation, interview and record review, the facility failed to ensure staff sat at eye level while assisting residents with meals for 1 (Resident #1) of 3 case mix residents. The findings are: Resident #1 was admitted to the facility on [DATE] with a diagnosis of Hydrocephalus. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/23 documented Resident #1 was rarely/never understood and required setup or cleanup assistance with eating. A Care Plan with an initiated date of 12/4/23 documented, .[Resident name] has an ADL [activities of daily living] self-care performance deficit due to Confusion, Encephalopathy, Dementia . On 2/29/24 at 1:01 pm, Resident #1 was served a lunch meal tray. On 2/29/24 at 1:02 pm, Licensed Practical Nurse (LPN) #1 began feeding Resident #1 while standing to the left side of the resident. On 2/29/24 at 1:08 pm, the Activity Director walked by LPN #1 and instructed her to sit down. LPN #1 slid a chair next to Resident #1 and sat down to continue feeding. On 2/29/24 at 1:10 pm, LPN #1 was asked why it is important to sit down while feeding a resident. LPN #1 stated, I don't know. I have never had to feed a resident before. This is new to me. On 2/29/24 at 1:12 pm, during an interview, the Director of Nursing (DON) confirmed that standing to feed a resident is a dignity issue and a resident does not want to be hoovered over while being fed. The Administrator provided a copy of the Resident Rights and Responsibilities policy which documented, The nursing facility protects and promotes the rights of each Resident/Elder admitted in order to provide a dignified existence, self-determination, and communication with and access to persons and services inside and outside the nursing facility. The nursing facility will protect and promote the rights of each Resident/Elder .

Based on observation, interview and record review, the facility failed to ensure hands were washed between clean and dirty tasks to prevent cross contamination. The findings are: On 2/29/24 at 12:40 pm, Dietary Cook (DC) #1 walked out of the kitchen and sat down at a dining table with one resident. DC #1 began sorting through meal tickets. When the sorting was completed, DC #1 entered the kitchen and went to the serving line and began serving food. DC #1 did not wash hands prior to serving food. On 2/29/24 at 3:05 pm, during an interview, DC #1 confirmed he/she did not wash her hands upon returning to the kitchen and began serving lunch, and should have washed his/her hands to prevent cross contamination. On 2/29/24 at 3:10 pm, during interview, the Dietary Manager confirmed DC #1 did not wash her hands when returning to the meal service food line and began serving food, that there was a potential for cross contamination, and has educated DC #1 on hand washing. On 2/29/24 at 2:44 pm, the Administrator provided a policy titled, Handwashing and Glove Usage in Food service, the policy documented, Objectives: 1. Understand the importance of handwashing in prevention of illness. 2. Identify when hands need to be washed .When Food Handlers must wash their hands: before starting work .After leaving and returning to the kitchen/prep area .Hands must be washed in a sink designated for handwashing .

Based on record review and interview, the facility failed to ensure that adequate supervision was provided to prevent elopement for 1 (Resident #2) of 4 (Residents #1, #2, #3 and #4) case mix residents. This failed practice resulted in past non-compliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Resident #2. The Administrator and Regional [NAME] President was informed of the past Immediate Jeopardy situation on 05/16/23 at 1:02pm. The findings are: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses of Diffuse Traumatic [NAME] Injury with Loss of Consciousness of Unspecified Duration. The Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/27/23 documented resident scored 13 on a Brief Interview of Mental Status (BIMS) and requires supervision with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. a. The Admissions Evaluation was completed on 04/20/23. The Admission Evaluation documented, Resident does not smoke. The Wandering risk scale resident scored 9 (9 - 10 indicates at risk to wander). b. The Care Plan with an initiation date of 05/05/23 documented, [Resident name] has a history of smoking. She smoked 2 ppd (packs per day) before her accident on 01/13/23. She does not have the funds to smoke, and her family will not support this habit. [Resident name] has not smoked or had nicotine since 01/13/23. On 05/09/23 Visualized [Resident name] with yellow crayon in her hand during outside supervised activity. [Resident name] brought the crayon to her mouth and inhaled repeatedly as if she was smoking a real cigarette .Calmly remind [Resident name] that she is no longer a smoker and state that you are proud of her then redirect .[Resident name] has an ADL [Activities of daily Living] self-care performance deficit r/t[Related to] diffuse traumatic brain injury with loss of consciousness of unspecified duration, bipolar disorder with severe manic episodes with psychotic features, neuromuscular disorder of bladder, gastronomy status, hx [history] of meth use, fx [Fracture] of neck unspecified, Dysphagia, and Schizophrenia . [Resident name] is an elopement risk/wanderer r/t talking to father on phone and repeated expressed desire to leave the facility and go to [named city/state] . Wander Alert: Placed on Left Ankle. Verify placement Q shift [Every shift] . [Resident name] has a diagnosis of Bipolar Disorder and Schizophrenia unspecified. She receives Antipsychotic medication . [Resident name] has actual impairment to skin integrity of LLQ [Left lower quadrant] gastronomy status . c. The Wandering Risk scale dated 05/09/23 documented, resident scored 9 At risk to wander. d. The Wandering Risk Scale dated 05/11/23 documented, resident scored 4 which indicates low risk to wander. The note section documented: Pushed screen out of window crawled out and walked to gas station. e. The E-Interact Form dated 05/11/23 documented, Removed screen from window, crawled out, went to gas station to purchase tobacco. The resident was transferred to the hospital. f. The Nursing Note with an effective date of 05/11/23 documented, Resident eloped to convenience store. Resident was heard playing piano in the dining room at approximately 1530-1545. At 1550, it was reported to this nurse that resident could not be located, and her window was open and screen was removed. Someone in the community that visits here recognized resident and notified facility that resident was at convenience store purchasing tobacco products. 4 staff members took facility van to retrieve resident. Brought resident back. No injuries noted during body audit. 1 to 1 initiated. Contacted [named] Care Consult Team to arrange placement of resident. Resident is now a danger to herself and others. Behavior is erratic and unpredictable. Will continue to monitor closely. g. The facility provided a copy of the Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, &Exploitation of Residents in Long Term Care Facilities, (Form DMS 762) on 05/11/23 and it documented, . On 05/11/23 at 3:55pm [Assistant Business office manager name] informed Administrator that she had received a call from [Name] (preacher who comes to facility) stating, I think one of your residents is at the gas station close to the facility.Resident [resident name] age 37 BIMS (13) was standing in gas station parking lot 644 meters from nursing facility trying to get a light for her [named little cigar] when van arrived [Resident name] got into van without any difficulty .When resident [resident name] was asked what had happened she stated, I kicked the screen out of my window in my room and crawled out. I have been feening all day I am an addict. I have been doing pencil therapy all day and it was not working. I went to gas station and bought some [named little Cigar] with my own money because they are a dollar. I was a bad girl and kicked the screen out of my window because I needed a smoke . h. On 05/17/23 at 9:41 am, an Interview with Director of Nursing, (DON) was conducted. The Surveyor asked, Who notified you that the resident's window was open, and the screen was out? The DON stated, I believe it was a CNA (Certified Nursing Assistant). It was all at one time. I was on A hall passing meds and working as the floor nurse. The Surveyor asked, What did you do when you were notified? The DON stated, They were already grabbing the van keys to go and collect her. [Administrator name] was here and she was aware, then we notified the family and MD [Medical Doctor]. [Administrator name] completed the reportable. We did 1 on 1 with her when she returned, and we notified [named] Care Consult Team. That is who we call for behavioral issues and they give us provider recommendations then we proceed. The Surveyor asked, Why was the resident sent to Behavioral Health? The DON stated, That was [named] cares recommendation. They told [APRN name] APRN and she wrote the order to transfer her there. We could not safely house her here anymore. The Surveyor asked, Was the resident having behaviors? The DON stated, Yes, she is severely Schizophrenic and bipolar, auditory and visual hallucinations were getting worse. She is [AGE] year-old woman with a BIMS of 13. She has not been declared incompetent by the state. If she wants to leave that is her right. I talked with her and told her that she needed someone to manage her medications and her care. She is very aware of her mental illness. She needs someone that is better trained in Psychiatric issues that can manager her disease process more effective than we can here. She was getting to where she was hyper focused on tobacco. The Surveyor asked, Can you explain that? The DON stated, She was a danger to herself, because she broke out and escaped through a window and on foot and that is very dangerous to her and others. Her behavior was erratic and unpredictable. I don't believe she would hurt anyone but with her being unpredictable and the vulnerable population we have here is why she needed to be somewhere more appropriate. i. The facility policy titled, Missing Resident Policy and Procedure, was provided by the Administrator on 05/16/23 at 2:00pm documented, Purpose: The purpose of a Missing Resident Policy and Procedure is to ensure that all necessary steps are taken in the event that a resident wanders away from the facility .

Based on observation, record review and interview, the facility failed to consistently off load the resident heels, consult the physician with changes in the resident ' s condition, obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #3) case mix residents who were at risk for the development of pressure ulcers. This failed practice resulted in actual harm to Resident #2 who developed Deep Tissue Injury (DTI) to both heels and had the potential to cause more than minimal harm to affect 12 residents who were at risk for development of pressure ulcers according to a list provided by the Administrator on 6/10/2021. The findings are: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission 5 Day Minimum Data Set with an Assessment Reference Date of documented the resident scored 13 (13-15 indicates cognitively intact) per a Brief Interview for Mental Status, required extensive assistance of two person for bed mobility and transfers, had functional limitation of one side of the upper and lower extremities and was at risk for development of pressure ulcers with skin tear. a. The Admission assessment dated [DATE] at 9:24 p.m. documented, .Skin integrity documented, skin tear, right antecubital and Face Bruising . Braden scale for predicting Pressure Ulcer Risk . Sensory Reception ability to respond meaningfully to pressure-related discomfort was marked 3. Slightly Limited: Responds to verbal commands but cannot always communicate discomfort or the need to be turned or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. Moisture, 2. Degree to which skin is exposed to moisture slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or the need to be turned or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities; marked 3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once per day. Activity 3. Degree of physical activity was marked 1. Bedfast: Confined to bed. Mobility 4. Ability to change and control body position was marked 3. Slightly limited makes frequent though slight changes in body or extremity position independently . Friction & Shear 6. Ability to move was marked 2. Potential Problem: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair restraints or other devices. Maintains relatively good position in chair or bed most of the time, but occasionally slides down. [A score of 15, a score of 15-18 indicates at risk for developing Pressure Ulcers.] .7. Care Planning: The resident is at risk for Impaired Skin Integrity/ Approach: Conduct body audit Approach: Evaluate risk for pressure ulcers using the Braden Scale Goal: Resident's risk for impaired skin integrity will be minimized through plan of care . b. The Braden Scale for Predicting Pressure Ulcers dated 4/23/2021 documented a score of 14. A score of 14 indicates moderate risk for developing pressure ulcers. c. A Body Audit dated 4/24/2021 at 11:19 p.m. by Licensed Practical Nurse (LPN) #3 documented, . General Skin Condition: Heels clear. Feet clear . d. A Body Audit dated 5/02/2021 at 00:27 [12:27 a.m.] by Licensed Practical Nurse (LPN) #3 documented, . General Skin Condition: Heels clear. Feet clear . e. A Body Audit dated 05/09/2021 at 5:06 a.m. by LPN #1 documented, . General Skin Condition: Skin breakdown to left heel. Feet: scab top of left foot. f. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Offload heels every day shift. Order Date 5/14/2021. g. A Skin & Wound Evaluation dated 5/14/2021 at 6:12 p.m. by the Treatment Nurse documented, .Type: .Pressure .15a. 5. Deep Tissue Injury: Persistent non-blanchable deep red, maroon, or purple discoloration . Location: Left Heel. Acquired: Present on Admission. Measurements: there were no measurements documented. Wound Bed: Epithelial 100% of wound covered, surface intact . h. A Skin & Wound Evaluation Dated: 05/17/2021 at 11:34 a.m. by the Treatment Nurse documented, Type: . Deep Tissue Injury: Persistent non-blanchable deep red, maroon, or purple discoloration . Location: Left Heel. Acquired: Present on Admission. Measurements: Length 2.9 cm [centimeters], Width 3.4 cm, Depth-[MEDICATION(S)]. Wound Bed: there was nothing marked. i. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Offload heels every day shift. Order Date 05/27/2021. j. A Body Audit for 5/27/2021 at 4:03 p.m. by LPN #3 documented, General Skin Condition: .Heels: DTI to the left and right heel. Painted with [MEDICATION(S)] and left open to air. Heels offloaded . Feet: DTI to the left and right heel. Painted with [MEDICATION(S)] and left open to air. Heels offloaded . k. The Comprehensive Care Plan documented, Problem [Resident #2] is at risk for impaired skin integrity r/t [related to] spondylolisthesis, weakness, history of falling, muscle wasting, reduced mobility, need for assist personal care, incontinent of b/b [bowel and bladder] Date Initiated: 04/16/2021 Revision Date: 05/28/2021 . Goal [Resident #2] will have intact skin with no new or worsening pressure injury this review date. Interventions Actual skin impairment 5-14-2-21 - DTI [Deep Tissue Injury] Left Heel-Pain Left Heel with [MEDICATION(S)] and leave open to Air daily. Off load Heels. Date Initiated: 5/14/2021. Conduct body audit weekly. Evaluate for pressure ulcers using the Braden Scale. Date Initiated 4/16/2021 . l. A Skin & Wound Evaluation Effective Date: 06/02/2021 at 11:57 a.m. by the Treatment Nurse documented, Type: Pressure . Stage: Deep Tissue Injury: Persistent non-blanchable deep red, maroon, or purple discoloration . Location: Right Heel. Acquired: Present on Admission. Measurements: Length 1.8 cm, Width 2.5 cm, Depth [MEDICATION(S)]. Wound Bed: Epithelial, 100% of wound covered, surface intact. m. The Skin & Wound Evaluation Effective Date: 06/02/2021 at 11:53 a.m. by the Treatment Nurse documented, Type: Pressure . Stage: Deep Tissue Injury: Persistent non-blanchable deep red, maroon, or purple discoloration . Location: Left Heel. Acquired: Present on Admission. Wound Measurements: Length 3.0 cm, Width 3.4 cm, Depth [MEDICATION(S)]. Wound Bed: Epithelial, 100% of wound covered, surface intact . n. The Braden Scale for Predicating Pressure Ulcers dated for 6/7/2021 documented a score of 12. A score of 10-12 indicates high risk for developing pressure ulcers. o. On 6/7/2021 at 1:22 p.m., Resident #2 was lying in bed on his back with the head of the bed slightly elevated. His bilateral heels were lying flat on the center of a pillow. Resident #2 stated. My heels are killing me, and I want something done. Isn't there a cream or something that can be put on them? My heels are black. Resident #2 was asked if he had told the Nurse. Resident #2 stated, Yes. p. On 6/8/2021 at 3:20 p.m., Resident #2 was lying in bed. The head of the bed was slightly elevated. Resident #2's bilateral heels were lying flat on the bed with one pillow under the upper calf and thigh area. Resident #2 complained of pain in his heels. He stated, She painted something on them isn't there something else that they can paint on the heels? Resident #2 asked if he could have a pain pill. This surveyor notified the nurse. q. On 6/8/2021 at 4:00 p.m., the Treatment Nurse accompanied the Surveyor to Resident #2's room. [Resident #2] was lying on his back with the head of the bed slightly elevated. His heels were lying flat on the mattress with one pillow under the upper calf and thigh area. [Resident #2] stated his heels were hurting and hurt worse when they are touching something. [Resident #2's] left heel had an approximately 3 cm x 3 cm x undetermined depth circular in shape purple-blackish in color wound. His right heel had an area to the outer side of the heel approximately 3 cm x 2.5 cm deep semicircular shaped wound purple-blackish in color. The Treatment Nurse stated that she had been employed for approximately 1 month. That when she started, she had difficulty with the camera and the computer system when she first started. The Treatment Nurse was asked, When was the first time you observed the areas on [Resident #2's] heels? The Treatment Nurse stated, I started on 5/11/2021 and checked the resident on 5/14/2021. There was a dressing on the left heel. The Treatment Nurse was asked, There was a dressing on the left heel? The Treatment Nurse stated. Yes. The Treatment Nurse was asked, Was there an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? The Treatment Nurse stated, No. But when I removed the dressing the left heel had the blackish area. The Treatment Nurse was asked, Do you know who put the dressing on the left heel? The Treatment Nurse stated, No, I thought it had been there since admission. The Treatment Nurse was asked, You thought the dressing had been on since admission. The resident was admitted on [DATE]? The Treatment Nurse stated, I don't know, that is all I can say, is what I did. The Treatment Nurse was asked, When I reviewed the resident's clinical records, there was a body audit on 5/9/2021 that documented redness to the left heel? The Treatment Nurse stated, I was not aware of that. The Treatment Nurse was asked if there was a treatment ordered at that time. The Treatment Nurse stated, Not that I am aware of. The first time that I saw the left heel was on 5/14/2021. That is when I got the treatment order for the left heel and to offload the heels. The Treatment Nurse was asked if there was an issue with the right heel at that time. The Treatment Nurse stated, Not at that time it was a few days later that I got the order for the right heel. The Treatment Nurse was asked if there had been any new interventions put in place at the time the right DTI was identified. The Treatment Nurse stated, No. The Treatment Nurse was asked, In reviewing the resident ' s clinical record there was a body audit documented for 5/9/2021 that documented redness to the left heel? The Treatment Nurse stated, I was not aware of that. The Treatment Nurse was asked, Was there a treatment ordered at that time? The Treatment Nurse stated, Not that I am aware of. The first time I saw the heels was on 5/14/2021, the left heel, that ' s when I got the treatment order. The Treatment Nurse was asked, When you documented the Skin Evaluation on 5/14/2021 for the DTI on the left heel you documented that the DTI on the left heel was present on admission. Was the DTI on the left heel present on admission? The Treatment Nurse stated, No. The Treatment Nurse was asked, Why was the DTI on the left heel documented as present on admission? The Treatment Nurse stated, That's how I was told to document it. The Treatment Nurse was asked, Who told you to document the DTI on the left heel was present on admission? The Treatment Nurse did not answer. The Treatment Nurse was asked, When was the DTI on the right heel identified? The Treatment Nurse stated, Later, 5/27/2021. The Treatment Nurse was asked, On the skin evaluation on 6/2/2021 the DTI on the right heel was also documented as present on admission. Was the DTI on the right heel present on admission? The Treatment Nurse stated, No. The Treatment Nurse was asked, Should the DTI on the right and left heels have been documented as present on admission when they aren't present on admission? The Treatment Nurse stated, No. The Treatment Nurse was asked, When a resident has an intervention that is not working as evidenced by the DTI on the resident's heels, should another intervention have been implemented? The Treatment Nurse stated, Yes. The Treatment Nurse was asked, Who would be responsible for implementing a new intervention? The Treatment Nurse stated, I just started. The Treatment Nurse was asked, There was one heel lift boot in the room. Has the resident worn the heel lift boots? The Treatment Nurse stated, Yes, it was tried, but he couldn't wear them due to the muscle spasms and he could kick them off. The Treatment Nurse was asked if the failed attempt for the heel lift boot had been documented. The Treatment stated, I didn't. The Treatment Nurse was asked, When were the heel lift boots attempted? The Treatment Nurse stated, I don't know. The Treatment Nurse was asked if there had been any other interventions attempted. The Treatment Nurse stated, I have looked at a couple of other type of boots. The Treatment Nurse was asked, Has there been any new interventions put in place beside the pillows The Treatment Nurse stated, No. The Treatment Nurse was asked, Who is responsible for ensuring that the heels remain offloaded? The Treatment Nurse stated, The nurses and the aides. r. On 6/9/2021 at 5:49 a.m., a phone interview was conducted with LPN #1. LPN #1 was asked, How do you off load a resident's heels? LPN #1 stated, With a pillow so the heels don't touch the bed. LPN #1 was asked, Who is responsible for ensuring that the heels are off loaded? LPN #1 stated, The staff, the nurses and the aides. LPN #1 was asked, Regarding [Resident #2] you had documented a body audit on 5/9/2021 that the resident had redness to the left heel. Did you tell anyone? LPN #1 stated, No, I documented that he had some redness to the left heel. LPN #1 was asked, Did you notify the Physician? LPN #1 stated, No. LPN #1 was asked, Did you put a dressing on the left heel? LPN #1 stated, There already was a dressing on the left heel and I had to take it off to look at the heel and I put a dressing back on the left heel. LPN #1 was asked, Was there an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? LPN #1 stated, I don't recall seeing one. LPN #1 was asked, Should there be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? LPN #1 stated, Yes. LPN #1 was asked, You put a dressing on without an order? LPN #1 stated, It was a pinkish type pressure relieving thing, it really wasn't a dressing. LPN #1 was asked if there was a dressing on the right heel. LPN #1 stated, No. there was just the dressing on the left heel. I put that on the body audit. LPN #1 was asked, Did you document that there was a dressing on the left heel? LPN #1 stated, No, it wasn't a dressing it was a pressure relieving device for the left heel. LPN #1 was asked, Do you know who put the dressing or the pressure relieving device on without a Physician Order? LPN #1 stated, No, there was already a dressing on the left heel. I had taken it off to look at the heel and I did put one back on. LPN #1 was asked, You didn't report the redness to the left heel to the Physician or the Treatment Nurse? LPN #1 stated, No. s. On 6/9/2021 10:30 a.m., Certified Nursing Assistant (CNA) #2 stated that they worked all the halls. CNA #2 was asked, How do you know the care that a resident is to receive? CNA #2 stated, The care plan on the kiosk. CNA #2 was asked, How often do you make rounds? CNA #2 stated, Every 2 hours. CNA #2 was asked, How do you know to off load a resident heels? CNA #2 stated, The care plan. CNA #2 was asked, How do you off load a resident's heels? CNA #2 stated, The boots and if they don't have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA #2 was asked, Has there been an issue with keeping [Resident #2's] heels offloaded? CNA #2 stated, Yes, sometimes they would be lying on the bed and the pillow would move. CNA #2 was asked, Did you tell the nurse? CNA #2 stated, No. CNA #2 was asked, When [Resident #2] was admitted did the resident have any areas on the heels? CNA #2 stated, Not that I recall. t. On 6/9/2021 at 10:59 a.m., LPN #4 stated that she works the 100 Hall most of the time. LPN #4 was asked, Who does the skin assessment on the admission assessment when a resident is admitted ? LPN #4 stated, The Treatment Nurse will usually do the body audit and Medical Records will do the medication part. This surveyor stated, The Medical Records LPN stated that she had filled in doing the treatments. LPN #4 stated, Yes, she worked a few hours a day doing treatments. We have always had someone doing the treatments. LPN #4 was asked, Who ensures that the residents plan of care is being implemented? LPN #4 stated, All the staff, aides and nurses. LPN #4 was asked, Has there been an issue with [Residents #2] heels being off loaded? LPN #4 stated, Not the staff, but more the resident, he really can't help it he has muscle spasms. LPN #4 was asked if the pillows weren't working was there an alternative intervention put in place. LPN #4 stated Not that I am aware of. LPN #4 was asked when a resident has a new skin issue, who does the CNA's report it to. LPN #4 stated, The Charge Nurse or the Treatment Nurse. LPN #4 was asked, When were you aware of the DTI on [Resident #2's] heels? LPN #4 stated, Right after the Treatment Nurse had done the body audit. LPN #4 was asked, Had you seen a dressing on the resident ' s left heel prior to 5/14/2021 when the Treatment Nurse noted the DTI. LPN #4 stated, No. u. On 6/9/2021 at 2:10 p.m., the Director of Nursing (DON) was asked, When a resident is admitted who is responsible for doing the body audit? The DON stated, The nurse that does the body audit on admission. If the Treatment Nurse is here, she will go down and do the body audit. The DON was asked, Should a dressing to relieve pressure be put on without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? The DON stated, No. The DON was asked, [LPN #1] had stated that there was what she described as a pressure relieving thing on his left foot when she did the body audit on 5/9/2021 and she put a pressure relieving dressing back on the heel. The heel was red. The LPN stated that they did not notify the physician or the family. When a nurse finds a heel that is red, should they off load the heels and notified the physician? The DON stated, Yes. The DON was asked, Should a dressing of any type be placed on a resident without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? The DON stated, No. The DON was asked, When the resident complains of pain, do they do a pain assessment? The DON stated, Yes. The DON was asked, Where would this be documented? The DON stated, If they medicated them for pain and they document the pain medication the assessment will be generated. They assess the residents for pain each shift. The DON was asked, When the CNA's are doing care should they report if there are any changes to the nurse? The DON stated, Yes. The DON was asked, Who monitors to ensure that the body audits are being done? The DON stated, The Medical Records LPN was doing the treatment prior to the current Treatment Nurse. Our census was low, and we were going to combine Medical Records and Treatments. But we decided to hire a Treatment Nurse. We weren't without a Treatment Nurse. The Nurses did the body audits and she was to make sure that they got done. The DON was asked, Could [Resident #2] reposition themselves? The DON stated, No. The DON was asked if the DTI on the bilateral heels could have been prevented. The DON stated, Possibly, he has muscle spasms, He has [CONDITION(S)]. The DON was asked, Where was this diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ? The DON stated, It was not carried over to our diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was on scheduled pain meds prior to coming here, he had some chronic pain issues. The DON was asked, The Treatment Nurse had mentioned that heel lift boots were attempted but was not sure of when the heel lift boots had been attempted. There was no documentation in the clinical records or the care plan of the failed attempt for a heel lift boot. Did they address the issue of the heel lift boots with you? The DON stated, No. The DON was asked, Were you aware that they had tried the heel lift boots? The DON stated, No. v. On 6/10/2021 at 10:10 a.m., the DON was asked if they had determined when and who had put the dressing on [Resident #2's] left foot prior to 5/9/2021. The DON stated, No. w. On 6/10/2021 2:01 p.m., the DON was asked, How is the initial care plan developed? The DON stated, It is triggered by the initial assessment. The DON was asked, Who is responsible for reviewing and determining the interventions? The DON stated, It depends on the area. It would be Interdisciplinary Team. The DON was asked, Who is responsible for assessing the interventions for pressure ulcers? The DON stated, The Treatment Nurse. The DON stated that pressure ulcers are discussed at our weekly meetings. The DON was asked, When was [Resident #2] discussed in the weekly meeting? The DON reviewed the weekly meetings and stated, [Resident #2] was discussed in the meeting on 5/27/2021. The DON was asked, What was discussed at this meeting? The DON stated, The DTI, offloading and treatment with [MEDICATION(S)]. The DON was asked, Was there any discussion related to the intervention since he had developed the DTI on bilateral heels or the intervention of offloading with the pillows was not working? The DON stated, No. The DON reviewed the weekly meeting on 6/6/2021 and stated, [Resident #2] wasn't discussed in the 6/6/2021 meeting. The DON was asked, How do you determine when a resident needs the heels off loaded? The DON stated, When the resident is not able to reposition themselves. The DON was asked, Could [Resident #2] reposition himself? The DON stated, No. The DON was asked, How do you relay changes in the plan of care to the staff? The DON stated, Through the care plan and the care plan on the kiosk. The DON was asked who was responsible for ensuring that the heels are being consistently off loaded? The DON stated, The Staff that are when they are making rounds. The DON was asked if the staff were having issues with the residents not keeping the heels off loaded what should they do? The DON stated, They should tell the Charge Nurse. The DON was asked who responsible for implementing new interventions when one intervention is not working regarding pressure ulcers? The DON stated, Depends on the area, for pressure ulcers that would be the Treatment Nurse. The DON was asked, In reviewing [Resident #2's] clinical records there had not been any new interventions implemented when the resident had developed the DTI. Should there have been a new intervention implemented? The DON stated, Yes. The DON was asked, In reviewing [Resident #2's] care plan, it was documented on 6/9/2021 that he removes his pillows. Does the resident remove the pillows? The DON stated, No, he has muscle spasms. He does not remove the pillows. The DON was asked, This is an incorrect statement? The DON reviewed the residents care plan and stated, Yes I will have this adjusted. The DON was asked, Have you determined who put the dressing on [Resident #2's] heel prior to 5/9/2021? The DON stated, No.

Complaint # (AR 482) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to prevent elopement, as evidenced by failure to ensure staff monitored residents at risk for elopement during periods when door alarms were malfunctioning, to prevent elopement for 1 (Resident #1) of 3 (Residents #1, #2, and #3) case mix residents who were at risk for elopement. The failed practice resulted in past non-compliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Resident #1, who had a history of [REDACTED]. The failed practices had the potential to cause more than minimal harm to 4 residents who were at risk for elopement, as documented on a list provided by the Administrator on 9/12/19 at 8:15 a.m. The Administrator was informed of the past Immediate Jeopardy condition on 9/11/19 at 5:14 p.m. The findings are: 1. A facility policy titled Elopement provided by the Administrator on 9/11/19 documented, .Evaluate Risk of elopement at admission . a change of condition . Care Plan for elopement in place and interventions . door alarms are checked weekly and documented . 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/19 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status; exhibited no behavioral symptoms; did not reject care; did not wander; required supervision with setup help with bed mobility; required supervision with transfer and when walking in corridor; had shortness of breath upon exertion and when sitting at rest; and did not have a wander / elopement alarm. a. A Care Plan dated 4/4/19 documented, .He has a history of wandering prior to placement . A few instances he was seen in the middle of highway with oncoming traffic and had to be apprehended by Police Department to prevent serious injury . At risk for elopement r/t (related to) history of elopement prior to admission . He has attempted to exit building since admission and is not easily redirected . Actual elopement (failed attempted) 7/28/19 . 7:05 a.m. Resident gathered belongings and went to exit door . Redirected without difficulty . Will encourage daily activity . (Resident) is resistant to care AEB (as evidenced by) he is apprehensive about placement of wander guard and has a potential to remove once applied . Observe that wander guard is in place every shift . b. The Elopement Risk assessment dated [DATE] documented, .Elopement Score .7 . b . Scoring of 5 or greater (equals) High Risk for Elopement . 5. History of wandering prior to nursing home placement . a.) Yes 8. Exit seeking . a.) Yes . c. An Office of Long Term Care (OLTC) Incident and Accident Next Day Reporting Form, Division of Medical Services (DMS) form 7734, documented, .Date of I/A (Incident and Accident) . 9/9/19 . Time . 7:00 a.m.Notifications . Family . Yes . Doctor . Yes . Law Enforcement . Yes . Administrator . Yes . Summary of Incident . At approximately 7:00 a.m., a facility employee noticed a man walking down the road that he recognized as a resident of (Facility Name) . At which time he assisted the resident to his vehicle and returned him to the facility . d. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long Term Care Facilities, DMS form 762, dated 9/9/19 documented, .Facility Staff Member Completing DMS-762 . Title . Administrator . Date and Time of Incident . 9/8/19 . Time . 7:00 a.m.Name of Involved Resident . Findings and Actions Taken . Resident current medical condition is unchanged due to elopement. He was sent to ER (emergency room ) for evaluation, and screening for Geri psych. He was admitted to Geri psych . A thorough investigation determined that Saturday the front door malfunctioned and was continuously alarming. The floor nurse turned off the system to the front door only. A CNA (Certified Nursing Assistant) was positioned in the lobby to ensure residents did not leave the facility. This continued the entire 2-10 (2:00 p.m. to 10:00 p.m.) shift and on the night 10-3:15 (10:00 p.m. to 3:15 a.m.) approximately. At 3:15 a.m., 9/8/19, the nurse pulled the CNA to sit with an agitated resident. There was no staff member sitting at the disarmed front door from 3:15 - 6:00 a.m. a [AGE] year-old male who resides in (room number) was last seen in the facility at 5 a.m. (5:00 a.m.) by the night CNA making her last rounds. She stated that he was coming out of the bathroom. When the day shift CNA made her first rounds, she assumed that he was already up and in the Day Room or Dining Room which is typical for him. An off-duty employee was driving down the road and saw (resident) carrying a box at approximately 7 a.m. (7:00 a.m.) walking down the side of the road . In his box, (resident) . had a pair of jeans, a t-shirt, a pair of socks and his razor . (Name), a CNA had been placed at the front door with the shift change at 6 a.m. (6:00 a.m.). At approximately 7:15 a.m., resident was returned to the facility . e. An OLTC (Office of Long Term Care) Witness Statement Form dated 9/8/19 at 7:10 a.m. documented, .(Name), this writer was traveling home from second job and noticed an elder on the side of the road, bent over picking up objects off ground. This writer turned around to assist elder and realized it was an elder from (Facility Name) . assisted elder to personal car and transported him back to nursing home. Informed nursing staff on duty of situation. f. An OLTC Witness Statement dated 9/8/19 at 8:00 a.m. documented, (Name) . Job Title . LPN (Licensed Practical Nurse) . Resident was noticed in bed at 4:15 a.m. was physically awaked by this nurse for AM (morning) dose of [MEDICATION NAME] . g. An OLTC Witness Statement dated 9/8/19 documented, .(Name) . Job Title . CNA . Shift . 10-6 (10:00 p.m. to 6:00 a.m.) . CNA on 9/7/19 from 10 a.m.- 6 a.m. My last time checking on and seeing (Resident) was at 5:00 a.m. during last rounds. He was coming out of his restroom . h. An OLTC Witness Statement dated 9/8/19 at 2:10 p.m. documented, .(Name) . Job Title . CNA .Shift . 2nd . I was asked to stay over and watch the door last, because of the alarm not working. I sat up at the door until the nurse pull me off it to sit with a resident that was trying get out of bed. That time was 3:15 (a.m.). I sat with her until 5:45 a.m. I then went to the desk. The oncoming shift was coming in. I did not see (resident) at any time this morning before I clocked out . i. The Maintenance Request Log provided by the Administrator on 9/11/19 at 2:05 p.m. contained no documentation of a problem with the front door of the facility continually alarming. The Maintenance Log also did not document dates / times entries were made into the log or the date / time maintenance requests were completed. j. On 9/11/19 at 10:50 a.m., several Licensed and Certified Staff were asked to explain Resident #1's Plan of Care, when and how the elopement occurred, circumstances around the incident, and the subsequent interventions. Their responses were as follows: 1). On 9/11/19 at 10:50 a.m., via telephone, Certified Nursing Assistant (CNA) #1 stated, Know his Care Plan by looking at the kiosk . He (Resident #1) wore a wander guard on his ankle. I didn't hear any door alarms sounding on 9/7/19 on 6-2 (6:00 a.m. to 2:00 p.m. shift) alarm. To my knowledge he was in the building. 2). On 9/11/19 at 11:10 a.m., CNA #2 stated, I look at the Kardex in the kiosk . I don't know what or when it happened; before 9/7/19 or 9/8/19. I seen (sic) him when I did my last round about 5:00 a.m., and he was coming out the restroom. I didn't have a concern with the door alarm sounding. The alarm didn't sound, as if I had a problem with it. I did hear the door was malfunctioning. There was someone sitting at the front-door . I do frequent checks on him. Sometimes he would try to get out the door, and he would jerk away, and I would re-direct him. We kept a log for maintenance at the Nurse's Station, and I'm not sure if we have a log for monitoring wander guards . I never heard the alarm sound . 3). On 9/11/19 at 11:31 a.m., via telephone, the 10:00 p.m. to 6:00 a.m. shift CNA (CNA #3) stated, I didn't know anything about the resident eloping until my co-worker called and told me. I didn't know the door wasn't working until I went on my lunch break at 1:30 a.m. I saw a CNA sitting at the door. I asked her why she was sitting there. She explained the door was turned off and wasn't working. 4). On 9/11/19 at 12:50 a.m., Licensed Practical Nurse (LPN) #1 stated, I'm familiar with his wandering around the building, Dementia, and he's ambulatory without assistance . 5). On 9/11/19 at 1:01 p.m., via telephone, Registered Nurse (RN) #1 stated, I really can't remember off the top of my head. The alarm, something went on with it Saturday, but the door still worked. We put a CNA at the front door. The alarm kept going off. He was asked if he checked the residents when the alarm first sounded and stated, Yes, (Name) notified someone that the door was not functioning properly. I think (Name) was the one that turned the door off. 6). On 9/11/19 at 1:07 p.m., LPN #3 stated, I heard on Monday he had eloped. We document the wander guard on the Medication Administration Record (MAR). I will look in his Care Plan. We keep a log at Nurse's Station for maintenance requests, and if urgent, we will call him. 7). On 9/11/19 at 1:20 pm, LPN #4 stated, I worked the 10:00 p.m. to 6:00 a.m. shift. When I clocked out at 6:00 a.m., I didn't know he was missing. I check on the residents every 2 hours. I didn't know the front door wasn't working properly, but there was someone around in that area. The resident was in the bed at 4:15 a.m. that morning. He hadn't attempted to elope on my shift in the past, and I'm not aware of any attempts. We have to go behind the CNAs and check their work. On that night, I had a new lady in (room number) that was slinging herself onto the floor. I had to move (CNA #4), that (sic) was sitting at the front door, to go do 1:1 (one-on-one) with the resident in (room number) I was sitting at the Nurse's Station. The alarm to the door had been turned off prior to me coming to work 10:00 p.m. to 6:00 a.m . k. On 9/11/19 at 1:50 p.m., during testing of all door alarms, the Maintenance Supervisor stated, I wasn't at the facility the Saturday when the alarm wouldn't stop sounding. I was in (city) with my grandbaby. I got a call Sunday around 9:00 a.m. from (LPN #2). She said the front door wouldn't stop alarming and (asked) what to do. Well I was in (city). I came in Monday and fixed the alarm on the front door and called the alarm company. The Maintenance Supervisor was asked if there had been problems with the front door alarming prior to 9/7/19 and if he kept a log of door alarm malfunctions. He stated, I don't have a log, and we hadn't had problems with the doors alarming. l. On 9/11/19 at 3:09 p.m., LPN #5 stated, I was coming from my second job around 7:00 a.m. when I found the resident about 1 mile down Highway 1, headed toward (City Name). He was walking down the highway. I picked him up, came to the building, and asked if anyone seen him. Someone said they last saw him around 5:00 a.m. m. On 9/11/19 at 2:40 p.m., the Administrator was asked if the front door was visible to the Nurse's Station. She stated, No. n. On 9/11/19 at 5:02 p.m., LPN #2, who worked the 6:00 a.m. to 10:00 p.m. shift, was asked about the elopement and stated, On Saturday, the alarm started sounding for no reason and wouldn't shut off. She was asked, were all of the residents accounted for during that time? She stated, Yes . the Maintenance Supervisor was out of town. I shut the door (alarm) off. I last saw the resident around 8:05 p.m. on 9/7/19. I round on residents every 2 hours, and if the resident is exit seeking more frequently until they have an elopement band. The resident didn't have an elopement band or wander guard. I'm not sure what happened. The front door was off. When I came in the next morning is when I was made aware of it. I'm not sure if He was with her or not. I had to get report. o. On 9/12/19 at 12:27 p.m., the Director of Nursing was asked, should a resident who has a history of exit-seeking be rounded on frequently in order to prevent elopement? She stated, Yes. She was asked, should all exit and entrance doors / alarms function properly? She stated, Yes. She was asked, if the front door is not functioning properly, should there always be a staff member monitoring the door? She stated, Yes, and documented on the MAR. She was asked, how often should wander guards and door alarms be checked for proper functioning? She stated, Once every shift. p. On 9/12/19 at 12:32 p.m., the Administrator was asked, should a resident who has a history of exit-seeking be rounded on frequently in order to prevent elopement? The Administrator stated, Yes. The Administrator was asked, should all exit and entrance doors / alarms function properly? He stated, Yes. He was asked, if the front door is not functioning properly, should there always be a staff member monitoring the door? He stated, Yes. He was asked, how often should wander guards and door alarms be checked for proper functioning? The Administrator stated, Wander guard every shift. Doors are checked weekly. We are checking the doors every shift for 5 days. q. The facility removed the immediate jeopardy and corrected the failed practices on 9/8/19, as evidenced by the following: 1.) The DMS-7734 dated 9/8/19 documented, Steps Taken to Prevent Continued Abuse or Neglect During the Investigation . In-service started on resident / facility elopement procedure initiated immediately. A thorough body audit was completed with no concerns. Physician notified and order received to send to ER (emergency room ) for evaluation and possible geri-psych (geriatric-psychiatric) admission. Resident placed on one-on-one until sent to ER. All other residents accounted for via head count no negative findings. All doors checked. Maintenance Supervisor notified. (City) Police notified . family notified. Investigation started . 2.) Inservice Education Reports dated 9/8/19 documented the following: .Conducted by: DON (Director of Nursing) . All staff: If a door alarm is not functioning properly, you must immediately place a staff member to monitor the door and they cannot be removed from that door for another assignment without someone relieving them. You must also immediately notify the Administrator or Director of any issues with doors and / or alarms . Conducted by: (Administrator) . No alarms are to be turned off (disabled) without approval of the Administrator or DON. Please notify Administrator or DON if a resident has exit-seeking behavior. Elopement Protocol and procedures - see attached . 3.) A Head Count form dated 9/8/19 documented all residents were accounted for on 9/8/19 at 7:45 a.m. 4.) A Record of Drills form dated 9/10/19 at 5:00 p.m. documented an elopement drill was conducted and that staff response was adequate. 5.) A Door Check form for (MONTH) 2019 documented the doors / alarms were being checked every shift, starting on 9/9/19.

Based on record review and interview, the facility failed to ensure before basic life support (cardiopulmonary resuscitation (CPR)) was withheld, a licensed nurse assessed for and confirmed lividity or rigor and absence of respirations for at least thirty seconds, absence of carotid pulse for at least thirty seconds, and absence of bilateral lung sounds for at least thirty seconds and documented these clinical signs of death in the medical record in accordance with state regulations when the resident was found without vital signs for 1 (Resident #120) of 7 (Residents #120, #24, #47, #54, #67, #23, and #16) sampled residents whose clinical records indicated full code status. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #120, who was a full code and did not receive CPR when found without vital signs, and had the potential to cause more than minimal harm to 34 residents who were documented as full code status, according to a list provided by the Administrator on [DATE] at 3:00 p.m. The Administrator was informed of the immediate jeopardy condition on [DATE] at 3:35 p.m. The findings are: 1. Arkansas Act 718 of 2009, [DATE], documents, .Withholding cardiopulmonary resuscitation in nursing facilities for unwitnessed deaths. (a) As used in this section: (1) 'Dependent lividity' means clear demarcation of pooled blood within the body . (3) 'Rigor' means that major joints such as the jaw, shoulders, elbows, hips, or knees are immovable .(b) Licensed nurses employed by nursing facilities may withhold cardiopulmonary resuscitation from residents of the facility, regardless of the presence or absence of a Do Not Resuscitate Order when:(1) The death of the resident was unwitnessed; and(2) The body evidences clear and unmistakable:(A) Dependent lividity; or (B) Rigor.(c) In cases of unwitnessed deaths under subsection (b) of this section, the following conditions also must be present:(1) Respirations are absent for at least thirty (30) seconds;(2) Carotid pulse is absent for at least thirty (30) seconds;(3) Lung sounds auscultated by stethoscope bilaterally are absent for at least thirty (30) seconds; and(4) Both pupils, if accessible, are nonreactive to light.(d) The nursing facility shall document the presence of the above-listed conditions in the resident's records . 2. Resident #120 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status. a. A physician's orders [REDACTED].Code Status: Full Code . b. The Care Plan dated as revised [DATE] did not address code status. c. Nurses' Notes dated [DATE] and signed by Licensed Practical Nurse (LPN) #1 documented, .Time: 6:46 a.m . Called to resident's room per nurse and CNA (Certified Nursing Assistant) at 0400 (4:00 a.m.). Upon entering resident's room, resident was noted with pupils fixed and dilated. No respirations, no B/P (blood pressure) detected and unable to palpate pulses. Mottling noted to extremities. Skin cool to touch on left arm and hand. Resident noted to be alert and oriented at 1:00 a.m. during rounds with no distress noted at that time. APN (Advanced Practice Nurse) notified at 4:15 a.m. with orders, 'may call coroner to pronounce and release body to funeral home of family choice.' Family member notified at 4:20 a.m. Coroner notified at 4:25 a.m. Family at facility 4:20 a.m. to pay last respects. Left facility at 5:00 a.m. None of the patient belongings were taken by family at this time. Coroner arrived at facility to pronounce at 4:45 a.m . There was no documentation the nurse checked and verified the presence of dependent lividity or rigor, and no documentation to indicate the carotid pulse, respirations and lung sounds were confirmed to be absent for at least 30 seconds before making the decision to withhold CPR. d. On [DATE] at 12:06 p.m., LPN #1 was interviewed via telephone. She was asked, do you know the Arkansas Law for withholding CPR? LPN #1 stated, Yes ma'am, I do. She was asked, when were you trained on the law? LPN #1 stated, It's been a couple of months ago. LPN #1 was asked, is there any other documentation by you anywhere about (Resident #120's) death except for the Nurses Note dated [DATE]? LPN #1 stated, I don't think so. I was not her nurse. I was just helping out (LPN #2). She's a new nurse. e. On [DATE] at 2:08 p.m., the Director of Nursing (DON), Assistant DON and Administrator were asked, who got the call that Resident #120 passed away? The DON stated, They called the MDS Nurse. He was on call. They were asked, when did you know about Resident #120 passing away? The DON stated, When I came in that a.m. (morning). She was asked, did you review the chart? The DON stated, Yes. She was asked, do you believe the documentation met the State Law requirements? The DON stated, I believe so. Yes, they did meet the law requirements. They checked pulses and everything. When I read the note, I felt that they did meet the law requirements. The DON was asked, did you take any further action? The DON stated, No. f. On [DATE] at 2:12 p.m., the MDS Nurse was asked, did you get a phone call when Resident #120 passed away? The MDS Nurse stated, Yes. She was asked, what time? The MDS Nurse stated, 4:15 a.m. She was asked, from who? The MDS Nurse stated, (LPN #1) called. She said (Resident #120) was unresponsive. Staff came and got her. I asked if they checked her, and I basically went over the procedures. I asked them, first of all, if she was a full code. They said, 'Yes.' We went over what you did, document it, and you just need to contact the MD (Medical Doctor), Coroner and family, and get a witness statement. She was asked, from who? The MDS Nurse stated, The CNA (Certified Nursing Assistant). I called back again at 5:00 a.m. She was asked, why? The MDS Nurse stated, To make sure they were okay. She was asked, and were they? She stated, They said they were okay. She was asked, did you review the documentation related to (Resident #120's) death? The MDS Nurse stated, I've reviewed it today. She was asked, is the note where it should be? The MDS Nurse stated, Yes. The witness statement dated [DATE] at 4:03 a.m. and signed by CNA #1 documented, Upon entrance into (Resident #120's) room, I noticed she did not respond to my calling of her name. I called her name again, she didn't respond. I went to inform nurse. g. On [DATE] at 3:15 p.m., LPN #2 was interviewed via telephone. She was asked, is there documentation done by you regarding the death of (Resident #120)? LPN #2 stated, No, ma'am. I am a new nurse. I just graduated in (MONTH) of this year. I was getting help from another nurse. h. On [DATE] at 8:31 a.m., LPN #2 was asked, why didn't you initiate CPR for Resident #120 when you found her? LPN #2 stated, When I found her, she was cool and didn't have a pulse. At 9:58 a.m., LPN #1 was asked, why didn't you initiate CPR on Resident #120 when you found her? LPN #1 stated, When I found her, she was mottled. Her pupils were fixed. I auscultated her lungs with no respirations. I checked several pulses for several seconds and there was none. i. On [DATE] at 10:00 a.m., the Administrator was asked for the facility policy and procedure on providing CPR. At 10:11 a.m., the Administrator stated, We have no policy or procedure on providing CPR. j. The Immediate Jeopardy was removed and the scope / severity reduced to G on [DATE] at 10:20 a.m., when the facility implemented the following Plan of Removal: 1). On [DATE], an outside Nurse Consultant trained the Administrator and the DON / designee on the Arkansas Law for Withholding CPR. 2). On [DATE], the DON / Designee will review the code status of all residents to verify accuracy in the electronic health records forms. 3). On [DATE], the DON / Designee has identified 34 residents that are full code status and the IDT (Interdisciplinary Team) team has verified that directives match physician's orders [REDACTED]. 4). Starting [DATE], in-service was started with nurses currently on duty and ongoing, training will be performed with all active nursing employees prior to working their next scheduled shift. DON/Designee directed staff to initiate CPR when cardiac or respiratory arrest occurs for residents who do not show obvious clinical signs of irreversible death; (1) Respirations are absent for at least thirty (30) seconds; (2) Carotid pulse is absent for at least thirty (30) seconds; (3) Lung sounds auscultated by stethoscope bilaterally are absent for at least thirty (30) seconds. (4) Both pupils, if accessible, are nonreactive to light. 'Dependent Lividity' means clear demarcation of pooled blood within the body. 'Rigor' means major joints such as jaw, shoulders, elbows, hips or knees are immovable. Nurses will be trained on how to document those items for any full code resident who expires in the facility. 5.) Starting 9 /27 /2018, during daily startup, any code status changes will be reviewed by the IDT team and charts, care plans & (and) physician's orders [REDACTED]. Any negative findings will be corrected upon discovery and reported to QA (Quality Assessment/Assurance) Committee for review and recommendation. Any further resident deaths will be reviewed to ensure staff responded and documented appropriately.

Based on record review, and interview, the facility failed to ensure a resident was transferred via mechanical lift in accordance with her assessed needs, to prevent injury for 1 (Resident #1) of 3 (Residents #1, #2 and #4) case mix residents who required mechanical lift transfers. This failed practice resulted in actual harm to Resident #1, who sustained injuries and pain as a result of a direct care staff member conducting a manual transfer instead of a mechanical lift transfer. The facility also failed to ensure staff were trained, supervised, and monitored during mechanical lift transfer procedures after 2 residents experienced incidents or injuries possibly related to mechanical lift transfers in a 1-month period, to determine if staff error may have contributed to those incidents and identify any further need for training, in order to minimize the potential for resident injury for 2 (Residents #2 and #4) of 3 (Residents #1, #2, and #4) case mix residents who required mechanical lift transfers. The failed practices had the potential to cause more than minimal harm to 19 residents who required mechanical lift transfers, as documented on a list provided by the Administrator on 3/20/17 at 9:45 a.m. The findings are: 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/5/17 documented the resident scored 8 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS), was totally dependent on the physical assistance of 2-plus persons for transfers, was totally dependent on the physical assistance of 1 person for locomotion on and off the unit, required extensive assistance of 1 person for bed mobility, received scheduled pain medication, received PRN (as needed) pain medication, and had no falls since admission or prior assessment. a. An Admission Care Plan not dated documented, .Pain . Goal, Resident will regain maximum function (and) comfort . Monitor pain q (every) shift / verbal (and) non-verbal S&S (signs and symptoms) . The Admission Care Plan did not document how the resident was to be transferred. b. The Certified Nursing Assistant (CNA) Care Plan (not dated) in the resident's closet documented, .Mobility . Wheelchair . Non-ambulatory . Transfer Skills . With 2 assist (assistance) (with) Mechanical Lift . c. A Nurses Note dated 2/7/17 at 12:00 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, .R (Resident) c/o (complained of) pain to L (left) leg rated 7/10 (7 on a scale of 1 to 10) on pain scale. PRN (as needed) analgesic given. Effective treatment of [REDACTED]. A Nurses Note dated 2/7/17 at 6:00 a.m., and signed by Licensed Practical Nurse (LPN) #1 documented, .R (Resident) c/o (complained of) pain to L (left) leg rated 7/10 on pain scale. No bleeding noted. PRN analgesic given. Effective treatment of [REDACTED]. A Nurses Notes date 2/7/17 on the 2:00 p.m. to 10:00 p.m. shift and signed by Licensed Practical Nurse (LPN) #2 documented, .Called to room by family member. R (Resident's) Lt (left) leg noted swollen and warm to touch. R c/o (complained of) pain. States 'They dropped me last night.' Unable to provide many details on when or how. Unsure if lift was used. N.O. (New Order) obtained for Mobile X-Ray of Lt Tib/Fib (Tibia/Fibula). Lt ankle (and) Lt Foot. R refused ER (emergency room ) visit. Fam (Family) notified. X-Ray ordered . d. An Incident/Accident Investigation Report dated 2/7/17 at 6:00 p.m., documented, .Called to room by family member. R (Resident) noted (with) swollen Lt (left) ankle and foot, warm to touch. C/O (complained of) pain. R states 'They dropped me last night.' Unable to provide details as to when or how. Unsure if lift was used or not. NP (Nurse Practitioner) notified (with) N.O. (new order) for mobile X-Ray of Lt Tib/fib (tibia/fibula), ankle (and) foot. R refused ER (emergency room ) visit . A Registered Nurse follow-up note dated 2/8/17, signed by the Director of Nursing (DON), documented, .Mobile x-ray (no) acute findings. CNA (Certified Nursing Assistant) identified, Disciplinary action. ER (emergency room ) visit . e. A Mobile X-Ray report dated 2/7/17 at 7:42 p.m. documented, .Tib/fib (tibia/fibula) 2 v (views) AP/Lat (anteroposterior/lateral) Left. Impression . Acute / subacute fractures involving the proximal fibula and distal tibia . f. A Nurses Note dated 2/8/17 at 10:10 a.m. documented, .R (Resident) in bed. c/o (complained of) L (left) leg pain rated 7/10. R request pain med. PRN (as needed) Percocet given per orders. R request ER (emergency room ) visit. Family (at) bedside. 10:30 a.m. R transported to (Hospital) via .EMS (Emergency Medical System) per request. Report called (Hospital) . g. A Hospital Admission Note dated 2/8/17 at 11:20 a.m. documented, .Extremities . Exam other-tenderness swelling L (left) ankle and L foot, ecchymosis, with ROM (range of motion) of shortened L (left) leg, pt (patient) complained of pain (left) leg, unclear tender (left) hip . A hospital x-ray report dated 2/8/17 at 12:31 p.m. documented, .XR (x-ray) (left) foot 3 views . Impression . Severe Osteopenia. No acute fracture identified. Achilles calcaneal spur. Partially visualized intramedullary rod in the tibia. Mild scattered degenerative changes in the left foot . The hospital record did not contain an x-ray report for the distal tibia / proximal fibula (the areas identified with fractures on the mobile x-ray dated 2/7/17). h. On 3/1/7 at 6:19 p.m., the Administrator was asked if the facility had determined the cause of the resident's leg injury and stated. It was determined that the resident had been transferred by (CNA #1) without using the mechanical lift. She wasn't really dropped. She was on the side of the bed and slid. The Administrator was asked where this was documented. The Administrator stated, I didn't document that. (CNA #1) had been terminated prior to this incident being discovered. The Administrator was asked if they had assessed any other residents this CNA had cared for to determine if there had been any other residents injured by improper transfers. The Administrator stated, No, we determined how (Resident #1) had been transferred, and no further investigation was conducted. The Administrator was asked if the CNAs were assessed for their skills to determine if they were proficient in safely performing their job duties. The Administrator stated she had looked for the annual evaluations that had been done by the previous Director of Nursing and could not locate them. 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/16 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS), was totally dependent on the physical assistance of 2 persons for bed mobility and transfers, had pain and required pain assessments. a. The CNA Closet Care Plan (not dated) documented, .Mobility Level . Non-ambulatory . Wheelchair (Electric) . Transfer skills . with 2 person assistance . Mechanical Lift . b. The Incident/Accident Investigation Report dated 2/16/17 at 5:00 a.m., documented, .R's (Resident's) family report that R stated that her arm was hurt the prior night while the CNAs were putting her to bed. She stated her R (right) arm was hurting . c. On 3/2/17 at 11:05 a.m., CNA #3 was interviewed via telephone. She was asked how long she had been employed by the facility. CNA #3 stated she had been employed by the facility for approximately 2 years. CNA #3 was asked if she cared for Resident #2 on 2/15/17. CNA #3 stated, Yes. I was helping (CNA #2) transfer her from the wheelchair to the bed and I turned around, and she said her arm hurt. CNA #3 was asked if the resident first complained of pain when she was in the mechanical lift. CNA #3 stated, Yes. CNA #3 was asked if she had reported this to anyone. CNA #3 stated, (CNA #2) reported it to (LPN#3). d. On 3/2/17 at 1:05 p.m., LPN #3 was interviewed via telephone. LPN #3 stated she had been employed by the facility for approximately 3 1/2 years and was the Unit Manager, but was currently filling in on the night shift. LPN #3 was asked if she recalled an incident with (Resident #2). LPN #3 stated, It was around 3:30 a.m., (CNA #2) reported that she (Resident #2) was complaining of pain in her arm. I assessed her, and her speech isn't always clear, and she said her left arm was hurting. 3. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/17 documented the resident scored 5 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status, had functional limitation in range of motion to both upper extremities, and was totally dependent on the physical assistance of 2 persons for transfers. a. The Resident Plan of Care dated 1/23/17 documented .Approaches . Resident is a mechanical lift with 2 person assist . ADL (Activities of Daily Living) . Two person assist with transferring using mechanical lift .Approaches . Mech (mechanical) Lift (times) 2 person assist . b. A Nurses Note signed by Licensed Practical Nurse (LPN) #1 and dated 2/21/17 at 12:30 p.m., documented, .CNAs (Certified Nursing Assistant) (times) 2 getting (Resident) up via lift. (Resident) grabbed lift and swung lift around and hit nose. No bruising or deviation noted. Denies pain . c. An Incident/Accident Investigation Report dated 2/21/17 documented, .Document an exact description of the incident/accident and circumstances surrounding it . CNAs came to grab this nurse to look at (Resident #4's) nose. CNAs reported to this nurse that (Resident) had swung the lift during transfer and hit her own nose. No bruising .RN (Registered Nurse) Follow-up . Instructed CNAs to always tell resident what you're going to do before you do it . 2/22/17 . d. On 2/28/17 at 7:20 p.m., the Director of Nursing (DON) was asked when the most recent incident with a lift had occurred. The DON stated, I and A (Incident and Accident) was 2/21/17 12:30 p.m. The DON was asked what date she had reviewed the incident report. The DON stated, The next day when I was going through nurses notes, I saw the note on 2/21/17 about the lift incident. I had (LPN #1) fill out an incident report on 2/22/17. e. On 2/28/17 at 11:30 p.m., Licensed Practical Nurse (LPN) #1 was asked which CNAs were present when the incident occurred on 2/21/17. The LPN stated, I don't know. I don't know them. f. On 3/1/17 at 5:55 p.m., the DON was asked how long she had been the DON. She stated, Since 2/14/17. The DON was asked when the I & A was completed for the 2/21/17 incident. The DON stated, I would probably say the following day. The DON was asked what she did when she discovered the incident. The DON stated, I told him (LPN #1) I needed an I & A. The DON was asked which staff were involved with the incident and who had reported the incident to the nurse. The DON stated, I was having a hard time figuring out who the staff was. He (LPN #1) didn't know. The DON was asked if she had referred to the staffing sign-in log for the assignments to try to determine who worked on 2/21/17. The DON stated, I couldn't tell. 4. On 3/2/17 at 2:55 p.m., the Director of Nursing (DON) was asked if CNAs were observed for competency using the mechanical lift after the above incidents. The DON stated, Since I have been the DON, I can't say I've done a spot check. 5. In-Service training documentation titled, Mandatory Transfer Training Using Mechanical Lifts, Gait Belts, provided by CNA #5 on 3/2/17 at 3:00 p.m. documented, This is a hands-on competency . All staff are expected to attend one of these sessions. If you do not attend, you will be taken off the schedule. Monday 1/9/17 . day shift . Tuesday 1/10/17 . evening shift . Wednesday 1/11/17 . night shift . No documentation was provided to indicate any further training or monitoring of mechanical lift transfers was conducted after 1/11/17. 6. On 3/2/17 at 2:55 p.m., the DON was asked if, after the February 2017 incidents involving Residents #1, #2 and #4, there had been any type of mandatory training on transfers and mechanical lifts. The DON stated, No, not further training. The DON was asked if there had been any in-services after the incidents. The DON stated, No. The DON was asked how the facility ensured staff was competent with skills, including use of mechanical lifts. The DON stated, Doing spot checks, observing more.

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure supervision with toileting was provided in accordance with the plan of care, to prevent further falls for 1 (Resident #19) of 3 (Residents # 6, #7 and #19) case mix residents who had a history of [REDACTED].#19, who fell from the toilet when left unattended, sustained a head injury and subsequently expired. This failed practice had the potential to affect 10 residents who had a history of [REDACTED]. The facility also failed to ensure staff followed safe practices when utilizing a mechanical lift to prevent potential injury for 1 (Resident #5) of 6 (Residents #3, #4, #5, #7, #13 and #14) case mix residents who required mechanical lift transfers. This failed practice had the potential to affect 22 residents who required mechanical lift transfers, as documented on a list provided by the Administrator on [DATE]. The findings are: 1. Resident #19 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 10 (,[DATE] indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), had mood indicators including slow, fidgety and restless and required one person physical assistance with transfers, toileting and ambulation and had no prior history of falls. a. The Fall Risk Assessment and Post Fall Assessment Form dated [DATE] documented the resident's total fall risk score was 12 and, "If total score is 12 or greater, the resident is considered to be at high risk for falls and placed on the fall prevention program immediately ..." The form documented the resident had intermittent confusion, no falls in the past 3 months, poor vision status, a balance problem, decreased muscular coordination and required the use of an assistive device (cane, walker). b. The Resident Plan of Care dated [DATE] documented, "...Problem: Resident is non-compliant with use of call light. At risk for fall-related injury related to [DIAGNOSES REDACTED]. c. The Nursing Assistant Care Plan (not dated) documented, " ...Mobility: Ambulatory with a walker ...Transfer skills: with one assist ..." d. The Event Investigation Report dated [DATE] documented, " ...Resident was walking to bathroom with walker. Resident fell backwards; hit back of head on dresser... Hematoma noted to right side posterior head... Sent to (hospital) for evaluation. Contributing medical condition: Non-compliance, weakness. Resident Activity: walking, attempting to transfer unassisted, and responding to bowel/bladder urgency. Interventions/plan: resident educated on utilizing call light for assistance and safety awareness. Resident had a UTI". e. The Event Investigation Report dated [DATE] documented, "While giving meds (medications), this nurse heard resident calling for help. Upon entering room, resident was found sitting in floor of bathroom. Resident states she just slipped. Upon exam, resident found to have bruise to right knee... Assisted back to bed ... Contributing medical condition: Non-compliance. Resident Activity: attempting to transfer unassisted ... Interventions/plan: non-skid strips to bathroom in case resident attempts to ambulate to bathroom unassisted." 1.) The Nurse's Note dated [DATE] at 9:00 p.m. documented, " ...Right knee 2+ (plus) edematous discoloration noted, resident ambulates with assist with a limp. Daughter at facility at 4 p.m. voiced concerns re: (regarding) resident being toileted every 2 hours and monitored closely. Nurse informed daughter that resident will be monitored closely and taken to bathroom every 2 hours and spoon fed meals. Reassured daughter that resident will be taken care of this shift." 2.) The Fall Risk Assessment and Post Fall Assessment Form dated [DATE] documented the resident's total fall risk score was 14 and, "If total score is 12 or greater, the resident is considered to be at high risk for falls and placed on the fall prevention program immediately ..." The form also documented the resident had conditions including intermittent confusion, ,[DATE] falls in the past 3 months, poor vision status, balance problem, decreased muscular coordination and required the use of an assistive device (cane, walker). f. Nurse's Notes dated [DATE] at 9:30 p.m. documented, "( Resident #19) to bathroom via walker with assist of CNA's (Certified Nursing Assistants)". g. The Physical Therapy Evaluation and Plan of Treatment dated [DATE] documented, "Reason for referral: patient referred to PT (physical therapy) due to decrease in strength, reduced balance, reduced ability to safely ambulate, decrease in functional mobility and increased need for assistance from others. This is a [AGE] year old female who was referred to PT following complaints of pain at right knee and limping during walking. Patient's bruising and swelling of right knee was documented on [DATE] nursing notes but has no mention of fall. Patient does not remember a fall when asked, however patient has some confusion" ... "Assessment Summary- Clinical Impressions: ...she has decline in functional mobility, especially with ambulation mostly due to pain at her right knee ...is at risk for falls ...skilled PT services are warranted to increase LE (lower extremity) ROM (range of motion) ..." h. The Event Investigation Report dated [DATE] documented, "Resident noted on floor lying on back, blood noted to back of head. 4 X (by) 4 gauze applied with pressure to back of head. Resident kept still at all times. Awake with confusion, speech garbled, hematoma to head, disoriented X 3. MD (Medical Doctor) called. Ambulance called. ER (emergency room ) called. Resident transferred via ambulance to (hospital) for evaluation ... Contributing medical condition: Non-compliance, weakness. Resident Activity: walking, attempting to transfer unassisted". 1.) A Witness Statement form dated [DATE] at 10:40 a.m. and signed by CNA #7 documented, "(CNA #8) came to tell me (resident) was wanted in beauty shop, I had arm full of linen went and laid in another resident room the bed alarm was going off as I entered (Resident #19's room) I then help resident stand who was asking for help I turn bed alarm off then help her (Resident #19) to bathroom and pull curtain I stood outside door in doorway then notice another resident call light was on I was only CNA on hall at the time so I went next door and answer resident light he was asking for his heat to be on and help on to the bed as I was leaving room I and housekeeper on hall heard a thump we ran to resident room and she was on the floor I ask her was she hurt then ran out to get the nurse." 2.) The hospital History and Physical dated [DATE] documented, "(Resident #19) is a [AGE] year old ... female who had fallen at the nursing home and had a small laceration. She was sent to the emergency room where she was examined by the emergency room physician who found that she had a small subdural hematoma on the right side of the brain that was probably 8 mm (millimeters) in one area and 7 mm in the other which is not really significant". 3.) The resident's Hospital Discharge Summary dated [DATE] documented, "Cause of Death Subdural Hematoma. Hospital course: This elderly white female resident of (Facility Name) had fallen at the nursing home and sustained a small laceration to the posterior scalp, so she was sent to the emergency room where the hematoma/laceration was closed with sutures. While in the emergency room she was found to have a small subdural hematoma on the right side of the brain which was not really significant at that time. Her daughter did not want anything heroic done for her, so she was returned to the nursing home, but later in the day her daughter decided to bring her back to the clinic and she was admitted from the clinic with a [DIAGNOSES REDACTED]. She was admitted for comfort care measures as she was a DNR (Do Not Resuscitate) patient. She was treated with IV (intravenous) fluids and IV Decadron, given Toradol IM (intramuscular) for pain, and oxygen and albuterol updrafts were used as needed. The following morning her CT (computed tomography) scan was repeated and showed marked increase in the size of the subdural hematoma on the right with significant midline shift to the left of approximately 10 mm. (Neurologist) was talked to on the phone to see about anything additional that needed to be done and he had no recommendations. Her daughter still wanted no feeding tube or heroic measures and just wanted comfort care measures only ... On the morning of [DATE], at 05:27 a.m. she expired with her family at her bedside". 2. Resident #5 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a staff assessment for mental status , was not ambulatory and required extensive assistance of 2 staff for transfers. a. The Resident Plan of Care dated [DATE] documented, " ...Resident at risk for fall related injury due to impaired mobility, Dementia, Parkinson's, Seizure Disorder. Mechanical Two Person Lift...". b. On [DATE] at 4:15 p.m., the resident was sitting in a Geri chair in his room. Certified Nursing Assistant's (CNA's) #3 and #4 entered the room and stated they were going to put the resident back to bed. CNA #4 pushed an Invacare Reliant 600 mechanical lift into the room. There was a lift sling already underneath the resident in the chair. The CNA's hooked the sling to the swivel bar by placing the 4 purple loops at each edge of the sling onto the swivel bar attachments. CNA #4 used the motorized control button to lift the boom to its highest position, which caused the angle of the boom arm to block the swivel bar from swiveling freely 360 degrees. The resident's head was facing the foot of the bed and the resident's feet were facing the head of the bed. CNA #4 forced the swivel bar past the boom arm while the resident was suspended in the lift, in order to turn the resident to the correct angle. The CNA stated "I don't like this lift; you have to force it to turn". The surveyor stopped the transfer and asked the CNA's to lower the resident back into the chair. The resident was lowered back into the chair. c. On [DATE] at 4:00 p.m., the surveyor demonstrated the inability of the lift swivel bar to move freely from the maximum height position to the Director of Nursing, Maintenance Supervisor and Nurse Consultant. The Director of Nursing stated, "I see exactly what you mean". The boom arm had two areas where the finish was marred and the paint and been scraped off, where the spreader bar had repeatedly come into contact with the boom arm. The Director of Nursing stated, "We took it out of use after you told us about the transfer yesterday and we're going to send the lift back to the company so it won't get used again". d. The manufacturer's instructions for the use of the lift did not address the boom height limitation in regard to the swivel arm but did document, "Use common sense in all lifts ... do not roll over uneven surfaces or obstacles that would create an imbalance of the patient lift and could cause the patient to tip over".