Every finding on record at The Blossoms at Cumberland Rehab & Nursing Center

Number of residents sampled: Number of residents cited: Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to prevent staff to resident abuse for one (Resident #76) of four residents reviewed for abuse. The findings include: Review of an admission Record indicated the facility admitted Resident #76 with diagnoses that included adjustment disorder with mixed disturbances of emotions and conduct, mood affective disorder, bipolar disorder, nicotine dependence, problem related to social environment, intellectual disabilities, symptoms and signs involving appearance and behavior and traumatic brain injury. Review of the quarterly Minimum Data Set with an Assessment Reference Date of 04/02/2026, revealed Resident #76 had a Brief Interview of Mental Status score of 14, which indicated the resident was cognitively intact. Resident #76's Resident Mood Interview was scored 0 for any negative symptoms. The assessment identified no behavioral symptoms towards others or rejection of care. Review of Resident #76's Care Plan Report, initiated on 07/04/2024, revealed the resident chose to smoke and required supervision to do so. Resident #76 expressed maladaptive behavior symptoms related to chronic mental illness and adjustment disorder with mixed disturbance of emotions and conduct interventions included separate and redirect, explain the desired behavior to the resident, remind the resident they were expected to behave respectfully and maturely, and utilize behavior management techniques to promote and shape the desired behaviors. Techniques such as controlling the environment noise level, over-stimulation, commotion, and close contact were indicated. The Care Plan also indicated to direct the resident to stay away from people who increase their agitation and provide opportunities to have space and fresh air. Review of an Office of Long-Term Care (OLTC) Incident & Accidents (I&A) Report dated 04/16/2026 summarized the incident as, resident put employee in headlock. While employee was trying to release the resident's grip from neck the resident alleged that they were hit with a cup. Certified Nursing Assistant (CNA) #1 reported that Resident #76 had her in a headlock, and they both hit the wall which caused the injury to the resident. CNA #2 reported CNA #1 hit Resident #76 in the head with a cup attempting to release herself from the headlock. CNA #2 separated both parties and reported the altercation to the charge nurse. The facility found CNA #1 did abuse Resident #78 during their investigation and she did not return to the facility following her suspension. Review of Resident #76's Witness Statement Form dated 04/17/2026, revealed CNA #1 was standing in the television room doorway being a [explicate] to the resident and called Resident #76 a [racial slur]. Resident #76 then called CNA #1 a [racial slur]. CNA #1 then grabbed at Resident #76 who grabbed back at CNA #1. Resident #76 then placed CNA #1 in a headlock. CNA #1 then hit Resident #76 in the head with her cup eight times. Resident #76 stated they started gushing blood and were taken to the bathroom by CNA #2 and cleaned up. Review of CNA #1's Witness Statement Form dated 04/21/2026, revealed 30 minutes after the start of the shift on 04/16/2026 Resident #76 began calling CNA #1 a racial slur and using profane language towards her. CNA #1 stated she followed protocol and reported it to the Social Director (Social) but was directed to inform someone else. CNA #1 stated she reported it to the Licensed Practical Nurse (LPN) #3 when she arrived. LPN #3 went and spoke with Resident #76 which temporarily de-escalated the situation for about one hour. Resident #76 resumed aggressive behaviors towards CNA #1. CNA #1 notified CNA #2, and when no other help arrived, CNA #1 and CNA #2 entered Resident #76 room in an attempt to verbally de-escalate the resident. The CNAs asked Resident #76 what was wrong and encouraged the resident to calm down. Resident #76 then became physically aggressive and attacked CNA #1. CNA #1 stated she followed protocol by reporting the escalating behavior early and sought assistance multiple times prior to the incident. Review of CNA #2's Witness Statement Form dated 04/17/2026, revealed when she arrived on the unit Resident #76 was yelling slurs at CNA #1. Resident #76 stated they did not like CNA #1 because she was always messing with the resident. CNA #1 walked into Resident #76's room asking the resident what she was doing to the resident [to clarify why the resident did not like CNA #1]. Resident #76 got up out of bed and stepped in CNA #1's face screaming and telling her, to do something. CNA #1 was face to face with the resident yelling back. Resident #76 swung at CNA #1, who swung back. They began fighting. CNA #2 attempted to separate them and was struck in the mouth. CNA #2 stepped back and attempted to call for help. CNA #2 observed Resident #76 bleeding and asked the resident to let go of CNA #1. Resident #76 let go and the two were separated. CNA #2 reported once CNA #1 left the resident's room she left the unit to get LPN #3. LPN #3 entered the unit and instructed CNA #2 to clean up the resident. Resident #76 was repeatedly asking to smoke, so CNA #2 was directed to take the resident on a smoke break as the Assistant Director of Nursing (ADON) arrived. Review of LPN #3's Witness Statement Form dated 04/16/2026 revealed, LPN #3 was notified by CNA #2 that Resident #76 jumped on CNA #1 and there was blood. When LPN #3 arrived on the unit CNA #1 was sent out to ensure separation of the two parties. Resident #76 was bleeding but would not allow LPN #3 to assess [the resident] until after the resident was allowed to smoke. CNA #2 took resident to smoke. The ADON entered the room and notified the Administrator. LPN #3 was later called to the Administrator's office and suspended for three days due to violation of Resident #76's right to a smoke break. Review of Resident #76's emergency room Records dated 04/16/2026 at 3:47 PM, revealed chief complaint of agitation. Resident #76 reported being struck in the head by a CNA at the nursing home facility. Emergency Medical Services (EMS) reported the resident was told no to a cigarette and placed a CNA in a headlock. Resident presented with a head laceration and reported the incident happened at 11:00 AM and had experienced a headache ever since. Head Computed Tomography (CT) Report revealed, no acute processes, symmetric volume loss of the cerebral hemispheres [diffuse reduction in brain tissue] greater than expected for age, and periventricular microangiopathy [chronic, progressive condition affecting the tiny blood vessels in the brain] greater than expected for age. The head laceration was cleaned, and six staples were placed without complications. The facility was contacted and stated they were comfortable taking the resident back. Review of a Police Report filed on 04/16/2026 revealed, the Administrator stated Resident #76 had been displaying aggressive behavior throughout the day and began using racial slurs. Resident #76 then jumped on CNA #1 and attempted to place her in a headlock, at which point both parties fell into a wall. Staff members intervened before the altercation escalated further. The Administrator stated she only needed a report for documentation purposes. On 04/17/2026 the officers responded to the emergency room and spoke with Resident #76 who revealed they did call CNA #1 a racial slur and told the CNA to do something about it. Resident #76 reported CNA #1 struck her in the head with a water mug causing the laceration. Officers reported observing a deep, dried scar on Resident #76's head. Nursing staff at the emergency room advised the officer the injury appeared to have been left untreated for an extended period. Review of a facility in-service titled Abuse In Long Term Care-Types and Reporting dated 04/16/2026, revealed the facility in-serviced 70 staff members on types of abuse, when to report, and the facility's Abuse, Neglect, and Exploitation policy. During an interview on 06/01/2026 at 3:09 PM, Resident #76's family member stated that the resident had memory and mental issues, but they could trust what the resident told them. Resident #76 reported being agitated about a smoke break and both the resident and the staff were calling each other names and racial slurs. Resident #76 would get aggressive over smoking. Both parties reported the other initiated physical contact, but the resident reported being struck in the head with a metal cup and received 7 staples to the head. The family member reported the resident had a history of a traumatic brain injury and they were told by a medical professional that the resident functioned around a sixth-grade level mentally. The resident had been homeless previously and would wander around and ask people for money. My main concern is [the resident] has been like this for years and they are a trained facility. I understand they have to defend themselves, but I feel like it was excessive. [The resident] was bludgeoned in the head multiple times and received staples. During an interview on 06/03/2026 at 10:44 AM, CNA #2 stated Resident #76 had been agitated all day, and an attempt was made to get assistance from Social, but she could not deal with it at the time. CNA #2 stated that the nurse was late passing out medications, that could have been a part of it. CNA #1 stopped in front of Resident #76's doorway to ask why the resident did not like her and kept saying stuff to her. I do not know if Resident #76 felt attacked, but the resident got in CNA #1's face. CNA #1 said to the resident swing on me, swing on me. CNA #2 told CNA #1 to get out of the resident's room, but Resident #76 swung at CNA #1. CNA #2 tried to separate them and was struck in the mouth. CNA #1 hit Resident #76 with a cup on the side of the head. When they got calmer and separated CNA #2 finally left the room, I left and got LPN #3. Attempts to clean up the resident was made but Resident #76 wanted to smoke. CNA #2 took Resident #76 out to smoke. I feel like [CNA#1] could have handled the situation different. I think if she would not have gone in the resident's room it would not have happened. During an interview on 06/03/2026 at 11:00 AM, CNA #1 stated about 30 minutes after the shift started Resident #76 started cursing and became aggressive towards her and other staff. CNA #1 notified Social and was redirected to someone else. CNA #1 stated the nurse was late that day too. Resident #76 was upset with staff regarding a smoke break. CNA #1 reported the resident was denied a smoke break due to their behavior and acting out and a housekeeper was getting the resident worked up about it. Resident #76 started with aggressive behaviors again and I told the nurse again; I need to get off the unit. When CNA #2 came on the unit we entered Resident #76 room and began to try and de-escalate the situation. CNA #1 stated, Resident #76 came at me and put me in a headlock, and the resident struck the wall. Resident #76 and I had been good before; I don't know if it was the smoke break. I feel like I was attacked because [the resident] was not allowed a cigarette. CNA #1 stated, The Administrator told me Resident #76 was a racist and didn't like women. If they knew that then why didn't they come help when I asked for it. During an interview on 06/03/2026 at 11:56 AM, the Ombudsman stated, They never have two staff on the unit and there were not two that day. They had to call for help. During an interview on 06/03/2026 at 2:30 PM, Social stated she received a call from CNA #1 regarding Resident #76 behaviors but was in court with another resident and directed CNA #1 to call LPN #3. LPN #3 did not respond to messages regarding an interview related to the incident. During an interview on 06/04/2026 at 10:08 AM, the ADON stated that during an investigation of the incident she suspended LPN #3 because she did not allow Resident #76 to smoke when the resident refused a shower. CNA #1 and CNA #2 stated the resident was upset because the resident needed a cigarette. When the ADON made rounds the morning of 04/16/2026, she heard Resident #76 saying they needed their smoke break. I did not know they were saying no shower, no smoke break. The ADON stated that staff cannot deny them a smoke break and that was why the ADON suspended LPN #3. Staff should report concerns immediately before they get out of hand. During an interview on 06/04/2026 at 11:07 AM, the Director of Nursing (DON) stated she was not employed in the facility during the 04/16/2026 altercation but the facility had made changes since then. The number of staff had been increased on the secured unit and staff had also been provided with an alert bell they wear on a lanyard. If the button was pushed it rings out to the nurses so people could respond and help. The DON stated the expectation of staff dealing with resident verbal aggression was to calmly walk away and not interact right then. If it gets physical, staff should push their button so others can respond. During an interview on 06/04/2026 at 11:55 AM, the Administrator stated after being contacted she had come to the building to investigate. She learned there had been an altercation between CNA #1 and Resident #76. The Administrator stated, It began as verbal name calling and escalated to a physical altercation. Resident #76 grabbed CNA #1 and put her in a headlock. The Administrator believed it started in the hallway and ended up in the resident's room. The determination was the allegation of abuse from CNA #1 to Resident #76 was substantiated. The Administrator stated suspicion of abuse should be reported immediately to their charge nurse, if staff did not believe anything was being done about it they could report it to the Administrator, DON, ADON, or Social to get it taken care of. Review of a facility policy titled, Abuse, Neglect, and Exploitation, revised in 12/2022 revealed, the facility's goal is to prevent abuse through annual and ongoing in-service of staff, maintaining confidentiality of information, informants, or concerns regarding interactions with residents, proactively addressing situations which may lead to abuse, providing thorough staff screening, training, and sufficient staff to effectively care for and monitor residents. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or anguish or the willful deprivation of necessary goods or services to maintain physical or mental health, or any sexual act, harassment or placing one in reasonable fear of serious bodily harm. Mental abuse was defined as the use of verbal or nonverbal conduct which caused or had the potential to cause the resident to experience humiliation or intimidation. The prevention and intervention program included ongoing monitoring of staff interactions with residents and identifying events that may constitute or contribute to abuse. The facility re-educated all staff following the incident on 04/16/2026, on types of abuse, when to report, and the facility's Abuse, Neglect, and Exploitation policy. In addition, CNA #1 was terminated after the incident involving Resident #76. These actions were performed before the survey team entered the facility, verified by document review and staff interview resulting in this finding being cited at past non-compliance.

Based on record review and interviews, it was determined that the facility failed to provide written bed hold notification to a resident or the resident's representative upon transfer to the hospital for two (Resident #3 and Resident #71) of two residents who were reviewed for transfers. The findings include: Resident #3 Review of an admission Record indicated the facility admitted Resident #3 with diagnoses that included vascular dementia, schizoaffective disorder bipolar type, and anxiety disorder. Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/23/2026, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of Resident #3's Order Summary Report revealed an order dated 02/13/2026 to transfer to the emergency room (ER) for further evaluation and treatment. Review of the MDS tab in Resident #3's electronic health record revealed a Discharge, Return anticipated MDS was coded on 02/13/2026, with an Entry MDS coded on 03/17/2026. Review of Resident #3's Progress Notes revealed the resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of a readmission – Bed Hold Policy included in the facility admission Packet was signed by Resident #3's Power of Attorney ([NAME]) on 06/20/2025. A written bed hold notice for the discharge of resident dated 02/13/2026 was not found in Resident #3's electronic medical records. During an interview on 06/02/2026 at 2:30 PM the Nurse Consultant (NC) stated there was not a bed hold completed on 02/13/2026 for Resident #3. Resident #71 Review of an admission Record indicated the facility admitted Resident #71 with diagnoses of adjustment disorder, multiple sclerosis, type II diabetes, and schizoaffective disorder. Review of a quarterly MDS with an ARD of 04/02/2026, revealed Resident #71 had a BIMS score of 15, which indicated the resident was cognitively intact. Review of Resident #71's Change of Condition included in the Progress Notes dated 05/06/2026, revealed Resident #71 complained of chest pains, with physician recommendation to send to the ER for evaluation. Review of Resident #71's Behavior Note included in the Progress Notes dated 04/18/2026 revealed recommendations from the physician to send to the ER for evaluation. During an interview on 06/02/26 at 2:30 PM, the Nurse Consultant (NC) stated there was not a bed hold completed on 04/18/2026 or 05/06/2026 for Resident #71. The NC stated, We have already started a Performance Improvement Plan (PIP) with the Social Director who is the one that is supposed to be doing those. During an interview on 06/04/2026 at 8:30 AM, the Social Director stated that she had been in the social position for three or four years. She stated that she was the one responsible for sending written bed holds to the residents or their representative. She reviewed Resident #3 and Resident #71's electronic records and stated that there were no bed holds for either resident. She stated that the purpose of the bed hold was when residents go out to hospital we put them on bed hold. It assures residents that they can come back and have a place to live. She stated that she was counseled one on one and a PIP was started the day before. She stated she did not think that failing to send a bed hold would affect the actual care of the resident, but she guessed it could affect the psychosocial care of a resident especially since we have several mental health residents. Review of a facility policy titled Bed Holds and Returns dated 04/24/2025, revealed Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: the rights and limitations of the resident regarding bed holds.

Number of residents sampled: Number of residents cited: Based on record review, interviews and facility policy review, it was determined that the facility inappropriately discharged one Resident (Resident #76) of three residents reviewed. The findings include: Review of an admission Record indicated the facility admitted Resident #76 with diagnoses that included adjustment disorder with mixed disturbances of emotions and conduct, mood affective disorder, bipolar disorder, nicotine dependence, problem related to social environment, intellectual disabilities, symptoms and signs involving appearance and behavior and traumatic brain injury. Review of the quarterly Minimum Data Set with an Assessment Reference Date of 04/02/2026, revealed Resident #76 had a Brief Interview of Mental Status score of 14, which indicated the resident was cognitively intact. Resident #76's Resident Mood Interview score was 0 for any negative symptoms. The assessment identified no behavioral symptoms towards others or rejection of care. Review of Resident #76's Care Plan Report initiated on 07/04/2024, revealed the resident chose to smoke and required supervision to do so. Resident #76 had no plans to discharge; the facility was their home. Interventions included knocking before entering resident's room, show respect and involve the resident in the plan of care to allow for decision making as able. Resident #76 expressed maladaptive behavior symptoms related to chronic mental illness and adjustment disorder with mixed disturbance of emotions and conduct. Interventions included separate and redirect, explain the desired behavior to the resident, remind the resident they were expected to behave respectfully and maturely, and utilize behavior management techniques to promote and shape the desired behaviors. Techniques such as controlling the environment noise level, over-stimulation, commotion, and close contact were indicated. Direct resident to stay away from people who increase their agitation. Provide opportunities to have space and fresh air. Review of Resident #76's Order Summary Report dated 06/02/2026, revealed Resident #76 had no discharge order given by a provider. Review of a Notice of Immediate Discharge for Resident letter dated 04/24/2026 and signed by the Administrator, revealed the decision has been made to immediately discharge you from the [Facility] due to inability of the facility to meet your safety needs and putting the safety of individuals in the facility in danger. The facility will assist you and your family in securing a safe place to discharge. Review of an Office of Long-Term Care (OLTC) Incident and Accident Report dated 04/16/2026, described an altercation between Resident #76 and Certified Nursing Assistant (CNA) #1 resulting in the suspension of CNA #1 and Resident #76 seeking treatment at the hospital. Review of Resident #76's Hospital Records dated 04/16/2026, revealed the hospital staff contacted the facility who stated they were comfortable taking the resident back. Review of Resident #76's Progress Notes from 04/16/2026 to 04/24/2026 revealed no documentation of aggressive behaviors by the resident towards other resident or staff. Review of the Grievance Log from 04/16/2026 to 04/24/2026, revealed no resident had filed a grievance regarding Resident #76. Review of a Progress Note dated 04/17/2026 at 12:02 PM, revealed Resident #76 stated they were in a good mood and loved living in the facility. Review of a Progress Note dated 04/18/2026 at 6:27 AM, revealed Resident #76 had no behaviors during the shift, had a pleasant attitude, and was compliant with medications. Review of a Progress Note dated 04/18/2026 at 12:15 PM, revealed Resident #76 stated they were in a good mood and loved living in the facility. Review of a Progress Note written by the Administrator dated 04/19/2026, revealed Resident #76 was in a good mood, no emotional upset voiced or noted. Resident was participating in activities, especially smoke breaks, and was observed talking pleasantly to the Social Director (Social). Review of a Progress Note dated 04/20/2026 2:10 PM, revealed Social and the Administrator spoke with Resident #76 after a phone call with the resident's family and they wanted to transfer the resident closer to them. Resident #76 agreed. Review of a Progress Note written on 04/20/2026 at 2:18 PM by Registered Nurse #6 the Director of Nursing (DON) at the time, revealed, Resident #76 was alert at baseline mental status. Staff reports reviewed and no further incidents had been noted since the resident had returned from the hospital. Interventions were in place, including staff awareness of the residents' triggers. No other progress notes were found regarding Resident #76 behaviors or discharge process. During an interview on 06/01/2026 at 3:09 PM, Resident #76's family member stated they discussed a transfer to a closer facility with Social the week after the incident and Resident #76 was agreeable to the transfer. Then the family received a call from the behavioral health hospital questioning placement. The behavioral health hospital stated the facility had discharged Resident #76 to the hospital. The family was unaware she had been moved and stated the resident was upset because they thought they were transferred closer to the family as discussed. During an interview on 06/03/2026 at 11:56 AM, the Ombudsman stated she was contacted by the Administrator after the incident between Resident #76 and CNA #1 but was misled regarding the timeline. I was told it just happened and it was eight days later. The Administrator took the resident back then denied it later. The Ombudsman reported she came to the facility and followed up with the Administrator regarding the falsification of the altercation. The Ombudsman stated the facility never had two staff members on the secured unit and there were not two staff members on the secured unit the day of the incident, the staff member had to call for help. During an interview on 06/04/2026 at 2:30 PM, Social stated, Resident #76 loved living here and did not want to move until the family wanted the transfer. Referrals were started, then prior to discharging to the behavioral health hospital a 30-day discharge notice was given. It was 04/24/2026, eight days after the incident. Social stated she was not aware of any aggression in those eight days towards other residents or staff. During an interview on 06/04/226 at 11:55 AM, the Administrator stated on 04/16/2026 Resident #76 and CNA #1 had an exchange of name calling which escalated to a physical altercation. Resident #76 was sent to the hospital for treatment and returned the same day. The Administrator stated, Resident #76 was heard boasting about the incident and if the resident was capable of the physical altercation that occurred with CNA #1 they did not need to be in their facility. The Administrator stated Resident #76 was not physically aggressive but would call staff names. Resident #76 family wanted the resident transferred closer to them. The transfer process was started on 04/20/2026 with referrals. The day after Resident #76 was transferred to the behavioral health hospital the resident's family was notified. The behavioral health hospital called to send the resident back and were told the facility was seeking placement closer to family. Review of a facility policy titled Discharge Planning Process dated 05/17/2022, revealed each resident will have a discharge plan that focuses on the residents' discharge goals, the preparation to be active partners. The planning process will include the caregiver, the resident, and the interdisciplinary team.

Number of residents sampled: Number of residents cited: Based on interviews, record review, and facility policy review, it was determined that the facility failed to perform blood sugar testing as ordered by a Physician for one (Resident #74) of one resident reviewed. The findings include: Review of an admission Record revealed the facility admitted Resident #74 on 04/21/2025 with diagnoses that included type 2 diabetes (the body cannot use insulin correctly and sugar builds up in the blood.) and hypoglycemia (level of sugar in the blood drops below what is healthy for the person) with an onset date of 06/06/2025. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severe cognitive impairment. Review of an Order Summary revealed Resident #74 had an order dated 06/08/2025 to check blood glucose every morning. If greater than 250 notify Medical Doctor (MD). Review of a June 2025 Medical Administration Record (MAR) revealed Resident #74 order to check blood glucose every AM, if greater than 250 notify MD was not on the June MAR. During an interview on 06/04/2026 at 10:29 AM, Licensed Practical Nurse (LPN) #7 stated that once she received an order from the Physician, she repeated the order to make sure the order was correct. She would then enter the order into the electronic record and notify the oncoming nurse about the new order. LPN #7 stated, the order automatically gets put on the MAR once the order was entered into the system and she did not go and check to make sure the order goes to the MAR. During an interview on 06/04/2026 at 11:41 AM, the Director of Nursing (DON) stated that when an order was received from the Physician the order was put into the electronic record and then the order flowed over to the MAR and then the order was carried through. The DON was asked to review Resident #74's Order Summary and June 2025 MAR. The DON reported that the order to check blood glucose every AM, if greater than 250 notify MD was in the Order Summary but was not on the June 2025 MAR. The DON stated that she expected the staff to put in orders correctly and to make sure that orders were carried out and done. The DON stated there were no in services completed with staff for following physician orders or entering physician orders. On 06/04/2026 at 10:32 AM, the Nurse Consultant stated the facility did not have a policy for Physician Orders, Blood Glucose testing, or Quality of Care. Review of an article dated December 8, 2025, and obtained from a database maintained by the American Diabetes Association of Professional Practice Committee for Diabetes, indicated people with diabetes residing in long-term care settings need careful assessment to establish individualized glycemic goals.

Number of residents sampled: Number of residents cited: Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to provide a comfortable, homelike environment for one (Resident #38) of three residents reviewed. The findings include: Review of an admission Record revealed the facility admitted Resident #38 with diagnoses that included chronic obstructive pulmonary disease (COPD), major depressive disorder, atrial fibrillation, pulmonary embolism (blood clot in the lung), allergic rhinitis (allergies) and housing instability (homeless in the last 12 months). Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/26/2026, revealed Resident #38 had a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact. The MDS also revealed Resident #38 identified as sometimes feeling lonely or isolated from those around, the resident required a walker for mobility, and experienced shortness of breath or trouble breathing with exertion, when lying flat, and was on oxygen therapy. Review of Resident #38's Care Plan Report initiated 08/26/2024, revealed the resident had no plans to discharge and the facility was their home. Resident #38 had impaired gas exchange related to COPD. Interventions included Bilevel Positive Airway Pressure (Bi pap), administer oxygen as ordered, monitor and report signs/symptoms of respiratory distress unrelieved with treatment, monitor resident for shortness of breath. The Care Plan also indicated to implement interventions as ordered, monitor and offer support if needed to prevent or decrease anxiety if increased shortness of breath occurs. The Care Plan did not mention the effects cleaning products had on the resident's breathing status or resulting anxiety. Review of an Order Summary Report revealed Resident #38 had an order dated 09/10//2024 for Bi pap at bedtime, to be removed in the morning, to provide positive airway pressure 10-12 breathes per minute at 100% oxygen related to COPD. The Order Summary also included an order dated 05/07/2026 for oxygen to be delivered through a nasal cannula (NC) at 2 Liters (L) per minute as needed. Review of the Medication Administration Record (MAR) dated 06/2026, revealed Resident #38 received inhalers twice a day and had a rescue inhaler available for emergencies. During a concurrent observation and interview on 06/01/2026 at 11:29 AM, Resident #38 was observed in their room wearing 2 L of oxygen per NC, a towel was seen on the floor inside the door. Resident #38 stated that the cleaning spray housekeeping used outside the door was exacerbating their COPD, and that the towel had been placed under the door in an attempt to block the fumes. During a concurrent observation at interview on 06/03/2026 at 6:57 AM, Housekeeper (HSKPER) #4 stated, there were three types of cleaners used in the facility; a bathroom cleaner, a chemical spray, and [Brand Name Glass Cleaner], the housekeeper showed a spray bottle of blue liquid and stated it was odor eliminating and used to keep down fragrance for allergies and things like that. The pink spray she used on a towel and wiped down the handrails in the hallways. HSKPER #4 stated no one had ever complained of the chemical spray, I keep an eye on them. I know there is a lot of asthma. During an observation of the facility on 06/03/2026 at 7:04 AM, this surveyor noted a heavy chemical smell in the hallway outside of Resident #38's room. During an interview on 06/03/2026 at 4:51 PM, the Housekeeping/Laundry Supervisor (HSKP Supervisor) stated the staff would get an empty bottle to fill and that the products were already diluted, just fill it up and you are ready to go. The pink cleaner was for bathrooms; the green cleaner was biohazard enzymes and was a deodorizer; and the blue cleaner was a multi surface cleaner. The HSKP Supervisor stated the blue cleaner should be used for the hallways, as it kills a lot of things in just a few seconds. The pink one was stronger as far as odor wise, we do not use it in resident rooms, only bathrooms, and try to catch the residents out at therapy or lunch before using it. The HSKP Supervisor stated he was aware of Resident #38's breathing issues and stated, they waited to clean Resident #38's room when the resident was out and sprayed it lightly because the pink cleaner does have more of an odor. Review of a Safety Data Sheet for the multi surface disinfectant cleaner (blue cleaner) issued 08/18/2022, revealed no inhalation health injuries were known or expected under normal use. Review of a Product Specification Document for the disinfecting acid bathroom cleaner (pink cleaner) dated 08/11/2021, revealed if the cleaner was inhaled remove the person to fresh air and treat symptomatically, get medical attention if symptoms occur. During an interview on 06/03/2026 at 5:15 PM, the Administrator and Nurse Consultant were made aware of the concern for an incorrect cleaning product being used outside of Resident #38's room. The Nurse Consultant instructed the HSKP Supervisor to start an in-service with HSKPER #4 and all other housekeepers the next morning regarding correct cleaning products. Review of a facility policy titled Resident Rights revised on 11/01/2022, revealed Federal and state laws guarantee certain basic rights to all residents of the facility These rights include the residents' rights to a safe, clean, homelike environment including but not limited to treatment and supports for daily living safely.

Based on interviews, record review, and facility policy review, it was determined that the facility failed to support resident's rights to accommodate a sexual relationship between consenting adults for two (Resident #3 and Resident #4) of five residents reviewed for resident rights. The findings include: Resident #3 Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/01/2026, revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #3 exhibited physical, verbal, and other behaviors not directed towards others one to three days in the look back period and had no issues with mood during the look back period. The MDS also revealed Resident #3 was independent for mobility. Review of Resident #3's Care Plan Report updated 03/11/2026, revealed Resident #3 had inappropriate seeking of other individual's attention. Care Plan interventions included to separate individuals and redirect. Review of Resident #3's Order Summary, revealed no orders for birth control, sexually transmitted disease testing, or consults to specialized clinics or doctors. Review of Resident #3's Progress Notes revealed no documentation of any education provided or conversations with staff regarding an incident with Resident #4 on 03/11/2026. A review of Resident #3's medical record and witness statements provided by the Administrator and Social Service revealed no assessment was completed for sexual activity before or after the incident. Resident #4 Review of an annual MDS with an ARD of 02/26/2026, revealed Resident #4 had a BIMS score of 12 which indicated the resident had moderate cognitive impairment. The MDS also revealed Resident #4 sometimes had social isolation behaviors only with no mood issues and was independent for mobility. Review of Resident #4's Care Plan Report updated 03/11/2026, revealed the resident had inappropriate seeking of other individual's attention. Care Plan interventions included to separate individuals and redirect. Review of Resident #4's Order Summary, revealed no orders for birth control, sexually transmitted disease testing, or consults to any specialized clinics or doctors. Review of Resident #4's Progress Notes revealed no documentation of any education provided or conversations with staff regarding the incident with Resident #3 on 03/11/2026. A review of Resident #4's medical record and witness statements provided by the Administrator and Social Service revealed no assessment was completed for sexual activity before or after the incident. During an interview on 03/24/2026 at 2:57 PM, Certified Nurse Assistant (CNA) #3 stated, she found Resident #3 and Resident #4 having sex on 03/11/2026. CNA #3 stated, When I opened the door both their pants were down and they were on the floor. CNA #3 stated she notified Licensed Practical Nurse (LPN) #2 and both staff tried to separate the residents. I think me opening the door made them stop. I was told [Resident #4] and [Resident #3] had a history. I think they both wanted it to happen. It looked like they were consenting. During an interview on 03/24/2026 at 4:51 PM, LPN #2 stated after she was notified of the sexual interaction between Resident #3 and Resident #4 the residents were separated and taken to their secure units. There was no plan in place for the residents to have a consensual sexual relationship and no plan for private time for them. LPN #2 stated she was told by her bosses it had happened before. During an interview on 03/24/2026 at 4:00 PM, Resident #3 informed this surveyor they had a relationship with another resident, they did not wish to discuss it and asked the surveyor to leave. During an interview on 03/24/2026 at 4:10 PM, Resident #4 stated, Resident #3 and I got caught. Resident #4 stated that the Administrator told them we could not do that anymore. Resident #4 stated, I want to get a place, we can live together and have all the sex we want. Resident #4 stated they and Resident #3 loved each other and there was no intent to hurt Resident #3. Resident #4 stated the Administrator talked with both residents one day later. Resident #4 stated, They told us not to do it and we don't. I know how to do safe sex; you don't do it no more. During an interview on 03/26/2026 at 1:08 PM, the MDS Nurse stated she was covering as Director of Nursing (DON) during the 03/11/2026 incident. The MDS nurse stated she was with the Administrator, and they spoke with Resident #3 and Resident #4 the day after the incident. We let them know if they wanted to have sex, we would make sure they had privacy and any kind of protection they needed at that time. The MDS Nurse stated the facility did not add anything to the Care Plan because Resident #4 was actually unable do to complete the act related to an Erectile Dysfunction (ED) problem. The MDS Nurse stated, I did not document any of these conversations or interventions. During an interview on 03/26/2026 at 9:07 AM, the Administrator stated on 03/11/2026 Resident #3 and Resident #4 did not actually have sex, they wandered in the room and pulled down their pants. The Administrator stated there was intent because they were seeking each other out. The Administrator also stated Resident #3 and Resident #4 stopped and jumped up when CNA #3 walked in because they thought they were in trouble. The Administrator stated the facility did not have a policy on resident sexual relations. Review of a facility policy titled Resident Rights reviewed date of January of 2024 revealed, Federal and state laws guarantee certain basis rights to all residents of the facility including a resident right to be treated with kindness and respect, communication with people inside the facility, self-determination, and the right to be supported by the facility in exercising their rights.

Based on interviews and record review, it was determined that the facility failed to Care Plan for residents' sexual health and relationship for two (Resident #3 and Resident #4) of five residents reviewed for revised Care Plans. The findings include: Resident #3 Review of an admission Record indicated the facility admitted Resident #3 with diagnoses that included traumatic brain injury, bipolar disorder, mood disorder, and an unspecified mental disorder. Resident #3 was their own person for all legal and medical decisions. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/01/2026, revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 11 which indicated the resident had moderate cognitive impairment. Resident #3 exhibited physical, verbal, and other behaviors not directed towards others one to three days and had no issues with mood during the look back period. The MDS also revealed Resident #3 was independent for mobility. Review of Resident #3's Care Plan Report updated 03/11/2026, revealed Resident #3 had inappropriate seeking of other individual's attention. Care Plan interventions included to separate individual and redirect. Resident #4 Review of an admission Record indicated the facility admitted Resident #4 with diagnoses that included Schizophrenia, Schizoaffective disorder bipolar type, dementia, and psychosis. Resident #4 was their own person for all legal and medical decisions. Review of an annual MDS, with an ARD of 02/26/2026, revealed Resident #4 had a BIMS score of 12 which indicated the resident had moderate cognitive impairment. The MDS also revealed Resident #4 sometimes had social isolation behaviors only, had no mood issues and was independent for mobility. Review of Resident #4's Care Plan Report updated 03/11/2026, revealed Resident #4 had inappropriate seeking of other individual's attention. Care Plan interventions included to separate individual and redirect. During an interview on 03/24/2026 at 2:57 PM, Certified Nurse Assistant (CNA) #3 stated, on 03/11/2026 she found Resident #3 and Resident #4 having sex. When I opened the door both their pants were down and they were on the floor. CNA #3 notified Licensed Practical Nurse (LPN) #2 and both staff tried to separate the residents. I think me opening the door made them stop. I was told [Resident #4] and [Resident #3] had a history. I think they both wanted it to happen. It looked like they were consenting. During an interview on 03/24/2026 at 4:51 PM, LPN #2 stated after she was notified of the sexual interaction between Resident #3 and Resident #4 the residents were separated and taken to their secure units. There was no plan in place for the residents to have a consensual sexual relationship and no plan for private time for them. LPN #2 stated, she was told by her bosses a past relationship existed between the two residents.During an interview on 03/24/2026 at 4:00 PM, Resident #3 stated they had a relationship with another resident but that it was none of my business and told the surveyor to leave. During an interview on 03/24/2026 at 4:10 PM, Resident #4 stated, Resident #3 and I got caught. Resident #4 stated that the Administrator told them, we couldn't do that anymore. I want to get a place, and we can live together and have all the sex we want. Resident #4 stated they and Resident #3 loved each other and there was no intent to hurt Resident #3. Resident #4 stated the Administrator talked with both residents one day later. They told us not to do it and we don't. I know how to do safe sex; you don't do it no more. During an interview on 03/26/2026 at 1:08 PM, the MDS Nurse stated she was covering as Director of Nursing (DON) during the 03/11/2026 incident. The MDS nurse stated she was with the Administrator, and they spoke with Resident #3 and Resident #4 the day after the incident. We let them know if they wanted to have sex, we would make sure they had privacy. And any kind of protection they needed at that time. The MDS Nurse stated she did not add anything to the Care Plan because Resident #4 was actually unable to complete the act related to an Erectile Dysfunction (ED) problem. The MDS nurse stated they did offer interventions for the ED issues. The MDS stated to Resident #4, we would talk to the doctor. She also stated, I did not document any of these conversations or interventions. This surveyor attempted to reach the Medical Director on 03/26/2026, no response to answer and no response to voicemail. During an interview on 03/26/2026 at 9:07 AM, the Administrator stated on 03/11/2026 Resident #3 and Resident #4 did not actually have sex, they wandered in the room and pulled down their pants. The Administrator stated there was intent because they were seeking each other out. The Administrator also stated Resident #3 and Resident #4 stopped and jumped up when CNA #3 walked in because they thought they were in trouble. The Administrator stated she had not provided any education for safe sex and was unsure if other staff had either. The Administrator stated she was not sure why sexual health and relationships were not on Resident #3 and Resident #4's Care Plans because by now it should have been given the time lapses since the event. The Administrator was not aware of the facility's interventions for birth control. I am sure we could get condoms or a prescription. We don't keep anything here for those circumstances. The Administrator stated the facility did not have a policy on resident sexual relations.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to prevent resident abuse for 2 (Resident #1 and Resident #2) of 6 residents reviewed for abuse. The findings include: A review of a facility policy titled, Resident Rights, dated 04/2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect. g. exercise his or her rights as a citizen of the facility. h. be supported by the facility in exercising his or her rights; A review of a facility policy titled, Resident [NAME] of Rights for Nursing Home Residents, dated 07/12/1988, indicated, 2. The right to a safe and clean environment. 10. The right to be free from physical or mental abuse A review of the facility's undated policy titled Abuse Prevention Program, indicated It is the policy of this facility to prevent resident abuse .VI. Protection of Residents. Residents who allegedly mistreat another resident will be immediately removed from contact with that resident. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of the other residents and employees of the facility. VII. Prevention staff will identify residents with increased vulnerability .or who have needs ad behaviors that might lead to conflict. For the purposes of this policy. 1. Abuse: the willful infliction of injury resulting in physical harm, pain, mental anguish or deprivation by an individual. 4. Physical Abuse: Hitting, slapping, pinching, kicking, etc. 1. A review of the Admission Record, indicated the facility admitted Resident #1 on 07/20/2023, with diagnoses that included transient cerebral ischemic attack (brief stroke like attack requiring immediate medical attention), cerebral infarction (interrupted blood flow to the brain causing brain tissue death), and malignant neoplasm of the prostate. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/23/2025, revealed Resident #1 had a Brief Interview for Menal Status (BIMS) score of 7, which indicated the resident had moderate cognitive impairment. Resident #1 was able to walk independently 150 feet and did not require the assistance of a wheelchair. Diagnoses included cancer and stroke. Resident #1 was 66 inches in height and weighed 117 pounds. Resident medications included an antidepressant and an antiplatelet (medication to prevent blood clotting). A review of Resident #1's Care Plan Report, revealed the resident was at risk for abnormal bleeding related to daily usage of antiplatelet and at increased risk for bruising and/or bleeding; was at increased risk for alteration in skin integrity related to cancer and antiplatelet medication; expressed maladaptive behavioral symptoms, related to blocked blood flow to the brain, that included inappropriate sexual behavior with female, urinating on the floor and spreading stool in bathroom. Interventions included monitor and report bleeding; protect skin from accidental injury, monitor skin daily for bruising or bleeding; admission to male secure unit, explain and remind resident of desired behaviors, psychiatric management. A review of Order Summary Report, revealed Resident #1 was admitted to the secured unit; was to be observed for signs and symptoms of bleeding/bruising every shift; and received an antiplatelet daily. A review of Resident Rights and Protection, dated 07/20/2023, indicated Resident #1 received resident rights and abuse protection information from the facility. A review of Consent for Admission to Special Care Unit, signed 10/27/2023, by Resident #1's representative, indicated the care unit provided a supportive, quieter living environment, structured to be a warm, nurturing environment to meet physical, mental, and psychosocial needs. Protection from external stressors and expectations promotes enhanced function and improved quality of life for the resident with dementia. There can also be some risks to residing on the Special Care Unit. Residents on the unit may have inappropriate verbal or physical behaviors, at times including incidents of resident-to-resident altercations. Residents may wander into the personal space of others. A review of eInteract Change in Condition Evaluation, dated 02/11/2025, revealed Resident #1 was sent to the hospital for injuries related to resident to resident. A review of Interact SNF (skilled nursing facility) to Hospital Transfer Form, dated 02/10/2025, indicated Resident #1 was sent to the emergency room at 11:59 PM, for an altercation with resident, was alert and disoriented, and had no skin/wound care. Resident #1's medical record from [Hospital Name] indicated: a. CT head without contrast Result Date:2/21/2025 Interval increased density of bilateral subdural hematomas. On the right measures 1.2 cm in maximum diameter with mildly increased mass effect on the frontal lobe and stable 3mm left midline shift. b. CT angiogram head and neck with 3D reconstruction Result Date:2/21/2025 Non-contrast CT head: Large right convexity subdural hemorrhage has mildly increased in size with interval dependent hyper-density within the collection suggestive of acute on chronic subdural hemorrhage. Moderate left convexity subdural hygroma has also increased in size. Mild 4 mm midline shift to the left without evidence of descending trans tentorial herniation. Left lens subluxation is again noted. c. X-Ray chest AP portable Result Date:2/21/2025 Diffuse emphysematous changes in both lungs. Interval new-ill-defined patchy airspace opacities are seen in the right lower lung, may represent developing pneumonia/aspiration. d. X-Ray foot right AP lateral and oblique Result Date: 2/11/2025 Findings and Impressions: Revisualization of distal fibular and tibial fractures are seen. e. X-Ray hand left AP and lateral portable Result Date: 2/11/2025 Findings and Impression: Diffuse soft tissue swelling is seen throughout the dorsum of the hand and wrist. f. CT head without contrast Result date: 2/11/2025 Stable acute on chronic subdural hemorrhage along the right cerebral convexity with 4mm leftward midline shift. Redemonstration of trace subarachnoid hemorrhage along the right temporal sulci. Left frontal, premaxillary and periorbital soft tissue contusions with traumatic lens subluxation. g. X-Ray hand left PA lateral and oblique Result Date:2/11/2025 Dorsal soft tissue swelling h. ED ultrasound ocular Result Date: 2/11/2025 Lens dislodged; Left lens dislocation; left vitreous hemorrhage i. CT maxillofacial area with contrast Result Date:2/11/2025 Redemonstration of large soft tissue hematoma overlying the left orbit and extending to the frontal and pre maxillary regions. Mild stranding within the left intraconal and extraconal regio concerning for post-septal hemorrhage. Mild proptosis of the left orbit with partial dislocation of the lens. Subtle hyper-densities within left globe concerning for vitreous hemorrhage. Mild displaced left nasal bone fracture. Redemonstration of 1.4 cm mixed density extra-axial fluid collection along the right cerebral convexity. j. CT head without contrast Result date 2/11/2025 Significant subcutaneous soft tissue contusions over the left frontal, orbital, and pre maxillary regions with associated post-septal hemorrhage. There is a partial dislocation of the left lens. Scalp soft tissue contusion over the left parietal convexity. Mixed density subdural hemorrhage. This measures approximately 1.4 cm in maximum dimension and exerts mass effect upon the right cerebral hemisphere. There is approximately 4 mm of leftward midline shift without evidence of herniation. The subarachnoid hemorrhage is also seen along right temporal sulci. 2. A review of the Admission Record, indicated the facility admitted Resident #2 with diagnoses that included Alzheimer's disease, adjustment disorder with disturbance of conduct, dementia with agitation, neurocognitive disorder due to known physiological condition with behavioral disturbance, hallucinations, and disorientation. The quarterly MDS, with an ARD of 01/08/2025, revealed Resident #2 had a BIMS score of 00, which indicated the resident had severe cognitive impairment. Resident #2 had physical and verbal behavior symptoms directed toward others, occurring 1 to 3 days, and other behavioral symptoms not directed toward others that occurred 1 to 3 days. Resident #2 was independent, walking 10 feet and required supervision or touch assistance to walk 150 feet. Active diagnoses included Alzheimer's disease, non-Alzheimer's dementia, adjustment disorder with disturbance of conduct, neurocognitive disorder due to known psychosocial condition with behavioral disturbance, hallucinations, and disorientation. Resident #2 had pain occasionally that rarely affected sleep or activities. Resident #2 was 67 inches in height and weighed 184 pounds. Resident #2 was taking an antipsychotic and antidepressant. A review of Care Plan Report, initiated 07/15/2024, revealed Resident #2 had maladaptive behavioral symptoms related to Alzheimer's dementia, neurocognitive disorder, and hallucinations, resident to resident altercation; used antipsychotic medications related to behavior management; used anti-anxiety medications. Interventions included: utilizing behavior management to promote and shape desired behavior, respectful conduct, no profanity or yelling, make effort to get along with peers; 02/11/2025 resident separated, and Resident # 1was sent via ambulance to the emergency room . A review of Order Summary Report, revealed Resident #2 was admitted to the secured unit on 12/03/2024; had [Brand Name extended-release medication used to treat dementia with agitation] had [Brand Name medication used to treat dementia with mild agitation]; and [Brand Name antidepressant] for neurocognitive disorder with behavioral disturbance and hallucinations. A review of Resident Rights and Protection, dated 07/02/2024, indicated Resident #2 received resident rights and abuse protection information from the facility. A review of Consent for Admission to Special Care Unit. Dated 07/02/2024, by Resident #2's power of attorney (POA)/guardian, indicated the care unit provided a supportive, quieter living environment, structured to be a warm, nurturing environment to meet physical, mental, and psychosocial needs. Protection from external stressors and expectations promotes enhanced function and improved quality of life for the resident with dementia. There can also be some risks to residing on the Special Care Unit. Residents on the unit may have inappropriate verbal or physical behaviors, at times including incidents of resident-to-resident altercations. Residents may wander into the personal space of others. A review of psychiatric Progress Note and Psychiatric Periodic Evaluation, revealed Resident #2 was seen via telemedicine and in person by Psychiatric Mental Health Nurse Practitioner (PMHNP) on 08/02/2024, 08/06/2024, 09/03/2024, 10/15/2024, 12/02/2024, and 12/17/2024. A review of Trauma Screening, dated 02/24/2024, indicated Resident #2 had no screening indicators. Questions 3, 5, 7, 8, and 9 were contradictory to resident diagnoses and documented behaviors. A review of Progress Notes, dated 02/10/2025 at 11:45 PM, indicated Resident #2 attacked another resident (identified as Resident #1), punched Resident #1 4 to 5 times after Resident #1 entered Resident #2's room. During a police interview, Resident #2 stated [pronoun] was in my room and my hand hurts. A review of Progress Notes, dated 02/11/2025 at 4:19 AM, indicated Resident #2 was transferred via EMS to Geri Psych at [Hospital Name]. A review of Progress Notes, dated 02/11/2025 at 2:40 AM, indicated Resident #2 had a change in condition nursing observation and evaluation described as This resident physically attacked another resident. This resident has no injuries. Intervention and recommendation indicated resident was transferred to Geri psych at [Hospital Name]. A review of Progress Notes, dated 02/11/2025 at 4:19 AM, indicated Resident #2 was transferred by ambulance to Geri psych [Hospital Name] per physician order. A review of Progress Notes, dated 02/16/2025 at 5:30 AM, indicated Resident #2 was one on one (constant supervised observation by staff member) and exhibited no behaviors. A review of [City Name] Police Department Incident Report, incident number 2025-017726 dated 02/10/2025 at 11:45 PM, indicated the offence was Battery 2nd degree; weapon force was blunt object; victim Resident #1 with possible internal injury; aggravated assault/homicide category was other circumstances. Suspect identified as Resident #2, mentally afflicted. Narrative stated upon law enforcement arrival, Resident #1 was observed on their knees bleeding from the head, left eye was swollen shut, had dark bruising, cuts and abrasions throughout head area. EMS called to transport to [Hospital Name] for treatment. Resident #2 identified themselves as a federal judge and US Marshall and was [AGE] years old. Neither party were in a clear mental state to answer questions. [Hospital Name] staff advised Resident #1 was stable with a brain bleed and detached eye lens. A review of Licensed Practical Nurse (LPN) # 2 witness statement indicated LPN #2 arrived after the incident occurred and observed Resident #1 laying on floor against Resident #2's bed, surrounded by blood on floor, eye was swollen, laceration to back of head, and blood dripping from nose. Wet floor sign was on the ground, bloody and broken. Resident #2 was agitated and escorted out of the room to the dayroom. LPN #2 returned to Resident #1 and called 911. A review of Resident #2's statement indicated Resident #1 entered Resident #2's room and jumped on Resident #2 four times before Resident #2 pushed Resident #1 out of room. Resident #1 bent Resident #2's finger back and they started fighting, [pronoun] is pretty strong, and I was still trying to get help. We were finally broken up. A review of OLTC Witness Statement indicated Certified Nursing Assistant (CNA) #1 was entering 700 Hall for shift, walked down the hall and went into Resident #2's room and saw Resident #2 hit Resident #1 with a wet floor sign, grabbed Resident #2 to move [pronoun] from room. Resident #2 broke away and swung and hit Resident #1 again. Calmed Resident #2 and went and got LPN #2 to come and check Resident #1. A review of a facility policy titled Abuse, Neglect, and Exploitation, indicated, We are committed to the safety and well-being of all residents. We believe that the resident has the right to be free from verbal, sexual, physical, or mental and psychosocial abuse, neglect, misappropriation of property, and involuntary seclusion. The facility's goal is to prevent abuse through annual and ongoing in-service of staff, maintaining confidentiality of information, informants, or concerns regarding interactions with the residents, proactively addressing situations which may lead to abuse, providing thorough staff screening, training, and sufficient staff to effectively care for and monitor residents. Resident #2 had diagnoses of Alzheimer's disease, adjustment disorder with disturbance of conduct, dementia with agitation, mild neurocognitive disorder with behavioral disturbance, and hallucinations. Resident #2 had a Brief Interview of Mental Status (BIMS) score of 00 (severely cognitively impaired) per quarterly Minimum Data Set (MDS). The MDS indicated that Resident #2 had physical behavioral symptoms directed towards others that occurred for 1 to 3 days. Resident #2 had a history of being in prison due to attacking someone with a baseball bat, and [pronoun] family does not have anything to do with [pronoun] as he is suspected of molesting [pronoun] granddaughter. [Pronoun] is hard of hearing, and in Adult Protective Services (APS) custody. Review of Resident #2's Care Plan, initiated 07/15/2024, revealed the resident used antipsychotic medications related to behavior management. Interventions included to monitor/record occurrence of target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, and document per facility protocol. Monitor, document, and report as needed adverse reactions to anti-anxiety therapy. Unexpected side effects of anti-anxiety therapy: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. A review of Resident #2's Progress Note dated 2/11/2025 at 4:19 AM, indicated that Resident #2 had physically attacked another resident. Resident #2 was transferred to Geri-Psych at [Hospital Name] for evaluation. A review of Resident #1's Medical Records from [Hospital Name] Medical Center dated 2/11/2025, indicated Resident #1 was assaulted at a nursing facility with a wet floor sign. A brain scan revealed bleeding on the brain, swelling around the eye, left nasal bone fracture, leg fractures, and eye dislocation. A review of Resident #1's Event Note dated 2/20/2025 at 11:41 PM, revealed Resident #2 was attacked by another resident. Resident #2 was punched 4-5 times and had a laceration across the back of [pronoun] head. [Pronoun] left eye was grossly swollen, nose was bloody, and left hand was badly bruised, with a cut on the top. Resident #1 was disoriented and weak, but conscious and able to respond to verbal prompting. Not oriented to time, place or location. Pain level was very high but not rated due to disorientation. Resident #1 was transported to [Hospital Name] around 40 minutes after the incident During an interview on 2/25/25 at 12:02 PM, Family member #4 indicated that Resident #1 had transferred to another facility because Resident #1 was afraid to come back to Facility #5 where the resident had been attacked. During a phone interview on 2/25/2025 at 11:45 AM Certified Nursing Assistant (CNA) #1 indicated that he was the only CNA working on the 700 Hall when Resident #2 attacked Resident #1. The 700 Hall was a locked unit at the back of the facility. CNA #1 indicated that he was in another room helping with the heater. CNA #1 indicated that he was making rounds and that's when he observed Resident #2 attacking Resident #1. He indicated that Resident #2 had a wet floor sign striking Resident #1 with it. CNA #1 indicated that Resident #2 had to have grabbed the wet floor sign from the hall, and the sign was not far from Resident #2 ' s room. CNA #1 indicated that the wet floor signs are usually hidden. CNA #1 indicated that Resident #2 had behaviors when the resident felt angry. CNA #1 indicated that he believed Resident #2 had a military background, and some days all the resident talked about was the military. CNA #1 indicated that Resident #1 had attacked another resident before, and it's on file. CNA #1 indicated that Resident #1 roamed into other resident's rooms, and if he takes Resident #1 to the resident ' s room, resident stays 2-3 minutes. I did a double that night and she [The Administrator] sent me home that night. CNA #1 indicated that he was sent home after the incident, and the Administrator informed him that she would give him some protocols to follow the next time he was assigned to the unit. During an interview on 2/25/2025 at 12:30 PM, with Resident #2 while the resident was on one-on-one observation, a staff member was observed sitting outside of Resident #2 ' s door. Resident #2 was deaf, and this surveyor wrote out questions on blank computer paper. Resident #2 was able to answer the questions. Resident #2 indicated that a person came in the resident ' s room around 4:00 in the morning and shut the door. Resident #2 indicated that the person was kicking and choking Resident #2. Resident #2 indicated that the person got meaner and meaner and Resident #2 had to defend theirself. Resident #2 indicated that the wet floor sign was right outside the door. Resident #2 picked up a sign and popped the person with it. Resident #2 indicated that the person was small, but Resident #1 was very strong. Resident #2 indicated that the person bent their hand all the way back, and the person was really trying to hurt Resident #2. Resident #2 indicated that they [EMS] came and picked the person up in a stretcher and took the person out of Resident #2 ' s room. During an interview on 2/26/2025 at 2:32 PM, the Administrator indicated that on 2/10/2025, Resident #2 attacked Resident #1. The Administrator indicated that Resident #2 was placed on one-to-one observations to protect other residents. The Administrator indicated that Resident #2 would be one-to-one observation until the stop sign for Resident #2 ' s door comes, and the resident was evaluated by the provider. The Administrator indicated that she had reached out to the State Hospital for possible evaluation for Resident #2 During an interview on 2/26/2025 at 4:28 PM, LPN #2 indicated Resident #1 was kneeling by the bed on the night Resident #1 was attacked by Resident #2. LPN #2 indicated that Resident #2 was still in Resident 2 ' s room and CNA #1 was standing in front of Resident #2 keeping the resident from approaching Resident #1 again. LPN #2 indicated she told Resident #2 to get out of the room. LPN #2 and CNA #1 escorted Resident #2 to the common area where Resident #2 sat down in a chair. CNA #1 stayed with Resident #2, and LPN#2 stayed with Resident #1. LPN #2 indicated that she did not know if she saw the wet floor sign right away. She indicated that her attention was focused on Resident #1. LPN #2 indicated that Resident #2 had to have gone out of the room and grabbed the wet floor sign, and when she saw the sign, it was shattered and bloody. LPN #2 indicated Resident #1 was kneeling in a praying position beside Resident#2's bed and she ended up leaving Resident #1 there after she determined a level of consciousness and made sure Resident #1 could talk and was breathing. LPN #2 indicated that she did not really want to move Resident #1 because the resident was not in very good shape. LPN #2 indicated that she needed to go call the police, and after determining Resident #1 was okay for the moment right where the resident was CNA #1 stayed with Resident #2. LPN #2 indicated that she came out of the room and called 911 and got an ambulance. LPN #2 indicated that there's a reason Resident #2 was in the room by themself. LPN #2 indicated that Resident #2 had not had a roommate because of Resident #2 ' s behavior. LPN #2 indicated that she thought Resident # 1 and Resident #2 used to be roommates, but there was a lot of hostility. LPN #2 indicated that Resident #1 had dementia and was confused most of the time. LPN #2 indicated that Resident #1 and Resident #2 had never had any other interactions other than being roommates. LPN #2 indicated that Resident #1 and Resident #2 had to be separated when they were roommates, but she was not sure how long ago it was. LPN #2 indicated that Resident # 2 had been on one-to-one observations since the incident happened. LPN #2 indicated that she and CNA #1 were the only staff that witnessed the incident. During an interview on 3/04/2025 at 10:20 AM, CNA #1 indicated that he was responsible for 10-12 residents on average. CNA #1 indicated that when he first made it to the unit Resident #1 was standing by the door close to Resident #1's room. CNA #1 indicated that he was informed by the Administrator that he should have put Resident #1 in the resident ' s room when CNA #1saw Resident #1 wandering. CNA#1 indicated that he lets Resident #1 walk up and down the hall until the resident is tired. CNA #1 indicated that when he entered Resident #2's room that Resident #1 was swinging and hitting Resident #2 when he walked in, and Resident # 2 swung over him. CNA #1 indicated that Resident #2 hit Resident #1 with the wet floor sign while he was in the room. CNA #1 indicated that the wet floor sign broke into pieces, and he got the pieces and put them outside.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure dented cans were promptly removed from stock; leftover meat products were used in a manner to maintain food quality; surfaces were cleaned to provide a sanitary environment for food preparation, floors, dish washer and kitchen walls, door and frames were free of, debris, dirt, grease, rust, stains, wall tiles were replaced; food items stored in the freezer were covered or sealed properly; expired food items were promptly removed from stock; ice machine was maintained in clean and sanitary condition; and dietary staff washed their hands before handling clean equipment for 1 of 1 meal observed. The Findings are: 1. On [DATE] at 1:05 PM, this surveyor observed a shelf on the bottom next to the two-door freezer in the pantry. The shelf had a sign that indicated dented cans go on that shelf. Other food product cans were stored above on different shelves in the pantry. The Dietary Manager (DM) was interviewed and was asked what she does if she had a dented can of food, she indicated kitchen staff put it on the shelf in the pantry and showed the surveyor the shelf in the pantry on the bottom that contained 20 dented cans. The DM was interviewed and was asked what happens to the dented cans if the provider gives them credit, or if she throws them away. The DM stated she normally just lets them sit there, our supplier does not give us credit for them and will not take them back. The DM then indicated she was not going to lie, she normally just let them sit there, unless she was short on stock and needed something, then the kitchen staff will use one of the dented can goods. 2. On ,d+[DATE].25 at 10:01 AM, there was a bag of leftover sausage on a shelf in the refrigerator. The DM was interviewed and was asked what the leftover meat items were for. She stated kitchen staff reheated them the next day and used them for mechanical soft diets. 3. On [DATE] at 10:10 AM, the following observations were made in the storage room: a. An opened box of crusts was on a shelf in the freezer. The box was not covered or sealed. b. A bag of potato chips was on a shelf and had an expiration date of [DATE]. 4. On [DATE] at 10:56 AM, the area in the ice machine panel where ice touches before dropping into the ice collector had wet pinkish, and black colors on it. The Dietary Manager was asked if she could wipe the area. The pinkish and black residue easily transferred to the tissue. She confirmed the ice machine panel had pinkish and black residue on it. The Dietary Manager was interviewed and was asked if she could describe what was observed and who used the ice from the ice machine and how often she cleaned it. The Dietary Manager stated kitchen staff used it to fill beverages served to the residents at mealtimes, and she cleaned it every month. 5. On [DATE] at 11:04 AM, Dietary [NAME] (DC) #1 removed a gallon of milk from the refrigerator and placed it on the counter, contaminating her hands. She used her contaminated gloved hands to pick up glasses by their rims and poured milk and placed them on the trays to be served to the residents for lunch. DC #1 was interviewed and was asked what she should have done after touching dirty objects and before handling clean equipment. DC #1 stated she should have washed her hands. 6. On [DATE] at 1:07 AM, Dietary [NAME] (DC) #2 used oven mitts to place a pan of oven roasted turkey in the oven. He then removed the mitts from his hands, and placed them below the counter, contaminating his hands. Without washing his hands, he picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. When DC #2 was about to place meat items into a blender, DC #2 was interviewed and was asked what he should have done after touching dirty objects and before handling clean equipment. DC #2 stated he should have washed his hands. 7. On [DATE] at 11:36 AM, the following observations were made in the kitchen areas: a. The wall by the door in the dishwashing machine leading to the dining room was cracked, exposing the sheet rock. b. The wall below the dish washing machine had sage color. c. The door frame in the dishwashing machine leading to the dining leading to the dining room was broken off at the bottom of the door, exposing the concert. d. There was a crack in the wall by the door in the dishwashing machine leading to the dining room, exposing the steel. e. The tile over the wall was broken off the wall, exposing the board. f. The overhead metal above the emergency window in the dishwashing machine had rusty stains. g. The inside of the vent hood above the dishwashing machine had rust stains. h. The panels across the ceiling in the dishwashing machine room had rust stains on them, and wood stand where dirty racks were kept was crumbled and had discoloration of rust stains. i. The 4 metal legs of the wood stand had discoloration of black and grayish colors on them. j. The wall below the hand washing sink had yellow stains on it. k. The floor by the deep fryer had thick buildup of grease on it. There was lint hanging from the edges of the deep fryer. l. The floor between the deep fryer and the oven had a buildup of greasy dry food stains settled on them. m. The back of the oven had brown stains. n. The wall below the 3-compartment sink was peeling off exposing the cement. o. The floor between the deep fryer and oven had thick buildup of grease on it. 8. On [DATE] at 12:06 PM, DC #1 opened the refrigerator door and removed a block of cheese slices and placed it on the counter, contaminating her hands. DC #1 untied the bread bag and placed it on the counter, which contaminated her hands. DC #1 removed slices of bread and placed them on plastic wrap laid on the counter. DC #1 removed a slice of cheese from a clear bag and when DC #1 was ready to place a slice of cheese on top of the bread to make a grill cheese sandwich to be served to the resident who asked for it, DC #1 was interviewed. DC #1 was asked what she should have done after touching dirty objects and before handling clean equipment. She stated she should have washed her hands. 9. A review of the facility policy titled Hand washing, not dated and provided by Dietary Manager indicated hands should be washed when entering the kitchen at the start of a shift and after engaging in other activities contaminating the hands.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. The findings are: 1. The [DATE] lunch menu documented the residents who received pureed diets were to receive a #10 scoop (3 ounces) of oven herb roasted turkey, a #8 scoop (,d+[DATE] cup) of candied sweet potatoes, a #8 scoop (,d+[DATE] cup) of seasoned mixed vegetables and a #16 (,d+[DATE] cup ) of pureed dinner roll and for the residents on mechanical soft diets were to receive one dinner roll, a #8 scoop (4 ounces) which ground turkey would be 3 ounces plus one ounce of gravy for total of 4 ounces, and the residents on regular diets were to receive one dinner roll each. 2. On [DATE] 12:30 PM, the following observations were made during the noon meal service. a. On [DATE] at 12:30 PM, dietary cook (DC) #1 served no dinner roll or bread to the residents who received regular diets with their lunch meal, instead of one dinner roll to each resident who received regular diets. b. On [DATE] at 12:33 PM, DC #1 used a 2-ounce spoon to serve a single portion of ground turkey to the residents who required mechanical soft diets, instead of 3 ounces. There was no dinner roll served to the residents on mechanical soft diets, instead of one dinner roll. c. On [DATE] at 12:44 PM, DC #1 used a 2-ounce spoon to serve a single serving of pureed mixed vegetable and pureed sweet potatoes each to the residents on pureed diets, instead of ,d+[DATE] cup of pureed sweet potatoes and ,d+[DATE] cup of pureed mixed vegetables. There was no pureed dinner roll served to the residents on pureed diets, instead of ,d+[DATE] cup of pureed dinner roll. There were substitutes in place of the pureed bread not given. d. On [DATE] at 12:50 PM, DC #1 was interviewed and was asked what spoon size she had used in serving pureed turkey meat and mechanical soft meat and how many servings she gave to each resident. She stated she used a 2-ounce spoon and gave a serving each. e. On [DATE] at 12:53 PM, DC #2 was interviewed and was asked the reason residents on regular diets, mechanical soft diets and pureed diet were not served dinner rolls and he stated there was no reason, he forgot. DC #2 was interviewed and asked if he reviewed the menu before deciding on how much meat and vegetables to serve to the residents on mechanically soft diets and residents on pureed diets. He confirmed he did not review the menu.

Based on record review, interview, and policy review the facility failed to ensure residents received wound care as per Physician's orders for 2 (Resident #2 and #48) of 2 sampled residents who were reviewed for pressure ulcer care. The findings include: 1.Review of an annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/2024, indicated Resident #2 had diagnoses of cancer, anoxic brain injury, and pressure ulcer stage 3, scored 3 (indicating severe impairment) on the Staff Assessment for Mental Status (SAMS), and had one stage 3 pressure ulcer. a. Review of a Care Plan that was updated 09/16/2024, indicated Resident #2 had a stage 3 pressure ulcer to the right heel and the goal of care was the resident would develop clean and intact skin by the review date. b. Review of a form titled Order Recap Report, dated Jan. 15, 2025, indicated Resident #2 had an order with a start date of 09/11/2024, and an end date of 01/08/2025, to cleanse pressure ulcer to right heel with [Name brand antiseptic] solution (topical antiseptic), apply [Narcotic pain medication] moistened gauze, and wrap with [name brand] wrap daily. c. Review of a Physician's Order dated 1/9/2025, indicated, Cleanse pressure ulcer to right heel with wound cleanser, apply silver alginate to wound bed, cover with gauze and wrap with [name brand] wrap. Change every other day and as needed (PRN) one time a day every Monday, Wednesday, Friday for wound management and as needed for missing/soiled dressing d. Review of Resident #2's November 2024, December 2024, and January 2025 Treatment Administration Records (TARs) did not show staff initials to indicate wound care was done as ordered on 11/02/2024, 11/03/2024, 11/05/2024, 11/10/2024, 11/16/2024, 11/17/2024, 11/17/2024, 11/19/2024, 11/23/2024, 11/29/2024, 11/30/2024, 12/02/2024, 12/03/2024, 12/07/2024, 12/11/2024, and 01/13/2025. e. On 01/16/25 at 9:10AM, the Treatment Nurse reviewed Resident #2's November 2024, December 2024 and January 2024 TARs in the electronic record and confirmed that wound care as per physician orders was not initialed as being done on 11/02/2024, 11/03/2024, 11/05/2024, 11/10/2024, 11/16/2024, 11/17/2024, 11/19/2024, 11/23/2024, 11/29/2024, 11/30/2024, 12/02/2024, 12/03/2024, 12/07/2024, 12/11/2024, and 01/13/2025. The Treatment Nurse stated that some of those dates were on the weekend and the floor nurses who are responsible for doing wound care might have forgotten to document. The Treatment Nurse confirmed the treatment record should have been initialed to verify the treatment was done and wound care orders should be followed for proper healing and to prevent infection. f. On 01/16/25 at 9:20 AM, the Director of Nursing reviewed the electronic record of Resident #2's TARs for November 2024, December 2024, and January 2025, and verified that wound care was not initialed as done as ordered on 11/02/2024, 11/03/2024, 11/05/2024, 11/10/2024, 11/16/2024, 11/17/2024, 11/19/2024,11/23/2024, 11/29/2024, 11/30/2024, 12/02/2024, 12/03/2024, 12/07/2024, 12/11/2024, and 1/13/2025. The Director of Nursing stated floor staff and agency staff sometimes are busy and forget to chart, but if it was not charted it was not done and it was important that wound care was done as ordered so wounds healed properly and timely. g. On 01/16/25 at 9:30 AM, the Administrator was asked for a policy on wound care. h. On 01/16/2025 at 9:40AM, the policy titled Wound and Pressure Ulcer Management Policy (revision date 11/01/2022), provided by the Administrator, indicated the organization is committed to providing a comprehensive wound management program and any resident with wounds receives treatment and services consistent with the resident's goals of treatment. 2. Review of a significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/2024, indicated Resident #48 had diagnoses of non-Alzheimer's dementia, hemiplegia (not able to move one side of the body), gastrostomy (feeding tube going directly to the stomach or G-tube), and encephalopathy (change in how the brain functions). Review of the December 2024 Treatment Administration Record (TAR) report, updated12/06/2024, indicated Resident #48 needed treatment for a stage 2 pressure ulcer to the left gluteal cleft (left buttock). The verbiage on the TAR was as follows: Cleanse pressure ulcer to gluteal cleft with wound cleanser, pat dry, apply calcium alginate to wound bed. Cover with foam dressing Mon, Wed, Fri one time a day every Mon, Wed, Fri. As indicated on the TAR, the order started 12/06/2024. The TAR also indicated Resident #48 needed a daily dressing change to the gastrostomy site (G-Tube). The verbiage on the TAR was as follows: Cleanse G-Tube site with wound cleanser, pat dry, and cover with dressing daily. One time a day for tar. As indicated on the TAR, the order started 12/06/2024. A review of Resident #48 ' s January 2025 TAR did not show staff initials indicating wound care was done for the pressure ulcer dressing changes for 01/13/2025. In addition, the TAR did not show staff initials indicating wound care was done for the G-Tube on 01/05/2025, 01/07/2025, 01/11/2025, and 01/13/2025. A review of Resident #48 ' s December 2024 TAR did not have staff initials to indicate wound care was done for the pressure ulcer for 12/07/2024 and 12/27/2024. In addition, a review of the TAR did not show staff initials to indicate wound care was done for the G-tube for 12/07/2024, 12/22/2024, and 12/27/2024. On 01/16/2025 at 11:00 AM, The DON was interviewed regarding the dressing changes and missing documentation. The DON verified there should be initials in the blanks of the dressing changes, to indicate it was done. For December 2024, it was verified by the DON there was missing documentation for the pressure ulcer on 12/07/2024 and 12/27/2024. For December 2024, it was verified by DON there was missing documentation for the G-tube 12/07/2025, 12/22/2024, and 12/27/2024. For January 2025, it was verified by the DON there was missing documentation for the pressure ulcer on 01/13/2025. For January 2025, it was verified by the DON that there was missing documentation for the G-tube 01/05/2025, 01/07/2025, 01/11/2025, and 01/13/2025. It was stated by the DON that it was important for staff to document regarding why a dressing change was not being done so the facility could see if another shift needed to be responsible for the dressing change, and to see if the sites were clean, check for infection, or getting worse. 51381

Based on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure that staff performed hand hygiene when changing gloves when contaminated during indwelling urinary irrigation catheter care for 1 (Resident #36) of 1 sampled resident reviewed for catheter care and failed to ensure staff performed hand hygiene when changing gloves during wound care for 1 (Resident #48) of 2 sampled residents observed for wound care. 1. Review of Resident # 36 ' s Order Summary revealed had diagnoses of coronary artery disease (CAD), neurogenic bladder, acute kidney failure. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/08/24, indicated that the resident scored 15 on the Brief Interview for Mental Status (BIMS) (13-15 indicates cognitively intact), and Resident #36 had a catheter (indwelling). a. On 01/15/2025 at 9:00 AM, this surveyor observed the Treatment Nurse irrigate indwelling urinary catheter with 60 cubic centimeters (cc) of normal saline. Gloves were changed correctly. Hand hygiene was not performed with glove changes. b. On 01/15/2025 at 9:15 AM, this surveyor interviewed the Treatment Nurse regarding what she should have done differently. The Treatment Nurse stated she should have performed hand hygiene. This surveyor asked what the reason for hand hygiene was. The Treatment Nurse stated the purpose was to prevent infection. c. On 01/15/2025 at 12:30 PM, this surveyor requested a hand hygiene/hand washing policy. d. On 01/15/2024 at 1:11PM, the Administrator stated they do not have a policy on hand hygiene/hand washing. Review of Resident #48 ' s significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/2024, indicated Resident #48 had diagnoses of non-Alzheimer's dementia, hemiplegia (not able to move one side of the body), gastrostomy (feeding tube going directly to the stomach or G-tube), and encephalopathy (change in how the brain functions). On 01/15/2025 at 9:00 AM, the Treatment Nurse was observed while changing the dressings for both the gastrostomy tube (G-tube) and the pressure ulcer to the left buttocks for Resident #48. Resident #48's room displayed Enhanced Barrier Precautions (EBP) signage. Steps in the process observed were as follows: 1) The nurse performed hand hygiene, donned gown and gloves, and removed the old G-tube dressing. 2) The nurse applied wound cleanser with 4x4 gauze. 3) The nurse took off dirty gloves and donned clean gloves without performing hand hygiene. 4) The nurse placed the new 4x4 gauze dressing around the G-tube and secured with tape. 5) The nurse removed the old dressing from the left buttocks, cleansed the area with wound cleanser, patted the area dry, and removed gown/gloves. 6) The nurse went into the corridor, performed hand hygiene, and donned new gloves and gown. 7) The nurse applied the new dressing to the buttocks. 8) The nurse changed gloves, without performing hand hygiene, and concluded Resident #48's care by repositioning the resident and restarting the tube feeding. On 01/16/2025 at 9:50 AM, the Administrator verified there was no hand hygiene policy. On 01/16/2025 at 11:55 AM, the Treatment Nurse was interviewed regarding hand hygiene for EBP, and the wound care performed on 01/15/2025 at 09:00 AM, for Resident #48. The Treatment Nurse stated the process should be to sanitize hands prior to donning a new pair of gloves, and that was not done consistently during the dressing change observations. The Treatment Nurse stated it was important to perform hand hygiene because it could help reduce the spread of infection. 51381

Based on record review and interview, the facility failed to ensure residents' decisions as to whether they desired to have, or did have, an advance directive, were documented in a prominent part of the clinical record, to ensure their wishes were known regarding acceptance or rejection of any life-sustaining treatments in the event of their incapacitation for 1 (Resident # 30) of 1 sampled resident whose clinical records were reviewed for advance directive information. The findings are: 1. Resident #30 was admitted to the facility on [DATE] and had a diagnosis of respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, cerebral palsy, anxiety disorder, and emphysema. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/2024 documented the resident scored 15 (13-15 indicates intact cognation) on the Brief Interview for Mental Status (BIMS). a. On 01/15/2025 at 9:45 AM, the Administrator (AD) provided a 2-page form for Resident #30, titled Physician Orders for Life-Sustaining Treatment (POLST), dated 11/29/2024, section D, was marked, Advance Directive dated (blank) available and reviewed. b. On 01/15/2025 at 9:45 AM, the AD provided a Resuscitation Designation Order dated 11/29/2024 for Resident #30. #2 was marked - I do have an Advance Directive, if yes, then select which of the following will be on file: Power of Attorney was selected. c. On 01/15/2025 at 9:45 AM, the AD provided a six-page document titled Iowa General Durable Power of Attorney, for Resident #30. The power of attorney was dated 08/24/2022. On the first page, second paragraph, it states, This power of attorney does not authorize the agent to make health-care decisions for you. d. On 01/16/2025 at 10:57 AM, this surveyor asked the AD to review Resident #30's durable power of attorney and see what the second paragraph said. The AD read the power of attorney ' s second paragraph out loud This power of attorney does not authorize the agent to make health-care decisions for you. This surveyor asked the AD if this durable power of attorney covered health care decisions. The AD indicated it did not. This surveyor asked the AD if Resident #30 would need an advance directive based on what she just read in the power of attorney. The AD indicated that Resident #30 would need an advance directive to indicate what the resident wanted or did not want. e. On 01/16/2025 at 12:19 PM, the Administrator provided a policy for advance directives titled Policies and Procedures Subject: Advance Directives, Revise date 11/01/2022. #1 on the first page states Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

Based on observations, interviews, record review, and facility document review, it was determined the facility failed to ensure the resident received a bath/shower per the schedule to promote good hygiene for 1 (Resident #44) of 18 sampled residents reviewed for assisting residents to perform activities of daily living (ADLs). Findings include: The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/06/2024, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Diagnoses on the MDS included diabetes (abnormal blood sugar), seizure disorder (neurological condition), obesity, and an ulcer on the lower extremity. The resident was observed, and records were reviewed, for ADLs being completed. 1) On 01/14/2025 at 9:35 AM, Resident #44 stated that some residents were not getting showers frequently enough. Resident #44 stated residents needed a shower three times per week and it was only carried out once or twice per week. Resident #44 stated [pronoun] needed minimal assistance but still must have staff in attendance to go to the shower and complete the shower. 2) On 01/16/2025 at 3:28 PM, Licensed Practical Nurse (LPN) #3 was interviewed regarding the process for residents to have a shower or bath. LPN #3 stated the process for the resident hall was even-numbered rooms get a bath/shower on Monday, Wednesday, and Friday. The odd-numbered rooms get a bath/shower on Tuesday, Thursday, and Saturday. A-beds are the responsibility of the aides on the 7A-3P shift. B-beds are the responsibility of the aides on the 3P-11P shift. When LPN #3 was asked how a nurse would know if a resident did not get a bath or shower, they stated they would notice the resident was in the same clothes. An alert resident would notify the nurse that they did not get bathed. Since the responsibility of a bath/shower was up to the aide, a nurse would follow up with the aide, if needed. 3) On 01/16/2025 at 3:37 PM, ADL records were reviewed for Resident #44 from October 2024 to the present. According to the process mentioned by LPN#3, there were 43 opportunities for a bath/shower to be documented and a total of 9 areas blank, with no staff initials to indicate a bath/shower was completed. The dates with no staff initials were as follows: a. 10/03/2024 - Thursday b. 10/05/2024 - Saturday c. 10/26/2024 - Saturday d. 11/02/2024 - Saturday e. 11/05/2024 - Tuesday f. 12/05/2024 - Thursday g. 12/14/2024 - Saturday h. 01/04/2025 - Saturday i. 01/09/2024 - Thursday 4) On 01/16/2025 at 9:00 AM, LPN #3 was interviewed regarding the documentation for bathing/showering/ADLs. LPN #3 responded that the nurses do not have access to the documentation, and they are not able to review it. 5) On 01/16/2025 at 11:00 AM, the Director of Nursing (DON) was interviewed regarding the gaps in the documentation of the ADLs for the records from October 2024 to the present. The DON verified that a total of 9 days of documentation were missing over the review period, to indicate a bath/shower was completed. The DON stated it was important to see if a bath was done or not done. The DON also stated that it was important to see if there was an issue with giving a bath, or if there was something they needed to fix.

Based on interviews, record review, and policy review, the facility failed to ensure staff monitored the skin and applied ointment as ordered by the physician for 1 (Resident #36) of 1 sampled resident reviewed for skin issues. The findings are: 1. Review of an Order Summary revealed Resident # 36 had diagnoses of spinal stenosis, coronary artery disease (CAD), neurogenic bladder, acute kidney failure. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/08/2024 documented that the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. On 01/15/2025 at 7:15 PM, review of a Physician's Order, dated 3/08/2024, stated: [brand name] external ointment (Emollient) Apply to bilateral lower extremities (BLE) topically one time a day for dry skin and apply to BLE topically as needed for dry skin. b. On 01/15/2025 at 7:30 PM, the Treatment Administration Record (TAR) report for January 2025 showed 3 missed days of [brand name] ointment not applied as ordered 01/7/2025, 01/11/2025 and 01/13/2025. c. On 01/16/25 at 8:35 AM, this surveyor interviewed the Treatment Nurse regarding missed treatments. The Treatment Nurse stated they were not aware of any missed treatment. d. On 01/16/25 at 8:40 AM, the surveyor interviewed the Administrator regarding residents not receiving treatments as ordered. The Administrator stated she was often made aware after this occurred, often with agency nurses. Attempted to provide treatments, it was often too late, the next day.

Based on observations, interviews, record review, and facility document review, it was determined the facility failed to provide safety during the process of medication administration for one (Resident #44) of 18 sampled residents reviewed for being free of Accident Hazards/Supervision/Devices. The findings include: Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/06/2024, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Diagnoses on the MDS included diabetes (abnormal blood sugar), seizure disorder (neurological condition), obesity, and an ulcer on the lower extremity. The resident was observed, and their record reviewed, for safe medication practices. 1) On 01/05/2025 at 7:50 AM the medication pass process was observed for Resident #44: a. Licensed Practical Nurse (LPN) #3 had a cup with two medications in the cup. LPN #3 stated the medicines were [name brand anticonvulsant and nerve pain treatment medication] 50 mg and [Name brand combination pain relief medication] 10/325 mg - which were both handled as a controlled substance at the facility. LPN #3 was observed walking into Resident #44's room, gave the cup of medicines to Resident #44, and left the room prior to the resident taking the medications orally. b. Medication Technician (MT) #4 was observed to place thirteen medications into a cup, walk into the room, give the cup of medications to Resident #44, and leave the room prior to the resident taking the medications orally. c. Upon interview of LPN #3 and MT #4 regarding the process of medication pass, they agreed that leaving the medications with the resident to take unsupervised could lead to them pocketing the medications and causing self-harm or unintentional harm. 2) On 01/16/2025 at 10:15 AM, the Administrator provided a policy/procedure titled Checklist for completing proper steps in the administration of medications. One step in the body of the document stated, Observe the resident take the medication. 3) On 01/16/2025 at 11:00 AM, the Director of Nursing (DON) was interviewed regarding the process of administering medications. The DON stated the step listed in the facility policy, observe the resident take the medications, was present to ensure a resident did not take pills out of their mouth.

Based on interviews, record review, and facility document review, it was determined the facility failed to have a medication as ordered for treatment available for 1 (Resident #36) of 1 sample resident who was reviewed for pain control. The findings are: 1.Review of an Order Summary revealed Resident #36 had diagnoses of spinal stenosis, coronary artery disease (CAD), and acute kidney failure. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/08/2024, indicated the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and took opioid (pain) medications. a. On 01/15/25 at 2:15 PM, review of Progress Notes on 12/15/2024 10:33, - Medication Administration Note Text: [Narcotic pain medication] Oral Tablet 5-325 milligrams (MG) Give 1 tablet by mouth two times a day for pain awaiting delivery from pharmacy. On 12/14/2024 09:24, Medication Administration Note Text: [Narcotic pain medication] Oral Tablet 5-325 MG Give 1 tablet by mouth two times a day for pain awaiting delivery from pharmacy. On 12/12/2024 12:19, Medication Administration Note Text: [Narcotic pain medication] Oral Tablet 5-325 MG Give 1 tablet by mouth two times a day for pain, Pharmacy Pending. b. On 01/15/25 at 2:35pm, this surveyor interviewed Licensed Practical Nurse (LPN) # 3 and asked if the residents have not had any medication, especially pain medication available for administration. LPN #3 stated, Yes. It can take 1-2 days for delivery and staff calls the pharmacy for delivery. c. On 01/15/25 at 2:45pm, this surveyor received a policy provided from the Administrator titled Ordering and Receiving Medications from Non-Contracted Pharmacy which noted if medication is delayed, the nurse may order from Pharmacy and the facility will assume responsibility. d. On 01/16/25 at 8:40 am, this surveyor interviewed the Administrator regarding the residents not receiving medications as ordered. The Administrator stated she was often made aware after this occurred, often with Agency nurses, and medication was ordered as soon as possible.

Based on observation, interview, and record review the facility failed to coordinate assessments with the PASARR (Preadmission Screening and Resident Review) program by obtaining a copy of the completed Level II PASARR, so any recommendations could be incorporated into the resident's assessment, care planning and transition of care for 1 (Resident #7) of 1sample resident reviewed for PASARR. These are the findings: 1. Resident #7 was admitted to the facility on [DATE] and had diagnoses of schizoaffective disorder, auditory hallucinations, delusional disorders, unspecified mood [affective] disorder and anxiety disorder. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 12/17/2024, documented that the resident scored 15 (13-15 indicating cognitively intact). a. Resident #7 ' s Care Plan with an initiated date of 9/19/2024, documented, Focus: Resident expresses maladaptive behavioral symptoms related to: A diagnosis of chronic mental illness (schizophrenia). The resident's problems/symptoms are manifested by hallucinations (auditory), the resident's problems/symptoms are manifested by delusions (irrational/bizarre thoughts). b. On 01/15/2025 at 9:45 AM, the Administrator (AD) provided a letter dated 08/28/2024, from the designated state agency, which indicated Resident has been approved for nursing home placement by OLTC (Office of Long-Term Care) and may enter nursing home of his/her choice, Attention Nursing Facilities: You Must contact [designated state agency] with the Client's admitted in order to receive your client's completed PASRR evaluation. c. On 01/16/25 at 11:23 AM, the AD indicated they could not locate a completed Level II PASRR evaluation for Resident #7. d. On 01/6/25 at 12:18 PM, the AD indicated they did not have a policy for PASRRs.

Based on observation, interview, and record review, the facility failed to ensure residents skin treatments were completed to promote healing per physician's orders for 3 (Residents #2, #3, and #4) of 4 sampled residents. The findings are: Review of an Order Summary Report revealed Resident #2 had a diagnosis of veinous insufficiency and chronic venous hypertension with ulcer of left lower extremity. An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/07/2024 documented a Brief Interview for Mental Status (BIMS) of 15 (13-15 indicates cognitive) and had two venous ulcers. Review of an Order Summary Report revealed Resident #2 had an order dated 08/02/2024 that indicated, Wound Care: wash all wounds on entire bi-lateral lower legs and feet with (antibacterial, antimicrobial skin cleanser), apply a thin layer of collagen gel to wounds, cover with pad and secure with woven gauze wrap, tape to secure and compression stockings to bilateral legs under (hook and loop) wrap every other day on Monday, Wednesday and Friday. Resident #2's Care Plan initiated 05/14/2024 documented staff were to perform wound care per physician's order. Review of Resident #2's Treatment Administration Record for June, July and August 2024, indicated 15 times treatment to lower extremities had not been documented as having been completed. On Wednesday, 08/21/2024 at 3:40 PM Resident #2 was asked if the treatment to their lower extremities had been completed that day. Resident #2 replied that it had not, they (nurses) get busy sometimes and it gets skipped. When questioned if treatments frequently were missed, Resident #2 confirmed they had been. Review of an Order Summary Report revealed Resident #3 had had diagnoses of acute pyelonephritis and hydronephrosis with ureteral stricture. A Quarterly MDS with ARD of 08/03/2024 documented a BIMS of 15 (cognitively intact) with no refusal of care behaviors, had a urinary catheter and an ostomy, and received scheduled pain medications with occasional pain rated at 5/10. Review of Resident #3's Physician's Orders revealed an order for, External Ointment (Emollient) Apply to bilateral lower extremities (BLE) topically one time a day for Dry Skin with an order date of 03/08/2024. Review of Resident #3's Care Plan revealed instruction to keep skin clean and dry, and to use lotion on dry skin. Review of Resident #3's Treatment Administration Record (TAR) for June, July and August 2024 indicated a total of 40 days the treatment to resident's lower legs had not been documented as being done. During rounding on 08/21/2024 at 10:09 AM, Resident #3 voiced concerns with his/her treatment not being completed consistently. Resident #3 reported concern about their lower legs becoming dry, flakey, and itchy again. Review of an Order Summary Report revealed Resident #4 had diagnoses of pressure-induced deep tissue damage of right heel, muscle wasting and atrophy, and dysphasia (resident unable to verbally communicate). The Quarterly MDS with an ARD of 06/21/24 documented a Staff Assessment of Mental Status (SAMS) of moderately impaired and indicated Resident #4ambulated in a wheelchair and had 1 unstageable deep tissue injury (DTI). Resident #4's August 2024 Physician Orders indicated, Cleanse unstageable pressure ulcer to right heel with dilute sodium hypochlorite, then apply dilute sodium hypochlorite moistened gauze and wrap with gauze wrap daily, change dressing to right heel wound daily and to offload heel using a pressure reducing boot. Resident #4's June, July and August 2024 TARs documented 25 times the treatment to right heel had not been documented as being done. Observation of Resident #4's dressing on 08/21/2024 did not indicate a date the dressing was placed. The dressing was soiled with a light brown substance that had soaked through the dressing. On 08/22/2024 at 12:30 PM, the Administrator was asked how agency staff is oriented. She provided 2 one-page orientation sheets, one for certified nursing assistants and one for licensed nurses. The Administrator stated this information was provided and the agency was orientated to the facility prior to beginning their shift. On 8/22/2024 at 12:50 PM the Director of Nursing (DON) (who had been at this position for approximately one month) was asked how agency staff was orientated. She confirmed they are given a one-page instruction sheet with computer log in, and that she didn't think it was much of an orientation. When questioned how staff is monitored to ensure tasks are being completed, she stated after shift, documentation is reviewed for completion and tasks are signed. When asked how appropriate staff are assigned to residents, she replied that the Administrator is in charge of staff scheduling at this time and that she tries to keep the same people working with the same residents for continuity of care. Review of the nursing one-page orientation sheet received from the Administrator 8/22/2024 at 12:30 PM revealed that all tasks are to be completed during the shift including documentation on the Medication Administration Record and Treatment Administration Record. The Wound and Pressure Ulcer Management Policy, obtained from the Administrator on 08/22/2024 at 1:55 PM, documented that treatments should be performed according to physicians orders.

Based on observation, interview, and record review, the facility failed to ensure nursing staff were completing treatments per physician's orders for 3 (Residents #2, #3, and #4) of 4 sampled residents. The findings are: 1. Review of an Order Summary Report revealed Resident #2 had diagnoses of veinous insufficiency and chronic venous hypertension with ulcer of left lower extremity. An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/07/2024 revealed a Brief Interview for Mental Status (BIMS) of 15 (13-15 indicates cognitive) and had 2 venous ulcers. Review of an Order Summary Report revealed Resident #2 had an August 2024 Physician's order that read, Wound Care: wash all wounds on entire bi-lateral lower legs and feet with (antibacterial, antimicrobial skin cleanser), apply a thin layer of collagen gel to wounds, cover with pad and secure with woven gauze wrap, tape to secure and compression stockings to bilateral legs under (hook and loop) wrap every other day on Monday, Wednesday and Friday. Resident #2's Care Plan, initiated 05/14/2024, documented staff were to perform wound care per the Physician's order. Review of the Treatment Administration Record for June, July, and August 2024 indicated 15 times treatment to Resident #2's lower extremities had not been documented as having been completed. 2. Review of an Order Summary Report revealed Resident #3 had diagnoses of acute pyelonephritis and hydronephrosis with ureteral stricture. A Quarterly MDS with ARD of 08/03/2024 documented a BIMS of 15 with no refusal of care behaviors, had a urinary catheter and an ostomy, and received scheduled pain medications with occasional pain rated at 5/10. Review of Resident #3's Order Summary Report revealed a Physician's orders that read, External Ointment (Emollient) Apply to bilateral lower extremities (BLE) topically one time a day for Dry Skin with an order date of 03/08/2024. Review of Resident #3's Care Plan documented staff were to keep skin clean and dry. Use lotion on dry skin. Review of Resident #3's Treatment Administration Record for June, July, and August 2024 indicated a total of 40 days the treatment to resident's lower legs had not been documented as being done. During rounding on 08/21/2024 at 10:09 AM, Resident #3 voiced concerns with treatments not being completed consistently. Resident #3 reported being concerned about their lower legs becoming dry, flakey, and itchy again. 3. Review of an Order Summary Report revealed Resident #4 had diagnoses of pressure-induces deep tissue damage of right heel, muscle wasting and atrophy and dysphasia (resident unable to verbally communicate). The Quarterly MDS with an ARD of 06/21/24 documented a Staff Assessment of Mental Status (SAMS) of 2, indicating moderate impairment, ambulated in a wheelchair, and had 1 unstageable deep tissue injury (DTI). Resident #4's August 2024 Physician Orders included an order that read, Cleanse unstageable pressure ulcer to right heel with dilute sodium hypochlorite, then apply dilute sodium hypochlorite moistened gauze and wrap with gauze wrap daily, change dressing to right heel wound daily and to offload heel using a pressure reducing boot. Resident #4's June, July and August 2024 Treatment Administration Records documented 25 times the treatment to right heel had not been documented as being done. On 08/21/2024 at 3:40 PM, Resident #2 was asked if ordered heel treatment had been completed that day, Resident #2 replied that it had not, they (nurses) get busy sometimes and it gets skipped. When questioned whether treatments frequently were not completed, Resident #2 confirmed they had been. On 08/22/2024 at 12:30 PM, the Administrator was asked how agency staff are oriented. She provided 2 one-page orientation sheets, one for certified nursing assistants and one for licensed nurses. The Administrator stated this information was provided and the agency was orientated to the facility prior to beginning their shift. On 8/22/2024 at 12:50 PM, the Director of Nursing (DON) was asked how agency staff was orientated. She confirmed they are given a one-page instruction sheet with computer log in, and that she didn't think it was much of an orientation. When questioned how staff is monitored to ensure tasks are being completed, she stated after shift, documentation is reviewed for completion and tasks are signed. When asked how appropriate staff are assigned to residents, she replied that the Administrator is in charge of staff scheduling at this time and that she tries to keep the same people working with the same residents for continuity of care. Review of the nursing one-page orientation sheet received from the Administrator 8/22/2024 at 12:30 PM documented that all tasks are to be completed during the shift including documentation on the Treatment Administration Record.

Based on record review and interview, the facility failed to provide necessary care and services to identify and manage skin complications, as evidenced by failure to accurately perform weekly body audits, which resulted in a delay in identifying and addressing a serious complication of the skin on the resident's left foot that resulted in the resident developing gangrene which resulted in body parts being surgically removed for 1 (Resident #323) of 1 sampled resident. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #323, who developed gangrene in the 3rd, 4th and 5th toes of the left foot resulting in surgical amputation of the 4th and 5th toes. This failed practice had the potential to affect all 74 residents who resided in the facility. The Administrator was notified of the Immediate Jeopardy on 1/31/24 at 4:34 PM; and failed to ensure Resident #66 had an order for a treatment to the left wrist area and the bandage was changed to prevent infection. This failed practice had the potential to affect 14 residents who resided on 600 Hall. The findings are: 1. Resident #323 had diagnoses of Type 2 Diabetes Mellitus with Hyperglycemia and Need for Personal Care. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/12/24 documented the resident had no venous or arterial ulcers, no other ulcers, wounds and skin problems, and no skin and ulcer/injury treatments. A Care Plan initiated on 02/15/22 documented the resident had a focus problem of Diabetes Mellitus and an approach was, Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness . Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails . [Resident #323] has an ADL [Activities of Daily Living] Self Care Performance Deficit r/t [related to] CVA [Cerebrovascular Accident] .BATHING: The resident is able to: Shower with physical assist x's [times]1 . Weekly Skin Audits for 12/20/23, 12/27/23, 1/3/24, and 1/10/24 documented the following: 1. Does resident have loss of skin integrity? (This includes the skin under a brace or splint) 1. No .2. Does resident have a new loss of skin integrity? 1. No .3. Following resident's current skin care interventions . The Progress Notes were reviewed for 11/01/23 to 01/11/24 and there was no documentation regarding any skin issues or treatments to Resident #323's feet. A Health Status note dated 1/12/24 at 12:32 PM documented, Note Text: Assessed left foot, top half of foot at an horizontal angle noted extremely dark in color, faint papable [palpable] pulses. The fourth, and fifth metatarsals are necrotic in color, scant amount of red drainage moted to 5th toe with less than an size opening at site. Provider nurse in facility . A Weekly Skin Check dated 1/12/24 documented, . 1. Does resident have loss of skin integrity? (This includes the skin under a brace or splint) 1. No . 2. Does resident have a new loss of skin integrity? . 2. Yes - Weekly Wound Evalution [Evaluation] required for each area of loss of skin interity [integrity] 3. Following resident's current skin care interventions . A Nursing Progress Note dated 1/12/24 at 1:28 PM documented, .[Provider Name] in facility, made aware of, stated to send resident to ED [Emergency Department] for admission . An SBAR (Situation Background Assessment Recommendation) Summary dated 1/12/24 at 1:33 PM documented, .Nursing observations, evaluation, and recommendations are: Resident c/o [complaints of] increased pain to L foot. upon assessment, dark eschar with purulent drainage noted to 4th and 5th digits Primary Care Provider Feedback .MD [Medical Doctor] in facility and assessed resident, verbal orders to send resident to ED for eval [evaluation]and treat [treatment] . An OP (Operation) Note dated 1/16/24 documented, . Procedure: Left transmetatarsal amputation . Findings: Left foot, 3, 4, 5 toes gangrene. Transmetatarsal amputation performed. Purulent necrotic tissue on the plantar fascia, fat pad, on the fourth and fifth flexor tendons, debrided to the heel and cultures sent, closed over a drain . If it fails to heal with antibiotics post-revascularization, he is at risk for below-knee amputation . A Nursing Progress Note dated 1/23/24 at 9:35 AM documented, Note Text: RES [Resident] RETURNED TO FACILITY PER [Ambulance Provider] STAFF ON STRETCHER .DRSG [dressing] INTACT D/T [due to] RECENT SURGERY OF PHALANGES AMPUTATION . There was no December 2023 Treatment Administration Record (TAR) in the electronic health record (HER). The December 2023 Medication Administration Record (MAR) documented, .Weekly skin audit Monday 11/7 at bedtime every Mon [Monday] -Start Date11/13/2023 . The following dates had initials in the box: 12/4/23, 12/11/23, 12/18/23 and 12/25/23. The January 2024 Medication Administration Record (MAR) documented, .Weekly skin audit Monday 11/7 at bedtime every Mon [Monday] -Start Date11/13/2023 . The following dates were blank: 1/1/24, 1/15/24 and 1/22/24. The resident was hospitalized from 1/12/24 to 1/22/24. A Physician's Order dated 1/24/24 documented, . Piperacillin Sod-Tazobactam So [Sodium] Intravenous Solution .Use 3.375 gram intravenously every 8 hours for surgical wound until 03/03/2024 .Admin [administer] medication over 1 hr. [hour] continue for 42 days . A Physician's Order dated 1/24/24 and discontinued 1/29/24 documented, .Cleanse foot wound daily with wound cleanser, paint area with betadine and cover with 4x4 and wrap with kerlix and ace wrap. one time a day for wound care . A Physician's Order dated 1/29/24 documented, .Cleanse left foot wound daily with wound cleanser, paint area with betadine and cover with 4x4 [4 by 4] and wrap with kerlix and ace wrap. one time a day for wound care . On 1/31/24 at 9:28 AM, Certified Nursing Assistant (CNA) #2 was asked if she was orientated on reporting any abnormal issues such as bruises, skin tears, sores and performing nail care. She stated, No. She was asked, Who would you report it to? She stated, I would report it to the nurse. If she didn't do anything, I would report it to the DON [Director of Nursing], if we had one or the ADON [Assistant Director of Nursing] if we had one. On 01/31/24 at 11:18 AM, CNA #2 was asked if she had ever worked with Resident #323. She stated, Yes, a little. I heard [Resident #323] was in the hospital for gangrene and had toes amputated. On 1/31/24 at 11:22 AM, Licensed Practical Nurse (LPN) #3 was asked if she had ever worked with Resident #323 and she stated, Yes. She was asked, Can you tell me anything about [Resident #323's] wounds, if you were aware? She stated, Well we missed [Resident #323's] body audits. [Resident #323's] leg was always discolored, and [Resident #323] had to go get toes amputated. The Immediate Jeopardy was removed on 02/01/24 at 11:13 AM, when the following Plan of Removal was implemented by the facility: Plan of Removal 1. The resident affected was immediately sent to the hospital upon identification of the wound on 01/12/24. He returned to the facility on [DATE] and is in stable condition. 2. On 01/15/23 _Residents body audits were completed on all residents with the potential to be affected with no negative findings. 3. On 01/15/24 inservices were initiated for nurses to re educate on body audits being done timely and accurately. Inservice will be completed by 3 [3:00] pm 02/01/24. 4. DON/ Designee will monitor 3 body audits per week for 4 weeks to ensure that audits are completed timely and accurately. Negative findings will be corrected immediately and then reported to the Administrator. 5. Administrator/Designee will report negative findings to the QAPI [Quality Assurance and Performance Improvement] committee quarterly or PRN [as needed] for review and recommendations. On 2/2/24 at 8:28 AM, the Administrator provided a staff in-service sheet titled Telephone Inservice on Body Audit dated 2/1/24 with nurses' names who were contacted and in-serviced by telephone and one dated 1/15/24 with the topic of All body audit are to be completed timely and accurately. On 2/2/24 at 11:50 AM, Licensed Practical Nurse (LPN) #2 was asked, Have you been in-serviced on body audits? She stated, Yes. She was asked, Tell me what a body audit consists of? She stated, Head to toe. I look at their skin and look for changes in their skin. I also look for new areas, checking behind their ears and heels. She was asked, When were you last in-serviced on body audits? She stated, Wednesday [1/31/24] and Thursday [2/1/24]. On 2/2/24 at 12:00 PM, LPN #3 was asked, Have you been in-serviced on body audits? She stated, Yes. She was asked, Tell me what a body audit consists of? She stated, Head to toe assessment. She was asked, When were you last in-serviced on body audits? She stated, I can't give you date but it was recently. On 2/2/24 at 12:01 PM, LPN #4 was asked, Have you been in-serviced on body audits? She stated, Yes. She was asked, Tell me what a body audit consists of? She stated, Undressing the patient and looking for new skin conditions. She was asked, When were you last in-serviced on body audits? She stated, Yesterday [2/1/24]. On 2/2/24 at 4:44 PM, the Administrative Supervisor stated they did not have a policy on body audits. 2. On 01/29/24 at 02:43 PM, Resident #66 had a bandage to the left lower arm dated 1/24 with initials. The bandage had a dark red substance the size of a half dollar dried on it. On 01/30/24 at 08:08 AM, Resident #66 was in the Dayroom, the bandage was still on left arm dated 1/24. On 01/31/24 at 08:53 AM, the Surveyor accompanied Licensed Practical Nurse (LPN) #1 room. LPN #1 was asked to look at the bandage on Resident #66's left wrist. LPN #1 stated, We had a treatment nurse yesterday and it was changed. The Surveyor asked about the date of 1/24 on the bandage. The LPN #1 stated, That is letting you know that it was done in January of 24. LPN #1 was asked how often the dressing is changed. LPN #1 stated, Every shift and when soiled. On 1/31/24 at 10:08 AM, LPN #3 was asked if she performed treatments on hall 600. LPN #3 stated, Not in a while. LPN #3 was asked if she was familiar with Resident #66. LPN #3 stated, Yes. LPN #3 was asked if she had put a bandage on Resident #66's wrist. LPN #3 stated, Yes last week sometime, I can't remember the day. I took off the old bandage and put on the new one dated and initialed it. LPN #3 was asked if a bandage had been put on with a date of 1/24 on it, what that would mean. LPN #3 stated, That would mean it was 1/24, the month and day, not the year. On 1/31/24, during record review the Physicians Orders did not address a treatment to the left wrist. On 2/2/24 at 10:15 AM, the Surveyor asked the Director of Nursing (DON) what should a nurse do before performing a treatment? The DON stated, Check the order. The DON was asked if a nurse should perform a treatment without an order. The DON stated, No they shouldn't. The DON was asked to locate an order to treat the left wrist. The DON stated, There isn't one and there should be.

Complaint # (AR 661) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure adequate supervision during a facility-van transport to an outside behavioral health facility for a resident with documented combative behaviors to reduce the risk of the resident attempting to exit while the van was in motion and exiting the van once the driver had stopped which placed the resident at risk for major injury and/or exposure to safety hazards due to unfamiliar surroundings for 1 (Resident (R) #5) of 3 (Residents #5, #6, and #7) sampled residents who had documented combative behaviors; and failed to formulate and communicate effective interventions, monitoring and staff education to prevent potential injury for residents who had documented combative behaviors during facility-van transport. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #5, who had exhibited combative behaviors that was documented but not communicated to the transport staff member prior to a facility-van transport on 10/14/2020. The failed practice had the potential to cause more than minimal harm to 8 additional residents who exhibited combative behaviors, according to a list provided by the Administrator on 10/21/2020 at 10:21 AM. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 10/19/2020 at 04:41 PM. The findings are: 1. R#5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 09/21/2020 documented the resident scored 11 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status and was independent requiring no setup or physical help from staff with bed mobility, transfers, locomotion, and toilet use; and required the extensive physical assistance of one person with personal hygiene. The Care Area Assessment (CAA) Summary documented, . Cognitive Loss/Dementia . Triggered: New .Presence of any behavioral symptom (verbal, physical, or other) as indicated by: Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, grabbing, abusing others sexually): Behavior of this type occurred 1 to 3 days . Behavioral Symptoms . Triggered: New . Resident hit nurse with a wet floor sign, resident redirected and moved to a secured unit . a. The Care Plan dated 9/25/20 documented, . The resident has potential to be physically aggressive r/t (related to) Dementia: . Administer medications as ordered. Monitor/document for side effects and effectiveness. (R#5) has impaired cognitive function/dementia or impaired thought processes r/t Dementia . Review medications and record possible causes of cognitive deficit: new medications or dosage increases; [MEDICATION NAME], opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity . b. The October 2020 Medication Review Report documented the following: .Order Date: 10/06/2020 X-Ray to left hip . Order Date: 10/07/2020 Repeat STAT (immediately) x-ray to left hip . Order Date: 10/08/2020 [MEDICATION NAME] Tablet Delayed Release 250 mg (milligram) give 1 capsule by mouth three times a day for behaviors . Order Date: 10/08/2020 [MEDICATION NAME] Capsule 300 MG give 1 capsule by mouth every 6 hours as needed for behaviors . Order Date: 10/10/20 Resident admitted to 700 hall one time only for Behavior for 1 Day . Order Date: 10/13/2020 [MEDICATION NAME] Solution 5 mg/ml (milliliter) inject 1 ml intramuscularly as needed for behavior disturbance related to altered mental status give times one dose for behaviors . Order Date: 10/14/2020 Send to (Name) Behavior Health for evaluation and treatment . c. The Nursing Progress Notes documented, . 9/28/20 11:57 AM Note Text: . Resident very combative today, trying to use the phone to call DHS (Department of Human Services) to get his check. Very confused and not easily redirected . 9/30/20 06:40 AM Note Text: . Resident remains alert, oriented to name. Ambulatory ad lib (at will), gait steady . Resident continues to refuse to wear underwear or pull-ups and at times, he urinates on the floor-potential for falls . 10/6/20 1520 (03:20 PM) Behavior - Rejection of Care . 10/6/20 1521 (03:21 PM) Behavior - Wandering Redirected . 10/7/20 2123 (09:23 PM) Received report from off-going nurse. That (Radiology) Express was here at facility and could not complete x-ray to left hip area D/T (due to) resident became combative towards staff. (Doctor) notified, received new orders to repeat stat (immediately) x-ray to left hip. Stat cbc (complete blood count), bmp (basic metabolic profile), Tylenol 650 mg (milligrams) po (by mouth) q6h (every 6 hours) prn (as needed) for pain. Also received order to give one-time dose of [MEDICATION NAME] 1 mg IM (intramuscular) prior to x-ray. Orders called in. Unable to give Tylenol 650 mg d/t refusal. Resident consumed 0% of his supper. Resident medications held d/t refusal . 10/8/20 1504 (03:04 PM) Behavior - Rejection of Care Redirected . 10/8/20 14:59 (02:59 PM) Behavior - Threatening Behavior; Res (Resident) redirected . d. A Late-Entry Nursing Progress Note, added by DON on 10/19/20 10:53 AM, documented, . Effective Date: 10/14/2020 16:46 (04:46 PM) . Got a call from transport that resident was attempting to open the door of the van and that she pulled over at the (convenience) store to attempt to calm resident down and he got out the van and went inside the store. Transport was instructed to stay with the resident and this nurse, and the Administrator went to the store. Upon arriving to the store, we assisted the resident back to transport and transported him to (Name) behavior without further incident. (Name) staff assisted us to get patient (in) the facility and he was left in his care . e. On 10/19/2020 at 11:31 AM, Certified Nursing Assistant (CNA) #1 was asked, Are you familiar with (R#5)? She stated, Yes, they sent him somewhere. She was asked, Does he have behaviors? She stated, Oh yeah. We have to have help with him all the time cause he has hit some of us and he doesn't want to do much. She was asked, What are his physical abilities? She stated, He can do most things by himself, but he just can't mentally. She was asked, What was going on with (R#5) leading up to his transfer? She stated, He hit a CNA. We always have two people in there cause he swings on people. She was asked, Do you know if anything happened on the way to the behavioral center? She stated, No. She was asked, Do you ever transport residents to outside appointments? She stated, I worked on the van a couple of times months ago. She was asked, What kind of transport training did you receive? She stated, How to lock in the chairs. She was asked, How were you trained to transport resident with combative behaviors? She stated, I wasn't (trained) but I would have at least one more person with me if I had to do that. f. On 10/19/2020 at 11:34 AM, CNA #2 was asked, Are you familiar with (R#5)? She stated, Yes. She was asked, Where is he? She stated, I believe he is at (Behavioral Facility). She was asked, What sort of behaviors does he have? She stated, Aggressive and hitting, trying to leave. She was asked, Were you here the day he was transferred? She stated, No. She was asked, Have you heard of anything happening? She stated, No. She was asked, Have you ever transported a resident in the facility van? She stated, No, but if I knew someone was aggressive then I would not take them by myself. She was asked, Did the facility train you to take two people to transport an aggressive resident? She stated, No, but that is what I would do. She was asked, Why? She stated, Because they could get to hitting you or anything. You never know what kind of stuff they are going to do. g. On 10/19/2020 at 11:38 AM, Licensed Practical Nurse (LPN) #1 was asked, Are you familiar (R#5)? She stated, Yes. I do the treatments on the weekends, so I don't know all that much about him. She was asked, Does he have behaviors? She stated, I know he has swung on some of the nurses. He has never done that with me. She was asked, Do you know where he is now? She stated, I think he is at (Behavioral Facility). She was asked, Do you know any information about his transport? She stated, I didn't know it was him, but I heard he was not too happy on the van. She was asked, Have you ever transported a resident in the facility van? She stated, No. She was asked, How are the CNAs trained to transport residents with behaviors? She stated, It seems like they should take another person if they are taking someone like (R#5). h. On 10/19/2020 at 11:43 AM, CNA #3 was asked, Are you familiar with (R#5)? She stated, Yes. She was asked, Have you ever transported residents in the facility van? She was asked, No. She was asked, How much assistance was needed for his ADLs? She stated, Always have to have people in there with ya cause he gets upset. i. On 10/19/2020 at 11:48 AM, CNA #6 was asked, Are you familiar with (R#5)? She stated, I take care of him sometimes. She was asked, What kind of behaviors does he have? She stated, Up and down. She was asked, Does he try to get out of the facility? She stated, If he could get out, he would. She was asked, Have you ever transported residents to outside appointment? She stated, A long time ago. She was asked, If you had to transport (R#5), how many aides would you feel comfortable with on the transport? She stated, He would have to have 2 people that is for sure. j. On 10/19/2020 at 11:51 AM, CNA #4 was asked, Did you transfer (R#5) to behavioral health? She stated, Yes. She was asked, How many people did you have in the van? She stated, Just me. She was asked, Was he exhibiting any behaviors? She stated, No. She was asked, Did anything happen on the way? She stated, Yes ma'am he attempted to get off the van. He was going to open the van door but when I noticed, I pulled over at the nearest gas station. He got out of the van and I just followed him. I called back to the facility and (The Administrator) and DON came out to help get him to the place we were going. She was asked, Approximately how many miles did you travel with him? She stated, To (neighboring town), I think about 20 miles. The facility is in (neighboring town) and we were about 2 miles away from (neighboring town) when he started trying to get out of the van. She was asked, Where was the resident sitting while in the van? She stated, In the front passenger seat. She was asked, Did he have the seatbelt on? She stated, Yes. She was asked, Were you driving when he started trying to get out of the van? She stated, Yes. I was lucky there was a place to pull over and I pulled all the way into the gas station and he had already had the seatbelt off and opened the door and went into the store cause he unbuckled his seatbelt while we were going. She was asked, Would it have possible for him to get out of the van while the van was moving? She stated, Yes, cause it (passenger-side door) can be opened from pulling the handle over there. She was asked, Does the front-passenger-side door have a safety or child lock? She stated, Not that I know of. She was asked, Would he have been able to get out of the van from the back if he had been back there? She stated, No because the lift blocks the door from opening. She was asked, What was he saying to you? She stated, He said he was not going anywhere, and he sat down. She was asked, Did you ever lose sight of him? She stated, No, I followed him into the store. She was asked, Have you had any training in transporting residents? She stated, Yeah, I mean about the lift and wheelchair locks. She was asked, When did you receive that training? She stated, When I first started doing transports. She was asked, When did you start transporting residents in the facility van? She stated, A few months ago. She was asked, Did you get checked off on the competencies? She stated, Yeah, I mean I rode with someone for 3 days and then they switched it, let me run through all of the stuff. She was asked, Did the training include transporting residents with behaviors, especially combative behaviors? She stated, No. She was asked, Have you had any training whatsoever in caring for residents who exhibit aggressive/combative behaviors? She stated, Yeah. She was asked, Do you know how many staff members are needed to provide care to (R#5)? She stated, No, not really. She was asked, What would be the reason you did not have someone in the van with you? She stated, He was calm when we were leaving. She was asked, Have you transported him prior to this? She stated, No, this was my first time. She was asked, Have you ever had anything similar happen on any other transport? She stated, No. She was asked, Have you ever transported any resident to that facility in the past? She stated, Not that I can remember. She was asked, To which type of facility were you transporting him? She stated, (Behavioral Facility) in (neighboring town). She was asked, What sort of behaviors had he been exhibiting that warranted the transfer to (Behavioral Facility)? She stated, I'm not sure. k. On 10/19/2020 at 12:05 PM, CNA #5 was asked, Are you familiar with (R#5)? She stated, He was combative every day. A few times I had to go get help to transfer him to his chair, but other than that, I don't know much about him. l. On 10/19/2020 12:55 PM, surveyor requested from the DON and Administrator the following information: i. The Facility's Behavioral Policy and Procedure. Upon the request, the Administrator stated, We do not have one. ii. The Transport Training and Competencies for CNA #4. Upon request, the DON stated, That book is in the Maintenance Supervisor's office and he will bring it to you. m. On 10/19/2020 at 01:17 PM, Behavior Health Facility (BHF) Registered Nurse (RN) #1 was asked, Did you get a report from the nursing home when the resident was transferred? She stated, No. We usually do but, they did not call report that day. She was asked, Do you know if anything happened on the transport? She stated, She (CNA #4) called me in a panic and was wanting me to go where she was to help her because he had gotten out of the van. I asked her if she was by herself and she said yeah. Apparently, they called someone from the facility to go help because a GMC pickup is what he was in and when I told them that the Dr wanted to get him checked out at the ER, (emergency room ) they refused. I told, I guess it was the Administrator of that place that the driver had called frantic and asked one of us for our help. She wanted us to go where she was to help her with him. I spoke with the nurse in charge here and we told her we could not leave our patients here to go help her there. I asked her if she was by herself and she said she was, and she was panicked. The way I looked at it was you would not call us to help if something bad hadn't happened. He got out of the GMC truck with the DON. They proceeded to come into our walkway, and he sat down on the ground. My DON instructed me to let them know that he needed to be checked out at the ER. They refused to take him to the ER - no bruising noted, and I did the assessment myself. The referral was that he was being noncompliant, aggressive with other people and residents. n. On 10/19/2020 at 01:25 PM, BHF DON #1 was asked, Were you at the (behavioral) facility when the resident was admitted ? He stated, Yes, he transferred to us .I know we received a phone call and they were asking for help .I was like we cannot go to Shell station . they said he opened the van door .they called their DON and she drove to help and I think the Administrator came too. There was a conflict of stories. We did not know if the van was moving when he got out. When he got here, he sat down on the ground and would not get up. o. On 10/19/2020 at 01:30 PM, CNA #4 was asked, Who did you call once you pulled over at the station? She stated, I called the place I was going cause they were closer than anyone. She was asked, What were you afraid might happen? She stated, At first I was scared he might get out while we were driving but then I thought he may get away from me and get lost. p. On 10/19/2020 at 01:33 PM, the DON was asked, What are the behaviors that (R#5) is taking [MEDICATION NAME] for? She stated, Refused care sometimes and refused to take his meds is why we sent him out last week. She was asked, How long has he been here? She stated, Not very long. She was asked, Did he admit with medication for behaviors or was that initiated here? She stated, We initiated them. She was asked, What did you initiate them for? She stated, Looks like it was for rejection of care and threatening behavior. She was asked, Where are behavior monitoring documented? She stated, Nursing Notes. She was asked, Why did he get transferred to behavioral health? She stated, Not taking his medication. She was asked, What happened during his transport on 10/16/2020? She stated, She (CNA #4) loaded him up and she left with him and she called the admin's (cell) phone and said that she had to pull over because he was trying to get out. By the time she got parked, he had the seatbelt off and got out of the van. She was asked, Is that the normal process of transporting a resident? She stated, I mean if they need more we do more. She was asked Who is supposed to make that decision? She stated, It is a group effort. She was asked, Who is the group? She stated, Me, administrator, MDS, nurse. She was asked, What was the group decision on his transfer? She stated, That he did not need assistance at that time. She was asked, What determines if a resident can ride in the front passenger seat? She stated, If they are ambulatory, they can ride in the front. q. On 10/19/2020 at 02:00 PM, Maintenance Supervisor was asked, What are the transport aides taught when they are trained on the safe transport of residents in the facility van? He stated, Seatbelts, locks on the floor that lock the wheelchair down and that kind of stuff is what the man that was doing this taught them. He was asked, Did you find the checkoff list for the current transport aide? He stated, I could not find it. He was asked, How would you train the transport aides to transport a resident who has behaviors? He stated, They should not transport them with just one person, that's the first thing. That is just common sense. He was asked, Does the passenger-side door automatically lock when the van is in drive? He stated, Yes, but it can be opened from the inside if you are in the front passenger seat. r. On 10/19/2020 at 02:15 PM, the transport van was observed by surveyor. The surveyor sat in the passenger-side seat and applied the seatbelt. CNA #4 put the van into drive and the passenger-side door lock did not lock and the door was able to be opened by pulling the handle. s. On 10/19/2020 at 02:31 PM, the Administration was asked, Can you tell me what you know about the transport of (R#5) on 10/16/2020? She stated The van was there by the front door. They left with his seatbelt on and she said he acted like he was going to try to open the door. A little later, I got a call from (CNA #4). She said she pulled over and he got out of the van. Me and (DON) went to the station and he got in the truck with (DON). For some reason, the person that came out at (Name) Behavior Health, she thought he had opened the door while the van was moving. She was asked, Who decides what the appropriate safety measures are to be implemented during a facility-van transport? She stated, We all do. She was asked, When is that decision made? She was asked, What are you talking about like how many people to send? We decide all together just before they leave. She was asked, Where was he being transported? She stated, Behavioral place (neighboring town). She was asked, What type of behaviors had he been exhibiting? She stated, I know he quit taking his medications and then he did not want them to give care. She was asked Had he ever been aggressive or combative? She stated, Yeah, he was in the secured unit. She was asked, What is the criteria for the secured unit? She stated, You mean why are they in there? She was asked, Yes, why would a resident be placed in the secured unit? Is it a behavioral unit? She stated, No, I mean it is for those who try to get out and who wonder around and stuff like that . She was asked, Who is responsible for training the staff in facility-van transports? She stated, The Maintenance Supervisor. t. On 10/19/2020 at 06:43 PM, the Immediate Jeopardy was removed, and the scope and severity reduced to E when the facility implemented the following plan of removal: 1. On 10/19/20 Resident is currently in geropsychiatric facility. 2. On 10/19/20 DON updated resident care plan to ensure the care plan includes two persons including the van driver during facility transport to prevent the actual or potential injury during transport. 3. On 10/19/2020 DON began the visual audit of residents with a [DIAGNOSES REDACTED]. 4. On 10/19/20 the DON began in-service to nursing staff to ensure all residents facility transported to psychiatric facilities have two persons including the driver to prevent the actual or potential injury during transport. 5. DON/designee will monitor all facility transports for psychiatric services to ensure that there are two persons including the van driver to prevent the actual or potential injury during facility transport 5x week x 8 weeks or until compliance is achieved, making corrections as necessary, and notifying the administrator of negative findings. 6. DON/designee will report negative findings to the QAPI (Quality Assurance and Performance Improvement) committee monthly for review and recommendations.

Complaint # (AR 443) 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 increase supervision during periods when a resident was verbalizing a desire and plans to leave the facility and after identifying that the resident was able to remove his Wanderguard bracelet, which resulted in the resident being able to leave the facility undetected for 1 (Resident #5) of 1 sampled resident who was at risk for elopement. The facility also failed to ensure the Wanderguard system and security features on the facility's exit doors were consistently monitored and maintained in proper working order, to minimize the potential for resident elopement. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who left the facility undetected and was found at a store approximately 0.2 miles from the facility, and had the potential to cause more than minimal harm to 3 residents who had a Wanderguard bracelet and were at risk for elopement, as identified by the Administrator on 9/10/19. The Administrator was informed of the Immediate Jeopardy on 9/5/19 at 5:07 p.m. The findings are: Resident #5 was admitted [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of 8/16/19 documented the resident scored 15 (13-15 indicates cognitively intact) on a brief interview for mental status, had wandering behaviors on 1 to 3 of the past 7 days which placed the resident at significant risk of getting to a potentially dangerous place, was independent with ambulation in his room, and required supervision with ambulation in the corridor. a. A physician's orders [REDACTED]. During the survey conducted from 9/9/19 through 9/10/19, this facility did not have a secure unit. b. The Plan of Care dated 8/14/19 documented, .The resident is an elopement risk / wanderer due to history of attempts to leave facility unattended, impaired safety awareness . Resident wanders aimlessly .Disguise exits: cover door knobs and handles, tape floor. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? . Intervene as appropriate. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes . Check Wanderguard to left ankle q (every) shift . c. A Nurses Note dated 8/16/19 at 1:45 p.m. documented, This nurse was informed via CNA (Certified Nursing Assistant) that pt (patient) wanderguard was not on his wrist anymore. This nurse ask pt why his wanderguard was off, he stated that it was too tight. This nurse put another one on his ankle this time. Pt stated to this nurse that he wanted to leave and go catch the bus to (intersection approximately 8 miles away from facility) to the bank. This nurse redirected him and told that the van driver will go to the bank for him and he walked off . There was no documentation in the clinical record to indicate the resident's Wanderguard bracelet was more closely monitored after this to verify it remained in place and no documentation of a care plan update to address the resident's ability to remove the Wanderguard bracelet. d. An Incident Description note dated 8/20/19 at 10:59 a.m. documented, Resident removed his Wanderguard for the three times and stated all morning he wants to leave and go get beer and snacks. Resident was noted by staff to be at the store. This nurse had seen resident in the hallway 15 mins prior to resident being at the store . Immediate Action Taken: Head count in whole building, body audit on resident with no negative findings, resident noted to have removed his wanderguard for the third time. APS (Adult Protective Services) notified. Resident is one on one at this time. 1.) A Nurses Note dated 8/20/19 at 11:08 a.m. documented, Resident is noted to have taken his wander guard off and wanted to go get beer and snacks. Resident was received in building by staff. This nurse assessed resident with no negative findings, wanderguard was removed from ankle. Resident is 1:1 with staff at this time. 2.) A Social Service Note dated 8/20/19 at 11:50 a.m. documented, SW (Social Worker) was informed by the Hospice CNA that she saw resident walking down Main Street. SW immediately notified Administrator. SW, treatment nurse, medical records, Activity Director, Maintenance, and lead CNA left the facility to look for resident. Resident was located at (grocery store name). When SW approached resident, he was attempting to buy a can of beer and pretzels. SW asked resident if he could return to the facility, resident stated, 'No, I've been there too long'. Eventually resident agreed to get in the car with the Activity Director as she drove resident back to the facility. Resident did not have on wanderguard. SW notified staff. Once resident returned, a wanderguard was placed on resident's ankle. SW was informed by resident's nurse, that resident continues to take off his wanderguard. Resident is now being placed on 1:1 (one-on-one). SW was informed by the DON (Director of Nursing) that Corporate is working on resident to transfer to a sister facility that has a locked unit. SW will note any changes. 3.) A Nurse's Note dated 8/20/19 at 7:31 p.m. and signed by Licensed Practical Nurse (LPN) #2 documented, This nurse was told that hospice CNA called the facility to report that the pt had gotten out the building. Upon returning to facility this nurse was informed that his wanderguard was removed for one, and two, he was next door at (grocery store name) trying to purchase a bag of pretzels and a can of beer. d/t (due to) him removing his wandergurard x (times) 2 he is now placed on 1:1. This nurse notified (name) APS (Adult Protective Services) of the matter. Will cont. (continue) to monitor . 4.) The grocery store indicated in the Nurse's Notes and Social Service Note dated 8/20/19 was 0.2 miles away from the facility, according to Google maps distance information. The aerial view on Google maps indicated the store was approximately 1 and a half blocks away from the facility. e. A Nurses Note dated 8/21/19 at 10:44 a.m., documented, SW spoke with resident's APS worker (name) on today to discuss resident's recent elopement. (Name) stated that she was made aware that resident left the faciity on yesterday, and that she was upset by this because she was under the impression that our facility was a locked unit. SW informed (name) that our facility does not have a locked unit, but we do have a wanderguard system that prevents elopement risk residents from leaving the facility. However, resident has been taking off his wanderguard. SW informed (name) that resident is currently on 1:1 at this time . An MDS with an assessment reference date of 8/26/19 documented, discharge assessment return not anticipated with a discharge date of [DATE]. There were currently 2 other residents in the facility who were at risk for elopement verified by the Director of Nursing on 9/10/19 at 4:35 p.m. f. On 9/5/19 at 3:00 p.m., all doors in the facility were checked for proper functioning. The Medical Records LPN checked the front door. A resident with a Wanderguard bracelet was present, and the front door worked properly. The Medical Records LPN opened a new Wanderguard and used it to test the 200 Hall exit door. The door did not lock down or alarm. The Medical Records LPN then went to get another new Wanderguard to double-check the door. The door still did not alarm or lock down. The Medical Records LPN then went to the kitchen to speak with the Maintenance Man and asked him to make rounds to check the doors. He declined and gave the Medical Records LPN a clipboard with a Wanderguard attached to check the doors. 1.) At 3:12 p.m., the Medical Records LPN proceeded to the 300 Hall door that exits to the laundry area. The door did not lock down or alarm. When the Wanderguard was near to door, the door would open to allow exit, but would lock down if the Wanderguard was on the outside of the door and not allow re-entry. 2.) At 3:18 p.m., the Medical Records LPN and the Laundry Supervisor checked the exit doors on the 500 and 600 halls. Neither door alarmed or locked down when the Wanderguard was near. g. On 9/5/19 at 3:25 p.m., the Maintenance Man was asked, how often are the doors checked to assure the Wanderguard system is working properly? He stated, I check it Monday through Friday and document on a log. He was asked, who checks the Wanderguard system on the weekend? He stated, The nurses. The Maintenance Man was asked, where do the nurses document? He stated, I'm not sure, probably in the chart. h. On 9/5/19 at 4:22 p.m., the Maintenance Man provided the (MONTH) 2019 Wanderguard log, and all dates from 8/1/19 through 8/31/19 documented the system was functioning properly. The Maintenance Man was asked, Does anyone have access to this log on the weekends? All days are filled in? He stated, No. He was asked, Do you have a log for September? He stated, No, I haven't had time to do it yet. i. On 9/5/19 at 4:40 p.m., the Director of Nursing (DON) was asked if she knew the Wanderguard system did not work properly? She stated, No. j. On 9/5/19 at 4:45 p.m., the Administrator and Regional Director of Operations were asked, do you know the Wanderguard system is not working properly? Both stated, No. k. The Immediate Jeopardy was removed and the scope and severity reduced to D on 9/6/19 when the facility implemented the following plan of removal: 1.) On 9/5/2019 all doors were checked for functioning and alarming for the wanderguard svstem. The two residents with wanderguards will be continuously monitored until the area is fixed. 2.) On 09/05/ 2019 inservicing completed with the administrator and maintenance director on the proper functioning of all door alarm systems. 3.) On 09/05/2019 Administrator/designee is going to inservice all staff on the appropriate notify action process for doors not alarming appropriately. 4.) Administrator/designee will monitor all exit doors 5 times a week for 8 weeks or until compliance is achieved to ensure all doors have been secured. 5.) Administrator/designee will report all negative findings to QAPI (Quality Assurance Performance Improvement) committee monthly for additional recommendations.

Complaint # (AR 276) was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure mechanical lift slings were routinely inspected for wear and tear and frayed and worn mechanical lift slings were removed from service and not used for transfer of residents, to prevent a fall with injury during transfer for 1 (Resident #1) of 4 (Residents #1, #3, #4, and #5) case mix residents who required mechanical lift transfers. This failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death for Resident #1, who fell from the mechanical lift when the sling broke, resulting in a laceration to the head, and had the potential to cause more than minimal harm to 15 residents who required transfers with a mechanical lift, as documented on a list provided by the Administrator on 11/26/18 at 12:32 p.m. The Administrator was informed of the past immediate jeopardy condition on 11/27/18 at 11:23 a.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 10/12/18 documented the resident scored 08 (08-12 indicates the resident was moderately impaired) on the Brief Interview for Mental Status, required extensive assistance of 2 staff and a mechanical lift for transfers, did not walk, and required extensive assistance for bathing. a. The Care Plan, revised on 10/23/18, documented, .The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Stroke with left sided [MEDICAL CONDITION] and fluctuating cognition . Total care - Use of 2 staff and Hoyer lift (full-body mechanical lift) for transfers .Extensive assistance for dressing dependent on staff for personal hygiene, showers, toileting via peri care and locomotion via geri chair - able to make needs known at times .All transfers per 2 staff and Hoyer lift . b. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A) documented, .Date and Time of Incident: 11/14/18 at 9:20 a.m. On 11/14/18 at 9:20 a.m., while transferring a resident using a mechanical lift, loops on the lift pad broke, resulting in the resident landing on the floor and receiving a 1 inch circular evulsion to the scalp posterior to the left ear. The patient was immediately sent to the ER (emergency room ) for further evaluation via (emergency ambulance service) with no additional injury noted and returned to the facility the same day . c. The Emergency Department Report dated 11/14/18 at 11:01 a.m. documented, .(Resident #1) .presents to the ED (emergency department) via (ambulance service) transfer from a local nursing home after falling this morning. The patient landed on her head and L (left) hip .Neurologic: Negative for dizziness, loss of consciousness, facial asymmetry and headaches .CT (computerized tomography) Head Without Contrast: No acute intracranial finding is visible .XR (x-ray) Hip 2V (views) Left: Osteopenia without acute osseous injury .diagnosed with [REDACTED].Contusion of left hip, initial encounter . d. On 11/26/18 at 10:00 a.m., the Administrator was asked to show the surveyor the sling that broke on 11/14/18 during the transfer of Resident #1. The Administrator advised the survey team that the sling had been discarded on or about 11/14/18. e. On 11/26/18 at 1:00 p.m., the Restorative Nursing Assistant (RNA) was asked, Did you see the sling that broke on 11/14/18 when (Resident #1) was being transferred? The RNA stated, I did see the sling. It was a shower sling. The RNA was asked, When did you see the sling? The RNA stated, Shortly after it broke. The RNA was asked, What condition was it in? RNA stated, It was faded, frayed, and worn. The RNA was asked, Would you have used the sling in the condition it was in? The RNA stated, Me, personally? No. I would not have used it. The RNA was asked, Who is responsible for ensuring the slings are inspected and that slings are taken out of rotation when they are no longer safe for use? The RNA stated, I am .now. I have them all numbered. I will find a sling no matter where it is to check it. I have it all written down. I am also to pull slings every 5-6 months, but no sling is gonna (sic) be in rotation over 6 months. The RNA was asked, Since when have you been responsible for this? The RNA stated, Since 11/14/18. The RNA was asked, Who was responsible for this prior to 11/14/18? The RNA stated, No one that I know of. The RNA was asked, When was the last in-service regarding lifts and slings? The RNA stated, Either 11/14/18 or 11/15/18 I believe. Anyway, it was right after the sling broke. RNA was asked, When was the most recent in-service regarding lifts and slings prior to the accident? She stated, Oh, my . I'm not even sure. f. On 11/26/18 at 1:20 p.m., the DON was asked, Did you see the sling that broke before it was discarded? The DON stated, I did see it, and it was a little worn. The DON was asked, What system was in place prior to the incident to ensure that the slings were being inspected and that the staff members were aware of what to look for? The DON stated, Before this happened? Nothing that I know of. I haven't been here very long, so I don't know what the staff members were told at that time. The DON was asked, Will you please provide the in-services and the competencies regarding lifts and slings before the accident and since the accident? The DON stated, The check-offs and the (medical equipment vendor) training since then are in the paperwork. We will have to look to try to find anything from before (prior to incident) on what we've done. g. On 11/26/18 at 2:27 p.m., Certified Nursing Assistant (CNA) #1 was asked, Can you tell me what happened when the sling broke when you all were transferring (Resident #1)? CNA #1 stated, I was going to take a break and saw my coworker (CNA #2) pulling the shower bed down the hall. I went and spotted her. Everything we needed was in the room. As far as I can remember, we were attaching the blue attachment ring. The blue is closest to the bottom. As we started to lift her, and it was like (CNA #2) was coming around and the sling snapped. The lift was about bed-level when the sling snapped, and she landed on her left side. It was the left side that snapped. CNA #1 was asked, Before you guys used the sling, did you inspect it and, if so, what did you see on it? CNA #1 stated, (CNA #2) had already had the lift and everything in the room. To the best of my abilities, it didn't look bad from the end I was looking at. CNA #1 was asked, Had you been trained to look for anything specific? CNA #1 stated, Any tears, any snags, if it looks faded out, if it looks worn and torn. We were told if it does not look right then don't use it. CNA #1 was asked, Prior to this incident, were the pads numbered and tracked? She stated, The one that we used that day had a number .it looked a little faded. CNA #1 was asked, Did she have any injuries? CNA #1 stated, She hit something behind her ear. We got the nurse immediately. We didn't touch her or anything, waited on the nurse. She was bleeding behind her left ear somewhere. She was talking, alert. (Emergency medical personnel) came and took her to the ER. The nurse told me that she was okay. She got sent back. CNA #1 was asked, What has the facility done to prevent recurrence of the situation? CNA #1 stated, We had to come for in-service. They told us what to look for on a lift. We were told the different kinds of pads. Inspect the loops and make sure nothing looks worn and torn and they told us a lot of things and kind of revitalized the training we had at first. It was good to go over all of that again. I learned a lot from the training . h. On 11/26/18 at 3:02 p.m., CNA #2 was asked, Can you describe, in your own words, what happened the day the lift sling broke? CNA #2 stated, I went to laundry and got 3 lift pads .all mesh .and I delivered the pads into each room (Resident #1), (Resident #3), (Resident #2) .we put her (Resident #1) on the lift pad and hooked the lift up to her; we did blue and green (sling) I went out into the hall to get the bed .she was not elevated yet .I got in between the head of the shower-bed so I could guide her feet and one side went too heavy and the sling broke. CNA #2 was asked, Before you used the sling, did you inspect it, and if so, how did it look? CNA #2 stated, It was worn. CNA #2 was asked, How could you tell it was worn? CNA #2 stated, It was fading and just worn. CNA #2 was asked, Did you notice before you used it? CNA #2 stated, Yeah, but it didn't seem so bad that it would snap like it did. CNA #2 was asked, What kind of training had you received prior to this incident regarding lifts/slings? CNA #2 stated, They have told us if they are ripped or torn do not use them. They had talked about the fadedness, but I thought it (sling) was impaired a little bit but not that much. The whole thing has really made me very nervous to use lifts, but I am feeling more confident now that we had the in-services and stuff. CNA #2 was asked, What has the facility done to prevent the situation from happening again? CNA #2 stated, We got training on it and we had to practice it ourselves and we got new lift pads and feel comfortable now using it . They kept training us on the lift pads, but it was not the shower pads. i. On 11/27/18 at 9:00 a.m., the Administrator was asked by the survey team to provide documentation of any training / check-offs of the direct-care staff on competency with mechanical lift transfers that were performed prior to this incident. j. On 11/27/18 at 9:50 a.m., Contracted Equipment Service Provider Representative #1 was asked, When a facility contracts your services, what recommendations to you give the facility regarding inspection of the equipment, specifically lift slings? Representative #1 stated, We always go over manufacturer's guidelines. Anytime you pick up a sling, it needs to be inspected. We go in and provide in-service training and I know we did that after the incident. Representative #1 was asked, Do you know the last in-service your company provided to the facility's staff members prior to the incident on 11/14/18? Representative #1 stated, The only thing I'm up to date on is the most recent training, but not the trainings prior to the accident. Representative #1 was asked, Can you look it up and let us know the date of the most recent training prior to 11/14/18? Representative #1 stated, The building (facility) will have signed sheets of those. Representative #1 was asked, Does your company recommend anything like scheduled inspections or rotation of the slings? Representative #1 stated, Inspection is the key to using the sling. Any and every time a sling is used it needs to be inspected. We do not tell the building how to make sure this happens .it just needs to happen. Representative #1 was asked, Are there any differences in the mesh slings and the solid slings? Representative #1 stated, Well other than the visual differences, there are no real differences in the practical use of the slings. The weight limits are the same. Representative #1 was asked, Are the loops that are used to attach the sling to the lift made of the same material? He stated, Yes, there is no difference. Representative #1 was asked, Should the sling have not been used? Representative #1 stated, Our people did not look at the sling that had been compromised. We basically just went in and provided training. k. As of 11/27/18 at 2:00 p.m., the Administrator was not able to provide the requested documentation of trainings, inspections or monitoring / supervision of mechanical lift transfers conducted prior to the 11/14/18 incident, including routine inspections / monitoring of the lift slings, the provider company's onsite in-service sessions, and competency check-off forms of the direct-care staff performing mechanical lift transfers prior to the incident. l. The facility removed the immediate jeopardy and corrected the failed practices on 11/14/18, as evidenced by the following: 1.) The Office of Long Term Care (OLTC) Incident and Accident Report (I&A) with an incident date / time of 11/14/18 at 9:20 a.m. documented, .On 11/14/18 DON (Director of Nursing) immediately took the failed lift pad out of use at the time of incident and discarded it. The DON at the time of the incident immediately did an audit of all lift pads with no further negative findings, some lift pads were noted to be near end-of-life but not defective but were replaced proactively. On 11/14/18, Maintenance Supervisor immediately at time of incident took all mechanical lifts including the one used during the incident out of use until inspections for safety were completed by contracted vendor on 11/14/18 with no negative findings. On 11/14/18, Housekeeping supervisor immediately in-serviced laundry staff on proper laundering of slings per manufacturer guidelines. On 11/16/18, lift vendor provided in-service to licensed staff on proper use of mechanical lifts. DON/designee will monitor all lift pads for wear, tear, loose stitching, [MEDICATION NAME], cuts, or frays weekly, removing those affected from use and reporting negative findings to administrator. Maintenance supervisor will monitor monthly to ensure that lift pads are labeled with date when put into use and replaced every 6 months, making corrections as needed and reporting to administrator negative findings. No abuse or neglect is suspected . 2.) On 11/27/18 at 10:35 a.m., the Administrator provided the following written action plan formulated by the facility on 11/14/18: a) Staff involved in the transfer of the resident were suspended and interviewed pending investigation. b) All slings were immediately inspected by DON, the failed sling was immediately removed from use. c) All lifts were taken out of service and return demonstration was started with all staff before replacing the lifts to service. d) Nursing staff was in-serviced on 11/14/18 regarding checking slings and lifts for any wear or tear. e) (Medical equipment vendor) inspected lifts on 11/14/18. f) (Medical equipment vendor) in-service was scheduled and completed on 11/16/18. g) As of 11/14/18, sling checks were assigned to RNA weekly. h) On 11/14/18, all slings were all numbered to ensure all are checked weekly. i) DON/Designee monitoring RNA check calendar weekly for 4 weeks, then monthly on-going. DON reviewed RNA sling check book on 11/19/18 and 11/26/18. j) New slings were ordered on [DATE], delivered on 11/16/18, replaced proactively. 6 new slings were replaced on 11/16/18. k) Staff suspended were returned from suspension with education on their following scheduled day on lifts and slings. l) As of 11/14/18, Facility Maintenance Director will keep track and replace all slings on 5-month rotations to ensure all are kept in good condition and to stay proactive. 3.) On 11/26/18 at 11:23 a.m., all of the facility's post-incident in-service training and return-demonstration check-off forms were reviewed by the survey team and verified as completed. Additionally, mechanical lift transfer observations were conducted on 11/27/18 at 11:05 a.m. with CNA #1 and 2 and the transfers were completed correctly, without incident.

Complaint # 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 resident elopement, by failing to ensure interventions were developed and implemented after the resident exited the facility undetected and failure to ensure increased monitoring was provided during periods when the resident was exhibiting exit-seeking behaviors for 1 (Resident #3) of 1 case mix resident who was at risk for elopement. The failed practices resulted in past noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #3, who eloped from the facility and walked to a local business approximately 0.2 miles away from the facility. According to the Administrator on 9/12/17 at 12:38 p.m., there were no other residents in the facility who were at risk for elopement. The Administrator was informed of the past immediate jeopardy condition on 9/12/17 at 4:16 p.m. The findings are: 1. The facility's Elopement Prevention and Management policy dated May 2017 documented, The facility strives to prevent resident/patient elopement . The facility defines elopement as follows: When a cognitively impaired resident/patient leaves the facility grounds unattended and without staff knowledge . 2. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 7/20/17 documented the resident scored 8 (8-13 indicates moderately impaired) on the Brief Interview for Mental Status, was independent with mobility and had no history of wandering. a. The Care Plan dated 4/24/17 documented, (Resident #3) is an elopement risk/wanderer related to episodes of sun-downing in the late evening/night. Disoriented to place secondary to history of Dementia with major neurocognitive disorder in a new environment .interventions: Assess for fall risk. Date Initiated: 4/24/17. Cue and redirect as needed. Date initiated: 4/24/17/ Revision on 8/25/17. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 4/24/17 Revision on :5/09/17. Monitor for fatigue and weight loss. Date initiated: 4/24/17. b. An Elopement Risk assessment dated [DATE] documented the resident was not at risk for elopement. c. A Nurse's Note dated 7/30/17 at 6:43 p.m. documented, At (3:10 p.m.) was notified that resident was out of the building. Located on 16th near the fence sitting under a tree. Resident stated he had to go to work in (town in South Arkansas). Resident was let out of the building by a visitor. Visitor was informed to make staff members aware if someone is trying to exit the building before opening the door for them. Resident was placed one on one and the police was notified. No new intervention was put in place for this resident found in the clinical record. d. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and (&) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 7/30/17 documented, CNA (Certified Nursing Assistant) was clocking out to leave for the day and was driving off of the property when she saw resident sitting under a tree at the corner. She went and notified the nurse on duty and they escorted resident back into the facility. While coming back in the facility, another resident's family member was standing outside the main entrance. She stated that she had just let the resident out approximately 5 minutes earlier as he stated he was going to (town in South Arkansas). She was unaware he was a resident here and apologized for allowing him to exit the facility. Resident was assessed by the nurse for any negative findings, including dehydration and there were no negative findings. Witness statements were gathered from staff present . A new sign was posted on the front door alerting all visitors to not hold the door open or allow anyone to exit the facility without first notifying staff. A letter is being sent to all family members as well that educates them on always asking or notifying staff if someone is wanting to exit the facility. An inservice was completed with staff on what to do when there is a missing resident . The facility's corrective actions did not include putting any individualized interventions in place for Resident #3, such as assessing to determine if there was a particular time of day or activity that may have contributed to increased exit-seeking behaviors by the resident, to facilitate staff's ability to determine when increased supervision may have been required to prevent further successful elopement attempts by the resident. The corrective actions also did not include documentation of an ongoing monitoring plan to determine if the signage and letters were effective in achieving visitor compliance with the facility's instructions. e. A Nurse's Note dated 8/2/17 at 7:30 p.m. documented, Res attempted to elope at 1545 (3:45 p.m.) this evening. Was redirected and informed that he could not go outside. Resident noted sitting in w/c (wheelchair) and attempted to redirect resident to nurse's station. Resident quickly refused. Notified DON (Director of Nursing) of refusal. Notified (physician) of resident combative like behavior. Questioning possibility of UTI (urinary tract infection). New order UA (urinalysis) with C&S (culture & sensitivity), BMP (basic metabolic panel), and CBC (complete blood count) due to increase in confusion . Resident on 1 on 1 this shift. Resident refused to urinate in urinal this shift . f. A Nurse's Note dated 8/17/17 at 1:02 p.m. documented, Resident attempting to leave facility. Keeps walking halls and walking up to front entrance. Monitored by staff and escorted back to room. g. A Nurse's Note dated 8/23/17 at 5:17 p.m. documented, It was reported to Administration at 4:20 p.m. that resident was unable to be located. Facility and grounds searched and resident was not located. 911 called at 4:30 p.m. Contact made with son at 4:42 p.m. to see if he had taken his father anywhere, son stated that he had his father, that (restaurant name) had called him after being given his number by his father. Son stated that his father was not hurt but that he was taking his father to (local hospital) to be assessed. Temperature outside was 80 degrees at the time. (Restaurant name) is 0.2 miles from facility and is a 5 minute walk per (online search engine results). Upon completing investigation, it was discovered on 3-11 (3:00 p.m. to 11:00 p.m.) shift that resident was missing when completing walking rounds at 3:30 p.m. Code silver was immediately called with a complete head count performed with all other residents accounted for at 3:40 p.m. All facility doors checked for proper functioning, all windows checked with no negative findings and facility door codes were immediately changed. CNAs (Certified Nursing Assistants) interviewed with discovery that resident was last seen sitting in the front lobby at 2:30 p.m. reading the newspaper by staff. APN (Advanced Practice Nurse) made aware. A DMS form 762 dated 8/23/17 documented, Upon making rounds at 3:30 p.m. it was discovered that resident was missing from the facility with code silver immediately initiated. At 4:42 p.m., resident's son was contacted whom (sic) informed staff that this resident was in his car being transported to (local hospital) to be assessed. Resident's son stated that this resident had given his phone number to the staff at (restaurant name) to contact him and that he immediately went to pick this resident up. Resident's son stated that he had his father for about an hour, hour and a half, before the facility contacted him. Resident's son stated that resident had ambulated with his cane to this cafe' which is 0.2 miles from the facility, a five minute walk per (online search engine results). Resident was wearing a short sleeved shirt, blue jeans with a belt, tennis shoes, and a hat. Temperature outside at the time was eighty degrees. Resident last seen by a staff member at 3:04 p.m. in the lobby reading a newspaper. Staff at (restaurant name) stated that he arrived there at about 3:30-3:35 p.m. and had given them his son's information to contact him. Charge nurse went to assess resident at (local hospital) on 8/23/17 with no distress noted, no injuries noted. Resident currently at (local hospital) awaiting placement at a facility with a secure unit . Interventions for all other residents at risk for elopement reviewed and in place. All facility doors and windows checked for proper working function with no negative findings noted. Codes to all doors in the facility changed. Key pad to the front door moved to a higher position on the opposite side of the front door with a cover placed over the key pad. Key pad changed with one with smaller numbers. Staff inserviced on facility elopement policy. Staff inserviced on ensuring the doors are closed to the administration hallway which leads to the front entrance between the hours of 5pm-7am and on supervision of residents whom choose to sit in the lobby between those hours. Sign posted on the doors leading to the administration hallway to alert residents and visitors of need for supervision of residents when choosing to sit in the lobby during the hours of 5pm-7am. h. A hospital History and Physical dated 8/24/17 documented, This patient is a 92 y/o (year old) demented . presented to the ED (emergency department) . by his son for evaluation after eloping from his nursing home . He requires total supervision. The patient is currently a resident of a NH (nursing home) and was found wandered away from the NH this afternoon, the NH was not aware that the patient was missing. The patient's son reports that he had eloped from the NH once before, and because this is the second time that he has eloped from the nursing home without the NH staff knowing, the son is concerned about his safety at the NH and is requesting that he be placed in another NH. Admission requested to facilitate same. i. On 9/12/17 at 9:00 a.m., CNA #5 was asked if she knew anything about the resident's elopements and stated, I found (Resident #3) down here at the stop sign, sitting on the ground with his cane beside him. I put my car in park and got out and told him to come ride with me and he got in my vehicle. CNA #5 was asked what kind of interventions were implemented after that and stated, They had 1:1 for like a day I think. The CNA was asked if she had been told to monitor him more closely and stated, They said just to keep an eye on him. j. On 9/12/17 at 12:38 p.m., the Administrator was asked about the elopements and stated, I was on maternity leave when he left the first time. I didn't even know about it until I called the son about this last elopement and he told me about the first one. From what I reviewed, they spoke to a visitor about letting him out and they sent out letters to notify family members to be aware. And they changed the code. A sign was posted on the door. We have no idea how he got out this last time but his cognition isn't good enough to remember a door code. The Administrator was asked what interventions were developed for the resident after the first elopement on 7/30/17 besides the 24-hour period of one-on-one monitoring after the first elopement. The Administrator stated, Supervision by staff, monitoring, standard nursing care. All doors are checked every day. The Administrator was asked who else in the facility was at risk for elopement and stated, As of right now, no one is considered to be at risk for elopement. k. On 9/12/17 at 1:49 p.m., CNA #6 was asked if she knew anything about the resident's elopements and stated, I sat with him one-on-one after that first time. He was on 6 hall, then moved to 5. He was confused as to where his room was and he kept trying to pay for his food. Then he was moved to 4, and that was closer to the front and he would wander up here by the door and try to leave. He would always say he wanted to go back to (town in South Arkansas). The CNA was asked if she was told to monitor the resident more frequently since he was at risk for elopement and stated, No. He was just routine. l. On 9/12/17 at 2:20 p.m., CNA #7 was asked if she knew anything about the resident's elopements and stated, I never even knew he left that first time until after he left the second time. He looks like a visitor. Very clean, well dressed. The CNA was asked if she was ever told to monitor him more closely because he was at risk for elopement and stated, No, they never said anything like that. m. On 9/12/17 at 3:27 p.m., the Director of Nursing (DON) was asked what kind of monitoring plan was put into place to determine if their interventions after the first elopement (signs on door, letters sent to families, code change) were effective. She stated, I checked on him every day I was here. I had the nurses monitoring him. I know the interventions were working because I heard family members asking for the new code and asking people if they were visitors or residents. And this last time, I had talked with him right before he left. n. The facility removed the Immediate Jeopardy and corrected the failed practices on 8/24/17, prior to the survey entrance date, as evidenced by the following: 1.) Resident #3 no longer resided in the facility at the time of the survey and, according to the Administrator, there were no other residents currently residing in the facility who were at risk for elopement. During the survey conducted from 9/11/17 to 9/26/17, no residents were observed exhibiting any exit-seeking behaviors. 2.) In-service documentation dated 8/24/17 documented staff were in-serviced on the facility's Elopement Policy. Instructions to staff included, If a resident is exit seeking, they are to be placed 1:1 (one-on-one) immediately and notify the DON immediately; the fire doors on the Administration hall are to remain closed between the hours of 5pm and 7am and residents are provided supervision when entering the front hallway; Signs were posted on doors leading to administration hallway to alert residents and visitors of need for supervision (8/23/17); Key pad to the front was moved to a higher position on the opposite wall and a cover was placed around the key pad; Code to all doors was changed; All facility doors and windows were checked for proper function. 3.) On 9/11/17 at 1:25 p.m., the surveyor and the Maintenance Supervisor checked all exit doors in the facility for proper functioning of the key pads and locking mechanisms. There were no problems observed. 4.) The Maintenance Supervisor was asked what interventions were put in place and stated, the front door key pad was moved from the front door to another wall and a guard was placed over it, the code was changed from a 3 digit code to a 4 digit code, and at 6:00 p.m., the electric timer kicks in and locks all the doors and unlock them at 5:00 a.m. The Maintenance Supervisior also stated that on Friday's all the doors are checked to make sure the key pads are working.

Complaint # (AR 419) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure necessary care and services were provided for hygiene and urinary catheter maintenance, as evidenced by failure to ensure perineal hygiene and catheter care were thoroughly and consistently provided per the plan of care, which resulted in a Urinary Tract Infection [MEDICAL CONDITION] and the presence of maggots in and around the urethral meatus for 1 (Resident #1) of 2 (Residents #1 and #6) case mix residents who had a urinary catheter. This failed practice resulted in past noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who contracted a UTI and maggots in and around the urethra, and had the potential to cause more than minimal harm to 2 residents who had a urinary catheter, according to a list provided by the Administrator on 9/13/17 at 9:00 a.m. The facility was informed of the past immediate jeopardy condition on 9/13/17 at 12:38 p.m. The findings are: Resident #1 was admitted to the facility 8/17/17 and had [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 8/30/17 documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status, was totally dependent on staff for activities of daily living and had an indwelling catheter. a. A Physician order [REDACTED]. b. A Certified Nurse Assistant (CNA) Bath Checklist dated 8/25/17 documented the resident refused a bath three times. Registered Nurse (RN) #1's initials were documented on the sheet as being aware of the refusal. c. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and (&) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 8/26/17 documented, While providing care to this resident it was noted that he had what appeared to be small maggots on his genital area. Pests immediately removed from genital area. Resident sent to the ER (emergency room ) for evaluation and returned with order for antibiotic related to lung infiltration. d. A Nurse's Note dated 8/26/17 at 4:04 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, Resident transported via (Emergency Medical Transport) to (hospital) at 3:15 a.m. On making rounds attempting to turn resident, observed very small maggots in the genital area coming from around the opening of the cath (catheter). CNAs (Certified Nursing Assistants) cleaned resident up, the nurse called the DON (Director of Nursing) to report findings. DON stated to clean resident up and send out to (hospital) ER (emergency room ) . e. A hospital Urinalysis (UA) dated 8/26/17 documented, UA Appear - cloudy, Reference Range - clear. UA Protein - 100, Reference Range - negative. UA Leuk Est (Leukocyte esterase) - Large, Reference Range - negative. UA WBC (white blood count) - 256, Reference Range - 0.0-3.0. UA RBC (red blood count) - 8.0, Reference Range - 0.0-3.0. UA Bacteria - 1+, Reference Range - negative. f. An ED (Emergency Department) Nursing Record note dated 8/26/17 documented, Removed several live maggots from the base of pt (patient) penis at the leg fold. Pt tolerated well. g. An ED Physician Note dated 8/26/17 documented, Diagnosis - UTI . Spoke with (physician). Doesn't see any reason to admit. Non septic at this time. Dose of [MEDICATION NAME] in ED . h. A Physician's Telephone Order dated 8/26/17 documented, [MEDICATION NAME] 500 mg (milligrams) 1 PT (per tube) QD (every day) x (times) 5 d (days). i. On 9/11/17 at 3:30 p.m., the resident's wife was asked if she had seen flies in the facility prior to the resident being found with maggots in his perineal area. She stated, I had seen some flies. They were on top of his sheet and in the window. But he had not had a bath for like seven days. He's supposed to get his shower on Monday, Wednesday and Friday. The CNAs were telling me that he couldn't get a shower because of his wound vac. And he wasn't getting a bed bath. I'm here all the time so I would know. j. On 9/12/17 at 8:25 a.m., Licensed Practical Nurse (LPN) #1 was asked what happened during the early morning of 8/26/17 and stated, The CNAs were making rounds, and I told (CNA #1) to let me know when she got to him so I could check everything. He was facing me and we pulled him up in bed and then she saw them. She said, 'Look!' And there they were. They were very small. I called (physician), and he said to go ahead and remove them. The DON said to clean him up and send him out. The LPN was asked if the maggots were going inside the penis where the catheter was inserted and stated, Yes, the maggots was (sic) coming out and going inside. The LPN was asked about the number of maggots and stated, There was quite a few of them. The LPN was asked if she had been seeing flies on the hall where the resident resided and stated, Yes. There were quite a few back there. In fact, I had to go buy a fly swatter. k. On 9/12/17 at 8:44 a.m., CNA #1 was asked what happened the early morning of 8/26/17 and stated, I raised his gown up and saw the maggots around his genital area and where the catheter goes in and the creases of his legs. The CNA was asked about the number of maggots and stated, I'm not going to say it was a handful, but it was a lot. They were little. The CNA was asked if the maggots were close to where the catheter was going into his penis and she stated, They were like going inside his penis. It's just gross. Nasty. l. On 9/12/17 at 9:17 a.m., CNA #2 (shower aide) was asked about the resident not receiving showers during the week from 8/21/17 through 8/26/17 and stated, His wife refused. I asked her, and she said no, because the treatment nurse had just put his dressings on. On another day, she just refused. And on another occasion, we gave him a bed bath. CNA #2 was asked who does catheter care in the facility and stated, The CNAs would do that. The CNA was asked if she reported the wife's refusal to have the resident showered to the nurse and stated, Yes, we've always reported. The nurse has to sign off on it, because there are certain things they have to do then. m. On 9/12/17 at 10:01 a.m., Registered Nurse (RN) #1 was asked if she did catheter care on the resident on 8/25/17, on the 7:00 a.m. to 3:00 p.m. (7-3) shift and stated, Yes I did. It was done very early in the shift with my med pass. RN #1 was asked if the wife refused for her husband to have a shower on 8/25/17 and stated, Not to my knowledge. There was an issue with her refusing on a different day, because the treatment nurse had just changed his wound vac dressing and we were trying to change his treatment days or his shower days, so he was given a bed bath that day. And on Friday (8/25/17), I didn't receive my bath sheets before any of the CNAs left, so I didn't get any refusals, and the CNAs didn't tell me she had refused. The RN was shown the bath sheet for 8/25/17 that documented the resident had refused a shower three times, and that her initials were on the bath sheet as being notified. The RN stated, That's not my signature. I didn't do that. I don't initial bath sheets. I put my full signature. She then pulled out the bath book and showed the surveyor multiple completed bath sheets, all of which documented her full signature, not her initials. n. On 9/12/17 at 3:11 p.m., CNA #3, who gave the resident a bed bath on 8/23/17 was asked if the resident's wife refused showers or bed baths and stated, She didn't refuse it on that Wednesday, but it was confusing, because we were trying to get his baths to coincide with his dressing changes. I don't know if he got a shower that week. I took care of him on Friday (8/25/17) as well. He was supposed to get a shower, but I don't know if he did. I was busy that day with a new resident who had [MEDICAL CONDITION], so I didn't have time to give him a bed bath. o. On 9/13/17 at 10:04 a.m., CNA #4, who provided care to the resident on the 3:00 p.m. to 11:00 p.m. (3-11) shift on 8/25/17, stated, I worked with him for a little while. The maggot incident was brought to my attention the next day. I didn't see anything on him my shift, but the flies were real bad down there, and it was warm. We had fly swatters. I have killed a couple of flies in his room and one was under the covers. But I didn't think anything about that. CNA #4 was asked if she did catheter care on the resident during her shift and stated, I did his catheter care right when I got there at 3:00 p.m. p. On 9/13/17 at 10:55 a.m., the Medical Director was asked if he knew about the incident that occurred on 8/26/17 and stated, I know they found maggots and I've gotten some mixed reports on where, exactly, the maggots were. He went to the ER and they found a few more. The Physician was asked if maggots in the urethra would potentially cause a UTI and stated, They did diagnose him with a UTI, which he has had before . Maggots are usually clean, but just the fact that they can crawl from outside to in can introduce something. I can't say that they caused his UTI, but I can't say they didn't. q. The facility removed the immediate jeopardy and corrected the failed practices on 8/26/17, prior to the survey entrance date, as evidenced by the following: 1.) The facility's corrective action plan on the DMS form 762 dated 8/26/17 documented all other rooms and residents were inspected on 8/26/17; Resident #1's room was deep cleaned on 8/26/17; a pest control company came to the facility to spray for flies on 8/29/17; other residents were interviewed concerning baths on 8/28/17; the Maintenance Director inspected the facility to check for openings that would allow pests to enter; the nursing staff was in-serviced on notifying nursing administration if residents refused showers on 8/28/17; the nursing administration performed peri-care and catheter care check-offs with nursing staff. The form also documented, .To ensure effectiveness of the interventions, department supervisors are making daily rounds, unit managers are pulling bath sheets daily, and the staffing coordinator developed a schedule to routinely observe catheter care and peri-care to ensure it's being done properly. On 9/12/17 at 9:00 a.m., the Administrator provided copies of pest control receipts and check-off sheets and daily rounds sheets to indicate the above corrective actions were completed and that monitoring was being continued on an ongoing basis, with no further negative findings identified. 2.) On 9/13/17 at 8:50 a.m., CNA #8 and CNA #9 were observed providing catheter care for Resident #6, and at 9:24 a.m., CNA #10 and #11 were observed providing catheter care for Resident #1. The CNAs followed proper technique, and there were no negative findings. 3.) On 9/11/17 through 9/13/17 at 12:30 p.m., observations were periodically made throughout the facility to determine if any pests were present. No flies were observed at any time during the survey.

Complaint # (AR 747) was substantiated, all or in part, with these findings. Based on observation, record review, and interview, the facility failed to ensure constant supervision was provided during smoking of tobacco products, in accordance with a resident's assessed smoking supervision needs, to prevent further potential burn injuries for 1 (Resident #3) of 8 (Residents #2, #3, #4, #5, #6, #7, #8 and #9) case mix residents who smoked tobacco products. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #3, who sustained at least 5 cigarette burn injuries in the past month while smoking, and had the potential to cause more than minimal harm to 20 residents who smoked tobacco products. The Administrator was informed of the Immediate Jeopardy on 2/7/17 at 2:25 p.m. The findings are: Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 10/18/16 documented the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status; was totally dependent on 2 staff for assistance with transfers; totally dependent on 1 staff for assistance with bed mobility, locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing; was not steady and only able to stabilize with staff assistance with surface-to-surface transfers; had functional limitation in range of motion in one upper extremity and both lower extremities; used a wheelchair for mobility; received a scheduled pain medication regimen; and received an antipsychotic and antidepressant for 7 of the past 7 days. a. A Safe Smoking Evaluation dated 10/18/16 documented, .Unsafe by self. Degree of supervision needed while smoking - Constant, per facility policy. b. A Grievance Form dated 12/28/16 documented, Statement of Concern: Family member reported that several residents were outside in the smoking area unattended. Immediate Action Taken: In-serviced staff about not leaving residents unattended. c. A Resident Incident/Accident (I&A) Report dated 1/8/17 documented, Description of Incident: Burned himself while smoking a cigarette on his left side of abd (abdomen). Immediate intervention put in place to prevent further incident: Made sure he understood he needed to be more aware of his cigarette at all times . Recommendations/New Interventions: Reassessed for smoking. Wear smoke apron when smoking. Staff in-serviced on smoking residents, making sure all residents smoke safely. Staff to assist resident while smoking. Treatment to abd, TAO (Triple Antibiotic Ointment). d. A handwritten care plan revision dated 1/9/17 (to a Plan of Care dated as initiated on 4/26/16 for a problem of alteration in neurological status) documented, 1/9/17 (Resident) with abdominal lesion secondary to cigarette burn . Interventions . Treatment to area as per MD (Medical Doctor)/(or)Tx (Treatment) nurse recommendations. Monitor for s/s (signs/symptoms) of infection. Observe for effectiveness of treatment. Smoke apron on when smoking. e. A Resident Smoking assessment dated [DATE] documented, .Ability to touch thumb to each finger on each hand. Ability to grasp small objects (i.e. (such as) pen) with each hand. Ability to open and close index finger and middle finger in scissor motion with each hand . Resident exhibits a clear understanding of the smoking policy as it has been explained, and in writing as evidenced by accurately answering questions related to designated smoking areas, storage and use of smoking materials, consequences of non-compliance and responsibilities of the resident to prevent other residents from obtaining smoking materials . Resident exhibits physical ability to smoke with minimal assistance as evidenced by the evaluation of motor skills. f. A Nurse's Note dated 2/1/17 (not timed) documented, RN (Registered Nurse) supervisor noted that this resident had a second degree burn to his right and left upper thigh. Areas appear to be caused from a cigarette burn. Staff states that this resident's wife takes this resident to smoke without staff supervision. Resident's wife encouraged to ask for assistance when taking this resident to smoke. Stated understanding . g. A care plan revision dated 2/1/17 for the above described Plan of Care documented, .Two cigarette like burns to thighs . Intervention . Inform wife staff only to take (resident) out to smoke. Watch closely while smoking. h. On 2/6/17 at 10:15 a.m., Certified Nursing Assistant (CNA) #1 had ten residents in the smoke area. Residents #2 and #3 had on smoke aprons. Resident #3 was in a wheelchair with his feet extended on the foot rests, and had heel protectors on both feet. The smoke apron extended down just past his knees. As Resident #3 smoked, cigarette ashes dropped down onto the smoke apron and rolled down the apron, onto his sweat pants. CNA #1 brushed the ashes off. The CNA was asked how she knew who was supposed to wear an apron. She stated, It's written down on this note inside the smoke box. The lid on the smoke box was opened and a piece of paper documented four resident's names. i. On 2/6/17 at 11:06 a.m., Resident #3 was in a wheelchair by the nurse's station. The resident was asked if he had ever burned himself while smoking. He stated, Sometimes. That spot right there on my hand is from a cigarette. A red circular area was on the resident's right hand (approximately 0.7 cm (centimeters)) in the area of the head of the 5th metacarpal. The resident was asked if he had any more cigarette burns. He tried to pull his shirt up but couldn't. He was asked how those burns happened if he wears a smoke apron. He stated, I don't know. The wind comes along every once in a while and causes a problem. j. On 2/6/17 at 2:00 p.m., Resident #3 was in bed. The resident had a circular scab on his left abdomen (approximately 0.8 cm), a circular scab on top of his right thigh (approximately 0.7 cm), a circular scab on his left thigh (approximately 0.5 cm), and 2 other circular, scarred areas to the left thigh that appeared to be healed cigarette burns. k. On 2/6/17 at 2:40 p.m., Resident #3's wife was asked, via telephone, about the cigarette burns on his thighs. She stated, They're trying to say those happened when I took him out to smoke. It didn't . I did notice he had some burn spots on his pants, but I didn't know his legs had been burned. She was asked if she had taken the resident outside to smoke without the smoke apron. She stated, Yes I have, but I'm right there with him. I watch him very closely. He can't safely hold a cigarette without that apron on. Sometimes he gets real sleepy, or his arm will droop, or he'll start to focus on other people and forget he's got one. She was asked if she had been told by staff to not take him out to smoke without staff. She stated, Yes they've said that. And there's something else. I bring his clothes home and wash them. Every time I'm there, I pick them up. This past Saturday, I threw away a pair of pants and three shirts because of burn holes. I have complained to (previous administrator) about this, because it happens all the time. l. On 2/7/17 at 8:25 a.m., CNA #2 took two non-case mix residents out to the smoke area to smoke. The residents pulled out their own cigarettes and the CNA lit them. At this time, Resident #8 was assisted out into the smoke area by another CNA, then that CNA went back into the building. Resident #8 asked CNA #2 to get him something to blow his nose because it was dripping. The CNA stepped back into the building and was gone for approximately 10 seconds, leaving the residents alone during this time. No smoke aprons were being used. m. On 2/7/17 at 9:16 a.m., CNA #3 was asked which residents needed smoke aprons. She stated, Four residents (Resident #2 and #3). I have seen (Resident #3) out there with his family without an apron. She was asked if she intervened when she saw Resident #3 outside smoking without an apron. She stated, I didn't. I don't know if anyone else has. (Resident #6) has taken himself to smoke without staff. (Resident #2) will do it too if that door isn't locked. We had an inservice recently about aprons, and smoking paraphernalia and to keep it locked up. It's hard because they've got family who brings them cigarettes. She was asked if anyone had gone out to monitor smoke breaks with them to ensure the residents were being watched closely enough. She stated, No. n. On 2/7/17 at 9:27 a.m., CNA #4 was asked who gets smoke aprons when she takes the residents to smoke. She stated, If we get a bunch of residents out there, I give the apron to those who shake. We have four or five aprons and the 2:30 p.m. break is busy. It's a tough choice but you do what you can do with limited supplies. She was asked if she knew there was a list of residents who gets a smoke apron. She stated, No, I didn't know that. She was asked if she puts one on Resident #3. She stated, Yes. She was asked how he gets the cigarette burns if he is wearing a smoke apron. She stated, I have no idea. She was asked if there had been any in-services recently on smoking. She stated, Yes. Making sure we give them time to smoke, use the aprons, they can't have their own cigarettes or lighter. o. On 2/7/17 at 9:45 a.m., the Director of Nursing (DON) was asked for an I/A for the cigarette burn on the resident's right hand. She stated she didn't know anything about a burn on the resident's right hand and that there is no I/A. The DON was asked how the facility had been monitoring the effectiveness of the in-services that had been done on smoking issues, and, For instance, has anyone been going out with the CNAs and residents to monitor the smoke breaks? She stated, No. No one has been going out with them. That's our fault. We obviously need to do better. p. On 2/7/17 at 9:59 a.m., CNA #5 was asked how long it had been since she took residents out to smoke. She stated, It was last Friday. She was asked who needed to wear smoke aprons. She named two residents and then stated, .and (Resident #2 and #3). (Non case mix resident) is in a geri-chair and he's contracted and if ashes fall he can't reach and get it. Neither can (Resident #3). She was asked if she had heard about any residents having cigarette burns. She stated, I've been told (Resident #3) has. You have to really watch him. She was asked how Resident #3 could get a burn on his abdomen and thighs if he was wearing a smoke apron. She stated, He didn't have it on apparently, or it wasn't positioned right. When everyone decides to go out and smoke, there needs to be more than one CNA. And we do have occasions where family or friends take them out. We tell (Resident #3's) wife about the apron. We try to tell everyone. She was asked if she knew of any occasions where residents have gone out to smoke unsupervised. She stated, Early in the morning there have been a few who know the code, that will be out there smoking without staff. I walk to work and that's when I see them. She was asked how recently this had happened. She stated, I saw that last week. She was asked who was out there. She stated, (Residents #6, #7, and #8). She was asked if there had been any recent in-services on smoking. She stated, Yes. We are not to leave the smoke area until everyone is finished. And they're supposed to keep their cigarettes in the box, but we have some who ain't gonna give them up. She was asked if anyone had gone out to the smoke area to monitor smoke breaks with the CNAs and residents, like someone from administration or a nurse. She stated, No. q. On 2/7/17 at 1:30 p.m., the DON was asked if she was aware if any of the residents knew the door code and if they were using it to go outside to smoke unsupervised. She stated, Yes, I was aware of that because I have written out some grievances that they were going out and smoking without staff . I would come in early to work and catch them out front. I told them to put out their cigarettes and come in. She was asked what the facility had done about that to stop it. She stated, (Maintenance) has been told and he is supposed to change the code. She was asked if he had done that. She stated, Not since I've been here, but he has been loaded up with stuff. r. On 2/7/17 at 2:15 p.m., Resident #3's daughter asked the surveyor to go outside and look at her dad. The resident was with his wife and was smoking with a smoke apron on. His wife showed the surveyor burn spots on each heel protector and then pulled off the left heel protector. There was a small round scab area on the left inner heel that resembled the resident's other cigarette burns. s. On 2/7/17 at 2:41 p.m., CNA #6 was asked if she had known any residents to go outside and smoke without supervision. She stated, When we come in in the morning time, they be out there, so we come in and get somebody bigger than us, like a nurse. We tell them 'ya'll know you ain't supposed to be out here' and they say 'don't worry about it'. She was asked how those residents got their smoking supplies. She stated, Some of them go to the store. You may collect 20 today, but 30 tomorrow. t. On 2/7/17 at 4:05 p.m., the Maintenance Director was asked if he had been told to change the door codes. He stated, The DON asked me right after she got here to change the codes and the next day, the residents knew them. I was asked again today to change them. u. The facility's Tobacco-Restrictive Policy Acknowledgement documented, Policy: It is the policy of the facility to discourage any smoking in the facility. However, we are also understanding of the fact that as a long term care facility some of our residents may choose to smoke. Therefore, the facility will designate an outside smoking area to accommodate the request of those individuals. Purpose: The purpose of restricting the smoking in the facility is to reduce . the risk of fire. Procedure: Every resident who smokes will be assessed for safety. Staff will dispense the resident's cigarettes, light the cigarette, and stay with the resident until the cigarette is properly extinguished. All residents smoke with supervision and will do so only in the designated area and at designated times. All cigarettes, lighters and any other smoking materials will be kept at the nurse's station . Smoking aprons are required if resident fails the smoking assessments . 2. The Immediate Jeopardy was removed and the scope and severity was lowered to an E 2/7/17 at 2:56 p.m. when the facility implemented the following Plan of Removal: a. Resident #3 was placed on 1:1 monitoring for his smoke breaks. b. Door codes have all been changed so that residents can not exit to smoke without supervision. c. Smokers will be supervised by 2 staff members at each smoke break and will be documented. d. Smokers will be offered assistance and encouraged to quit smoking with patches provided by the facility. e. The above interventions will start on 2/1/17 at 2:45 p.m. and will be completed by 4:00 p.m. In-servicing by the DON/designee will begin on 2/7/17 at 2:45 p.m. and will be completed by 4:00 p.m. Any staff not present will be in-serviced prior to being allowed to provide care. Monitoring of smoke breaks will occur by the Administrator/DON/designee 2x (times per)/day for the next 2 weeks, then 1x/day, 3 days per week for 2 weeks. Monitoring of staff supervision of smoke breaks will be documented.

Complaint #'s (AR 820) and (AR 813) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed provide Resident #1 the necessary treatment and services to promote healing of a wound and prevent infection. The facility failed to identify the need for treatment of [REDACTED].#1) of 4 (Resident #s 1 - 4) case mix residents who had a non-pressure related wound. The failed practice resulted in Immediate Jeopardy, which caused or could have cause serious injury, harm or death to Resident #1 whose unmonitored/untreated wound developed gangrene and required a left [MEDICAL CONDITION] and had a potential to affect 13 residents who had non pressure related wounds. The facility was informed of the Immediate Jeopardy on 11/12/15 at 10:10 a.m. The facility also failed to ensure treatments/dressings to non-pressure related wounds were provided according to the physician orders [REDACTED].#s 2 - 4) of 4 case mix residents (Resident #1 - 4), who had a physician order [REDACTED]. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. a. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & (and) Exploitation of Residents in Long Term Care DMS-762 dated 9/26/15 time of incident 4:45 p.m. documented, On 9/26/15 (Saturday) treatment nurse (Licensed Practical Nurse (LPN) #2) notified charge nurse (LPN #3) that resident's foot was bleeding when he entered the room he noticed a deep laceration under the great left toe of her left foot. He asked the (Certified Nurse Assistant (CNA) #1) that was assigned to resident did she know anything about how this may have happened and she stated she did not know what happened. Charge nurse notified the doctor and received order to send to hospital. Administrator, DON (Director of Nursing), was notified and charge nurse was instructed to look at residents w/c (wheel chair) and bed to see if resident may have hit her foot on the w/c or bed and to complete I&A (Incident and Accident) to investigate to see how this injury may have occurred. Family notified. On 9/27/15 Administrator was notified by charge nurse that (Resident #1) had a fracture on her great left toe in two areas and a deep laceration between her great toe and her second toe that required eight stitches, 1cm (centimeter) deep x 4cm long. Received splint on left foot. During investigation discovered, CNA #1 was getting resident up for dinner and she did not follow the care plan for transferring . b. The hospital ED (Emergency Department) progress note dated 9/26/15 at 8:00 p.m. documented, .seen on 9/26/15 for laceration around base of left great toe, x-ray showed minimally displaced fracture of lateral aspect of base of proximal phalanx and another small [MEDICAL CONDITION] on medial aspect. Orthopedic Surgery consulted, awaiting recommendations.Pt (patient) checked out to ER (emergency room ) (doctor) at end of shift. c. The Nurse's Note dated 9/27/15 at 2:30 a.m. documented, R (resident) received via (ambulance service) returning from hospital ER D/Cing (discontinuing) nurse phoned in D/C (discontinued) report to return to facility with splint to left leg. Laceration to affected area eight sutures intact to wound site . The Nurses Note did not document whether or not there was a dressing to the foot or any assessment of the wound. There was no documentation of any treatment order or other instructions regarding monitoring the condition of the wound on the left foot. 1) On 11/11/15 at 9:11 a.m., LPN #4 was on duty at the time the resident returned from the hospital on [DATE] (Saturday at 2:20 a.m.) LPN #4 was asked about instructions on care of the wound or monitoring of the condition of the wound and she stated, .I didn't get anything back from the ER as treatments or what to do with it. The sutures, the family told me how many the resident had. The hospital didn't tell me. 2) On 11/11/15 at 9:35 a.m., LPN #5 stated he was (Resident #1's) nurse on the weekends. LPN #5 stated, I did not see the resident until I came back to work (7A/7P). I knew she had a wound. LPN #5 was asked would the LPN generally be expected to call the doctor for treatment orders and document the condition of the wound. LPN #5 stated, There should have been some kind of order written when she returned from the hospital or at least by the next day. 3) On 11/10/15 at 2:30 p.m., LPN #1/Treatment Nurse stated she did not work the weekends, They had (LPN #2) do treatments on the weekends. They moved (LPN #2) from Saturday and Sunday back to just Saturday. If you see any blanks on the TAR (Treatment Administration Record) for Sundays, the treatments weren't done. The floor nurses will not budge on that (meaning the floor nurses did not do the treatments). LPN #1 stated that the resident returned from the hospital on [DATE]. I did not see her on 9/28/15. LPN #1 was questioned why there was no treatment order for the left foot wound. LPN #1 stated there were no treatment orders sent from the hospital and all she did was monitor the foot. The LPN stated, I was reprimanded for not getting at least an order for [REDACTED].#1 could not provide documentation that the condition of the wound was consistently monitored. d. The Progress Note dated 9/28/15 (the day after the resident returned from the hospital) and signed by the Advance Practice Nurse (APN #2) documented, .Plan: continue current POC including dressing and daily follow up by tx.nurse . The Progress Note dated 9/29/15 and signed by the Advance Practice Nurse (APN #2) documented, .Plan: . Continue to monitor closely for worsening s/sx (signs and symptoms). There was no documentation to indicate the condition of the wound. e. The Nurse's Note dated 9/30/15 at 8:00 a.m. documented, (Doctor) has been contacted r/t family request for resident to be seen by orthopedic surgeon. There was no documentation found in the Nurses Notes to indicate the wound had been monitored or to indicate the physician or APN was notified of a change in (Resident #1's) left foot wound until 10/20/15 when the Primary Care Physician (PCP) assessment and documented on 10/20/15, approximately 3 weeks later. The Orthopedic consult dated 10/2/15 documented, .there is no evidence of infection noted.I recommended that she use a postop shoe to help protect the foot from the environment. She will return to clinic in a month . f. The Nurse's Note dated 10/5/15 at 9:30 a.m. documented, .Resident c/o (complained of) pain and this nurse notified staff nurse for pain med (medication) to be admin (administered) per MD (Medical Doctor) orders. Sutures present at base of left great toe, black boot present to assist with stabilizing foot . There was not further documentation found in the Nurses Notes in the clinical record from 10/6/15 until 10/20/15 (a total of 14 days) to indicate the nursing staff assessed and monitored the condition of the resident's left foot wound. g. The Primary Care Physician's Progress Note dated 10/20/15 documented, .I was informed by the treatment nurse that her (resident ' s) family is concerned about the end of her big toe. She fractured it with a laceration. Orthopedics has seen and placed her in a boot. Assessment/Plan: great toe fracture - I am concerned about the end of the toe. I cannot be sure at this point if this is dry gangrene. There is scabbing as well. I am going to start ASA ([MEDICATION NAME] acid) just in case. The toe itself is warm. She is comfortable. Will follow up. h. A physician's telephone order dated 10/21/15 at 8:40 a.m. documented, Apply [MEDICATION NAME] to left great toe and cover with dry dressing and off load daily. Dx. (diagnosis): Unstageable Pressure Ulcer. A treatment order for the left foot wound was obtained 23 days after injury with sutures. There was no further documentation of any assessment of the resident ' s wound found in the Nurses Notes or elsewhere in the clinical record from 10/23/15 until 10/31/15 (a total of 9 days). On 11/11/15 at 10:42 a.m., LPN #6 was asked why there was no documentation regarding the condition of (Resident #1's) left foot wound. LPN #6 stated, We always checked her condition. We assessed when CNAs would tell me she was in pain. The treatment nurse is here Monday through Friday. I was assuming she was in charge of her treatment. I was in charge of her care. The wound was always wrapped up. I never saw the wound. I assumed she had a treatment and the treatment nurse documented on it. i. The Nurse's Note dated 11/1/15 documented, .(APN #1) ordered labs and doppler of lower extremity but daughter of (Resident #1) asked for her to go to the hospital for evaluation. Labs were drawn before ambulance transported the resident . j. The hospital's Bilateral Lower Extremity Arterial Duplex dated 11/1/15 documented, [AGE] year old female with left foot gangrene. Impression: Severe [MEDICAL CONDITION] with occlusion of the right popliteal and posterior tibial artery as well as the left posterior tibial arteries. Monophasic waveforms are present throughout the left leg suggesting inflow disease. The hospital operative report dated 11/3/15 documented, The patient is an [AGE] year old female, who has developed progressive worsening pain in her left leg associated with dry gangrene. This did seem to increase after an injury about a month ago. Given the findings, operative intervention was discussed . Preoperative Diagnosis: [REDACTED]. 2. Left leg [MEDICAL CONDITION]. Procedure: Left below-the-knee amputation. k. On 11/11/15 at 11:17 a.m., the Administrator was asked about changing the treatment nurse on weekends. She stated, We had a treatment nurse on Saturday and Sunday. A couple of weeks ago we decided to have the treatment nurse come in on Saturday only. We verbally told the weekend RN (Registered Nurse) supervisor. The Administrator was asked if they had identified an issue with the nurses not obtaining a treatment order and not monitoring and documenting the condition of the resident's foot. The Administrator stated, At the time no. I assumed the treatment nurse was doing it. She was then asked, Do you think the nurses should've assessed and documented the condition of the wound? The Administrator stated, Yes. 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/21/15 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS and required extensive to total assistance with ADLs and had no wounds. a. The Care Plan dated with a review date of 6/19/15 documented, (Resident #2) .surgical incision -(handwritten) dehisced . b. The October 2015 Treatment Administration Record (TAR) documented, Cleanse surgical dehisce wound to right hip with wound cleanser, pat dry, apply silver alginate and cover with adhesive border dressing daily. The form documented 3 (10/5/15, 10/18/15 and 10/25/15) of 31 days were left blank with no initials indicating the treatment had not been done. c. The November 2015 Treatment Administration Record (TAR) documented, 10/2/15 - Cleanse surgical dehisce wound to right hip with wound cleanser, pat dry, apply calcium alginate, and cover with dry dressing every day. The form documented 2 days (10/18/15 and 10/25/15), were left blank with no initials indicating the treatment had not been done. d. The Non-Pressure Skin Condition report dated 11/6/15 for the right hip documented, size in cm (centimeter) 2 x 2 with a depth of 1.5 cm unstageable, purulent moderate amount of scant exudate, slight odor, surrounding skin color was pink. e. The Care Plan dated 11/9/15 documented, D/C (discontinue) previous treatment to right hip dehisce wound. Clean wound right hip, dehisce - irrigate with normal saline (NS) and clean peri wound with NS. Apply packing strip to wound bed loosely, cover with dressing gauze apply skin prep per wound every day (QD) and cover with bordered dressing QD. May be seen at wound clinic to assess right hip dehisce wound. f. On 11/9/15 at 12:25 p.m., this surveyor entered the resident ' s room. The resident had a dressing on her right hip dated 11/7/15. The drainage from the wound had saturated the dressing to the point the drainage had leaked onto the coverings of the bed. The drainage stains were brownish in color. Resident #2 stated the area was painful and required pain medication at this time. g. On 11/9/15 at 1:25 p.m., the dressing to the right outer hip was removed. There was a large amount of serosanguinous drainage to the area. The wound itself measured 1.5 x 1.2 x 2.2 cm. The surrounding area was very red and measured 19.5 x 11.0 cm. The resident was asked if it was ok to take pictures of her wounds. She stated yes. The area was cleaned with Microkleng and 4x4s. The Treatment Nurse/ Licensed Practical Nurse (LPN) #1 was asked about the redness surrounding the wound. She stated she had not seen it in a while, but the redness was not there. She stated, Drainage has caused that I guess. Calcium Alginate was placed over the wound, covered with bordered foam. LPN #1 stated, The order needs to be changed. It wasn't that deep last time I saw it. 3. The Medication Review Report dated June 2015 documented, 9/27/15 Cleanse surgical dehisce wound to (right) side of knee with wound cleanser, pat dry and apply silver alginate, collegan (and) cover with adhesive border dressing daily. To the side of this intervention on the care plan was a note hand written that documented, 10/2/15 - changed to every days. The October and November 2015 TAR documented, Cleanse surgical dehisce wound to right side of knee with wound cleanser, pat dry apply silver alginate, and cover with adhesive border dressing every 3 days. The treatment order had not been adjusted to accommodate the new order to be changed every day. 4. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/7/15 documented the resident scored 8 (8-12 indicates moderately impaired) on the brief interview for mental status required extensive to total assistance with ADLs and had no wounds. a. The November 2015 TAR documented, Cleanse BLE (bilateral lower extremities) with NS, pat dry. Apply Vasoline ointment, apply [MEDICATION NAME] and wrap with kerlix daily. One time a day for skin care start date 9/24/15. As of 11/9/15 at 12:53 p.m., the form documented 2 (11/1/15 and 11/8/15) days were left blank indicating the treatment had not been done daily. b. On 11/9/15 at 12:20 p.m., the resident was in his room in a wheelchair. The resident gave permission to this surveyor to observe his lower extremity dressings. LPN #1 pulled his pant legs up and resident's legs were wrapped and dated 11/7/15. LPN stated, I am getting ready to change that. The LPN was asked about the orders for the wound to be changed daily and the LPN stated, Not very many people do that around here. Blood was observed on the resident ' s right leg just above dressing. c. On 11/9/15 at 3:15 p.m., the resident was lying in bed. LPN #1 removed the wrap around the wound on the left leg. The kerlix was stuck and had yellowish brown drainage saturated through the dressing. When it was removed, there were areas of dried drainage outside the wound bed on the lower extremity (LE). One area was open and bleeding and measured 2.5 x 2.0 cm. There was a blister just above that measured 1 x 1.3 cm. LPN #1 stated, He's so swollen. They didn't wrap it tight enough. The wrap on the right LE was removed. It was also stuck in places. There was an open area that measured 1.7 x 1.5 cm and another that measured 1.0 x 1.5 cm. They were bleeding. The TAR documented the legs are to have [MEDICATION NAME] (vasoline gauze) applied. There were no [MEDICATION NAME] underneath the kerlix when the dressings were removed. LPN #1 stated, There's no vasoline gauze on his legs. The order says to put it on. Both LE are also notably red. 5. Resident #4 had [DIAGNOSES REDACTED]. The 60 day MDS with an ARD of 10/23/15 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS and required no assistance with ADLs. a. The Non-Pressure Skin Condition report dated 10/30/15 for the left lower posterior leg documented, size 0.5 x 0.5 cm no depth, no exudate, no odor, area improved. b. The November 2015 TAR documented, Clean wound to RLE (right lower extremity) with wound cleanser, pat dry, apply Calcium AG (Alginate), (and) cover with adhesive border dressing, every other day. Start date 9/19/15. The form documented 1 (11/8/15) day was left blank indicating the treatment had not been provided QOD according to the physician order. c. On 11/9/15 at 2:50 p.m., the resident was lying in bed. A dressing was on the right posterior LE and was not dated. LPN #1 removed the dressing. The wound was covered with dark brown/black drainage and the wound had a foul odor. Resident #4 was asked when the dressing was last changed. He stated, It's been a while. Resident #4 was asked if it was changed yesterday 11/8/15. He stated, No. The TAR documented the treatment was to be conducted every other day (QOD) and documented a wound treatment on 11/6/15 and was due to be changed yesterday 11/8/15. The area measured as 0.7 x 05 cm. Calcium Alginate was applied to the wound, covered with bordered dressing. 6. The immediate jeopardy was removed and the scope and severity lowered to an H when the facility implemented the following plan of removal on 11/12/15: a. On 11/9/15 all wounds were assessed, observed, and measured for treatments/dressings being accurate as ordered by the physician and 3 treatments were completed at this time. Resident #2, Resident #3 and Resident #4. (not completed on 11/8/15). b. On 11/9/15 all Treatments Administration Records (TAR) were reviewed for treatments documented as completed. No negative findings except Resident #2, Resident #3 and Resident #4 were not signed for 11/8/15. c. On 11/9/15 all physician orders [REDACTED]. d. On 11/9/15 all current wound documentation was reviewed for assessment, description, measurements with no negative findings. e. On 11/9/15 education was provided for all nurses related to treatment nurse and charge nurse responsibilities for completing, documenting treatments and documentation of observation of wounds. f. Beginning on 11/10/15 all nurses were educated related to: Obtaining physician orders [REDACTED]. Assess and describe skin abnormalities (pressure sores: wounds, stasis ulcers, surgical wounds, skin tears, or any break in skin integrity) documenting on the skin assessment form upon admission/readmission. Weekly observation, measurements, description of any skin abnormalities will be completed by treatment nurse. Any decline or deterioration of any skin abnormalities within two weeks physician/family will be notified. g. Beginning 11/11/15 around 11:00 a.m. 100% of all residents had a complete body audit by licensed nurses to identify any skin abnormalities and documented on skin observation form. All wounds identified will be documented on skin condition report with physician and family notification immediately. h. Beginning 11/11/15 by 11 p.m., education (step #6) will be repeated on every nurse prior to their shift starting. i. Beginning 11/12/15 all readmissions and new admissions will be reviewed for any skin abnormalities with documentation on skin observation form, and physician/family notification by D.O.N. (Director of Nursing)/designee daily seven days a week until compliance achieved. Any negative findings will be corrected immediately. j. Beginning 11/12/15, D.O.N/designee will compare treatment Administration Record with daily nursing documentation to ensure observation/assessment of skin abnormality is described daily (7 days a week). Any negative findings will be corrected immediately. k. Beginning 11/12/15 DON/Designee will observe each wound and treatment weekly comparing observation with weekly documentation on skin condition report completed by treatment nurse to ensure accuracy of description, measurements, and treatment appropriateness with physician/family notified within two weeks of any deterioration of wound. Any negative findings will be corrected immediately.

Complaint #'s (AR 820) and (AR 813) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure adequate supervision was provided to prevent resident injury during staff assisted transfers as evidenced by the facility ' s failure to ensure staff was knowledgeable in the mode of transfer and amount of assistance needed or where to locate the information and the consistency of implementing the correct plan of care to reduce the potential for injury for 1 (Resident #1) of 2 (Resident #1 and #2) case mix residents who required the use of a mechanical lift for transfers. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to Resident #1 who had a fracture of the left great toe after incorrect transfer and 22 residents who had been assessed as requiring the use of a mechanical lift for transfers as identified by a list provided by the Administrator on 11/12/15 at 10:40 a.m. The facility removed the Immediate Jeopardy prior to the survey but did not correct the underlying failed practices. On 11/11/15 at 10:10 a.m., the Administrator was informed of the Immediate Jeopardy (removed). The findings are: Resident #1 had [DIAGNOSES REDACTED]. a. The Lift/Mobility assessment dated [DATE] documented the resident required the use of a mechanical lift with 2 person assist with head support for transfers. b. The Care Plan dated 6/16/15 documented, (Resident #1) requires assistance with ADLs r/t (related to) Disease process/medical condition; (Dementia) bed mobility - dependent x1, transfers - toileting, shower, and dressing - dependent x1, eating - dependent x1, gerichair for locomotion, while out of bed, contracture to right hand. Transfers x 2 staff secondary to Non-weight bearing with mechanical lift. c. The nurse's notes dated 9/26/15, no time and unsigned documented, This nurse was called to resident's room by LPN #2. She stated that resident's foot was bleeding profusely. CNA #1 stated that she was unaware how she injured her foot. (Resident #1's) sock was saturated. We found laceration on the bottom of her foot under her great toe left foot. The laceration was deep. We contacted the ambulance and she was transported to the hospital . The Incident and Accident (I/A) report dated 9/26/15 and signed/prepared by LPN #5 documented, This nurse was called to the resident's room. There was blood on the floor and a deep laceration under the great toe of the left foot. CNA stated that she wasn't aware how it happened. d. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & (and) Exploitation of Residents in Long Term Care DMS-762 dated 9/26/15 and time of incident 4:45 p.m. documented, On 9/26/15 (Saturday) treatment nurse (Licensed Practical Nurse (LPN) #2) notified charge nurse (LPN #3) that resident's foot was bleeding when he entered the room he noticed a deep laceration under the great left toe of her left foot. He asked the (Certified Nurse Assistant (CNA) #1) that was assigned to resident did she know anything about how this may have happened and she stated she did not know what happened. Charge nurse notified the doctor and received order to send to hospital. Administrator, DON (Director of Nursing), was notified and charge nurse was instructed to look at residents w/c (wheel chair) and bed to see if resident may have hit her foot on the w/c or bed and to complete I&A (Incident and Accident) to investigate to see how this injury may have occurred. Family notified. On 9/27/15 Administrator was notified by charge nurse that (Resident #1) had a fracture on her great left toe in two areas and a deep laceration between her great toe and her second toe that required eight stitches, 1cm (centimeter) deep x 4cm long. Received splint on left foot. During investigation discovered, CNA #1 was getting resident up for dinner and she did not follow the care plan for transferring . A witness statement dated 9/28/15 and signed by CNA #1 documented, I went to (Resident #1's) room to get her out of the bed and ready for dinner and I body lifted her out of bed into her wheelchair and I didn't see anything wrong with her foot until I was leaving out to take her to the dining room that's when I see the blood on the floor. e. The hospital ED (Emergency Department) progress note dated 9/26/15 at 8:00 p.m. documented, .seen on 9/26/15 for laceration around base of left great toe, x-ray showed minimally displaced fracture of lateral aspect of base of proximal phalanx and another small chip fracture on medial aspect. Orthopedic Surgery consulted, awaiting recommendations.Pt (patient) checked out to ER (emergency room ) (doctor) at end of shift. f. The Nurse's Note dated 9/27/15 at 2:30 a.m. documented, R (resident) received via (ambulance service) returning from hospital ER D/Cing (discontinuing) nurse phoned in D/C (discontinued) report to return to facility with splint to left leg. Laceration to affected area eight sutures intact to wound site . g. An inservice conducted on 3/10/15 documented, Please make sure you are transporting and transferring residents according to resident's care plan, located in closet and at nurses station. The signature sheet indicated approximately 21 CNAs attended the inservice, one of which was CNA #1. On 11/11/15 at 11:17 a.m., the Administrator was asked how the facility monitored the effectiveness of their inservices. The Administrator stated, We monitor by sight, sometimes by demonstration. We do rounds daily or throughout the shift. The nurses do the inservices. The staffing coordinator and restorative are on the halls monitoring. h. A Staff Inservice and sign in sheet dated 9/28/15 on following care plan for all transfer .sizes of lift pads, and residents who require lifting location was provided by the Administrator. Based on the comparison between a list of current employees and the signature sheet of the inservices, 23 of 44 certified nursing assistants were not inserviced. Staff interviews were conducted with staff regarding Resident #1 ' s mode of transfer: 1) On 11/10/15 at 4:49 p.m., CNA #2 stated that prior to the I/A (9/26/15), Resident #1 was a 2 person assist transfer. I am not sure when she went to using a hoyer lift. During a review of the facility's inservice dated 9/28/15 that addressed appropriate transfers for each resident, CNA #2's signature was not present indicating she had not attended the inservice. 2) On 11/10/15 at 5:00 p.m., CNA #4 was asked to find her signature on the inservice sign in sheet. During a review of the facility's inservice dated 9/28/15 that addressed appropriate transfers for each resident, CNA #4's signature was not present indicating she had not attended the inservice. 3) On 11/10/15 at 5:15 p.m., CNA #5 stated, Before the I/A (9/26/15) we would use 2 person assist with gait belt transfers. Then all of a sudden the hoyer lift was used. CNA #5 was asked to find her signature on the inservice sign in sheet. During a review of the facility's inservice dated 9/28/15 that addressed appropriate transfers for each resident, CNA #4's signature was not present indicating she had not attended the inservice. 4) On 11/11/15 at 9:57 a.m., CNA #3 stated (Resident #1) was total care and was a 2 person assist so after the I/A, they changed her to the hoyer lift. It was clarified with the CNA that prior to the I/A are you sure the resident was a 2 person assist? CNA #3 stated, Yes. CNA #3 was informed the facility stated the resident had been a hoyer lift since her admission on 12/4/15 and that prior to the I/A on 9/26/15 she had been transferring Resident #1 inappropriately. CNA #3 stated, Oh that makes me feel bad. I didn't know. i. The facility removed the Immediate Jeopardy prior to the survey and reduced the scope/severity to G when the facility implemented the following interventions on 9/27/15: 1) On 9/27/15, CNA #1 was immediately terminated for not following the proper technique for transferring. 2) Complete body audits were done to make sure there were no other injuries, there were no negative findings. 3) CNAs were inserviced on reading and following care plans for each resident and inserviced on abuse video concerning what is abuse and how to report abuse. 4) Alert and oriented residents were interviewed to see if CNAs were trasnferring then correctly and following the correct care plan. 5) CNAs were interviewed to ensure they are following the correct care plan for residents. 6) Resident had an orthopedic appointment on 10/2/15.

Complaint # was substantiated all or in part based on these findings: Based on record review and interview, the facility failed to ensure necessary care and services were provided to ensure Resident #5 attained or maintained the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure that residents who experienced a fall were assessed for injury/pain, monitored for injury/pain subsequent to the fall, reported/suspected pain was managed and the physician immediately consulted upon suspicion of injury and given pertinent assessment information to ensure prompt treatment for 1 (Resident #5) of 10 (Residents #1 thru #10) case mix residents who were at risk for significant changes in condition. The failed practice likely resulted in a pattern of actual harm to Resident #5, who experienced a fall that resulted in a delay in treatment for [REDACTED]. The findings are: 1. The facility policy entitled Charting and Documentation received 6/9/11 at 1:45 p.m. from the DON documented, "All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Policy Interpretation and Implementation 1. All observations, medications administered, services performed, etc. must be documented in the resident's clinical records. ...3. All incidents, accidents, or changes in the resident's condition must be recorded. ...6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: ...c. The assessment data and/or any unusual findings obtained..." 2. Resident #5 had [DIAGNOSES REDACTED]. The 5 Day Medicare MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 4/29/11 documented the resident scored 5 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), was totally dependent on staff for transfers, did not ambulate, was not steady with balance when moving from surface to surface transfer, and had functional limitation in range of motion that placed the resident at risk for injury due to impairment on side of the upper extremity and impairment on both sides of the lower extremity. a. The Resident Plan of Care dated 11/2/10 and updated 5/3/11 documented, "Risk for increase of alteration in comfort...Monitor for S/S (signs and symptoms) of pain and or discomfort and report to nurse. Give meds as ordered. Monitor for effectiveness of medications and report to MD (Medical Doctor) if not effective. Assist with repositioning and remind staff to use caution to help reduce risk of pain. ...Safety Problem Date: 11/2/10 (resident) is at risk for falls or injury R/T (related to)[MEDICAL CONDITION] and [MEDICAL CONDITION] and [MEDICAL CONDITION]. (Resident) will be kept safe as possible from significant injury daily thru next review date. Approaches: Keep living area as clutter free as possible to help reduce risk of injury should fall occur in room. Assist with transfers. Remind (resident) not to attempt self transfers." b. An Incident/Accident Report dated 1/24/11 documented, "Date of Incident 1/24/11 Time of Incident/Accident 10:25 a.m. Exact location of Incident/Accident ...Beauty Shop...Describe exactly what happened;...Hair dresser stated that resident was sitting under hair dryer (and) got out of chair unassisted (and)fell on floor. ...Type of Injury...None Apparent (check mark)...List the intervention/s that is going to be used for this Incident. Inform resident not to transfer unassisted Talked to beauty shop operator about getting help before residents start transfers." A form attached to the Incident report entitled, An In-House Investigation Witness Statement form from the Beautician dated 1/24/11 documented, "(Resident #5) was sitting under the hair dryer when she tried to get into her wheel chair. When I saw her trying to get in her chair I told her to wait but she kept trying then she fell down on the floor." c. A physician's orders [REDACTED]." A physician order [REDACTED]." d. The ADL (activities of daily living) Care Plan dated 5/7/11 documented, "Assistance-Transfers Sit to Stand lift...Use Sit and Stand lift for transfers." e. Nurses Notes dated 5/25/11 at 9:30 a.m. documented, "Was called into beauty shop by CNA (Certified Nursing Assistant). Resident on the floor. R (Resident) stated "I was trying to get in the chair, tripped (and) fell on floor. No c/o (complaint of) pain voiced, swelling, redness, or injury noted." The Incident /Accident (I&A) Report dated 5/25/11 documented, "5/25/11 at 9:30 Exact location...Exact location of Incident/Accident...Was called into beauty shop (Resident) on floor. (Resident) stated I was trying to get in the chair, tripped and fell on floor. No c/o (complaint) pain, swelling, redness, injury..." Neither the Nurses Notes nor the I&A documented an assessment of range of motion to ensure no tissue or bone damage. f. Nurses Notes dated 5/26/11 (no time indicated) and signed by Licensed Practical Nurse (LPN) #1 on the 7-3 shift documented, "Up ambulating self in w/c (wheelchair). Skin w/d (warm and dry) to touch. Resp (respirations) even (and) unlabored. No c/o pain or discomfort voiced from previous fall. The Nurses Notes did not document an assessment of range of motion to ensure no tissue or bone injury from 5/25/11 fall. Nurses Notes dated 5/26/11 at 2:15 p.m. by LPN #1 documented, "Late Entry 1430 (2:30 p.m.)... Resident in the hallway screaming stating that both her legs hurt. Call to (doctor) to see about getting an x-ray. Await call back. (Doctor) called. This nurse asked about getting x-ray on both legs d/t resident c/o pain. (Doctor) asked this nurse where specifically area on legs. Nurse asked (resident) and resident stated, 'both legs hurt.' Informed (doctor) what resident said. (Doctor) said, 'We can't do x-ray of both legs because we don't really know where on her legs the resident is hurting at.'..." The Nurses Notes did not document an assessment of range of motion to ensure no tissue or bone damage from 5/25/11 fall. Nurses Notes dated 5/26/11 at 2:30 p.m. by LPN #1 documented, "Resident in hallway yelling and crying. Stating her leg was hurting her ...They (CNAs) state resident has been acting like this since she fell yesterday. I asked the resident if she was having pain she said yes I watch as she repositioned herself and she grimaced... LPN Charge Nurse to give pain medication as well." The Nurses Notes did not document an assessment of range of motion to ensure no tissue or bone damage from 5/25/11 fall. The May 2011 Medication Administration Record (MAR) did not document that any type of pain medication was administered to the resident during this shift. Nurses Notes dated 5/26/11 at 6:20 p.m. documented, "Call (physician) about resident swollen (left) eye, received orders to monitor overnight." There was no previous assessment of the resident's left eye until this notation. There was no documentation on the May 2011 Medication Administration Record (MAR) that indicated the resident received pain medication at any time on 5/26/11. The May 2011 MAR documented, "4/26/11 Assess Pain (every) shift utilizing 0-10 pain scale (10 being the greatest)." There was no documented pain scale assessment of the complaint of pain that the resident had, as documented in the Nurses Notes dated 5/26/11. g. Nurses Notes dated 5/27/11 by the DON documented, "(at) 8:45 a.m. (Doctor) contacted about resident's legs again...(left) leg is now markedly turned to (left) unable to tolerate ROM (range of motion) (without) screaming out in pain. Relayed this to (doctor) asked to send resident out to hospital for eval (evaluation). He agreed. ...screams out when the (left) leg is moved." This was the first documentation of range of motion assessment for the resident since the fall 5/25/11. Nurses Notes dated 5/27/11 at 9:10 a.m. by LPN #1 documented, "Call to (ambulance service) to transport resident to (local hospital) ER (emergency room ) to evaluate...bil (bilateral) extremities for possible fracture" There was no documentation on the May 2011 MAR that indicated the resident received pain medication on 5/27/11 prior to emergency room visit. The May 2011 MAR documented, "4/26/11 Assess Pain (every) shift utilizing 0-10 pain scale (10 being the greatest)." There was no documented assessment of the complaint of pain that the resident had as documented in the Nurses Notes dated 5/27/11. h. The Resident's Pain Assessment Log dated May, 2011 contained no documentation that there was any type of medication administered at any time in May for pain. i. An Emergency Physician Record dated 5/27/11 at 10:49 a.m. documented, "Chief Complaint: fell Injury Occurred: 2 days ago...Location of injuries:...left hip...(left) greater trochanter fracture...Fracture Femur, intertrochanteric..." The ER Nursing Record dated 5/27/11 at 10:50 a.m. documented, "...c/o (left) hip pain tender to touch..." A History and physical dated 5/27/11 documented, "(resident) is a noncommunicative nursing home patient...reportedly fell and is complaining of left hip pain. She was noted to have an intertrochanteric femur fracture...She has very painful left hip. ...X-rays show a nondisplaced intertrochanteric femur fracture. There appears to be an element of avulsion of the greater trochanter, as well. The patient will be admitted for medical clearance and planned operative fixation. ...Left [MEDICAL CONDITION]" j. On 6/9/11 at 11:37 a.m. to 12:15 p.m., LPN #1, who documented the Nurses Notes dated 5/26/11 where the resident was screaming in pain, was asked how the resident was monitored for pain and changes in condition and the LPN stated, "We just watched her and observed her. I don't know if I did document. She stayed in the bed until transfer to hospital. I talked to the DON (Director of Nursing)... I remember she told me to watch her." The LPN was asked if there was anything done that kept the resident comfortable and the LPN stated, "I don't know if I gave any pain medication. No. I did check if resident had pain medication." The LPN was then asked what pain medication was ordered for the resident and if there was medication given. LPN #1 stated, "I don't know. I haven't seen one (medication order). I didn't look to see." The LPN was asked if she had tried to reassess the resident for the specific site of pain since the resident had fallen the previous day and the LPN stated, "We thought it was the red area between the legs. I don't remember... DON went down there Friday. She (resident) was screaming in the bed. I don't know, I could just hear her screaming. The DON called the doctor. Resident went to the hospital. I called the family. I talked to (resident's) niece." The LPN was asked if there was a facility policy or protocol if a resident is hurting or having a problem and the LPN stated, "I don't know." The LPN was asked if a change or any problems are to be documented and the LPN stated, "Supposed to document the same day. I don't even remember if I did." The LPN was asked how the resident was assisted off of the floor after the fall on 5/25/11 and the LPN stated, "One person under each arm, feet on the floor, she was screaming." The LPN was asked if the resident was hurting after the fall and the LPN gave no answer. The LPN was asked how often the resident complained of pain after the fall and the LPN stated, "She did it twice, once in the bed and again in the wheelchair." The LPN was asked when the doctor was notified and the LPN stated, "The 26th. He kept asking me for specifics about legs. The day after the fall is when she screamed. I asked him for x-rays. He said couldn't x-ray both legs, needed to know where the resident hurt. I tried to tell him both legs. He wanted to know exactly where she was hurting. It looked the same to me. I don't know if I even did look again." The LPN stated she did not remember medicating the resident when the resident screamed out in pain and was asked if she checked for an order and stated, "I didn't look to see." k. On 6/9/11 at 12:35 p.m., the Director of Nursing (DON) was asked what had occurred with the resident's fall since there was not any type of investigation attached to the incident report. The DON stated, "She was trying to self transfer into chair. From what I understand she was not hurt. The beautician should have gotten help to transfer. Sit to stand lift to transfer into beauty shop chair. The beauty shop operator was the only one in the shop at the time of the transfer. Beautician signed a contract not to lift or transfer any resident. I did let beautician know resident had a change of condition. The beauty shop chair wasn't locked at the time..." The DON was asked what measures were put in place at the time of the fall on 5/25/11 and the DON stated, "I started the 26th. Resident was screaming at top of lungs. They hurt me with that lift Refused to let me examine her, she wasn't getting back into bed. Resident grimaced when she scooted back into wheelchair." The DON was asked what type of transfer the resident is to have and the DON stated, "Sit to stand lift. After 5/3/11 she could not transfer self. Sit to stand lift to be used and should have been used 5/25/11. The beauty shop operator should not have tried to transfer her (resident) by herself. Beauty shop operator did not even lock the chair. " The DON was asked if the resident had received any type of pain medication. The DON reviewed the May 2011 MAR and stated, "They said they did." After review of the MAR, the DON was asked if there was any Tylenol or any pain medication given and the DON stated, "I don't see anything." The DON was asked if a nurse had assessed the resident and the DON stated, "I can't say that she did." The DON was then asked if the doctor should be notified of a change in a resident's condition and the DON stated, "Of course." The DON was asked if the resident was reassessed and if there was an investigation of the incident on 5/25/11. The DON then submitted to the surveyors, a DMS (Division of Medical Services) -762 " Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents Report to the Office of Long Term Care (OLTC). The DMS-762 dated 5/31/11 Section II documented, "On 5/25/11 (Resident #5) was in the beauty shop to get her hair done. She attempted to transfer to beauty shop chair and it swiveled on her resulting in a fall to the floor. The beauty shop operator call the C.N.A. for help. (CNA #1) responded as well as (LPN #1). (LPN #1) said that (Resident #5) was laughing about the fall when she entered the beauty shop, denied any injuries or pain and that she and (CNA #1) assisted (Resident #5) up from the floor and into the beauty shop chair..." A 24 Hour Report attached to the DMS-762 report documented on 5/25/11, I/A (incident and accident) Resident #5 and there was no documentation that indicated that Resident #5 was monitored or reassessed for pain. l. On 6/10/11 at 2:45 p.m., Physician #1 was asked if the nursing staff had notified him of the resident's fall or of any change in condition after the resident's fall. The Physician stated, "They called me when she fell and she did not have any injury. They called actually 24 hours later and then again 24 hours after that. They asked about x-rays for the complaint of pain in her legs but no specifics were given about this. The nurse just said she had bilateral leg pain but did not give specifics about the pain and did not call back until 24 hours later, the next day when they called about the leg and I had her sent to the ER." m. A statement dated 5/27/11 by the DON included in the DMS-762 documented, "8:30 a.m. DON had CNAs place resident back in bed to look at the rash that was causing her so much pain. The rash was on her thighs and was some excoriation. After looking at her thighs DON asked her where her leg was hurting and performed range of motion. Resident screamed out in pain. Her Left leg is markedly turned out to the left. ...DON explained that after looking at the rash she performed ROM (range of motion) and the resident could not tolerate this and screamed out in pain. Her left leg was also markedly turned out to the left..." n. On 6/10/11 at 6:25 p.m., LPN #3 was asked what is to be done if there is a change of condition and the LPN stated, "Call the doctor immediately and get vital signs,...If they fall that day then call right then. Send them out. ...You assess, call doctor." The LPN was asked if the information obtained from an assessment of the resident's pain or injury should be as specific as possible and the LPN stated, "Yes."

Complaint # was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure supervision was provided to ensure planned interventions to prevent further falls were consistently implemented and failed to ensure that fall risk assessments were accurate to facilitate the ability to develop appropriate fall-prevention interventions for 1 (Resident #5) of 8 (Residents #1, #2, #3, #4, #5, #8, #9 and #10) case mix residents who sustained falls or were at risk for falls. The failed practice resulted in actual harm to Resident #5, who sustained a fractured femur as a result of a fall, and had the potential to affect 20 residents who were at risk for falls, as documented by the Director of Nursing on 6/10/11. The findings are: Resident #5 had [DIAGNOSES REDACTED]. The 5 Day Medicare Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/29/11 documented the resident scored 5 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), was unable to recall any of the 3 words on the recall portion of the BIMS, was totally dependent for transfers, did not ambulate, was not steady with balance during surface-to-surface transfers, had functional limitation in range of motion in one upper extremity and both lower extremities, had active [DIAGNOSES REDACTED]. a. The Resident Plan of Care dated 11/2/10 documented, "Safety Problem Date: 11/2/10 (resident) is at risk for falls or injury R/T (related to) CVA and [DIAGNOSES REDACTED] and Seizures. (Resident) will be kept safe as possible from significant injury daily thru next review date. Approaches: ...Assist with transfers. Remind (resident) not to attempt self transfers." b. An Incident/Accident Report dated 1/24/11 documented, "Date of Incident 1/24/11. Time of Incident/Accident 10:25 a.m. Exact location of Incident/Accident... Beauty Shop... Describe exactly what happened: ...Hair dresser stated that resident was sitting under hair dryer (and) got out of chair unassisted (and)fell on floor... Type of Injury... None Apparent ... List the intervention/s that is going to be used for this Incident. Inform resident not to transfer unassisted. Talked to beauty shop operator about getting help before residents start transfers." An In-House Investigation Witness Statement form dated 1/24/11 and signed by the beautician documented, "(Resident #5) was sitting under the hair dryer when she tried to get into her wheelchair. When I saw her trying to get in her chair, I told her to wait, but she kept trying, then she fell down on the floor." c. An Incident/Accident Report dated 2/9/11 documented, "2/9/11 - 9:30 p.m., ...(Resident) in shower (with) CNA (Certified Nursing Assistant). Slid to floor. No apparent injury, laceration, or bruise noted. Resident was trying to stand up in shower and her self (illegible) three times and almost fell . Then I was trying to get her dried and in chair when she slipped ... List the interventions that is going to be used for this Incident. Res. (Resident) cannot stand alone very well. Needs assistance when in shower with at least 2 CNA's..." The Facility In-Service Training Report dated 2/10/11 documented, "Change of Care Plan on (Resident #5): R (Resident) requires an assist of 2 when doing showers to prevent falls." d. The Fall Risk assessment dated [DATE] documented the resident scored 14, with a score of 10 or more indicating the resident was at high risk for falls. e. The Incident/Accident Report dated 5/7/11 documented, "5/7/11... 1:00 p.m. While transferring from toilet (right) leg was weak... List the intervention/s that is going to be used for the Incident. (Resident) is to use bathroom in shower room so the lift can be used in transferring..." 1.) The Resident Plan of Care dated 5/7/11 documented, "If res. (resident) verbalizes need to use bathroom, take her to shower room and use lift for safety (with) toileting (fall)." 2.) The ADL Care Plan (not dated) documented, "...Assistance - Transfers 5/7/11 Sit to stand lift Sit (and) stand... Special Needs: ...Use Sit and Stand Lift for transfers." 3.) The Fall Risk assessment dated [DATE] documented the resident scored 9, with a score of 10 or more indicating a high risk for falls. The sections of the assessment that addressed medication criteria and predisposing diseases were not accurately completed. The Medications section documented the resident took only 1 to 2 of the listed medication classifications in the past 7 days (which gave her a score of 2 for the medications section); however, the May 2011 MAR documented the resident received 3 or more of the listed medication classifications in the past 7 days (which would have given the resident a score of 4 on the medication section of the assessment). The Predisposing Diseases section of the assessment documented the resident had 1-2 of the listed predisposing conditions, which gave the resident a score of 2 on this section of the assessment; however, the May 2011 Physician order [REDACTED]. If completed accurately, the total fall risk score would have been 13, which indicated a high risk for falls. f. Nurses Notes dated 5/18/11 at 12:00 a.m. documented, "Nurse (Licensed Practical Nurse (LPN) #1) notified this nurse that (resident) is behaving different. She is not able to make a step..." g. The Incident /Accident Report dated 5/25/11 documented, "5/25/11 at 9:30 (a.m.). Exact location... Was called into beauty shop. (Resident) on floor. (Resident) stated I was trying to get in the chair, tripped and fell on floor. No c/o (complaint of) pain, swelling, redness, injury..." 1.) Nurses Notes dated 5/25/11 at 9:30 a.m. documented, "Was called into beauty shop by CNA. Resident on the floor. R stated 'I was trying to get in the chair, tripped (and) fell on floor.' No c/o pain voiced, swelling, redness, or injury noted." 2.) The Fall Risk assessment dated [DATE] documented the resident scored 9, with a score of 10 or more indicating high risk for falls. The sections of the assessment designated for medication criteria and predisposing diseases was not accurately completed. The Medications section documented the resident took only 1 to 2 of the listed medication classifications in the past 7 days (which gave her a score of 2 for the medications section); however, the May 2011 MAR documented the resident received 3 or more of the listed medication classifications in the past 7 days (which would have given the resident a score of 4 on the medication section of the assessment). The Predisposing Diseases section of the assessment documented the resident had 1-2 of the listed predisposing conditions, which gave the resident a score of 2 on this section of the assessment; however, the May 2011 Physician order [REDACTED]. If completed accurately, the total fall risk score would have been 13, which indicated a high risk for falls. 3.) Nurses Notes dated 5/26/11 at 2:15 p.m. documented, "Late Entry 2:30 p.m. Resident in the hallway screaming stating that both her legs hurt. Call to (doctor) to see about getting an x-ray. Await call back. (Doctor) called. This nurse asked about getting x-ray on both legs d/t (due to) resident c/o pain. (Doctor) asked this nurse where specifically area on legs. Nurse asked (resident) and resident stated, "Both legs hurt." Informed (doctor) what resident said. (Doctor) said, "We can't do x-ray of both legs, because we don't really know where on her legs the resident is hurting at..." 4.) Nurses Notes dated 5/26/11 at 2:30 p.m. documented, "Resident in hallway yelling and crying. Stating her leg was hurting her... They (CNA's) state resident has been acting like this since she fell yesterday. I asked the resident if she was having pain, she said yes. I watch as she repositioned herself and she grimaced..." 5.) Nurses Notes dated 5/27/11 at 8:45 a.m. documented, "(Doctor) contacted about resident's legs again... (left) leg is now markedly turned to (left) unable to tolerate ROM (range of motion) (without) screaming out in pain. Relayed this to (doctor) asked to send resident out to hospital for eval (evaluation). He agreed ... screams out when the (left) leg is moved." 6.) A hospital History and Physical dated 5/27/11 documented, "(Resident) is a noncommunicative nursing home patient... reportedly fell and is complaining of left hip pain. She was noted to have an intertrochanteric femur fracture... She has very painful left hip... X-rays show a nondisplaced intertrochanteric femur fracture. There appears to be an element of avulsion of the greater trochanter, as well. The patient will be admitted for medical clearance and planned operative fixation... Left hip fracture..." h. A Witness Statement Form dated 5/28/11 and signed by the beautician documented, "(Resident) fall on 5/25/11. As she got out of her wheelchair, she was getting in the styling chair and as she was about to sit down, the styling chair turn from underneath her and she fell down. I (beautician) went to get her aid..." i. On 6/9/11 at 11:37 a.m., Licensed Practical Nurse (LPN) #1 was interviewed. The LPN was asked if the resident had a history of [REDACTED]. It has been a few months earlier. I had to tell CNA and beautician that she needed 2 people to transfer both of the times in the beauty shop... She was weak on the left side. I am thinking the beauty shop lady transferred the resident. I don't remember what the beauty shop person said." LPN #1 was asked how the resident was transferred after the fall on 5/25/11, if a lift was utilized, and stated, "...We both lifted under her arms and stood her up. One person under each arm, feet on the floor." The LPN was asked if the resident got out of bed after the fall and stated, "She was screaming, 'My leg hurts, my leg hurts' for 2 days after the fall... She was bearing weight during transfers. She was screaming, that surprised me..." The LPN stated, "The DON went down there Friday (5/27/11). She was screaming in the bed... I could just hear her screaming. DON called the doctor. (Resident) went to the hospital..." j. On 6/9/11 from 12:35 p.m. to 12:40 p.m., the Director of Nursing (DON) was interviewed. The DON was asked to describe the incident that occurred in the beauty shop on 5/25/11. The DON stated, "She was trying to transfer into a chair. From what I understand, she was not hurt. The beautician should have gotten help to transfer. Sit-to-stand lift to transfer into the beauty shop chair. The beauty shop operator was the only one in the shop at the time of the transfer. Beautician signed a contract not to lift or transfer any resident. I did let beautician know the resident had a change of condition. The beauty shop chair wasn't locked at the time..." The DON was asked what measures were put in place at the time of the fall on 5/25/11 and stated, "I started the 26th. Resident was screaming at the top of her lungs, 'They hurt me with that lift'. Refused to let me examine her, she wasn't getting back into bed ... grimaced when she scooted back into the wheelchair." The DON was asked what type of transfer the resident was to have and stated, "Sit to stand lift. After 5/3/11, she could not transfer herself... Sit to stand lift... should have been used 5/25/11, but the beauty shop operator should not have tried to transfer her by herself. The beauty shop operator did not even lock the chair." When asked what was done after the resident fell in the beauty shop on 1/24/11 to prevent further incidents in the beauty shop, the DON stated, "I didn't know about it until I found it today... It's my understanding she (beautician) was counseled after the fall..." k. On 6/9/11 at 1:10 p.m., LPN #2 stated, "...She had 2 falls in the beauty shop with the beautician transferring the resident." The LPN was asked what was done about this and stated, "After the first fall, the beautician was counseled not to transfer the resident." There was no evidence the facility monitored or supervised the residents in the beauty shop after the January 2011 fall to ensure assistance with transfers was provided by a qualified facility employee.

Complaint # , substantiated (all or in part) in these findings. Based on record and interview, the facility failed to promptly consult with the physician regading abnormal lab findings and inability to change foley catheter so that treatment was initiated promptly for 1 (Resident #9) of 3 (Residents #5, #7 and #9) case mix residents with indwelling catheters. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious injury, harm, impairment or death, for Resident #9 and had the potential to cause serious injury, harm, impairment or death for 3 residents with indwelling catheters currently residing in the facility, as documented on the Residents Census and Conditions of Residents provided by the Administrator on 9/14/10. The facility was informed of the Immediate Jeopardy on 9/15/10 at 12:00 p.m. The findings are: 1. Resident #9 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had no short or long term memory problems, was independent in cognitive skills for daily decision making, had an indwelling catheter and had no urinary tract infection in the last 30 days. a. A Laboratory Report with date collected 7/26/10 documented, "Urinalysis ... Bacteria 4+ ... Urine Culture (Pending)." A Urine Culture Report documented, "... Culture Report: 07/28/2010 Proteus Mirabilis Greater Than 100,000 ..." There was no documentation that the culture result was reported to the physician. On 9/15/10 at 10:28 a.m., the Assistant Director of Nursing (ADON) was asked if the culture results from the residents urinalysis collected on 7/26/10 was reported to the physician and she stated, "I don't see where they notified the Doctor of the culture results. Once the culture results come in they should notify him via phone or fax." b. The Resident Plan of Care updated 8/11/10 documented, "... Problem Identify Date: 05/08/09 Risk For Complications Related To Indwelling Catheter ... Approaches ... Obtain UA (urinalysis) As Ordered and Review For Possible Infection, Report To Physician Negative Findings. ... Change Indwelling Catheter Tubing And Bag As Ordered, Using Sterile Technique. Assess Color, Consistency, And Odor Of Urine. Record And Report Any Significant Change Promptly To Physician. ..." c. The August 2010 physician's orders [REDACTED]. d. The August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" The area on the MAR for the 14th had the nurses initials circled. The back of the MAR indicated . 1) On 9/15/10 at 9:52 a.m., the Director of Nursing (DON) was asked what the procedure was if an indwelling catheter was unable to be removed and she stated, "Personally I would call the Doctor and see what the next step was. I don't see anywhere on the 24 hour report that the nurse reported about the catheter." 2) On 9/15/10 at 11:04 a.m., Licensed Practical Nurse (LPN) #2 was interviewed regarding the inability to remove the resident's catheter on 8/14/10. LPN #2 was asked if she had notified the physician when she was unable to remove the catheter and she stated, "I didn't call the Doctor, it was late in the night. I don't know if the catheter got changed later in the month, I didn't change it. I reported it to the oncoming nurse (LPN #1). I reported it verbally, I didn't write it on the 24 hour report." 3) On 9/15/10 at 11:09 a.m., LPN #1 was asked if she remembered LPN #2 reporting to her on 8/15/10 that she was unable to remove the resident's catheter. She stated, "Yes." The LPN was then asked if she had notified the Doctor that the catheter was unable to be removed. She stated, "I did not call the Doctor. I did not change the catheter, we were waiting for the supplies to come in. I did not change the catheter later in the month. I just passed it on that his catheter hadn't been changed, I didn't write it down." e. A Nurses Note dated 8/24/10 at 0800 (8:00 a.m.) documented, "Resident awake and not responding to verbal command as usual, skin cool and clammy at this time. v/s (vital signs) 110/60 (blood pressure)-24 (respirations)- 102 (pulse) - 99.8 (temperature)... Foley Catheter patent and draining cloudy yellow urine. Ref (refused) breakfast this AM 0810 (8:10 a.m.) Resident yelling out (at) intervals, skin cool and clammy (at) this time. Attending PCP (Primary Care Physician) notified of (resident's) condition orders received to transfer ..." f. An ER (Emergency Record) dated 8/24/10 documented, "1200 (12:00 noon) replaced indwelling ... with 26 fr (french) / 30cc bulb due to no urine output. Would not urinate large amts (amounts) pus immediate return". 1) A Bacteriology - Routine Testing Report from the hospital documented, " ... Procedure: Urine Culture Collected 08/24/10 12:10 CDT (central daylight time) Final Report verified: 08/26/10 10:07 CDT > (greater)100,000 ...Providencia stuartii > ... Proteus mirabilis". 2) A History and Physical with an admission date of [DATE] documented, " ... Impression: 1. Septic Shock, 2. Urinary Obstruction, 3. Acute [MEDICAL CONDITION] Secondary to Obstruction ...". 3) A Consult report from the hospital documented, "... Date Of Consultation 08/25/2010 ... complaints of a urinary tract infection. He was found to be in septic shock. ..." A second Consultation dated 08/25/2010 documented, "... He was also profoundly hypotensive at presentation with systolic pressure in the 30s. He does not have a known history of [MEDICAL CONDITION]. At the time of my evaluation, patient was intubated and maintained on the respirator." 2. The Immediate Jeopardy was removed and the scope/severity reduced to "H" on 9/15/10 at 4:08 p.m., when the facility implemented the following plan of removal: a. All residents in the facility with a foley catheter will be assessed on 9/15/10 by 14:00 (2:00 p.m.) to assure foley is intact and functioning properly and changed as ordered. Any issues will be addressed/corrected immediately on discovery. b. The DON/ADON will in-service all licensed nurses for necessary monitoring of residents with foley catheters; changing foley catheters as ordered; and monitoring and reporting labs to doctor PRIOR to beginning their shift from 9/15/10 until all have been completed. c. Licensed nurses will, today on 9/15/10, review 100% of all current resident labs by 14:30 (2:30 p.m.) to assure any abnormal findings were reported to physician. Any negative findings noted will be corrected immediately with doctor notification. d. ADON/designee, beginning 9/16/10 will monitor all lab reports received seven days a week for negative findings and assure physician notification has occurred. This practice will continue as ongoing regular practice. e. The current Social Worker/ LPN has assessed all stock of foley supplies on 9/15/10 at 13:50 (1:50 p.m.) with no negative findings. f. The treatment LPN will monitor all catheter and nursing supplies five days a week to ensure all necessary supplies are readily available beginning on 9/16/10 to be maintained at set par levels to assure that residents have necessary supplies to meet their care needs. g. The DON/ADON will ensure all licensed nurses receive inservice concerning timely notification of physician on all significant changes in condition, (ie: abnormal labs; inability to change catheter; lab results; elevated temps etc.) and that documentation occurs at that time. The licensed nurses NOT currently working will be in-serviced prior to their next scheduled work shift.

Complaint # , substantiated (all or in part) in these findings. A. Based on record and interview, the facility failed to ensure the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for residents with foley catheters as evidenced by the facility's failure to promptly consult with the physician regading abnormal lab findings and inability to change foley catheter so that treatment was initiated promptly and to assess/reassess resident condition after urine culture and inability to remove catheter for 1 (Resident #9) of 3 (Residents #5, #7 and #9) case mix residents with indwelling catheters. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious injury, harm, impairment or death for Resident #9 and had the potential to cause serious injury, harm, impairment or death for 3 residents with indwelling catheters currently residing in the facility per the Residents Census and Conditions of Residents provided by the Administrator on 9/14/10. The facility was informed of the Immediate Jeopardy on 9/15/10 at 12:00 p.m. The findings are: 1. Resident #9 had [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented the resident had no short or long term memory problems, was independent in cognitive skills for daily decision making, had an indwelling catheter and had no urinary tract infection in the last 30 days. a. A Laboratory Report with date collected 7/26/10 documented, "Urinalysis ... Bacteria 4+ ... Urine Culture (Pending)." A Urine Culture Report documented, "... Culture Report: 07/28/2010 Proteus Mirabilis Greater Than 100,000 ..." There was no documentation that the culture result was reported to the physician. On 9/15/10 at 10:28 a.m., the Assistant Director of Nursing (ADON) was asked if the culture results from the residents urinalysis collected on 7/26/10 was reported to the physician and she stated, "I don't see where they notified the Doctor of the culture results. Once the culture results come in they should notify him via phone or fax." b. The Resident Plan of Care updated 8/11/10 documented, "... Problem Identify Date: 05/08/09 Risk For Complications Related To Indwelling Catheter ... Approaches ... Obtain UA (urinalysis) As Ordered and Review For Possible Infection, Report To Physician Negative Findings. ... Change Indwelling Catheter Tubing And Bag As Ordered, Using Sterile Technique. Assess Color, Consistency, And Odor Of Urine. Record And Report Any Significant Change Promptly To Physician. ..." c. The August 2010 physician's orders [REDACTED]. d. The August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" The area on the MAR for the 14th had the nurses initials circled. The back of the MAR indicated As of 9/15/10, there was no documentation in the Nurses Notes of any resident assessment (urinary output, color/consistency of urine, whether bladder was distented, resident discomfort, etc.) or consultation with physician regarding the inability to remove the catheter. 1) On 9/15/10 at 9:52 a.m., the Director of Nursing (DON) was asked what the procedure was if an indwelling catheter was unable to be removed, and she stated, "Personally I would call the Doctor and see what the next step was. I don't see anywhere on the 24 hour report that the nurse reported about the catheter." 2) On 9/15/10 at 11:04 a.m., Licensed Practical Nurse (LPN) #2 was interviewed regarding the inability to remove the resident's catheter on 8/14/10. LPN #2 was asked if she had notified the physician when she was unable to remove the catheter and she stated, "I didn't call the Doctor, it was late in the night. I don't know if the catheter got changed later in the month, I didn't change it. I reported it to the oncoming nurse (LPN #1). I reported it verbally, I didn't write it on the 24 hour report." 3) On 9/15/10 at 11:09 a.m., LPN #1 was asked if she remembered LPN #2 reporting to her on 8/15/10 that she was unable to remove the resident's catheter. She stated, "Yes." The LPN was then asked if she had notified the Doctor that the catheter was unable to be removed. She stated, "I did not call the Doctor. I did not change the catheter, we were waiting for the supplies to come in. I did not change the catheter later in the month. I just passed it on that his catheter hadn't been changed, I didn't write it down." e. As of 9/15/10, there was no documentation in the Nurses Notes of any resident assessment (urinary output, color/consistency of urine, whether bladder was distented, resident discomfort, etc.) from 7/28/10 (date of urine culture results) until the 8/24/10 Nurses Notes at 0800. f. A Nurses Note dated 8/24/10 at 0800 (8:00 a.m.) documented, "Resident awake and not responding to verbal command as usual, skin cool and clammy at this time. v/s (vital signs) 110/60 (blood pressure)-24 (respirations)- 102 (pulse) - 99.8 (temperature)... Foley Catheter patent and draining cloudy yellow urine. Ref (refused) breakfast this AM 0810 (8:10 a.m.) Resident yelling out (at) intervals, skin cool and clammy (at) this time. Attending PCP (Primary Care Physician) notified of (resident's) condition orders received to transfer ..." g. An ER (Emergency Record) dated 8/24/10 documented, "1200 (12:00 p.m.) replaced indwelling ... with 26 fr (french) / 30cc (cubic centimeters) bulb due to no urine output. Would not urinate large amts (amounts) pus immediate return." 1) A Bacteriology - Routine Testing Report from the hospital documented, " ... Procedure: Urine Culture Collected 08/24/10 12:10 CDT (central daylight time) Final Report verified: 08/26/10 10:07 CDT > (greater)100,000 ...Providencia stuartii > ... Proteus mirabilis". 2) A History and Physical with an admission date of [DATE] documented, " ... Impression: 1. Septic Shock, 2. Urinary Obstruction, 3. Acute [MEDICAL CONDITION] Secondary to Obstruction ..." 3) A Consult from the hospital documented, "... Date Of Consultation 08/25/2010 ... complaints of a urinary tract infection. He was found to be in septic shock. ..." A second Consultation dated 08/25/2010 documented, "... He was also profoundly hypotensive at presentation with systolic pressure in the 30s. He does not have a known history of [MEDICAL CONDITION]. At the time of my evaluation, patient was intubated and maintained on the respirator." 2. The Immediate Jeopardy was removed and the scope/severity reduced to "H" on 9/15/10 at 4:08 p.m., when the facility implemented the following plan of removal: a. All residents in the facility with a foley catheter will be assessed on 9/15/10 by 14:00 (2:00 p.m.) to assure foley is intact and functioning properly and changed as ordered. Any issues will be addressed/corrected immediately on discovery. b. The DON/ADON will inservice all licensed nurses for necessary monitoring of residents with foley catheters; changing foley catheters as ordered; and monitoring and reporting labs to doctor PRIOR to beginning their shift from 9/15/10 until all have been completed. c. Licensed nurses will, today on 9/15/10, review 100% of all current resident labs by 14:30 (2:30 p.m.) to assure any abnormal findings were reported to physician. Any negative findings noted will be corrected immediately with doctor notification. d. ADON/designee, beginning 9/16/10 will monitor all lab reports received seven days a week for negative findings and assure physician notification has occurred. This practice will continue as ongoing regular practice. e. The current Social Worker/ LPN has assessed all stock of foley supplies on 9/15/10 at 13:50 (1:50 p.m.) with no negative findings. f. The treatment LPN will monitor all catheter and nursing supplies five days a week to ensure all necessary supplies are readily available beginning on 9/16/10 to be maintained at set par levels to assure that residents have necessary supplies to meet their care needs. g. The DON/ADON will ensure all licensed nurses receive in-service concerning timely notification of physician on all significant changes in condition, (ie: abnormal labs; inability to change catheter; lab results; elevated temps etc.) and that documentation occurs at that time. The licensed nurses NOT currently working will be in-serviced prior to their next scheduled work shift.