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

Based on record review, interview, facility document review, and facility policy review, the facility failed to ensure Physician's Orders were transcribed without error and consistently administered and followed for two (Resident #7 and Resident #26) of five sampled residents, reviewed for medications. The findings include: Resident #7 A review of Resident #7's admission Record revealed the facility admitted Resident #7 on 10/21/2025 with diagnoses which included type two diabetes mellitus and acquired absence of left great toe. A review of Resident #7's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/2025, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #7's MDS also revealed the resident was a diabetic and received insulin injections daily. A review of Resident #7's Physician's Orders, initiated 11/21/2025, for December 2025 and January 2026, revealed orders for a [fast acting] insulin injection solution 100 UNIT/ML [milliliter] inject as per sliding scale: if 0 - 150 = 0; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10. Resident #7's Physician's Orders also revealed, <60 or >400, notify MD [medical doctor], subcutaneously with meals related to type two diabetes mellitus. A review of Resident #7's Care Plan Report, with an initiated date of 11/11/2025, revealed Resident #7 had a diagnosis of diabetes mellitus and had a potential for complications, due to elevated blood sugar. Resident #7's Care Plan Report included interventions, which directed staff to provide medication as ordered. Resident #7's Care Plan Report revealed the resident was also at risk for skin breakdown, related to diabetes mellitus. A review of Resident #7's Lab Report dated 11/04/2025, revealed a HbA1C (A blood test showing an average blood sugar over 2-3 months) result of 11.0 (normal was below 5.7%). Resident #7's Lab Report also revealed a Glucose (the sugar level of the blood) result of 307 (74-109 was normal). A review of Resident #7's Medication Administration Record (MAR) dated from 12/01/2025 through 12/31/2025, revealed on 12/11/2025 at 7:00 AM, the result of Resident #7's blood sugar test was documented as 469. During an interview on 01/07/2026 at 10:40 AM, the Director of Nursing (DON) reported after requesting documentation for Resident #7 that the provider had been contacted as ordered on 11/21/2025, for the out of parameter blood sugar result of 469. The DON remarked, I'm having trouble getting them [nursing staff] to document findings. During an interview on 01/07/2026 at 10:46 AM, Medication Aide-Certified (MA-C) #1 confirmed they were the person working that day [12/11/2025] and who took Resident #7's blood sugar reading. MA-C #1 also confirmed that the elevated blood sugar reading of 469 was reported to the charge nurse, Licensed Practical Nurse (LPN) #2. MA-C #1 did not recall if LPN #2 contacted the provider. During a phone interview on 01/07/2026 at 11:04 AM, the Medical Director (MD) reported that usually the Physician's Assistant (PA) would have been notified initially, of the resulted blood sugar reading that was out of parameters and given orders. The MD then said that the Physician would be notified if the facility could not contact the PA. The MD did not recall being contacted for the out of parameter blood sugar reading of 469 for Resident #7. During an interview on 01/07/2026 at 12:06 PM, the PA reviewed their phone messages received from the facility on 12/11/2025, and Resident #7's electronic medical record. The PA reported there was no evidence of being contacted for the reported out of parameter blood sugar reading of 469, by anyone at the facility on that date. The PA reported that if they had been contacted, an order for an increased insulin dose would have been given at that time for Resident #7. During an interview on 01/07/2026 at 12:32 PM, the DON confirmed the nursing staff were expected to follow facility policies and Physician's Orders. If the order was written to notify the Physician for a blood sugar reading of over 400, and the reading was 469 for Resident #7, then the Physician or the PA should have been notified. During an interview on 01/08/2026 at 8:36 AM, LPN #2 confirmed being notified of the out of parameter blood sugar reading for Resident #7 of 469 on 12/11/2025. LPN #2 indicated the provider had been notified but did not recall if the notification was documented. LPN #2 confirmed having medication administration training and was knowledgeable of contacting the provider when there was a change in the resident or following an order that indicated the provider should be contacted. A review of Resident #7's Progress Notes did not reveal documentation of the provider notification for the resident's blood sugar reading of 469, on 12/11/2025. A review of a Licensed Nurse Competency Skills Check-Off dated 11/07/2025, with LPN #2's name at the top, revealed under performance objectives, LPN #2's initials. Competency #5 indicated the purpose was to provide nursing care based on scientific principles and sound theoretical knowledge. 3. able to recognize a change in a resident's acuity. 4. the ability to report pertinent information in a timely manner to the appropriate person. A second Competency #5 indicated the demonstration of the knowledge of nursing documentation. 5 b. Notification of the provider and appropriate documentation. Competency #6 revealed the ability to administer medications according to the policy and procedures. Competency #10 indicated a responsibility for one's own actions. This competency report was signed on the last page with LPN #2's name. During an interview on 01/08/2026 at 10:08 AM, Registered Nurse (RN) #4 confirmed they completed the medication administration competencies with the facility and the expectation of reporting changes with a resident, out of parameter findings, or missed doses to the provider. RN #4 reported that any time a provider was contacted, the conversations should be documented in the Progress Notes. RN #4 indicated a missed medication dose would be a medication error, the provider should be contacted, and it should be documented in the Progress Notes. During an interview on 01/08/2026 at 10:13 AM, LPN #5 confirmed they had completed the medication administration competencies (training). LPN #5 reported following Physician's Orders was expected and if there was a problem with an order, the orders would be clarified. LPN #5 then stated, if an order specifically required the provider to be contacted with an out of parameter result, then the provider should have been contacted, and the conversation documented. During an interview 01/08/2026 at 10:27 AM, the Assistant Director or Nursing (ADON) confirmed completing the nursing competency for medication administration. The ADON reported that if a Physician's Order specifically directed nursing staff to contact the provider with out of parameter results, then the provider should have been contacted and the conversation documented. During an interview on 01/08/2026 at 11:03 AM, MA-C #3 did not recall the specific situation that occurred on 12/11/2025 but reported generally if a blood glucose reading was out of the parameters set by the provider, the charge nurse would have been notified. Then, the charge nurse would contact the provider and get new orders, if any. MA-C #3 confirmed the initials on the MAR were their initials and would indicate for 12/11/2025, they had taken the blood sugar reading and documented the results for Resident #7, although MA-C #3 was unable to recall the specific situation. MA-C #3 confirmed they completed Medication Assistant competencies. A review of a Medication Assistant -Certified Skills Check-Off document dated 12/04/2025, read in part, Blood Glucose Monitoring demonstrated the ability to notify nurse if blood sugar was outside of the parameter set by the provider. This section had the initials of MA-C #3 and was dated 12/09/2025. Resident #26 A review of Resident #26's Face Sheet revealed the facility admitted the resident on 10/17/2025, with ulcers on both heels, and the resident's left toes. Resident #26 had medical diagnoses, which included atherosclerosis of native arteries of extremities with intermittent claudication, left leg, type two diabetes mellitus, traumatic subcutaneous emphysema, peripheral vascular disease, and chronic kidney disease. A review of Resident #26's Transfer admission Orders, received from another facility, revealed the resident was to have two antibiotics per day for seven days. The medication was entered on Resident #26's MAR at this facility as, patient is to have 1 tablet twice a day every 7 days. A review of Resident #26's MAR revealed the patient received the initial dose of medication on the day admitted to the facility, 10/17/2025, and did not receive another dose until 10/20/2025, when the DON caught the error and cancelled the incorrect order and re-entered the correct dosage. At that time, Resident #26 began receiving the correct dosage. During an interview on 01/07/2025 at 10:57 AM, the MD confirmed that the facility nursing staff made a transcription error when entering Resident #26's orders. This error caused the resident to miss two days of antibiotics. During an interview on 01/07/2026 at 12:32 PM, the DON stated that facility staff were expected to follow medication administration policies and Physician Orders. If a medication error was made, then the physician should have been notified. During an interview on 01/08/2026 at 10:26 AM, the ADON confirmed that, if a Physician's Order was not clear, they [nursing staff] should contact that Physician to get the order clarified. If a medication error was made, the Physician would be contacted and documentation needed to be made on the residents' MAR. During an interview on 01/08/2026 at 10:54 AM, RN #6 did not recall entering Physician's Orders into the electronic record system for Resident #26. RN #6 did confirm that when a medication error was made the Physician and DON should be notified, and documentation should be done on the resident's MAR, along with a nurse's Progress Note. During an interview on 01/08/2026 at 12:23 PM, the Administrator stated that facility staff were expected to follow medication administration orders. The Administrator confirmed that the DON monitored Physician's Orders that were entered into the resident's electronic medical records and would notify the Physician of any errors. During an interview on 01/08/2026 at 12:41 PM, the PA indicated that Resident #26's medication error was made prior to her employment with the facility but expected to be notified when an error was made. The PA said that medication administration policies and procedures should be followed, as well as any Physician's Orders that were given. A review of the Medication Administration Policy with a reviewed date of 11/25/2024, indicated medications must be administered in accordance with the orders, including any required timeframe. The policy also indicated, if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.

Based on observations, interview and record review, the facility failed to ensure hand sanitizer was used between delivery and set up of resident meal trays. The findings are: 1. On 12/18/23 at 05:30 PM, the Business Office Manager (BOM) used hand sanitizer before getting the meal tray. The BOM delivered the meal tray to the resident and did not use hand sanitizer before getting the next meal tray. At 05:33 PM, the BOM was observed using a cell phone. The BOM placed the cell phone in her pocket and proceeded to pick up another meal tray without using hand sanitizer. The BOM delivered the meal tray to the resident and then used hand sanitizer. 2. On 12/18/23 at 05:40 PM, the BOM was asked how often are you supposed to sanitize your hands when passing meal trays? The BOM stated, Each time. 3. On 12/22/23 at 08:21 AM, the Infection Control Preventionist (ICP) was asked how often should hands be sanitized during meal tray service? The ICP answered each time. The ICP was asked why? The ICP answered to prevent cross contamination.

Based on observation, record review and interview, the facility failed to ensure call lights were placed in reach for resident's use and failed to ensure residents with functional limited range of motion call lights were placed in reach and accessible for use for 1 (Resident #30) of 1 sampled resident. The findings are: a. On 12/19/23 at 09:23 AM, Resident #30 was resting in bed. The resident's call light was behind the bed against the wall. The call light was not within reach of the resident. b. On 12/19/23 at 09:25 AM, Certified Nursing Assistant (CNA) #1 was asked to locate the resident's call light. CNA #1 reached over the bed and pulled the loose call light up to the bed and showed it to the resident and explained to the resident that it was a call light to use if needed and then CNA #1 clipped the call light to the blanket. CNA #1 was asked how often are the call lights checked to ensure that they are in reach of the residents? CNA #1 answered every morning, I think.

Based on observation, interview and record review, the facility failed to ensure housekeeping and maintenance services were provided to repair scrapes, scratches and cuts in the walls and floors in the resident rooms; furniture and residents geriatric and specialized chairs were in good repair; and areas in the facility were free of odors to maintain a safe, clean, and homelike environment in 1 (C-North) of 5 Resident Halls. The findings are: 1. On 12/19/23 at 6:02 AM, Resident room [ROOM NUMBER], had half inch deep scratches/cuts on the trim of the entrance to the bathroom door, about 1/2 to 1 inch long and 2 to 2 1/2 inches wide on the wall next to the right side of the entrance to the bathroom. 2. On 12/19/23 at 6:06 AM, Resident room [ROOM NUMBER], had the trim peeling off the side corner of the wall, on the right side of the bathroom wall entrance. In addition, the entrance floor trim to the bathroom was missing. At 6:08 AM, Certified Nursing Assistant (CNA) #2 was asked to accompany the Surveyor Resident room [ROOM NUMBER]. The Surveyor asked if CNA #2 was aware of the trim peeling on the side wall and the missing floor trim to the bathroom entrance. CNA #2 replied, This is usual. The wheelchairs must have knocked the trim off. The anti-catch on the wheelchair may have knocked it off. 3. On 12/19/23 at 6:09 AM, in Resident room [ROOM NUMBER], when standing at the entrance door, looking toward the right wall protector board, there were numerous scraps/cuts 1/2 to 1 inch long and 2 to 21/2 inches wide above the resident's low bed. 4. On 12/19/23 at 6:35 AM, Resident room [ROOM NUMBER] on the right side of the bathroom door had gashes below the lower hinge. 5. On 12/19/23 at 1:25 PM, the Surveyor asked Maintenance Manager #1 if he was aware of the scratches/cuts and the wall in room [ROOM NUMBER], side wall trim peeling off and entrance floor trim in room [ROOM NUMBER], numerous scratches on the wall board in the room [ROOM NUMBER], and the gashes on the lower hinge of the bathroom door in room [ROOM NUMBER]. The Maintenance Manager #1 stated, I was not aware, I have only been in the maintenance position for three months. I am working first on safety issues, as this is cosmetics. By the time you come back next year, all this will be completed. 6. On 12/21/23 at 08:39 AM, Maintenance Manager #1 presented a work-log dated from 03/17/23 to 11/19/23. The repairs were not listed on the work-logs for C-North Hall. 7. On 12/21/23 at 3:20 PM, the Director of Nursing (DON) was asked, Are you aware of the scratches/cuts, trim peeling off in rooms, numerous scratches in the wall boards, and gashes on hinges? The DON stated, I am aware, and we are working toward repairs. 8. The facility policy and procedure titled, Accidents and Hazards Policy provided by the DON on 2/21/23 at 8:50 AM read in part, .Facility-Oriented Approach to Safety 1. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes . Systems Approach to Safety1. The facility-oriented and resident-oriented approaches to safety are used together to implement a system approach to safety, which considers the hazards identified in the environment and individual resident risks factors, and then adjusts interventions accordingly . 46723 9. On 12/18/23 at 2:30 PM, the Dining Room by the kitchen, Hall 50 and the Secured Men's Unit had a strong urine smell. 10. On 12/18/23 at 5:46 PM, Resident #19 was sitting in her geriatric chair and the right arm padding was torn. 11. On 12/18/23 at 5:47 PM, Resident #63 was in the Dining Room. The left arm of his chair was torn and cracked with a hole that was missing the leather. 12. On 12/18/23 at 5:49 PM, during the dinner observation, the Surveyor observed the left side of Resident #17's (specialized chair) was dirty and the left arm rest was ripped. 13. On 12/19/23 at 10:02 AM, the vinyl loveseat in the Secured Men's Unit smelled of urine and had a torn corner that exposed the material underneath. 14. On 12/20/23 at 12:02 PM, the Secured Men's Unit continues to smell of urine. 15. On 12/22/23 at 08:39 AM, Licensed Practical Nurse (LPN) #1 was asked why the Men's Secured Unit smells so strongly of urine. LPN #1 stated, They use the bathroom on themselves. If the CNAs notice, they change them. 16. On 12/22/23 at 08:51 AM, the Director of Nursing (DON) was asked why the Men's Secured Unit smells of urine. The DON said they have some men that are combative and will not let you change them at first, we have to try again later. The DON was asked do you think it may be in the loveseat or mattresses. She stated, The loveseat is fairly new, and they have been replacing mattresses recently. 17. On 12/22/23 at 09:18 AM, The DON was asked if Resident #17's (specialized chair) had been checked for any tears or cleanliness and was informed that Resident #17's (specialized chair) on the left side is both dirty and cracked and has holes. The DON accompanied the Surveyor to look at Resident #17's (specialized chair) and she started cleaning the left side. The DON said she would order Resident #17 a new (specialized chair).

Based on record review, interview and observation, the facility failed to ensure Resident #3 oral care was performed to ensure daily personal hygiene needs for 2 (Residents #3) of 2 sampled residents on C-North Hall. The findings are: a. On 12/19/23 at 11:45 AM, observed Resident #3 sitting in a wheelchair in the Dining Room. Resident #3 stated, No one has brushed my teeth. The lower and top teeth had a yellowish white film coating that was compacted and embedded into the gums. b. On 12/20/23 at 08:45 AM, Resident #3's toothbrush was lying on the bedside table. Resident #3 was sitting in her wheelchair in the Dining Room. The Surveyor asked if the facility had brushed her teeth. Resident #3 stated, If they brushed my teeth, I was asleep or dead. Resident #3's lower and top teeth had a yellowish white film coating that was compacted and embedded into the gums. c. On 12/20/23 at 3:30 PM, the Surveyor asked Registered Nurse (RN) #1who was responsible for oral hygiene and had Resident #3 had her teeth brushed. After examining Resident #3, RN #1 stated, Teeth needs to be brushed, white and yellow stuff on teeth. CNA [Certified Nursing Assistant] is responsible to brush their teeth, will have them brush her teeth. d. On 12/20/23 at 10:15 AM, the Director of Nursing (DON) provided a document titled, Plan of Care (POC) Response History. A review of the section for Oral Care was not dated for 12/14/23, 12/15/23, 12/16/23, 12/17/23, 12/18/23 and 12/19/23. In addition, on 12/15/23 at 05:33 and on 12/19/23 at 03:44 was dated as, No. e. On 12/21/23, at 1:15 PM, the Surveyor asked CNA #3 Who is the aide on this hall and has [Resident #3] had her teeth brushed? CNA #3 stated, I am on this hall today, and I will brush her teeth. f. On 12/22/23 at 06:45 AM, the Surveyor asked the DON Who brushes the resident's teeth and how and when is it documented? The DON stated, CNAs or the RNs brush the resident's teeth. If a resident refuses, it is reported. Teeth are brushed after meals or when it needs to be done to prevent infections. g. The Policy and Procedure titled Oral Care (Revised 12/27/2022) stated, .The purpose of this procedure is to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent oral infections. Documentation The following information should be recorded in the resident's medical record: The date and time the mouth care was provided. All assessment data concerning the resident's mouth . If the resident refused the treatment, the reason(s) why and the intervention taken . Reporting Notify the supervisor if the resident refuses mouth care . 46723

Based on observation, record review, and interview, the facility failed to perform hand hygiene when giving eye drops and nose spray for 1 (Residents #48) of 1 sampled resident. The findings are: A review of an Admission Record indicated the facility admitted Resident #48 with diagnoses of Alzheimer's disease and cirrhosis of the liver. The Quarterly MDS with an ARD of 10/19/2023 revealed Resident #48 scored 11 (8-12 indicates moderately cognitively impaired) on a BIMS and required moderate assistance for activities of daily living (ADLs). A review of Resident #48's Physician Orders, for December 2023 revealed an order dated 10/26/2021 for Artificial Tears instill 2 drops in each eye four times a day related to dry eye syndrome and an order dated 6/19/2023 for Flonase Allergy Nasal Suspension 2 sprays in each nostril one time a day for allergies. On 12/21/2023 at 8:10 AM, when Licensed Practical Nurse (LPN) #2 proceeded to administer Nasal Spray to Resident #48, LPN #2 applied clean gloves, but did not ask the resident to blow his nose before administering the nose spray. LPN #2 gave one spray in each nostril. On 12/21/2023 at 8:15 AM, Licensed Practical Nurse (LPN) #2 prepared to give eye drops to Resident #48. Without performing hand hygiene, LPN #2 applied gloves and proceeded to administer the eye drops into both eyes. On 12/21/23 at 9:14 AM, Licensed Practical Nurse (LPN) #2 was asked how hand hygiene is performed between giving nasal spray and eye drops? LPN #2 said, Before, after, in between, gloves and hand care. On 12/21/23 at 8:50 AM, the DON provided the insert for Flonase Prescribing Information which documented, Using your FLONASE Nasal Spray: Step 1. Blow your nose to clear your nostrils . Review of the facility policy titled, Hand Hygiene, documented, Purpose: To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs, and infections. Policy: All personnel will use the hand-hygiene techniques, as set forth in the following procedure. The CDC has recommended guidelines on when to use non- antimicrobial soap and water, an antimicrobial soap and water or an antimicrobial-based hand rub . Before each patient encounter . After coming in contact with bodily fluid, dressings, mucous membranes, etc., and hands are not visibly soiled . After contact with medical supplies in patient areas. Always after removing gloves .

Based on observation, interview, and record review, the facility failed to ensure residents received care in accordance with professional standards of practice as evidenced by the residents not being cleaned and dried during the night shift for 3 Residents (#1, #2, #3) of 4 (#1, #2, #3, and #5) case mix Residents. The findings are: 1. Resident #1 was readmitted to the facility on [DATE] with diagnoses of Hemiplegia, Paraphilia, and Dementia. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/25/23 documented resident scored 10 (8-12 indicates moderately cognitively impaired) on the Brief Interview for Mental Status (BIMS) and requires total dependence for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene and is always incontinent of bladder and bowel. a. The Care Plan initiated on 02/25/14 documented, Require total assistance X2 with bed mobility, transfers, toileting, and dressing. Total assist X1 with locomotion, eating, personal hygiene and bathing r/t [related to] Closed head injury, Dementia, left hemiparesis . Resident #1 is incontinent of bowel and bladder r/t dementia, Medication Usage; does not recognize the urge to void . Resident #1 is at risk for skin breakdown and pressure ulcers r/t Incontinence, Decreased Mobility, decreased sensation . b. On 04/25/23 at 5:50am., the Surveyor was on the Male Secure Unit. Certified Nursing Assistant (CNA) #2 was sitting at the end of the hall. The Surveyor asked, How many of the men on this unit do you change and get up in the morning? CNA #2 stated, Only one. The rest get themselves up and change themselves. The Surveyor asked, The men on this memory care unit are able to get themselves up and change their own brief every day? CNA #2 stated, Yes. They do for themselves. c. On 04/25/23 at 6:26am., the Staff got Resident #1 up, in his wheelchair, and out of his room. The sheets and mattress were wet. The sheets were removed from the bed and there was a wet spot on the mattress approximately 3 feet by 2 feet. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, Other Personality Disorder, Cerebral Infarction. The Annual MDS with ARD of 02/23/23 documented resident scored 7 (0-7 indicates severely cognitively impaired) on the BIMS and requires extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene and is frequently incontinent of bladder and bowel. a. The Care Plan initiated on 05/17/21 documented, . Resident #2 has bladder incontinence r/t Impaired Mobility. Dependent on staff with transfers to and from toilet .I require extensive assist x 2 staff with bed mobility, transfer, and require extensive assist x 1 staff with locomotion, dressing, hygiene, and bathing. Total assist x1 with toileting .If I am incontinent of bowel and bladder, please check me q [every] 2 hours and prn [as needed] and give me incontinent care and change my brief and or pull up depending on which one I am using . Resident #2 is on diuretic therapy r/t hypertension . b. On 04/25/23 at 6:29am., there were two assistants in Resident #2's room getting her up and into her wheelchair. The Surveyor asked Resident #2, Is your brief wet? Resident #2 stated, Yes, it is. The Surveyor asked, Are your sheets wet? Resident #2 stated, I'm not sure. The Surveyor asked, Did anyone come in during the night to check on you and get you changed? Resident #2 stated, No. c. On 04/25/23 at 6:34am., the Surveyor asked CNA #1, Is the resident's sheet and bed wet? CNA #1 stated, I know the sheets are wet, but I am not sure about the bed. 3. Resident #3 was admitted to the facility on [DATE] with diagnoses of Dementia, Psychotic Disturbance, and Cerebral Ischemia. The Quarterly MDS with an ARD of 04/12/23 documented 3. the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and requires total dependence with transfer, dressing, eating, toilet use, personal hygiene and is always incontinent of bladder and bowel. a. The Care Plan initiated on 07/26/22 documented, .I require extensive assist x 1 staff with bed mobility, transfer, dressing, personal hygiene, eating and locomotion. Total assist x1 with toileting .I am incontinent of bowel and bladder please check me q 2 hours and prn and give me incontinent care and change my brief and or pull up depending on which one I am using . b. On 04/25/23 at 6:28am., Resident #3 had already been gotten up and was in the Dining Room. The sheets had been removed from her bed and the mattress had a wet area approximately 2 feet by 3 feet. 4. On 04/25/23 at 11:17am., the Director of Nursing (DON) stated, We do not have a policy about checking on incontinent residents every two hours. That is standard of care practice. 5. On 04/26/23 at 10:43am., the Surveyor asked Licensed Practical Nurse (LPN) #1, How often are you required to check on incontinent residents? LPN #1 stated, Every two hours. 6. On 04/26/23 at 10:46am., the Surveyor asked CNA #3, How often are you required to check on incontinent residents? CNA #3 stated, Every two hours. The Surveyor asked, What can happen if you don't check on them every two hours? CNA #3 stated, They can get skin breakdown or a rash. 7. On 04/26/23 at 10:49am., the Surveyor asked CNA #1, How often are you required to check on incontinent residents? CNA #1 stated, Every two hours. The Surveyor asked, What can happen if you don't check on them every two hours? CNA #1 stated, They can get skin breakdown or maybe have a fall. 8. On 04/26/23 at 10:51am., the Surveyor asked the Assistant Director of Nursing (ADON), How often are you required to check on incontinent residents? The ADON stated, Every two hours. The Surveyor asked, What can happen if you don't check on them every two hours? The ADON stated, They can get skin breakdown.

Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items; to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen, failed to ensure food items stored in dry goods area were sealed; failed to ensure 1 of 1 ice machine scoop/holder was maintained in a sanitary condition, and trash receptacles were clean and in hands free working order. The failed practices had the potential to affect 92 residents who received meals from 1 of 1 kitchen according to a list provided by the dietary manager on 9/29/22 at 9:00 AM. The findings are: 1. During a tour of the kitchen on 09/26/22 at 10:50 AM, the following were observed: a. The trash can located next to the handwashing sink was covered with dried liquid running vertically down all sides of the canister. The outside and inside of the canister was covered in dried food and other types of debris in varying shades of brown. The foot pedal was broken and did not lift the lid. b. The trash receptacle in the kitchen next to the worktable was covered in dried food and liquid running vertically on all sides of the canister, inside and out. c. The pot/utensil rack above the worktable was covered in a greasy substance which was sticky to the touch. Attached to the sticky substance was dust and grime particles that appeared fuzzy. d. The end of the range located next to the fryer was covered in grease and food particles. e. There were 3 large baking sheets located on the center worktable filled with slices of bread. The trays are uncovered. f. There were insulated domes stored top down on top of the worktable in front of the serving window. Water was observed inside the domes. g. The floor covering in front of the range and in front of and to the side of the fryer was torn and missing. The floor was covered in food particles. The side of the range adjacent to the fryer was covered in a greasy residue that contained food particles varying in shades of tan and brown. h. There was a 10.5-ounce (oz) container of poultry seasoning and onion powder on the shelf above the back worktable with the tops open to air and contaminants. 2. On 9/26/22 at 11:05 AM, Dietary Aide (DA) #1 washed her hands. She obtained a box of spaghetti noodles from the dry storage area which contaminated her hands. She donned gloves, opened the box, obtained the noodles with contaminated gloves and added the noodles to a pan of boiling water. She sealed the box with her gloved hands. She discarded her gloves, washed her hands, returned the box of spaghetti to the dry storage area, and contaminated her hands. 3. On 9/26/22 at 11:10 AM, DA #2 retrieved a rolling cart which contained an ice chest and a tray of glasses. DA #2 donned gloves, did not was her hands. DA #2 obtained a box containing clear plastic wrap and used the same contaminated gloves to wrap the tops of the drink glasses with plastic wrap after they were filled. In the process the DA #2 spilled a glass of water. Utilizing the same pair of gloves she wiped the counter, retrieved a mop, mopped the spill, returned the mop to storage, and continued to fill the glasses. She did not change her gloves or was her hands during the process. 4. On 9/26/22 at 11:15 AM, DA #3 prepared thickened liquids for lunch. She carried the pans of thickened liquid to the table wearing gloves. She obtained her trays of glasses. Before she proceeded to fill the glasses, she did not change her gloves or wash her hands. Once the glasses were filled, DA #3 changed her gloves but did not wash her hands. 5. On 9/26/22 at 11:22 AM, slices of garlic toast were placed on the steam table and left uncovered. 6. On 9/26/22 at 11:25 AM, Dietary Assistant (DA) #1 did not wash her hands before she placed the bowl on top of the robo coupe and placed the blade in the bowl. The Surveyor observed DA #1 with unwashed hands on her hips as she and the dietary manager reviewed the recipe for the pureed diets. DA #1 placed 12 helpings of meat sauce into the blender bowl and pureed. After she poured the pureed meat sauce into the steam table pan, she carried the bowl, blade and top to the dish room. The items were returned for use remained wet with water dripping from each piece of equipment. 7. On 9/26/22 at 11:34 AM, the Dietary Manager (DM) obtained a pitcher and chicken base with unwashed hands. She touched her name tag which was hanging around her neck and swung it over her shoulder. She obtained a sheet of aluminum foil and covered the top of the steam table pan which contained the pureed spaghetti sauce and placed it in the oven. She obtained a large mixing bowl and placed it on top of the worktable. She opened two #10 cans of diced peaches and one #10 can of diced pears using the table based can opener. The Can opener had dried food stuck to the side. Each can was opened and the contents dumped into an aluminum bowl. Just prior to use the bowl was stored right side up on the bottom of the worktable. 8. On 9/26/22 at 11:43 AM, DA #1 pureed the vegetables and water poured out of the back of the robo coupe due to the bowl being returned wet from the dishwasher. DA #1 stopped and dried the spill of water from the robo coupe. When DA #1 finished pureeing the vegetables, she returned the bowl to the dish room to be cleaned. When DA #1 returned, she carried the wet bowl against her person. 9. On 9/26/22 at 11:52 AM, Dietary Assistant #1 obtained clear hard plastic tub of potato flakes from the dry storage area. With contaminated hands she proceeded to stir the potato flakes into the water and returned the steam table pan back to the stove. 10. On 9/28/22 at 8:45 AM, there were multiple, clear plastic tubs on the bottom shelf of the dry storage area. The tops of the tubs were covered in a film of dust and food particles. The tubs that contained dry white beans, dry brown beans and potato flakes were not sealed. 11. On 9/28/22 at 9:15 AM, there was an ice scoop resting in a holder attached to the wall on hall C Short. There was approximately 1.5 inches of water in the bottom of the container. The DM stated, .I don't know how that happened . 12. On 9/28/22 at 10:00 AM, the DM provided the Policy & Procedure for Hand Washing. The Procedure stated, the time to wash hands is before, engaging in food preparation including working with exposed food, clean equipment, or service utensils and after touching any part of the body including the body or clothing, handling soiled equipment or utensils, engaging in any other activity that contaminates the hands . The Food storage policy Provided by the DM on 9/28/22 at 10:00 AM states items that are opened but the entire contents of the package are not used, place the unused food in a NSF approved container with a securely fitting lid. Keep the floor, shelves, and walls clean.

Based on record review and interview the facility failed to inform the residents, their representatives, and families of those residing in facilities by 5 PM, the next calendar day following the occurrence of either a single confirmed infection of COVID-19 or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. The failed practice had the ability to affect the 95 residents who reside in the facility, according to the room/bed list provided by the Business Office Manager (BOM) on 9/26/22 at 11:00 AM. The findings are: a. On 9/28/22 at 1:12 PM, the Director of Nursing (DON) provided a list of the 5 most recent residents and employees who were COVID-19 positive. b. On 9/28/2 at 1:20 PM, The Surveyor asked the Administrator who was responsible for notifying the resident's and their family/representative of a change in COVID status of the building. He stated, .the Social Director (SD) is responsible for making those calls .they would be recorded as a social note in the progress note section of the medical record . c. On 9/28/22 at 1:30 PM, a review of the list identified an employee or resident as having tested positive on 8/26/22, 6/28/22, 6/25/22, 6/6/22, 5/31/22 and 5/27/22. A review of the electronic medical record for R #54 and R #90 revealed that there were no notifications made the following day for any of these dates. d. On 9/28/22 at 2:45 PM, The Surveyor asked the SD if she was responsible for notifying the residents, their family/representative of a change in COVID-19 status in the building. She stated, .yes . The SD was questioned concerning the absence of notifications present in the medical record. She stated, .when our old administrator was here, he made those calls .I actually think he sent out a group text .he left in July, I think . Concerning the lack of notification on 8/26/22 she stated, .it was the BOM who was positive that day, so she just notified the residents/families that she had had contact with that day . the Surveyor asked the BOM to clarify that not all residents/families were notified that day. SD stated, .no, not all of them .just the ones she had contact with . e. On 9/28/22 at 3:00 PM, the Administrator provided the policy and procedure for Reporting COVID Results, Residents. The policy states, The facility will inform residents, their representatives, and families of those residing in facilities by 5 PM the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other.

Based on observation and interview the facility failed to dispose of refuse properly. The failed practice had the potential to impact all 95 residents residing in the facility according to a list provided by the Business Office Manager (BOM) on 09/26/22 at 11:00 AM. The findings are: a. On 09/26/22 at 10:50 AM, the dumpster in the facility parking lot had the door on the right side of the receptacle open, allowed the possibility of spillage and the perpetuation of rodents. The dumpster housing recycling materials overflowed with boxes on the ground in front of the receptacle. b. On 09/27/22 at 7:50 AM and at 4:00 PM, the dumpster had the door on the right side of the receptacle open. c. On 9/28/22 at 7:45 AM and at 11:00 AM, the dumpster had the door on the right side of the receptacle open. d. On 09/29/22 at 9:40 AM, the Dietary Manager stated .I have closed that door on the that dumpster multiple times this week but I guess no one else does .

Based on observation, record review, and interview, the facility failed to ensure bottles of eye drops stored in 2 (C South and B North medication carts) of 2 medication carts were labeled, dated, and disposed of in accordance with the manufacturer's instructions to prevent potential administration of eye drops that had been opened and stored beyond the manufacturer's specified timeframes and failed to ensure that medication was not left at the bedside. The failed practice had the potential to affect 4 (Resident's #10, #52, #76, #80) sample residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: a. On [DATE] at 02:58 PM, The Surveyor checked the medication cart for C South with Registered Nurse (RN) #1. There were six boxes of artificial tears containing opened eye drop bottles and one open artificial tear bottle with no box that had no opened date on them. The Surveyor asked, Should these have an opened date on them? She stated, Yes. b. On [DATE] at 03:15 PM, The Surveyor checked the medication cart for B North with Licensed Practical Nurse (LPN) #1. There was one open bottle of Xalantan with no opened date on the bottle. There was one bottle of [MEDICATION(S)] with an opened date of [DATE]. The Surveyor asked LPN#1, Should eyedrops be labeled when opened? She stated, Yes. 3. On [DATE] at 10:05 AM, The Surveyor asked the DON, Should eye drops be labeled with the date they were opened? She stated, Yes. The Surveyor asked, Should opened expired eye drops be used? She stated, No. The Surveyor asked, What should be done with them? She stated, They should be discarded. 4. The manufacturers insert for [MEDICATION(S)] documents under How Supplied .Once a bottle is opened for use, it may be stored at room temperature up to 77 degrees for 6 weeks . 5. A facility policy titled Storage of Medications received by the DON documents, .1. Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received . and .4. The facility shall not use discontinued, outdated, or deteriorated drugs . and .Medication will not be stored in a resident room unless the resident has been approved for self-administration of medication. If approved, the resident will be provided with a lockbox to safely store medications . Resident #19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 7 (,d+[DATE] indicates severely impaired) on a Brief Interview for Mental Status. a. On [DATE] at 11:55 AM, Resident #19 was lying in bed. A medication cup was observed on the overbed table with 2 tablets in it. At approximately 12:00 PM, the resident sat on side of bed and took the tablets in the med cup. There was no staff present in the room. b. On [DATE] at 09:41 AM, The Surveyor asked (LPN)#4 if it is acceptable to leave medications in a medication cup on Resident #19's overbed table. She stated, No, especially down here, [secured locked unit] it is not acceptable.

Based on observation, interview and record review the facility failed to ensure that tube feedings hanging in bag were labeled with type of formula, date, time, and initials in accordance with acceptable standards of practice for 2 (Resident #52, and #87) of 4 (Resident #52, #77, #87, and #94) sample residents with feeding tubes. The findings are: 1. Resident #52 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. On 09/26/22 at 12:19 PM, Resident #52 was lying on back on-air mattress, covered with a sheet and the head of the bed was up 30 degrees. Tube feeding was labeled with date of 9/26/22 but not the type of feeding, the time it was hung, or the initials of the person that hung it and infusing at 65 liters per hour. b. On 9/28/22 at 10:05 AM, The Surveyor asked the Director of Nursing (DON), Should feedings be labeled with type, time and initials? She stated, Yes. c. A facility policy received from the DON on 9/28/22 titled Enteral Tube Feeding via Gravity Bag documents .4. On the formula label document initials, date, and time the formula was hung/administered, and initial the label was checked against the order . 2. Resident #87 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/1/2022 documented Shortness of breath or trouble breathing when sitting at rest, oxygen therapy, and the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) required extensive two plus person assistance for bed mobility and dressing, total dependence on assistance of 1 person with toileting, eating, and personal hygiene. a. On 09/26/22 at 01:18 PM, the Surveyor observed a 1000 ml tube feeding bag of formula that was not labeled. The bag was dated 9/26/22 at 10:50 AM and was running at 65 ml(milliliters) per hour via feeding pump. Approximately 850 ml light brown liquid remained in the feeding bag. b. On 09/26/22 at 01:45 PM, The Surveyor asked LPN #2 what was in Resident #87's feeding bag? She stated I have to check, returned and stated Osmolyte 1.5, I should have put it on there. I did it when I was busy. c. On 09/27/22 at 08:37 AM, Resident #87's 1000 ml tube feeding bag was dated 09/26/22 at 1050, and was not labeled, it appeared to be the same bag as yesterday, approximately 750 ml light brown liquid remained in the bag, and it was running at 65 ml hr. d. On 09/27/22 at 03:45 PM, Resident #87's tube feeding was running at 65 ml/hr. via feeding pump, the bag was approximately one quarter full (250 mls). It was the same bag observed on 09/27/22 at 8:37 AM.

Based on observation, interview, and record review the facility failed to provide treatment and care in accordance with professional standards of practice as evidenced by providing treatment without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: Resident #60 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/11/22 documented the resident scored 4 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS) and required extensive assistance of one person for personal hygiene. 1. The Comprehensive care plan documented, .Resident has an alteration in skin integrity AEB (as evidenced by): Skin Tear(s). 07/30/22 actual skin tear- fingernails trimmed . 2. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Document unusual findings in progress note, every shift for Anticoagulant use . 3. Weekly skin checks dated 9/24/22, 9/17/22, 9/11/22, 9/1/22, 8/25/22, 8/18/22, 8/11/11, 8/6/22 documented, .1. Does the resident have loss of skin integrity? No .2. Does the resident have a new loss of skin integrity? No . Weekly Skin Check dated 7/30/22 documented, .1. Does the resident have a loss of skin integrity? no .2. Does the resident have a new loss of skin integrity? yes-Weekly wound evaluation required for each new area of loss of skin integrity .3. Following resident's current skin care interventions . a. On 09/26/22 at 12:52 PM, Resident #60 sitting in dining room waiting on lunch, a bandage was observed on right wrist that was not dated. b. On 09/29/22 at 07:56 AM, Resident #60 was sitting in a wheelchair in the hallway. A band aid was observed on the right wrist. c. On 09/29/22 at 09:41 AM, The Surveyor asked Licensed Practical Nurse (LPN) #4 if she placed the bandage on the resident's wrist. She stated, no, ma'am, I didn't know anything about it. The Surveyor asked, Do you know if there is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, not that I know. d. On 09/29/22 at 10:09 AM, The Surveyor asked LPN #5 what her role in the facility was. She stated, Medical Records, but I'm doing treatments because they don't have a wound nurse right now. The Surveyor asked if Resident #60 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, [LPN #4], just mentioned it to me, no, I don't. I went and did some research; he had a self-inflicted area on 8/1 and he keeps picking at it. The Surveyor asked, Does he have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, No treatment orders as of right this second, no. A document provided by the Director of Nursing on 9/29/22 titled, Skin Tears-Abrasions and Minor Breaks, Care of, documented, Obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Check the treatment record .Complete in-house investigation of causation .Report other information in accordance with facility policy/guideline and professional standards of practice .

Based on observation, interview, and record review the facility failed to provide nailcare to promote good hygiene and prevent possible skin infections for 1 (Resident #49) of 20 (5, 10, 12, 19, 28, 49, 52,60, 61, 66, 72, 73, 76, 77, 80, 87, 89, 94, 196, 346) of 20) sampled residents who require assistance with nail care. The findings are: Resident #49 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/27/22 documented, the resident scored 0 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance of one person for personal hygiene. The Comprehensive Care Plan documented, .I am currently independent with all my Activity of Daily Living (ADL)'s but at times but do require supervision and cueing to ensure tasks are completed. Limited assist x1 with dressing, hygiene, and bathing. Date Initiated: 05/06/2022 .Check my fingernails and toenails and trim as needed unless I am diabetic then please notify my nurse . a. On 09/26/22 at 12:10 PM, R#49 was lying in bed. Her fingernails were various lengths with uneven jagged edges and peeling red fingernail polish. b. On 09/26/22 at 02:24 PM, R#49 was lying in bed. Her fingernails were various lengths with uneven jagged edges and peeling red fingernail polish. c. On 09/29/22 at 07:52 AM, Resident #49 was sitting on side of bed eating breakfast, her fingernails were various lengths with uneven jagged edges and peeling red fingernail polish. d. On 09/29/22 09:06 AM, The Surveyor asked Certified Nursing Assistant (CNA) #1 to look at Resident #49's fingernails. She stated, They need to be clipped again. I'll do it later. The Surveyor asked how often the residents received nail care. She stated, It depends on how often they grow. I do it 2 to 3 times a week. We tried yesterday and she wouldn't let us. We told the nurse. The Surveyor asked, Which nurse? She stated [Licensed Practical Nurse #4] e. On 09/29/22 at 09:41 AM, The Surveyor asked Licensed Practical Nurse #4 to look at Resident #4's fingernails. She did so and stated, Oh, gosh. They are ragged. The Surveyor asked if the staff had attempted to provide care and she refuse. She stated, She is real cooperative, if she did, they didn't tell me. A document titled, Care of Fingernails/Toenails, provided by the Director of Nursing on 9/29/22 documented, .keep nails trimmed, and to prevent infections .notify the supervisor if the resident refuses care .

Based on observation, record review, and interview the facility failed to ensure proper hand hygiene and universal precautions were followed to prevent the spread of infection as evidenced by staff not wearing gloves for blood glucose monitoring during the medication pass observed on 09/27/22. This failed practice had the potential to affect 18 residents who required Capillary blood glucose levels to be checked according to a list provided by the Assistant Director of Nursing (ADON) on 09/29/22 at 10:00 AM. The findings are: 1. On 09/27/22 at 11:20 AM, Licensed Practical Nurse (LPN) #3 performed capillary blood glucose by fingerstick on Resident #89. Resident #89's finger was cleansed with alcohol prep, finger was stuck with lancet device, finger was squeezed to obtain a blood drop, the blood was applied to glucose strip in glucometer, the strip was removed from glucometer and resident #89's finger with residual blood visible was cleansed with alcohol prep after fingerstick. The LPN did not wear gloves to perform the fingerstick, remove used the glucometer strip from the glucometer, or while cleansing the blood drop from resident #89's index finger. On 09/29/22 the Surveyor interviewed the DON and asked if it is appropriate to perform a fingerstick blood sugar, remove used glucometer strip, and clean residual blood from resident finger with no gloves on. She stated No The Surveyor asked, Why? She stated, because it is blood and a cross contamination issue. 2. The facility policy and procedure on obtaining Fingerstick Glucose level was reviewed and documented .Purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level .5. wear clean gloves .

Based on observation, record review, and interview the facility failed to ensure a baseline care plan was developed and implemented for 1 resident (Resident #196) of 5 (Resident #10, #54, #66, #89, #96) sample residents that included the instructions needed for safe smoking and storage of smoking materials to provide effective and person-centered care of the resident that meet professional standards of quality care. This failed practice had the potential to affect 22 residents who use tobacco products according to a list provided by the Assistant Director of Nursing (ADON) on 09/29/22 at 10:00 AM. The findings are: 1.Resident #196 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medicare 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/25/22 was still in progress and documented no Brief Interview of Mental Health Status (BIMS) score or use of tobacco by resident. a. On 09/26/22 at 12:40 PM, Resident #196 was being screened and the Surveyor asked if she smoked and who stored her smoking materials? Resident #196 stated, I store my own cigarettes and lighter, and pointed beside her in wheelchair. I don't get to smoke as much as I want. b. On 09/26/22 at 1:35 PM, the Director of Nursing (DON) approached the Surveyor and stated, I got these and had cigarettes and a lighter in her hand, Resident #196 is new and didn't know she couldn't keep them. c. On 09/27/22 at 3:15 PM, a record review of a nursing assessment dated [DATE] documented, . resident orientation to unit smoking policy checked. Evaluation documented resident requires supervision - includes retrieval . d. On 09/27/22 at 3:15 PM, Resident #196's Care Plan was reviewed and documented .I may not like it at times, but please store all my smoking materials, including lighters, matches, etc., in a safe place; remind my family not to give smoking materials directly to me. Date Initiated: 09/26/2022 . 2. On 09/28/22 at 11:30 AM, The facility policy and procedure Resident Smoking was reviewed and documented, .1. On admission, residents shall be informed of the facility smoking policy .the policy will be given to the resident to sign and acknowledge receipt .13. Residents may not have or keep any smoking articles, including cigarettes, tobacco, electronic smoking devices of any kind etc. In their possession. The facility will store all smoking articles .

Based on observation, record review, and interview the facility failed to ensure one resident (resident # 87) of 4 (resident #77, #87, #89, #196) sampled residents reviewed who had orders for oxygen therapy had dates on oxygen tubing and humidity bottle consistent with professional standards of practice to prevent possible infection and complications from using equipment past standard accepted practice for infection control. This failed practice had the potential to affect 10 residents who had orders for oxygen therapy according to a list provided by the ADON on 09/29/22 at 10:00 am. 1.Resident # 87 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/1/2022 documented Shortness of breath or trouble breathing when sitting at rest, oxygen therapy and the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) required extensive two plus person assistance for bed mobility and dressing, total dependence on assistance of 1 person with toileting, eating, and personal hygiene. Section O documented oxygen therapy were performed for the last 14 days. a. On 09/26/22 at 01:20 PM resident # 87 was in room, in bed with oxygen(O2) at 3 LPM [liters per minute] via [CONDITION(S)], there was no date on the oxygen tubing or humidity bottle. b. On 09/27/22 at 08:18 AM, Resident # 87 was in bed, oxygen at 3 LPM via [CONDITION(S)], there was no date on the humidity bottle or oxygen tubing. c. On 09/28/22 at 02:00 PM, The Surveyor asked the DON to observe the oxygen tubing and humidity bottle and tell surveyor if there was a date on either? She stated 09/28/22 on tubing but none on humidity bottle. The Surveyor asked, what policy is for changing oxygen tubing and humidity bottles out? She stated every Wednesday night shift and as needed; it should be dated. d. On 09/28/22 at 10:30 Am, A record review of current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . every shift for SOB related to ACUTE AND CHRONIC [CONDITION(S)], UNSPECIFIED WHETHER WITH [CONDITION(S)] OR HYPERCAPNIA Active 08/24/2022 . Change humidifier bottle once weekly on (Wednesday) during the (10-6) shift and PRN. As needed related to ACUTE AND CHRONIC [CONDITION(S)], UNSPECIFIED WHETHER WITH [CONDITION(S)] OR HYPERCAPNIA change humidifier bottle as needed Active 08/24/2022 . Change oxygen cannula/tubing once weekly on (Wednesday) during the (10-6) shift and PRN. Every night shift every Wed related to ACUTE AND CHRONIC [CONDITION(S)], UNSPECIFIED WHETHER WITH [CONDITION(S)] OR HYPERCAPNIA Active 08/24/2022 . e. On 09/28/22 at 11:00 AM, resident # 87's care plan was reviewed and documented . O2 as ordered per [CONDITION(S)] collar. Date Initiated: 08/24/2022. The care plan did not address changing the humidity bottle or oxygen tubing weekly. f. On 06/28/22 at 11:30 AM, the facility policy and procedure on oxygen safety was reviewed and had no documented procedure for changing out and dating oxygen equipment. g. On 09/29/22 at 8:31 AM, The Surveyor asked the DON if it is appropriate to not label oxygen tubing and humidity bottles with a date? No, if not you don't know if it is fresh. Asked what complications could occur if not changed weekly. It is an infection control issue.

Based on interview and record review, the facility failed to notify the state agency for a Pre-Admission Screening and Resident Review (PASARR) for a new mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident #94 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The resident's face sheet documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. There was no PASARR screening in the Resident's electronic health record. a. On 09/29/22 at 11:50 AM, The Surveyor asked the Director of Nursing (DON) when Resident #94 received the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, .It came from a doctor's visit. I don't have a PASARR. The Surveyor asked the DON if Resident #94 should have had a PASARR screening when he was diagnosed . She stated, yes, it was a new diagnosis.

Based on observation, record review, and interview, the facility failed to ensure 2 of 2 designated smoking areas were clean and free of clutter and debris. This failed practice had the potential to affect 21 residents who smoke in the facility according to the list provided by the Director of Nursing (DON) on 9/15/2022. The findings are: a. On 09/13/2022 at 07:13 AM, The Surveyor was directed and escorted by Licensed Practical Nurse (LPN) #1 to the courtyard outside where residents take their smoke break. There were twelve (12) cigarette butts on the concrete along with one (1) discarded pack of cigarettes. Underneath a patio chair that was sitting in the grass area next to a glass top patio table surveyor observed approximately thirty (30) cigarette butts underneath the chair along with one (1) discarded cigarette pack. The Surveyor interviewed LPN #1 in the courtyard and asked, Should the resident smoke area be littered with cigarette butts and cigarette packs on the ground? She stated, No, it should not. The Surveyor asked, Who is charge of cleaning the area? She stated, I'm not sure of that. b. On 09/15/2022 at 10:30 AM, The surveyor observed on the ground in the resident courtyard smoking area approximately ninety (90) cigarette butts, one (1) plastic ramakin lid, three (3) plastic cigarette wrappers, one (1) wet wipe, one (1) [candy] wrapper, one (1) silver gum wrapper, two (2) empty cigarette packs, one (1) Styrofoam cup, one (1) partially opened paperclip. c. On 09/16/2022 at 08:33 AM, The surveyor observed approximately fifty (50) cigarette butts on the ground in the lady's secure unit (hallway C-South) smoking area. d. On 09/15/2022 at 10:33 AM, The Surveyor interviewed Certified Nurse's Assistant (CNA) #1 who was in the courtyard and asked, Should the resident smoke area be littered with cigarette butts? She stated, It shouldn't. The Surveyor asked, Should the resident smoke area be littered with trash and debris? She stated, No. The Surveyor asked, Who is in charge of keeping the resident smoke area clean? She stated, Whoever is out here is to pick it up. Several people come out and clean it throughout the day. The Surveyor asked, Can you give me an approximate estimation of how many cigarettes butts you see on the ground? She stated, I'd estimate about fifty (50). The Surveyor asked, How many pieces of trash and debris to you see? She stated, A couple pieces of trash out here. e. On 09/15/2022 at 03:51 PM, The surveyor interviewed the Director of Nursing (DON) and asked, Should the resident smoke area be littered with cigarette butts? She stated, No, it shouldn't be. The Surveyor asked, Who is in charge of cleaning it up and maintaining the smoking area? She stated, We need to PIP it and appoint that task. The Surveyor asked, Currently is there anyone cleaning it up? She stated, No, we don't have anyone specifically assigned to do it yet. f. On 09/16/2022 at 08:36 AM, The Surveyor interviewed the CNA #2 on the lady's secure unit (hallway C-South) outside in the smoking area and asked, Who is responsible for cleaning up the lady's smoking area? She stated, Housekeeping I would say. I think CNA's pick them up back here. The Surveyor asked, How many cigarette butts do you see on the ground? She stated, A lot. g. On 09/16/2022 at 08:39 AM, The surveyor interviewed the DON and asked, Should the smoking area on the lady's secure unit be littered with cigarette butts? She stated, No, they should all be clean.

Based on observation, record review, and interview, the facility failed to ensure a wooden wheelchair ramp was secure to prevent accidents for 10 of 10 residents located on C-South Hallway lady's secure unit as per the list provided by the Director of Nursing (DON) of 09/16/2022. The findings are: 1. On 09/16/2022 at 08:33 AM, The surveyor observed on the lady's secure unit (C-South Hallway) outdoor courtyard a wooden ramp outside of door for wheelchair use that was not secured and moved. The ramp was approximately one in a half inch from the door in one area. Certified Nurse's Assistant (CNA #2) pushed the board back up against the door during her interview, so the surveyor was unable to measure it. 2. On 09/16/2022 at 09:16 AM, The surveyor obtained measurements of the wood ramp on the lady's secure unit C-South hallway. The ramp measured four (4) feet wide by two (2) feet long with a two (2) inch raise. 3. On 09/16/2022 at 08:36 AM, The Surveyor interviewed CNA #2 and asked, What is the board by the outside exit door used for? She stated, Wheelchairs. The Surveyor asked, Should there be a gap between the board and the door? She stated, There should not be. The Surveyor asked, Should the board be secured? She stated, Yes. The Surveyor asked, Why? She stated, So accidents don't happen. The Surveyor asked, How long has this board been here unsecure? She stated, I'm not sure. 4. On 09/16/2022 at 08:39 AM The surveyor interviewed the DON and asked, Should the ramp board on the lady's sure unit at the smoking area/courtyard door be secured or able to move? She stated, No. The Surveyor asked, Should the ramp board be secured on the lady's unit? She stated, I'm fixing to take care of that right now. The Surveyor asked, How long has this board been here unsecure? She stated, I'm not sure. The Surveyor asked, How long has this board been here unsecure? She stated, It don't know exactly how long. 5. On 09/16/2022 at 08:54 AM The Surveyor interviewed Maintenance Employee on the lady's secure unit outside the door in the smoking area/courtyard and asked, What is this board/ramp made of? He stated, Three-quarter inch deck board. The Surveyor asked, Should it be secured or able should it be able to move? He stated, Secured. When asked, Why? He stated, It's a fall issue. The Surveyor asked, Should there be a gap between the board and the door? He stated, No more than half an inch per regulation. I'm going to tap it down and attach it to the concrete. 6. On 09/16/2022 at 09:11 AM, The facility policy on Accidents and Hazard's was provided by the Assistant Director of Nursing (ADON) and documented, . Facility- Oriented Approach to Safety 1. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting process . 3. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents Individualized, Resident- Centered Approach to Safety 1. Our individualized, resident-centered approach to safety address and accident hazards for individual residents System Approach to Safety 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjust interventions accordingly

Based on observation, record review and interview, the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Resident #1) of 3 (Residents #1, #2, and #3) case mix residents who were at high risk for elopement. This failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused was likely to cause serious harm, injury, or death to Resident #1, who wandered from the facility and was found the next day by the police in a different city and had the potential to have more than minimal harm to 23 residents who were identified as High Elopement Risks, according to a list provided by the Director of Nursing (DON) on 5/04/2022. The Administrator was notified of the Past Immediate Jeopardy on 5/05/2022. The findings are: 1. Resident #1 had diagnoses of [CONDITION(S)] following Cerebral Infarction, [CONDITION(S)] with Behavioral Disturbance, and [CONDITION(S)], Depressed, Severe, with Psychotic Features. The Annual Minimum Data Set with an Assessment Reference Date of 2/13/2022 documented the resident had modified independence in cognitive skills for daily decision making per a Staff Assessment for Mental Status and was independent with transfers and toileting. a. The Elopement Risk Evaluation dated 9/09/2021 documented, .Score 11 .4. Cognitive Processes Impulsive Behavior . Additional Comments: (if score is 10 or higher but not at risk, provide rationale) Resides in Secure Men's Unit . b. The Elopement Risk Evaluation dated 4/13/2022 documented, .Score 11 .4. Cognitive Processes Impulsive Behavior . Additional Comments: (if score is 10 or higher but not at risk, provide rationale) Resides in Secure Men's Unit . c. The DMS [Division of Medical Services] Form 762 documented, .Date and Time of Incident (if known): 4/28/2022 Time: 644 AM .Date and Time of Discovery: 4/28/2022 Time: 644 AM .Date Incident Reported to OLTC [Office of Long Term Care]: 4/28/2022 Time: 11 AM . On 4/28/2022 the Administrator was notified about an elopement concerning [Resident #1] the following is a timeline of the events that occurred with [Resident #1] . 4/28/2022 [another city] police called facility notifying they found [Resident #1] on [downtown] officer to call and update location per dispatcher . 4/28/2022 0700 [Police Officer] returned call stated that they had released [Resident #1], as they have no reason to hold him and were currently dispatching all officers for a search and dispatching the fire department to assist. 4/28/2022 0737 [7:37 a.m.] Notified by [Police Officer] that [Resident #1] was found safe at [street address] . 4/28/2022 0747 [7:47 a.m.] [Resident #1] was sent to [Hospital] for assessment with no negative findings. 4/28/2022 0848 [8:48 a.m.] [Resident #1] arrived back at the facility Body audit conducted with no negative findings. [Resident #1] is currently on 1:1 . In conclusions, [Resident #1] has a BIMS [Brief Interview for Mental Status] of 15 and he can make decisions for himself. It was determined that he failed to sign himself out. He communicated to the DON and ADON [Assistant Director of Nursing] that his chest was hurting and that he was going to the hospital when he left the facility. The facility also suspects that since [Resident #1] has a BIMS of 15 . he watched Staff use the keypad and memorized the code and let himself out since the alarm on the door didn't go off when he exited the building . d. The OLTC [Office of Long-Term Care] Witness Statement Form dated 4/28/2022 documented, .Witness Full Name [DON] . I and the ADON completed an interview and full assessment of [Resident #1] upon returning to the facility . During the interview [Resident #1] revealed he purposefully waited until CNA [Certified Nursing Assistant] took out his trash at end of shift. He then rattled the dining room door until it opened - used a chair to climb over the fence - He indicated he wanted to go to Hospital due to chest pain. He did not alert the nursing staff of c/o [complaints of] chest pain, nor did he alert the staff he wished to go to the hospital. e. The OLTC Witness Statement Form dated 4/28/2022 documented, .Witness Full Name [DON] .Verbal Counseling of [CNA #3] 1. must always notify charge nurse when leaving your duty station 2. must always complete walking rounds at shift change . f. The OLTC Witness Statement Form dated 4/28/2022 documented, .Witness Full Name [CNA #5] .Came into work @ [at] 5:39 a.m. walked on men's south and seen all doors to rooms are closed and the Dayroom was dark and one CNA was in the room in front of the TV and one CNA was in the hallway sitting in chair, as I was walking through when I see the light and a crack in the door but did not open the door and look in resident usually comes out in hall and ask for a cup of ice every morning at 5:45 a.m. and then goes back to his room. I didn't open his door to check on resident at all this morning. g. On 5/04/2022 at 10:23 a.m., the Maintenance Supervisor was asked, Did you make any changes to the door that goes out into the courtyard on the South, Secure Men's Unit after [Resident #1] got out of the facility? The Maintenance Supervisor stated, I changed the keypad code. It was a simple code. I think 1111. I put another door alarm on that door. The door alarm was placed in the middle of the door, and I put another alarm on the top part of the door. I also put a door closure device on that door. On the top part of the door, you can see the previous screw holes. You could open the door, but it would not close. You would manually have to close the door. The alarms on the door are battery operated devices that stick to the glass. They have a small switch on the side that turns them on and off. The door already had an alarm on the door, and it would alarm if the door was opened or pushed on hard. The keypad code disengages the mag lock on the door. h. On 5/04/2022 at 1:14 p.m., CNA #1 was asked, What time did you go on to the South, Secure Men's Unit to start your shift? CNA #1 stated, It was around 10:15-10:30 p.m. [CNA #2] was already over there. CNA #1 was asked, Did you get report from [CNA #3] and did you make rounds before starting your shift? CNA #2 stated, I can't remember his name, but he told us everything was OK and that nothing had happened that day. CNA #2 was asked, Why did you not check to see if [Resident #1] was in his room? CNA #2 stated, Another resident had gone to the hospital a few nights ago. I was confused who went to the hospital. I was thinking [Resident #1] went to the hospital. I never thought about [Resident #1] escaping. I usually don't work over there. [Resident #1] usually stays in his room. [Resident #1] will come to us asking for towels. [Resident #1] keeps to himself. i. On 5/04/2022 at 1:51 p.m., CNA #2 was asked, What time did you go on to the South, Secure Men's Unit to start your shift? CNA #2 stated, I worked a double that day. The person working the unit was not feeling well. I was asked to take his spot on the unit. It was at 10:15-10:30 p.m. [CNA #1] was already back there. I thought [CNA #1] was there when I got there. CNA #2 was asked, Did you get report from [CNA #3] and did you make rounds before starting your shift? CNA #2 stated, I met [CNA #3] in the Hallway. He was taking out the trash. He didn't know the code to the front door. I let him out the door. [CNA #3] told me that everything was good on the unit. I think [CNA #2] was already on the unit. I don't remember seeing [CNA #3] back on the unit again. CNA #2 was asked, Why did you not check to see if [Resident #1] was in his room? CNA #2 stated, I hardly ever work the units. I was told they sent two people out to the hospital. I thought [Resident #1] got sent out. j. On 5/04/2022 at 2:16 p.m., CNA #3 was asked, Did you work on the South, Secure Men's Unit on 4/27/2022? CNA #3 stated, Yes, I worked 2-10 [2:00 p.m.-10:00 p.m.] CNA #3 was asked, Did you work on the Unit by yourself and how many residents are on the South, Secure Men's Unit? CNA #3 stated, Yes, I was by myself on the unit. I think around fourteen residents. CNA #3 was asked, When was the last time you saw [Resident #1] on 4/27/2022? CNA #3 stated, It was around 9:20 p.m. [Resident #1] came out of his room and asked for a towel. CNA #3 was asked, Did you give report to the next shift prior to leaving? CNA #3 stated, I took the trash out and told [CNA #1] that everything was OK on the Unit. CNA #3 was asked, Did you make rounds on the Unit with [CNA #1]? CNA #3 stated, No. k. On 5/4/2022 at 10:43 p.m., the Day Area and specifically the door and the courtyard on the South, Secure Men's Unit was observed. The Maintenance Supervisor was also present. The door had a small circular alarm device attached to the middle portion of the glass. The device had a visible switch that turned the alarm on and off. The keypad to the door was located on the wall to the right of the door. Once the keypad code was punched in the door would open. The door did alarm when the door was opened due to the circular alarm device that was attached to the door. The door was then closed, and the alarm stopped or was no longer audible. The door was pushed on and the door did not alarm. The door did give when pushed on but did not open due to the magnetic lock. The door was not pushed on with any force and did not alarm. The courtyard was enclosed by a wooden fence. This fence was worn and in need of repairs. The fence leaned inward. The fence also had a gate that was secured with a padlock. Two old chairs were observed against the wall of the facility. A walkway was in between the facility fence and another wooden fence that provided some privacy for residential homes. This wooden fence was also worn and in need of repairs. It also leaned inward, and boards were placed horizontally as a makeshift brace. A portion of this outer fence was missing two to three boards that were laying on the ground. l. On 5/4/2022 at 3:15 p.m., the facility's surveillance video was reviewed with the Administrator. At 9:40 p.m., CNA #3 was observed taking two plastic containers out the exit door of the South, Secure Men's Unit. At 9:43 p.m., Resident #1 was going down the hallway looking into each room as he went down the hallway. At 9:44 p.m., Resident #1 went back to his room and then came back out. At 9:45 p.m., Resident #1 went into the Day Area and did not come back out in the hallway. Resident #1 was not seen again on the video footage. At 9:49 p.m., CNA #3 brought the two plastic containers back onto the South, Secure Men's Unit. At 10:02 p.m., CNA #3 was leaving the Secure Unit. CNA #3 did not go back on the Secure Unit. At 10:09 p.m., CNA #1 and CNA #2 were observed entering the South, Secure Men's Unit. 2. The facility initiated corrective action immediately after the incident on 4/28/2022 by implementing the following: a.4/28/2022 at 0640 [6:40 a.m.], Notified [Resident #1] was not in his room. A search of the facility was immediately initiated. A census was conducted with all residents accounted for on 4/28/2022 at 0645 [6:45 a.m.]. b. On 4/28/2022, the DON [Director of Nursing] supervised the completion of a new elopement risk assessment for the resident. c. On 4/28/2022, the resident was sent to the emergency room for evaluation with no negative findings. d. On 4/28/2022, the DON supervised the review and update of the resident care plan. e. On 4/28/2022, the Maintenance Supervisor changed the mag lock code immediately and ordered additional alarm mechanisms. f. On 4/28/2022, staff interviewed on duty and collected statement. g. On 4/28/2022, the Maintenance Supervisor verified doors worked mechanically on all exterior doors . (Communication Company) was contacted to ensure all doors are in proper working order .the Maintenance Supervisor verified door alarms worked appropriately on all exterior doors. h. On 4/28/2022, the DON supervised the review of elopement risk assessments for all residents and updated Elopement Binder. i. On 4/28/2022, Administrator supervised the re-education of staff on elopement policy and procedures. j. On 4/28/2022, Administrator supervised the re-education of staff on behavior management by a behavior management company. k. On 4/28/2022, the Administrator completed an Ad Hoc QAPI [Quality Assurance Performance Improvement]. l. Administrator/designee will complete elopement drills using a monitoring log every shift X [times] 1; then 1 shift daily X 5, then 3x week x7 weeks or until compliance is achieved, making corrections as needed, and notifying administrator of negative findings. m. Maintenance Supervisor/Designee will check door and windows daily to ensure door and windows are in working order every shift x1; then 1 shift daily x5, then 3x week x7 weeks or until compliance is achieved, making corrections as needed, and notifying administrator of negative findings. n. Abuse, neglect, elopement, rounds and reporting any mechanical failure in-services were conducted .key alarms have been ordered for all outside exit doors .Care plan updated as appropriated .Family, [local] Police Department and medical Director were notified at the start of this investigation . [Resident #1] was transferred to another facility .

Complaint # (AR 757) was substantiated, all or in part, with these findings: Based on observation, record review, and interview the facility failed to ensure interventions were in place to help prevent elopement for 1 (Resident #1) of 2 (Resident #1 and #2) sampled residents who had interventions in place for elopement. This failed practice resulted in Past Immediate Jeopardy for 1 Resident who left the building unattended on 10/30/20 and had the potential to affect 7 residents who are at risk for elopement based on list provided by Administrator on 11/04/20 at 11:35 a.m. The Administrator was notified of the past Immediate Jeopardy on 11/05/20 at 12:05 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Medicare 5 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/20 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and ambulates freely on his own. a. The Plan of Care dated 08/26/20 documented, .attempting to leave facility without a responsible escort (elopement) . On 11/4/2020 at 1:40 PM, there was no documentation in the care plan reflecting monitoring for elopement risk after his return from Psych stays 10/02/20 and 10/28/20, or interventions or prevention measures after his return to the facility. b. The Elopement Risk Assessment form dated 8/26/2020 documented the resident scored 13 (A score of 10 or higher is at risk), according to facility elopement risk evaluation. c. A Nurse Progress Note dated 09/16/20 at 1:20 pm documented, . Resident followed housekeeper out of men's unit. When redirected back in he began hitting exit door with the back of his hand and his cane . d. A Nurse Progress Note dated 09/16/20 at 1:49 pm documented, . he stated, if he did not get out of here soon, he was going to do something. And he stated this is not a threat it is a promise . e. A Nurse Progress Note dated 09/16/20 at 3:15 pm documented, . Resident continues to have agitation with staff and continues to attempt to leave facility. f. A Nurses Progress Note dated 09/16/20 at 4:00 pm, .resident left facility for (behavioral hospital). g. A Nurse Progress Note dated 10/07/20 at 12:14 pm documented, . resident began hitting the door to the locked men's unit demanding to be let out . h. A Nurses Progress Note dated 10/07/20 at 5:17 pm documented, .placed one on one for safety. Sent to (geri-psyche unit) unit at 07:20pm . i. A Nurses Progress Note dated 10/28/20 at 03:15 pm documented, .resident to agitated attempting to pull plastic divider walls down in hallway (yellow zone of COVID unit) . j. A Nurses Progress Note dated 10/29/20 at 06:01 pm documented, .was reported by CNA (Certified Nursing Assistant) resident was up all night going into other residents' rooms and taking things that don't belong to him. Was hard to redirect. k. A Nurses Progress Note dated 10/31/20 at 05:48 am documented, . Police call us at 12:15 am and asked us if we were missing a patient because they found a [AGE] year old male , After immediate search we found out that resident had broken his bedroom window glass and had crawled out of his room and off the facility grounds . l. The Office of Long Care (OLTC) Incident and Accident Report Division of Medical Services (DMS) form 7734 Submitted to Office of Long-Term Care (OLTC) dated 11/01/20 at 11:00 AM documented, . Date and time of incident 10/31/20 at 12:15 am. Type of incident . Elopement . Name of Involved Resident (Resident #1). (Police department) stated an (ride sharing service) driver called them at 11:48 pm stating he picked up this resident on street (name), which is the street next to the facility, on the south side. As the (ride sharing service) driver was driving, he figured there was something not right with passenger, so he pulled over at pharmacy and called the . police. (The police) received that call at 11:48 (p.m.). It is suspected, resident eloped by breaking out his window with the back of the commode lid. The screws that prevented window from being raised, were still intact. Resident was last seen by Licensed Practical Nurse (LPN) at 11:40 pm when he administered Tylenol to this resident. m. OLTC witness statement form dated 10/31/20 at 12:15 am Licensed Practical Nurse #1. Stated. I received a call from . police department that they had found a [AGE] year-old white male with long hair and a gray beard and wanted to know if we were missing anyone. We did an immediate check and found the resident was gone and had eloped by breaking the window in his room. I had last seen him around 11:40 pm when I gave him Tylenol for general pain. He was lying in bed at the time and he was stable. n. An Office of Long Term Care (OLTC) witness statement form dated 10/31/20 at 12:16 am documented, The resident has walked up to me and asked if we could have some pain medicine at 11:30 (p.m. 10/30/2020). I notified the nurse, and the nurse brought him his medicine, and that was the last time I had seen the resident before he escaped. o. An OLTC witness statement dated 10/31/20 at 12:15 am written by (CNA) documented, I gave the hall to the 3rd shift he was in his room [ROOM NUMBER]:20 (p.m.). p. On 11/04/20 at 10:05 am, Licensed Practical Nurse #3 was asked, Has the resident ever told you that he wanted to leave? She stated, No. Not me. LPN #3 was asked, Have you heard that he has said it? She stated, I have heard it. q. On 11/04/20 at 10:15 am, Certified Nursing Assistant (CNA) #1 was asked, Has the resident ever told you that he wanted to leave? She stated, No. CNA #1 was asked, Have you heard that he has said it? She stated, Yes. r. On 11/04/20 at 1:40 P.M., the Director of Nursing (DON) was asked, What room was the resident in when he eloped? She stated, He was in the men's unit last room on the right (room [ROOM NUMBER]). The DON was asked, How many staff were on the hall? She stated, Its night shift, 1 CNA. The DON was asked, Has the resident ever spoken about leaving? She stated, No. In fact I was taking resident back to their rooms on the unit that day and he held the door open for me. The DON was asked, What was the resident wearing? She stated, I am not sure. The DON was asked, What interventions were in place before elopement to prevent elopement? She stated, We had locks on windows, CNA back there, and frequent rounds. The DON was asked, Was there any written monitoring before resident eloped? She stated, No. The DON was asked, How did he get out of the fenced area? She stated, We're not sure, the lock was off the gate. The DON was asked, Was resident an elopement risk when he admitted ? She stated, I'm not sure. The DON was asked, What interventions were in place to keep resident from eloping? She stated, I'm not sure I will have to look. s. On 11/04/20 at 12:10 am., Licensed Practical Nurse (LPN) #1 was asked, What room was the resident in when he eloped? He stated, He was in the last room on the right by the back door. LPN #1 was asked, How many staff were on the hall? He stated, There was a CNA, he was sitting in a chair on the other end of the hall. There were plastic sheets up to divide the unit at that time. He didn't hear anything. LPN #1 was asked, Is that CNA here tonight? He stated, No. LPN #1 was asked, Has the resident ever spoken about leaving? He stated, He has made attempts to get off the hall. LPN #1 was asked, What was the resident wearing? He stated, When I gave him his Tylenol he had on his clothes. LPN #1 was asked, What interventions were in place before elopement to prevent elopement? He stated, It's a unit, CNA is on the unit and the doors are locked. LPN #1 was asked, Are the resident's doors always shut at night? He stated, Yes. That's the way they like it. LPN #1 was asked, Was there any written monitoring before resident eloped? He stated, Not before he eloped. LPN #1 was asked, How did he get out of the fenced area? He stated, I really don't know, he had a plan and he executed it. LPN #1 was asked, How did he get out? He stated, He broke out his window and he left. LPN #1 was asked, When did you realize he was gone? He stated, When the police called and ask if we were missing a resident. We did room searches and found the broken window and he was gone. LPN #1 was asked, Do you remember what time it was? He stated, Not exactly it was after midnight. t. On 11/04/20 at 12:40 am, Licensed Practical Nurse #2 was asked, Were you here the night that the resident eloped? She stated, Yes. LPN #2 was asked, How did you know he was gone? She stated, I was the one that answered the phone when the police called and asked if we were missing a resident. LPN #2 was asked, What did you do? She stated, We started a room to room search and they found the broken window and the resident missing. LPN #2 was asked, Do you know where the resident was found? She stated, No. The police did not say. They just said they were taking him to (hospital) for evaluation. LPN #2 was asked, How did the resident get out of fenced area? She stated, I'm not sure but the pad lock was missing off the gate. LPN #2 was asked, So, the gate was open? She stated, Well yes, we looked for the pad lock but couldn't find it. u. On 11/05/20 at 08:50 am, the Maintenance man was asked, Can you measure the window the resident crawled out of? The measurements were approximately 11 inches tall and 27 inches wide. The glass was replaced, and alarms were on windows. We went outside to see fenced area. The wooden fence is approximately 5 foot 5 inches tall. There was a combination lock on the gate. The The maintenance man was asked, Who knows the combination? He stated, The staff in case of emergency. The Maintenance man was asked, Was the lock on the gate the night the resident eloped? He stated, We never found the lock. v. On 11/05/20 at 09:00 am, The Director of Nursing was asked, Did you find any interventions that were put in place for the resident? She stated, When he was admitted he was an elopement risk that is why he was placed on the unit. On the behaviors that occurred in September we had him to (geri-psyche facility) within three hours. I think that's pretty good. The DON was asked, What did you change to prevent this from happing again, example more activities, one on one time, anything? The DON did not answer. The DON was asked, On 10/28/20 resident returned from Geri Psych were any interventions put in place to help with his behaviors or exit seeking? She stated, I did not do anything. He was pleasant to me. I had no knowledge of his previous behaviors I have been the Director of Nursing only since October 13th (2020). The DON was asked, Were you the Assistant before becoming Director? She stated, Yes. But I had a baby and was off. w. On 11/05/20 at 10:00 a.m., the Administrator was asked, Have you been aware of resident's behavior? She stated, Yes. That is why he was admitted . The Administrator was asked, In September (2020) he was exit seeking and aggressive he was sent to psych facility, when he returned do you know of any interventions that were put into place to help him adjust? She stated, I think activities. The Administrator was asked, In October (2020) on the 7th he became physically aggressive and tried to leave, he was sent to (geri-psyche facility). What interventions or changes did the facility make to help prevent another occurrence? She stated, I don't know. I will have to look we talk about it, but I don't know. The Administrator was asked, On the 28th of October he returned, what interventions did you put in place? She stated, I don't know. I will have to see the care plan. The Administrator was asked, Was your Social Services person involved in his behavior management? She stated, We discuss his behavior I will have to check. x. On 11/05/20 at 10:35 am., the Social Service was asked, How are you involved in the resident behavioral management? She stated, I communicate with them. Social Services was asked, What have you offered this resident to distract him from his behaviors and exit seeking? She stated, I did a phone visit with his wife. Social Services was asked, Did that help calm him down? She stated, Yes. Social Services was asked, How often did you do that? She stated, Once. Social Services was asked, Did you ever ask him why he was acting out? She stated, No. 2. The facility removed the immediate jeopardy and corrected the failed practices on 11/2/2020, prior to the survey, as evidenced by the following: a. The resident was transferred to a geri-psyche unit on 10/31/2020. b. On November 2, 2020, the facility placed motion alarms on the windows in the mens' unit. c. On November 2, 2020, on return from the hospital the resident was placed one on one until he was discharged to psych facility on November 4, 2020. d. A combination lock was placed on the gate. e. An elopement assessment was completed on all residents who resided on the secure unit.

Based on observation, interview and record review, the facility failed to ensure measures were taken to protect a resident after the first attempt of suicide and failed to ensure monitoring was in place to keep a resident with [MEDICAL CONDITION] safe after the return to the facility for 1 (Resident #57) of 2 (Residents #57 and #176) sampled residents. This failed practice resulted in Immediate Jeopardy for Resident #57. The Administrator was notified of the Immediate Jeopardy on 9/17/20 at 5:25 pm for the facility not putting interventions in place after the resident's first suicide attempt on 6/29/20 and for not implementing safety measures after the resident's return on 8/14/20. This failed practice had the potential to affect 3 total residents in the facility with [MEDICAL CONDITION], based on a list provided by the Administrator on 9/17/20 at 7:40 pm. The findings are: 1. Resident #57 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 6/24/20 documented the resident scored 11 (8-12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status and required extensive assistance with all ADL (activity of daily living) tasks. a. The Care Plan dated 10/13/16 documented, has a history of [MEDICAL CONDITION] . There was no documentation on the care plan reflecting the resident's hospitalization on [DATE] and return on 8/14/20, monitoring for [MEDICAL CONDITION], or prevention measures after his return to the facility. b. A Nurse's Progress Note dated 6/29/20 at 14:35 pm documented . Staff notified this nurse that resident attempted to strangle himself twice with his call light stating that he 'didn't want to live' anymore. Upon assessment no redness noted to neck. No pain observed. Resident was immediately placed on 1:1 with CNA (Certified Nursing Assistant). APN (Advanced Practice Nurse) in facility and aware. Referral to send out to behavior health. Call back message left for (name of relative). Resident resting in bed, with staff at bedside. No pain or discomfort noted at this time. Will continue to observe . c. A Nurse's Progress Note dated 6/29/20 at (4:06 p.m.) documented .Referral sent to (Health Facility #1) (Health Facility #2) and (Health Facility #3) for psych eval (evaluation) related to [MEDICAL CONDITION]. Health Facility #1 and #2 denied and Health Facility #3 does not have any beds available . And on 6/30/20 at 10:47 a.m., .Followed up with (Health Facility #3). No beds available. Referral sent to (Health Facility #4) . And at (4:17 p.m.) .Resident has been accepted to (Health Facility #4) in (City). Family aware and in agreement. Emergency Medical Transport here picking up resident now . d. The hospital discharge summary dated 8/14/20 documented, .He had attempted suicide by wrapping the call cord around his neck at (Nursing Facility). He has attempted suicide on several occasions before this one . e. A Nurse's Progress Note dated 8/14/20 at (4:45 p.m.) documented .Admit to facility with hs (history) of [MEDICAL CONDITION] and Dementia. VS (vital signs) are WNL (within normal limits). Arrived per stretcher per mobile transport Able to express needs to staff. Requires assist for all ADL's. Alert to self only and has periods of delusions . f. On 9/16/20 at 3:15 pm, the Administrator was asked, (after this surveyor had requested the [MEDICATION NAME] from 6/15/20 to current and could not find one for this incident), for the Incident and Accident report, to which she replied, We don't have one. When asked why there wasn't one (based on the information in the above entry) she replied, He didn't actually wrap it around his neck, he just threatened it. So, we put him one-on-one and started working on getting him sent out. I called the Nurse Consultant who said an Incident and Accident report wasn't needed. She was asked to provide a copy of the one-on-one documentation. At 3:41 pm she provided a copy of the 1 on 1 which documented the resident's constant observation began at 2:00 pm and continued until 4:00 pm the following day. g. On 9/17/20 at 2:45 pm, Licensed Practical Nurse (LPN) #4, was asked to recall the events of 6/29/20 and she replied, He wasn't actually my resident that day, but the aide came and got me and said that she found the resident with the call light cord wrapped around his neck and she had removed it from his neck. I went immediately to his room and assessed him, he didn't have any red marks on his neck, he seemed fine, and nothing was out of the ordinary. I immediately put him one-on-one with an aide and notified the APN, and the resident's family member. h. On 9/17/20 at 3:10 pm, CNA #4, was asked to recall the events of 6/29/20, and she replied, . (CNA #5) told me she had found him with the cord around his neck and put the call light cord further down in his bed were she thought he wouldn't be able to reach it, and told his nurse, but we were concerned about him so we started checking on him about every 10-15 minutes. It was about 30 or 45 minutes later I went into his room and found him with the cord wrapped around his neck. I removed the cord and put it up on the top of the wall light and grabbed the first nurse that I seen and told her. Then the resident was put one-on-one from then on. She was asked how the cord was on his neck and she stated, It was all the way around his neck, but not tight. She was asked, Did you notice any marks on his neck and she said No, there weren't any red marks on his neck. i. On 9/17/20 at 4:15 pm, the Administrator was asked what has been done to prevent any further suicide attempts and she replied, I'd have to look at his care plan. He's getting his meds as ordered, and he hasn't made any further attempts of suicide since he returned to the facility. She was asked, Does he have a call light in his room right now and she replied, I believe so, I got a tag once for a resident not having a call light. 2. Copies of Job Descriptions for the Administrator and the Director of Nursing (DON) were provided on 9/18/20 at 9:00 am. The Administrator's job description documented, .Demonstrates ability to identify and respond appropriately to potential behavioral outbursts . a. The DON's job description documented, .Reviews all Accidents and Incidents (A/I) daily and develops an appropriate plan to prevent future accidents and incidents. Conducts periodic reviews of documentation for inconsistencies on each unit .Conducts periodic reviews of Care Plans to ensure they are interdisciplinary and updated by the Charge Nurse daily as changes occur . 3. The Plan of Removal was submitted; the scope was reduced to level E and was accepted at 7:44 pm on 9/17/20 with the following documentations: 1.) The Maintenance Director applied pipe foam to resident's call light complete by 9/17/20. 2.) Resident's plan of care was updated to reflect resident's history of [MEDICAL CONDITION] with current interventions in place to include: 1. Pipe insulation foam to resident's call light. 2. Report any [MEDICAL CONDITION] to charge nurse, DON, and administrator immediately after resident is safe. 3.) Nurse to report to MD/DON/administrator if resident refuses medication. 4.) Resident to be 1:1 (one on one) if any [MEDICAL CONDITION] present. Complete by 9/17/20 5.) Staff will be in serviced before their next shift begins on reporting any [MEDICAL CONDITION] to the charge nurse, DON and/or administrator immediately after ensuring residents safety Complete by 9/21/20. 6.) All licensed Nurses will be in serviced prior to their next shift, that when they are informed of an incident they immediately go and assess the resident. 7.) All residents with [MEDICAL CONDITION] [DIAGNOSES REDACTED]. 8.) Facility will create a post in-service test on how to handle [MEDICAL CONDITION] to ensure staff retained the training/knowledge received during in-service of [MEDICAL CONDITION]. Complete by 10/17/20. 9.) DON/Designee will review nurses notes for the last 5 months to ensure incident and Accident report was generated on any occurrences Complete by 9/21/20. 10.) Administrator/Designee will review all current resident records from the past 90 days to ensure any [MEDICAL CONDITION] was addressed appropriately and Plan of care was updated. Complete by 9/25/20.

Based on observation, interview and record review, the facility failed to implement administrative guidance, monitoring, and follow-up to protect a resident after the first attempt of suicide and failed to ensure monitoring was in place to keep the resident with [MEDICAL CONDITION] safe after the return to the facility for 1 (Resident #57) of 2 (Residents #57 and #176) sampled residents who had [MEDICAL CONDITION]. This failed practice resulted in immediate jeopardy for Resident #57. The Administrator was notified of the Immediate Jeopardy on 9/17/20 at 5:25 pm for the facility not putting interventions in place after the resident's first suicide attempt on 6/29/30 and for not implementing safety measures after the resident's return on 8/14/20. This failed practice had the potential to effect 3 total residents in the facility with [MEDICAL CONDITION], based on a list provided by the Administrator on 9/17/20 at 7:40 pm. The findings are: 1. Copies of Job Descriptions for the Administrator and the Director of Nursing (DON), were provided on 9/18/20 at 9:00 am. The Administrator's job description documented, .Demonstrates ability to identify and respond appropriately to potential behavioral outbursts . The DON's job description documented, .Reviews all Accidents and Incidents (A/I) daily and develops an appropriate plan to prevent future accidents and incidents. Conducts periodic reviews of documentation for inconsistencies on each unit .Conducts periodic reviews of Care Plans to ensure they are interdisciplinary and updated by the Charge Nurse daily as changes occur . 2. Resident #57 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 6/24/20 documented the resident scored 11 (8-12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status and required extensive assistance with all ADL (activity of daily living) tasks. a. The Care Plan dated 10/13/16 documented, has a history of [MEDICAL CONDITION] . There was no documentation on the care plan reflecting the resident's hospitalization on [DATE] and return on 8/14/20, monitoring for [MEDICAL CONDITION], or prevention measures after his return to the facility. b. The hospital discharge summary dated 8/14/20 documented, .He had attempted suicide by wrapping the call cord around his neck at (Nursing Facility). He has attempted suicide on several occasions before this one . c. A Nurse's Progress Note dated 6/29/20 at 14:35 pm documented . Staff notified this nurse that resident attempted to strangle himself twice with his call light stating that he 'didn't want to live' anymore. Upon assessment no redness noted to neck. No pain observed. Resident was immediately placed on 1:1 with CNA (Certified Nursing Assistant). APN (Advanced Practice Nurse) in facility and aware. Referral to send out to behavior health. Call back message left for (name of relative). Resident resting in bed, with staff at bedside. No pain or discomfort noted at this time. Will continue to observe . d. A Nurse's Progress Note dated 6/29/20 at 16:06 documented .Referral sent to (Health Facility #1) (Health Facility #2) and (Health Facility #3) for psych eval (evaluation) related to [MEDICAL CONDITION]. Health Facility #1 and #2 denied and Health Facility #3 does not have any beds available . And on 6/30/20 at 10:47 a.m., .Followed up with (Health Facility #3). No beds available. Referral sent to (Health Facility #4) . And at 16:17 .Resident has been accepted to (Health Facility #4) in (City). Family aware and in agreement. Emergency Medical Transport here picking up resident now . e. On 8/14/20 at 16:45 a Nurse's Progress Note documented .Admit to facility with hs (history) of [MEDICAL CONDITION] and Dementia. VS (vital signs) are WNL (within normal limits). Arrived per stretcher per mobile transport Able to express needs to staff. Requires assist for all ADL's. Alert to self only and has periods of delusions . f. On 9/16/20 at 3:15 pm, the Administrator was asked, (after this surveyor had requested the [MEDICATION NAME] from 6/15/20 to current and could not find one for this incident), for the Incident and Accident report, to which she replied, We don't have one. When asked why there wasn't one (based on the information in the above entry) she replied, He didn't actually wrap it around his neck, he just threatened it. So, we put him one-on-one and started working on getting him sent out. I called the Nurse Consultant who said an Incident and Accident report wasn't needed. She was asked to provide a copy of the one-on-one documentation. At 3:41 pm she provided a copy of the 1 on 1 which documented the resident's constant observation began at 2:00 pm and continued until 4:00 pm the following day. g. On 9/17/20 at 2:45 pm, Licensed Practical Nurse (LPN) #4, was asked to recall the events of 6/29/20 and she replied, He wasn't actually my resident that day, but the aide came and got me and said that she found the resident with the call light cord wrapped around his neck and she had removed it from his neck. I went immediately to his room and assessed him, he didn't have any red marks on his neck, he seemed fine, and nothing was out of the ordinary. I immediately put him one-on-one with an aide and notified the APN, and the resident's family member. h. On 9/17/20 at 3:10 pm, CNA #4, was asked to recall the events of 6/29/20, and she replied, . (CNA #5) told me she had found him with the cord around his neck and put the call light cord further down in his bed were she thought he wouldn't be able to reach it, and told his nurse, but we were concerned about him so we started checking on him about every 10-15 minutes. It was about 30 or 45 minutes later I went into his room and found him with the cord wrapped around his neck. I removed the cord and put it up on the top of the wall light and grabbed the first nurse that I seen and told her. Then the resident was put one-on-one from then on. She was asked how the cord was on his neck and she stated, It was all the way around his neck, but not tight. She was asked, Did you notice any marks on his neck and she said No, there weren't any red marks on his neck. i. On 9/17/20 at 4:15 pm, the Administrator was asked what has been done to prevent any further suicide attempts and she replied, I'd have to look at his care plan. He's getting his meds as ordered, and he hasn't made any further attempts of suicide since he returned to the facility. She was asked, Does he have a call light in his room right now and she replied, I believe so, I got a tag once for a resident not having a call light. 3. The Plan of Removal was submitted; the scope was reduced to level E and was accepted at 7:44 pm on 9/17/20 with the following documentations: 1. The Maintenance Director applied pipe foam to resident's call light complete by 9/17/20. 2. Resident's plan of care was updated to reflect resident's history of [MEDICAL CONDITION] with current interventions in place to include: 1. Pipe insulation foam to resident's call light. 2. Report any [MEDICAL CONDITION] to charge nurse, DON, and administrator immediately after resident is safe. 3. Nurse to report to MD/DON/administrator if resident refuses medication. 4. Resident to be 1:1 (one on one) if any [MEDICAL CONDITION] present. Complete by 9/17/20 5. Staff will be in services before their next shift begins on reporting any [MEDICAL CONDITION] to the charge nurse, DON and/or administrator immediately after ensuring residents safety Complete by 9/21/20. 6. All licensed Nurses will be in serviced prior to their next shift, that when they are informed of an incident they immediately go and assess the resident. 7. All residents with [MEDICAL CONDITION] [DIAGNOSES REDACTED]. 8. Facility will create a post in-service test on how to handle [MEDICAL CONDITION] to ensure staff retained the training/knowledge received during in-service of [MEDICAL CONDITION]. Complete by 10/17/20. 9. DON/Designee will review nurses notes for the last 5 months to ensure incident and Accident report was generated on any occurrences Complete by 9/21/20. 10. Administrator/Designee will review all current resident records from the past 90 days to ensure any [MEDICAL CONDITION] was addressed appropriately and Plan of care was updated. Complete by 9/25/20.

Complaint # (AR 848) was substantiated, all or in part, with these findings. Based on observation, record review, and interview, the facility failed to ensure adequate supervision and monitoring was provided and the facility's wander alert system was maintained in proper working order and routinely inspected / tested for functioning in accordance with the manufacturer's instructions to prevent elopement for 1 (Resident #1) of 3 (Residents #1, #2 and #3) case mix residents who resided in the general population area of the facility (not in a secure unit), wore Wanderguard ankle bracelets and were at risk for elopement / wandering. The failed practices resulted in Immediate Jeopardy, which caused or was likely to cause serious harm, injury or death to Resident #1, who eloped and wandered away from the facility, fell outside, was picked up by a good Samaritan who contacted the police and was subsequently transported to the hospital. The failed practice had the potential to cause more than minimal harm to 3 residents who resided in the general population area of the facility, wore Wanderguard bracelets and were at risk for elopement, as documented on a list provided by the Administrator on 11/25/19. The Administrator was informed of the Immediate Jeopardy on 11/25/19 at 5:05 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 9/13/19 documented the resident scored 11 (8-12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status (BIMS), was independent for bed mobility, transfer and walking in room, required supervision only with walking in corridor and locomotion on and off the unit and had no documented wandering behavior. a. physician's orders [REDACTED].Apply wanderguard to right ankle. Nurse is to check placement Q (every) shift . Nurse to check functioning of wander guard daily. every day shift . b. The Plan of Care dated 10/24/18 documented, .The resident is an elopement wanderer and history of 'door checking' .Distract resident from wandering by offering pleasant diversions, structured activities . Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate . WANDERGUARD to (R) (right) ankle. Nurse to check placement every shift. RNA (Restorative Nursing Assistant) to check function of Wanderguard QD (every day) . c. Nursing Notes dated 10/24/18 through 12/20/18 documented the following: 10/24/18 . This nurse observed resident checking and pushing on doors on front hall. Order received to apply Wanderguard. Wanderguard applied to right ankle. Placement to be checked every shift by nurse, RNA to check function of wanderguard QD . 11/16/2018 . Describe Behavior/Mood: Resident is wandering. What was the resident doing prior to or at the time of behavior/mood: Resident was in the dining room looking for her bathroom. Interventions attempted: Redirected. Effectiveness of the interventions: Effective . Resident is alert and oriented to self. She is calm, pleasant, and cooperative. Confused at times as to where her room is . Ambulates self with a steady gait . 11/20/2018 . Resident noted to be wandering. This is not unusual for resident. She continues to wander and ask where her room is. She is easily redirected with no issues . 12/20/2018 . Resident is alert and oriented to self only with a BIMS score of 7 (0-7 indicates severe impairment). She believes the month to be 'the 6th month' and the year to be 2014. Her memory and cognition are severely impaired . d. The Police Incident Report dated 11/17/19 documented, .Incident Date/Time: 11/17/2019 5:26:30 PM . (Resident #1) told me she was a 23 y/o (year old), month was September, and advised she had just arrived in (town) via a bus from Massachusetts. (Resident #1) was wearing what appeared to be medical type socks, what appeared to be a gray medical-type monitor on her right ankle. (Resident #1) advised her head did not hurt but stated she did have scratches on her right arm from the fall and indicated it still hurt (Good Samaritan) advised she observed (Resident #1) fall on the curb as if her leg gave out at an unknown location on S (South) Dixieland Road, south of the intersection with W (West) Walnut Street. (Good Samaritan) offered to give (Resident #1) a ride home and noticed (Resident #1) did not know where to go . At this point (Good Samaritan) pulled over at call location and contacted PD (police department) . 11/17/2019 17:58 (5:58 p.m.) . Called (Facility) to let them know that female was being transported to (Hospital) . Note: the intersection referenced in the Police Incident Report was checked via Google maps and was located 0.9 miles from the facility. Per the Police Report, the resident did not travel all the way to the referenced intersection before falling and being picked up by the good Samaritan. e. The Hospital Record dated 11/17/19 documented, .11/17/2019 18:17:11 (6:17 p.m.) . Pt seen at Cypress and Walnut. Bystanders witnessed patient trip and fall. Abrasion to right elbow with pain. Also complains about pain in right foot. Ankle bracelet to right foot. Pt appears confused. Unknown baseline mentation . Impression and Plan Fall . Elbow contusion . Radiology results: Interpretation: No fracture or dislocation seen in the elbow . Condition: Stable. Disposition: Medically cleared. discharged : Time 11/17/2019 19:20 (7:20 p.m.) to home . f. The 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 11/18/19 documented, .Date and Time of Incident (if known): 11/17/2019 Time: 5:30 PM . Date and Time of Discovery: 11/17/2019 Time 5:57 PM . Date Incident Reported to OLTC (Office of Long-Term Care): 11/18/2019 Time: 4:29 PM . (Resident #1) . dementia patient exited the facility at approximately 5:15 p.m. The resident has a habit of wandering the facility looking for her 'group'. Pleasantly confused, resident is friendly, social, and perpetually remarks she has 'lost her group'. Sunday, (MONTH) 17, 2019, was active with a large family and activities turn out in the facility. (Licensed Practical Nurse (LPN) #1) witnessed resident at table playing cards at approximately 5:05 p.m. as they waited on supper meal service. The time was 5:27 p.m. when (Good Samaritan) reported to the police she had offered resident a ride when she had seen her stumble while walking on Dixieland Road. Resident reports to police she has been on an outing. Police notified facility. Facility notified family member, DON (Director of Nursing), Administrator, & (and) physician. Police transported resident to (Hospital) for further evaluation to confirm no adverse medical outcomes. Resident transported back to facility via (transport) at 8:30 p.m. Resident states when returned to facility 'A lady held the door open for me and then a lady gave me a ride in her car.' Resident cannot remember the make or model of the car, or descriptive of the lady . Resident placed on one-to-one with q (every) 1-minute visual checks noted throughout the remainder of the night and remains on one-to-one status now. Head to toe body audit reveals a scratch on arm toward right elbow, a red area where strap to wanderguard had rubbed leg, and a bruised right great toe. Skin audits will remain in effect once a day for the next 72 hours to ensure any still developing bruises or presently unremarkable areas don't appear. The resident's wanderguard which remained intact on right ankle was tested for function and repositioned to prevent further chaffing to leg. Staff immediately re-educated to facility elopement protocol and procedure with elopement drill preformed. Plan of removal for problem identified was formulated and initiated. Care Plans were initiated to alert present and future staff to tendency of resident to seek 'group'. One to one staff noted all activities to identify any previously uncharted exit seeking behaviors. The findings are submitted Q (every) shift to nurses for documentation. Alarm volume was adjusted to be more audible at the exit/entrances. Keypad changed to prevent any unauthorized user from keying in override if known. Education performed with competency test for remainder of staff. Elopement drills performed until each shift had participation. Visitor education shared with family members and visitor guest sign in/out book placed prominently at front entrance with new elopement warning signs and resident sign out instructions. Resident council educated to new systematic changes to enhance safety for all residents. Follow up by social services with resident's family was given to see if the option of seeking placement for family member was desirable and the family denied the need for different placement. Closed circuit monitoring cameras ordered for exit and entrances of the facility . g. The Elopement Drill Form dated 11/17/19 documented, .Shift: 3rd .1. Did Exit door alarm appropriately? Yes, but not loud enough . Comments/Further education provided alarm not loud enough had to ultimately tell staff to watch door. This form was signed by the Director of Nursing (DON). h. The facility's corrective action plan dated 11/18/19 documented the following: 1.) Head to toe body audit. Assess resident for presence of wander guard. Reassess elopement risk. Daily head to toe assessment x (times) 72 hours. 2.) Document 1:1 (one-on-one) . Assess all residents for wander guard presence. Reassess all resident elopement risk. Re-assess wander guard functioning of door by maintenance . Verify notice at door to not allow residents out . Witness statement from all alert and oriented residents. Witness statement from staff working in all departments that shift. Recode door immediately using month/year. Change over ride code so only maintenance and administrator have code. Clarify wander guard functioning on E-Mar (electronic Medication Administration Record) for nurses. 3). Inservice staff on elopement policy with competency test. Complete elopement drill on all three shifts (ensure that staff immediately respond to alarm). Educate scheduled visitors, like church groups/beautician, etc. (et cetera) on elopement potential of residents and alarm at door. Recode door monthly to month/year by maintenance .Immediacy to be removed by completion of the Plan of Removal tasks herein listed by 11/18/2019. Systemic changes to include close circuit monitoring to enhance effectiveness of wander guards at the exits and entrances. 4). Elopement drill documented on in-service sheet to be completed by staff 1 x (time) week x 8 weeks, making corrections as necessary and notifying Administrator of negative findings. 5). Administrator will present negative findings to QAPI (Quality Assurance Performance Improvement) committee for review and additional recommendations. The facility provided documentation to the surveyor of the in-service, 1:1 monitoring, witness statements and elopement drills, as per their corrective action plan. i. The Elopement Drill Forms documented the following: 11/19/19 . Shift: (First) . Comments / Further education provided key pad alarm goes off loudly. Maglock (alarm) is fairly quiet . This form was signed by the Administrator. 11/19/19 . Shift: (Second) . CNA (Certified Nursing Assistant) responded to alarm by left bldg (building) . Comments/Further education provided extremely impressed the CNA responded in 7 seconds as the door was sounding quietly . This form was signed by the Administrator. 11/23/19 . Shift: (First) . 1. Did exit door alarm appropriately? Low sounds if push against door . This form was signed by the Administrator. 11/24/19 . Shift: (Third) . Comments/Further education provided Aid shut off alarm w/o (without) looking outside failed to hear in back . This form was not signed by the Administrator. j. A typed page dated 11/25/19 documented, .The three exit doors on the back hallway are not releasing. It appears that this is a setting issue which we will call our alarm company to evaluate. The doors are unlock and the mag lock is holding them shut. This page was signed by the Administrator. k. The Sigma Sentinel User Manual, provided by the Director of Nursing (DON) on 11/25/19 documented, .The actions the Sigma Sentinel Unit takes when detecting a resident depends on the configured Selective Mode Reaction. If configured as 'All', the Sigma Sentinel will arm the door for all residents detected. If configured as 'Specific', the Sigma Sentinel Unit will arm the door for only those residents whose flags are cleared in their records. If the locking function was chosen, the door will lock during the armed period. If the door is open when the Sigma Sentinel Unit arms the door, an alarm will locally sound. If an optional Nurse Station Unit is networked, the alarm will also sound there . l. On 11/25/19 at 12:20 p.m., the front doors were checked with the DON present. The doors would alarm and open when pushing on the door handle for approximately 15 to 20 seconds. The audible alarm was loud and was disarmed by keying in specific numbers at the Sigma Gard keypad to the left of the door. m. On 11/25/19 from 12:25 p.m. to 12:30 p.m., the North and South doors on A Hall were checked with the DON present. The doors did alarm after pushing on the handle for approximately 15 to 20 seconds. The alarm was audible in the hallway and could only be disarmed by keying in specific numbers at the Sigma Gard keypad to the left of each door. n. On 11/25/19 at 12:31 p.m., the smoke break door (Employees Only) across from the kitchen was checked with the DON present. The door did not alarm when pushed on but was locked. The DON was able to open by keying in specific numbers at the Sigma Gard keypad to the left of the door. The door did not latch properly but was held or secured by a magnetic device at the top of the door. The courtyard was enclosed by a worn wooden fence. The gate to the fence was latched but with no lock. o. On 11/25/19 from 12:37 p.m. to 12:52 p.m., the doors on B Hall were checked with the DON present. The North Hall door on B Hall had no push handle but had a doorknob to turn. The door would not open unless specific numbers were pressed on the Sigma Gard keypad to the left of the door. The North Hall door had no Wanderguard device or antenna on or around the door to detect Wanderguard bracelets. The Short Hall door on B Hall would not open unless specific numbers were pressed on the Sigma Gard keypad to the left of the door. The Short Hall door on B Hall had no push handle but had a doorknob. The Short Hall door on B Hall did not have a Wanderguard device or antenna on or around the door. The South Hall door on B Hall had a doorknob and would not open unless specific numbers were pressed on the Sigma Gard keypad to the left of the door. The South Hall door on B Hall did not have a Wanderguard device or antenna on or around the door to detect residents with Wanderguard bracelets. p. On 11/25/19 at 1:08 p.m., CNA #1 was asked how many residents wore Wanderguard bracelets and stated, We have 4 Wanderguard bracelets. No, actually just 3 residents' with Wanderguard bracelets. CNA #1 was asked how she tested the Wanderguard bracelets to ensure they were working properly. CNA #1 stated, I test them every day. We got this gadget here, a tester (Sigma Transmitter Tester). We put it against the bracelets and if a red light comes on it means the bracelets are working. CNA #1 was asked if she went to the doors with the residents who wore Wanderguard bracelets and tested the door alarms with the Wanderguard bracelets. CNA #1 stated, No, I don't go to the doors and test the bracelets. CNA #1 was asked who tested the Wanderguard bracelets on the weekends and stated, The weekend supervisor does it on the weekends. q. On 11/25/19 at 1:48 p.m., the DON was asked which door Resident #1 exited on 11/17/19 and stated, We don't know for sure, but we think she went out the front door. (Resident #1) told me that somebody let her out the front door. (Resident #1) was not an elopement risk. She did wander and would always ask where her room was at and she always wants to know where her group is at. We have not had any other elopements that I know of. We discovered we had a flawed system when we were doing Elopement Drills. We would take the Wanderguards. I had one in my pocket. We would set off the alarms but failed to hear them in the back. Although the alarms did work, not everybody could hear them. We did increase the volume and sounders were ordered. We did witness statements with every employee that worked that night, and no one witnessed her going out. We did witness statements with cognitively intact residents and no residents witnessed (Resident #1) leaving the building. We did have a lot of visitors that weekend on Sunday (11/17/19). We had 2 church groups in here that day. We had a lot of families here that are normally not here. We do have signs posted on the doors. We now have a podium at the front doors for visitors and guests to sign in and sign out. The DON was asked if anybody worked in the front offices on A Hall on weekends. The DON stated, No, but we have staff coming in and out of the front doors during the weekend. They would not let (Resident #1) out. The DON was asked if the facility had somebody come out from the security company to check the door and Wanderguard alarms. The DON stated, No, we had our Maintenance Manager look at it. We do have a Service Technician out here now. r. On 11/25/19 at 2:16 p.m., Registered Nurse (RN) #1 was asked if she used the Sigma Transmitter Tester to ensure the Wanderguard bracelets were working properly. RN #1 stated, I have never seen that device before. I wouldn't even know where it is located. RN #1 was asked if she checked the residents with Wanderguard bracelets on the weekends? RN #1 stated, I usually just bring them up to the front door and check their Wanderguard bracelets to make sure they are working. RN #1 was asked if she checked residents with the Wanderguard bracelets on the weekend of 11/23/19 and 11/24/19 and stated, I didn't check them last weekend. It slipped my mind. I did check them the weekend before. We take a walk. We usually go to the smoking door and the front doors. s. On 11/25/19 at 2:21 p.m., the front door Wanderguard system was checked with Resident #1 approximately 10 feet from the front doors. Resident #1 did have her Wanderguard bracelet on her right ankle. The DON was present. The Sigma Gard keypad did have a red-light indicator light come on when Resident #1 was approximately 10 feet from the door. The doors were able to open when the handle was pushed on for approximately 15-20 seconds. The keypad audible alarm was loud and detectable and had to be reset at the keypad. The Wanderguard alarm did have an audible alarm when Resident #1 exited the left door. The Wanderguard alarm was only detectable in the front entryway of the A Hall. t. On 11/25/19 from 2:28 p.m. to 2:35 p.m., the North Hall and South Hall doors on A Hall were checked with Resident #1 and the DON present. The Sigma Gard keypad did have a red-light indicator light come on when Resident #1 was approximately 10 feet in front of the door. The Wanderguard system did not alarm until the resident walked out the door and was outside of the door. The Wanderguard alarm was audible outside of the doorway but was very faint and definitely not detectable at the front entrance of the building. u. On 11/25/19 at 2:36 p.m., the Employee Smoking Area door was checked with Resident #1 and the DON present. The Wanderguard System did not alarm when Resident #1 was approximately 10 feet from the door and a red indicator light was not visible on the Sigma Gard keypad to the left of the door. The Wanderguard system did not alarm when the resident exited the door or when standing outside in the Employee Smoking Area. v. On 11/25/19 at 4:04 p.m., the Maintenance Manager was asked what the Sigma Transmitter Tester does. He stated, It tests to make sure the battery is not dead and that the transmitter (bracelet) is not damaged. I don't test them; someone else does. The Maintenance Manager was asked how long he had worked at the facility. He stated, I have been here since (MONTH) 2019. I have not had any previous long-term care experience. The Maintenance Manager was asked if he had any training on the Wanderguard Alarm Systems and stated, I have been trained on the mag locks but not on the Wanderguard System. Not until after this incident when someone got out. The Maintenance Manager was asked if the alarms on the Wanderguard systems were working correctly and stated, I know the system worked at the keypad. You cannot get out the back doors unless you use the keypads. The back door (North B Hall) does not have an antenna or transmitter for the Wanderguard System. It was not picking up. The antenna was not picking up the transmission from the bracelet. It was not picking up any Wanderguards by the break room (North B Hall). I know the audible alarm was not very loud and you couldn't hear it in the back. w. On 11/25/19 at 5:00 p.m., the Field Technician was asked about the Wanderguard alarms and if they were functioning properly. The Field Technician stated, I am adjusting the settings on all the doors. It has more to do with the settings. I haven't dealt with this manufacturer. The Wanderguard system should always be programmed to alarm when the patient exits. The system has one single master override. The codes get shared a lot. The egress or sentinel alarm has a 30 second delay before you will get an audible alarm. A patient could have went out the right door in the front and the Wanderguard alarm might not have alarmed. I did reset those settings. This alarm system does have a Loiter Alarm. A 10-foot potential count down timer. The Wanderguard system will beep at some time. You will have two audible beeps happening at the same time. x. The immediate jeopardy was removed, and the scope/severity reduced to [NAME] on 11/25/19 at 7:00 p.m. when the facility implemented the following plan of removal: 1. (Facility) will monitor the front doors, beginning on 11-25-2019 at 7:00 PM, until Sounders are installed on the Dyna Lock Mag Locks on Wednesday, 11-27-2019. 2. Certified Technician is examining all doors to ensure they are functioning properly. 3. Maintenance Director will test all doors with residents who are wearing Wanderguards daily for two weeks and then weekly. This will be done by the Maintenance Director taking all residents with Wanderguards to each of the doors these residents have access to, testing the Wanderguards at each door. 4. Inservice Maintenance Director and Restorative Nurse Aide on testing procedure and monitoring tools. 5. Elopement Risk Assessment to be done Q (every) shift all residents with Wanderguards x 2 weeks, then continue daily for 6 months, then resume quarterly scheduled nursing monitoring with UDAs (user-defined assessments).

Complaint # (AR 924) was substantiated, all or in part, with these findings. Based on record review, and interview, the facility failed to ensure a resident with a history of intracranial injury received the necessary care and services as evidenced by failure to ensure the licensed nurse in charge of the resident's care at the time of the fall called for emergency transport in lieu of non-emergent transport to prevent a delay in treatment after the resident, who was on anticoagulant therapy, was found in the floor with a bleeding laceration to the head; failure to ensure a thorough assessment was conducted prior to placing the resident back in bed and that the assessment findings were documented, failure to ensure ongoing neurological assessments (neuro checks) were conducted by qualified nursing staff until the resident was transferred to the hospital to facilitate prompt identification of any neurological changes that could indicate possible [MEDICAL CONDITION]; and, failure to ensure accurate information regarding the resident's coagulation status was communicated to hospital staff to ensure they were aware of the resident's increased bleeding risk for 1 (Resident #4) of 6 (Residents #1 through #6) case mix residents who had a history of [REDACTED].#4, who experienced an unwitnessed fall and sustained a head injury with subdural hematoma that resulted in a 14-day hospital stay. These failed practices also had the potential to cause more than minimal harm to 73 residents who were assessed by the facility as being at risk for falls, according to the Midnight Census Report provided by the Administrator on 1/24/18. The Administrator was informed of the Past Immediate Jeopardy condition on 1/24/18 at 2:49 p.m. The findings are: 1. A facility policy titled Neurological Assessments, received from the Director of Nursing via fax on 2/6/18 documented, .Neurological assessments are performed to evaluate a resident's nervous system including brain function . Early detection of an injury or underlying condition provides the best chance of decreasing long-term complications . Neurological assessments will be completed by a licensed nurse . To assess level of consciousness for a traumatic or potentially traumatic injury to the head . To assess neurological status after an un-witnessed fall . Neurological assessments will be completed as follows . every 15 minutes (times) first hour . every 30 minutes (times) 2 hours . every hour (times) 2 hours . every 8 hour shift (times) 72 hours . Then as primary healthcare provider orders . The licensed nurse will complete the Neurological Assessment Flowsheet for data collection . 2. Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Discharge Return Anticipated Minimum Data Set with an Assessment Reference Date of 1/7/18 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, required extensive assistance with bed mobility and transfer, received antidepressant, hypnotic, and anticoagulant medications on 3 out of the last 7 days, and had 1 fall with major injury since admission or prior assessment. a. A physician's orders [REDACTED].[MEDICATION NAME] Sodium Solution 40 mg (milligrams) per 0.4 ml (milliliters) . Inject 1 dose subcutaneously one time a day . b. The Plan of Care dated 1/3/18 documented, .Resident is at risk for falls R/T (related to) Dx (diagnosis) of TBI ([MEDICAL CONDITION]) . Date Initiated . 1/3/2018 . Assess for s/s (signs / symptoms) of agitation .Resident is on anticoagulant therapy . administer anticoagulant medications as ordered by physician . monitor for side effects and effectiveness every shift . The resident's Closet Care Plan (not dated) documented, .Fall Interventions . Fall mat at bedside . c. A Resident Incident and Accident Report form dated 1/7/18 documented, .Time: 03:56 (3:56 a.m.) . Incident Description . Res. (Resident) was found on the floor by staff, lying face down toward (the) end of bed. Cognitively impaired due to past head injury . peg (percutaneous endoscopic gastrostomy) tube intact . Immediate Action Taken . Description . Neuros (neurological checks) started, VS (vital signs) 152/98 (blood pressure), 78 (pulse), 22 (respirations), 98.2 A (axillary temperature) 98 % (percent) (oxygen saturation level), Assessed condition and placed in bed. Notified (Physician #1) DON (Director of Nursing) and family (Name). Called ambulance, report given to ambulance and called report to (Hospital #1) hospital. Dressing applied to laceration . No assessment findings were documented, other than vital signs, oxygen saturation and the condition of the PEG tube. d. The Fall Description Details Form dated 1/7/18 documented, .Time of Fall . 0245 (2:45 a.m.) . Staff / Witness present at / or finding resident after fall . (Certified Nursing Assistant (CNA) #1) . Factors observed at time of fall . Bed height not appropriate . e. An Office of Long Term Care (OLTC) Witness Statement Form dated 1/7/18 and signed by Registered Nurse (RN) #1 documented, .CNAs notified me (Resident #4) was on the floor. Res (Resident) was lying face down. Found laceration and bump to L (left) side of head. Staff assisted res (Resident) to bed. Blood on floor was red and wet. CNAs had been checking on res (Resident). I noticed his brief was dry. I did a peg tube feeding (at) 0000 (12:00 a.m.). I had been doing freq (frequent) room checks on res q (every) 30 min (minutes) to 1 hr (hour). Res had gotten [MEDICATION NAME](hypnotic medication) (at) 2000 (8:00 p.m.) . called ambulance and was told it would be apx. (approximately) 45 min. (minutes). Cleaned wound, applied drsg (dressing). Staff stayed with res until ambulance arrived . f. An OLTC Witness Statement Form dated 1/7/18 and signed by CNA #2 documented, .During rounds the night of Jan. (January) 6 to Jan. 7 (11:00 p.m. to 7:00 a.m. shift) around 3:30 a.m., (CNA #1) and I were doing our rounds on South Hall. As we began to start our rounds on North Hall, we started with (Resident #4) and found him on the floor. He (Resident #4) was face down and his entire body was at the footboard of his bed. His feet were also touching the closet. There was blood in the floor by his head. (CNA #1) and I noticed the (resident's) bed was raised to about shoulder height of us. (CNA #1) then goes on to ask (RN #1), our nurse, if she left the bed raised when she went in to do his (the resident's) feeding. She replied, 'Oh I must have forgotten'. (CNA #1) and I then gown up with Iso (isolation) precautions and walk into the room with (Resident #4). (CNA #1) and I asked our nurse, (RN #1), what she wanted us to do. So, she wanted us to pick him up and put him back on the bed, and get his vitals and she would call EMS (emergency medical services). (RN #1) asked me to stay in the room with (Resident #4) until EMS arrived. (CNA #1) started neuro (neurological) checks and I done (sic) them every 15 mins (minutes). I asked the nurse what was taking so long for the ambulance, and she said that it wasn't that emergent, so they called transport, not 911. As I stood there by (Resident #4's) side, my leg was getting wet and I noticed that the nurse had spilled tube feeding all over his bed and floor. She also never even told (CNA #1) or myself about it so we could go in immediately to clean him up . g. An OLTC Witness Statement Form dated 1/7/18 and signed by CNA #1 documented, .During rounds, (CNA #2) and I was (sic) doing our rounds on South Hall. When we went to start the rounds on North, (CNA #2) and I looked in on (Resident #4) face first on the floor. His head was at the end of the footboard, his feet was (sic) touching the closet. (Resident #4's) bed was raised up to about shoulder length (height) with me. So, the bed was about 4 1/2 ft (feet) high. There was tube feeding all over the floor and mattress. Before I entered the room, I asked my nurse, (RN #1), if she left the bed raised. She replied, 'Oh, I must've forgotten.' (CNA #2) and I gowned up and went to make sure the resident was ok (okay) and stable. Once (RN #1), myself and (CNA #2) carefully transferred him onto his bed, (CNA #2) got his vital signs as I went to get the neuro (neurological check) sheet. (RN #1) called for an EMT (emergency medical transport). Until the EMT arrived, (CNA #2) stayed with (Resident #4) doing (every) 15 minute vitals. The nurse asked me to write witness statement . h. A Neurological Assessment Form dated 1/7/18 documented, .Time . 2:45 (a.m.) .B/P (blood pressure) . 152/98 . Pulse . 78 . Respiration . 22 . Temperature . 98.2 A (axillary) . Initials . (CNA #1) . The neurological assessment information was documented by a CNA, rather than a licensed nurse, and no other neurological assessment information, such as level of consciousness; pupil size, shape, reaction to light and accommodation; facial symmetry (presence or absence of facial drooping); hand grips; extremity strength, et cetera (etc.), was documented on the form. There were no further entries on the form to indicate ongoing assessments of the resident's neurological status were conducted until the transport service arrived at the bedside at 3:30 a.m. (45 minutes after the initial, incomplete neurological assessment was documented. i. The Hospital #1 Medical Transfer Form dated 1/7/18 documented, .Received .0246 (2:46 a.m.) . Dispatched . 0248 (2:48 a.m.) . Enroute . 0250 (2:50 a.m.) . On Scene . 0326 (3:26 a.m.) . At Patient . 0330 (3:30 a.m.) . Depart Scene . 0337 (3:37 a.m.) . Arrive Hospital . 0345 (3:45 a.m.) . Medical Dx (diagnoses) . Intracranial inj (injury) (with) L(NAME) (loss of consciousness) . [MEDICAL CONDITIONS] .[MEDICAL CONDITION](hypertension) . Chr (chronic) Hep C ([MEDICAL CONDITION]) . Agitation . (and) restlessness . The Nursing Home to Hospital Transfer form dated 1/7/18 and signed by RN #1 did not document the resident's use of anticoagulation medications. The section titled, Risk Alerts listed anticoagulation as one of the possible risk alerts, but this was not checked to indicate the resident was receiving anticoagulation therapy. The items that were checked under the Risk Alert section were, .Falls . Aspiration . [MEDICAL CONDITION] . j. The Hospital #1 Patient Registration Form dated 1/7/18 documented, .admitted / Time . 1/7/18 . 03:47 (3:47 a.m.) .Diagnosis . 1: fall head lac (laceration) .Rationale . he (Resident) presented after a fall at the nursing facility . Laceration was irrigated and closed at bedside. Head CT (computed tomography) shows a left parafalcine hemorrhage, with maximum thickness of 7 (to) 8 millimeters extending from the left frontal to left parietal region. He also has a left frontal subdural hematoma with maximum thickness of 1 cm (centimeter). There is no midline shift . 5:49 a.m.Initially we were told that he was not on anticoagulants, but the nursing facility now informed us that he does receive [MEDICATION NAME] injections daily . I discussed this case with (Hospital #2 Physician) at (Hospital #2). (Hospital #2) has accepted the patient transfer, given that we do not have neurosurgical coverage at our facility this weekend . k. The Hospital #2 History and Physical Report dated 1/7/18 documented, .Result Date . January 7, 2018 . 16:05 (4:05 p.m.) . Apparently, he (Resident) was at a skilled nursing facility at (location) when got out of bed and had a fall and hit his head. He was apparently taken to an outside hospital. The patient was seen at (Hospital #1) in (City). He had imaging of the brain that apparently revealed a subdural. He had a repeat CT done here at (Hospital #2) that shows an acute left frontal subdural measuring 7 (to) 8 mm (millimeters) in thickness. Evidence of his previous craniotomies also noted . Result Date . January 12, 2018 (at) 14:29 (2:29 p.m.). Preoperative Diagnosis . Acquired Post Traumatic [DIAGNOSES REDACTED] . Procedure . 1. Ventricular peritoneal shunt . 2. Diagnostic laparoscopy . The Hospital #2 Final Report / Discharge Summary dated 1/21/18, documented the resident was discharged back to the facility on [DATE], 14 days after the incident. l. On 1/23/18 at 4:20 p.m., RN #1 was asked about Resident #4's fall on 1/7/18. RN #1 stated, I took care of him for two days. The first night, he just laid there. The second night, he was more alert and fighting. I went to wash my hands, totally was distracted, his bed was higher than I normally did. I had 3 feeding tube patients that night. I was standing by the nursing station, and one of the CNAs came out and said, 'Did you leave his bed up?', and I said, 'Yes, I did.' She said, 'He has fallen and is laying (sic) face down.' Three of us went in there. He (the resident) was down at the foot of the bed on his stomach. The right side of his head had a laceration on his right temple. He was on [MEDICATION NAME] (anticoagnulant medication). We shipped him right out. I was told by the hospital staff that they had sent him to another hospital. They didn't treat neurological issues at (Hospital #1). The RN was asked if the resident's bed should have been placed in a lower position before leaving the room and stated, Common sense said it (the bed height) should have been lowered. I should have had the bed lowered. I always raise the bed because of my back. The first night I did lower the bed back. The RN was asked to describe how she and the CNAs responded to the resident's incident and injury and stated, We slowly turned him around. I looked at his injuries. He was hard to assess. We had to get him up into the bed. We lifted him into bed, he was very thin. He had bolus feedings, he was not continuous. I told one of the CNAs to stay with him, she was in panic mode. I put a bandage on him. I assessed him, he was restless in the bed. We lifted his whole body into the bed. The RN was asked if an assessment was conducted prior to moving the resident off of the floor and into the bed and stated, I did an assessment on the floor and in bed. I did vital signs. They (the CNAs) started neuro checks. The RN was asked what was included in the assessment she conducted while the resident was on the floor and stated, I made sure he could bend when he was on the floor, his extremities. He could not answer any questions due to his neurological condition. He wasn't talking, wasn't groaning. He was moving more the second night, he was moving on the floor. m. On 1/23/18 at 5:50 p.m., CNA #1 was asked about Resident #4's fall on 1/7/18. The CNA stated, (CNA #2) quit. She works at (another facility). We were doing our rounds. We had gowned up. We noticed right away that the bed was in a high position. (CNA #2) asked (RN #1) if she left the bed up, and she said, 'Oh, my goodness. I must have forgot'. He (the resident) was on the floor; he was bed bound. It was strange where he was at. He was on his belly, face down, he was at the end of his foot board. I know his bed was all the way up when we started rounds. The CNA was asked if the resident was at risk for falls and stated, He was a fall risk, because (RN #2) told me. She is very specific when we start our shift. He did have a fall mat - it was not by his bed - it may have been underneath his bed. The CNA was asked to describe the staff response to the resident's incident and injury and stated, (RN #1) came in and looked at him. I put my hand under his head. You could tell he had hit the side of his head. The CNA was asked if the resident was bleeding and stated, Yes, he was bleeding. The CNA was asked approximately what time the resident was initially discovered to have fallen on the floor and stated, It was like 1:30 a.m.; you could tell she (RN #1) had just got done with him. (CNA #2) stayed with him in the room. (CNA #2) stayed in the room for 30 minutes, at least. He was moaning, really badly. He looked like he was in pain. It sounded like he was in a lot of pain. I got down in front of him. He moaned more when I put my hand under his head. (RN #1) just stood there. We asked her if she wanted us to put him back in the bed. The CNA was asked if the RN assessed the resident prior to having the CNAs pick him up off of the floor and stated, (CNA #2) and I were the only ones that got on the floor. (RN #1) did not touch him when I was in the room. The CNA was asked if the RN assessed the resident when he was back in bed and stated, I'm not sure, once I helped him transfer to the bed. (RN #1) had walked out before I had left. The CNA was asked how the resident was transferred back to bed and stated, I grabbed him underneath his arms and (CNA #2) grabbed him around his knees. He was not very mobile. He was completely naked. His hospital gown was by his bed. We did lower his bed. I have only worked weekends 3 to 4 times. I did incontinent care with him, and he was like dead weight. n. On 1/24/18 at 11:10 a.m., Licensed Practical Nurse (LPN) #1 was asked if Resident #4 was a fall risk. LPN #1 stated, I worked with him a short period of time. He was alert, but very confused, fidgety, and restless. The LPN was asked if the resident had ever attempted to climb out of bed, prior to the incident, and stated, He did attempt to get out of bed once. He tried to stand up, he sat up right in bed. I redirected him and he just laid back down. The LPN was asked about providing care with the bed elevated and stated, I raised his bed and lowered it back down (when care was completed). He was a fall risk. The LPN was asked if staff were aware that the resident was at risk for falls and stated, Yes, because I put it in his care plan to lower his bed after care. The LPN was asked if the resident had a fall mat in place and stated, I don't think there was a fall mat in there. o. On 1/24/18 at 11:28 a.m., CNA #3 was asked if Resident #4 was a fall risk. CNA #3 stated, I worked with (Resident #4) a couple of days. His bed was always lowered, or in its lowest position, at all times. The CNA was asked if the resident moved around or attempted to climb out of bed and stated, Yes, at times he was moving around in bed. The nurse (RN #1) knew. He did have a fall mat. One time, he was trying to get out of bed. We got him up in a high-back wheelchair. p. On 1/24/18 at 11:37 a.m., CNA #4 was asked if Resident #4 was a fall risk. CNA #4 stated that on one occasion, (Resident #4) was sitting on the side of the bed. He had pulled his call light out of the wall. His bed was in the lowest position. I don't believe he had a fall mat. He was a fall risk. He wanted changed, he said he was wet. Maybe, I asked him if he was wet. q. On 1/24/18 at 1:42 p.m., RN #2 was asked about Resident #4's fall on 1/7/18. RN #2 stated, I didn't read a care plan. I keep all of my residents safe. Some of the beds don't go as low as the others. He was not mine; there were 3 (staff members) in his room when I first became aware (of the incident). I handed (RN #1) a bandage from the doorway. (Resident #4) was in isolation, no need for me to go in there. I called (Medical Transport Company). I did not see the area on his head. I saw him moving around on the floor making noises and trying to get up. I was just trying to assist her. (RN #1) was not in there (the resident's room) terribly long. I did see that they got him up out of the floor and into bed. The RN was asked if it was appropriate to move the resident when there was an apparent head injury and the resident was groaning and / or exhibiting other signs of pain. The RN stated, Anytime a resident is in pain, I would not get (them) up. I don't touch them. The RN was asked about the height of the resident's bed at the time of the incident and stated, The bed was in a high position; I did see that. I know (RN #1) told me that next time, she would need assistance when feeding (Resident #4). I know when she came out of his room (after the incident), she went down the hall and lowered the beds of her two other tube feeding residents. r. The facility removed the immediate jeopardy and corrected the failed practices on 1/8/18, prior to the survey, as evidenced by the following: 1.) An In-service Education Report dated 1/8/18 documented, .Topic(s) . Resident in (Resident #4's Room Number) is to be returned to lowest position after care has been provided . Fall mat at bedside . The in-service sign-in sheet was signed by 22 staff members. 2.) A facility Action Plan dated 1/8/18 documented, .Supervisor Signature . (Director of Nursing (DON)) . Date . 1/8/18 . Issue .1. Neuro (neurological) checks not being completed by licensed nurse per policy . Goal to be obtained . 1. Neuro checks to be completed by licensed nurse as per policy . Plan of Action (POA) . 1. In-service with staff that neuro checks are to be performed by licensed nurse as per policy . 2. Monitoring neuro checks are done as per policy 5 (times) (per) week (times) 2 weeks . 1/8/18 . In-service began . Issue . 1. Residents' beds not being kept in a low position when occupied per resident . Goal to be obtained . 1. Beds to be in low position when occupied per residents as resident will allow . Plan of Action . 1. In-service staff to keep beds in low / safe position when occupied per resident . 2. Monitor beds are in low position when occupied per residents 5 (times) (per) wk (week) (times) 2 weeks . Issue . 1. Residents with apparent head injury not sent out timely . Goal to be Obtained . 1. All residents with apparent / suspected injury to be sent out (to hospital) timely . Plan of Action . 1. In-service staff to send residents out with apparent suspected injury timely via 911 (emergency transport) . 2. Monitor residents requiring emergent transfer are sent out timely 5 (times per) week (times) 2 weeks . 3.) On 1/23/18 at 9:31 a.m., the Administrator was asked if Registered Nurse (RN) #1 was still employed at facility. The Administrator stated, She does not work here anymore. Some CNAs had made some statements about the (resident's) bed being left up in a high position and she (RN #1) would not come in. The DON texted her to come in and she texted back, 'Are you going to fire me?' She never did come in. (Resident #4) had fallen and they had moved him back to bed. The DON had called (RN #1) and asked her why the CNAs had moved (Resident #4) when having a head injury. (RN #1) self-terminated by not coming in. 4.) On 1/24/18 at 2:06 p.m., the DON was asked about (RN #1). The DON stated, I texted her on 1/8/18 that she needed to come in. She didn't respond. Then, she sent me a text that said, 'Are you going to fire me?' I texted her back that I had some concerns that I wanted to discuss with her and to let me know when available. She texted me back, 'You never answered my question about being fired'. She never came in again. We wanted to talk to her about leaving the bed up. She self-terminated herself, because she never returned to her work. She came in yesterday, because she wanted her check. 5.) On 1/24/18 at 2:30 p.m., the facility's monitoring forms, provided by the DON, documented the following: i.) .Beds in low positions when occupied . This monitoring form documented that rounds were made 5 times weekly by the DON from 1/8/18 to 1/24/18, and ongoing, to randomly check the height of residents' beds on various shifts. There were no negative findings documented in the monitoring. ii.) .Emergent Transfers Timely . This form documented monitoring for any hospital transfers was conducted by the DON 5 times weekly from 1/8/18 to 1/24/18, and ongoing, to ensure any emergent transfers were conducted promptly, with no negative findings. iii.) .Neuros (neurological checks) performed per policy . This monitoring form documented any neurological assessment documentation was audited by the DON 5 times weekly from 1/8/18 to 1/24/18, ongoing, with 1 negative outcome on 1/10/18. The response to the one negative finding was, .Neuros initiated, not completed. Disciplinary (action) (with) staff .

Complaint # (AR 924) was substantiated, all or in part, with these findings. Based on record review, and interview, the facility failed to ensure a resident who had a history of [REDACTED]. lowered the resident's bed to a safe height after providing care and before leaving the resident unattended, and failed, after the resident fell from the elevated bed and sustained an apparent head injury, that the resident was not moved prior to being assessed and stabilized by qualified nursing or emergency medical personnel, to prevent potential exacerbation of existing injuries for 1 (Resident #4) of 6 (Residents #1 through #6) case mix residents who had a history of [REDACTED].#4, who experienced an unwitnessed fall from a bed that had been left at a height of approximately 4.5 feet above the floor, and sustained a laceration to the head and subdural hematoma that resulted in a 14-day hospital stay. These failed practices had the potential to cause more than minimal harm to 73 residents who were assessed by the facility as being at risk for falls, according to the Midnight Census Report provided by the Administrator on 1/24/18. The Administrator was informed of the Past Immediate Jeopardy condition on 1/24/18 at 2:49 p.m. The findings are: 1. Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Discharge Return Anticipated Minimum Data Set with an Assessment Reference Date of 1/7/18 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, required extensive assistance with bed mobility and transfer, received antidepressant, hypnotic, and anticoagulant medications on 3 out of the last 7 days, and had 1 fall with major injury since admission or prior assessment. a. A physician's orders [REDACTED].[MEDICATION NAME] Sodium Solution 40 mg (milligrams) per 0.4 ml (milliliters) .Inject 1 dose subcutaneously one time a day . b. The Plan of Care dated 1/3/18 documented, .Resident is at risk for falls R/T (related to) Dx (diagnosis) of TBI ([MEDICAL CONDITION]) . Date Initiated . 1/3/2018 . Assess for s/s (signs / symptoms) of agitation . Resident is on anticoagulant therapy . administer anticoagulant medications as ordered by physician . monitor for side effects and effectiveness every shift . The resident's Closet Care Plan (not dated) documented, .Fall Interventions . Fall mat at bedside . c. A Resident Incident and Accident Report form dated 1/7/18 documented, .Time: 03:56 (3:56 a.m.) . Incident Description . Res. (Resident) was found on the floor by staff, lying face down toward (the) end of bed. Cognitively impaired due to past head injury . peg (percutaneous endoscopic gastrostomy) tube intact . Immediate Action Taken . Description . Neuros (neurological checks) started, VS (vital signs) 152/98 (blood pressure), 78 (pulse), 22 (respirations), 98.2 A (axillary temperature) 98 % (percent) (oxygen saturation level), Assessed condition and placed in bed. Notified (Physician #1) DON (Director of Nursing) and family (Name). Called ambulance, report given to ambulance and called report to (Hospital #1) hospital. Dressing applied to laceration . No assessment findings were documented, other than vital signs, oxygen saturation and the condition of the PEG tube. d. The Fall Description Details Form dated 1/7/18 documented, .Time of Fall . 0245 (2:45 a.m.) . Staff / Witness present at / or finding resident after fall . (Certified Nursing Assistant (CNA) #1) . Factors observed at time of fall . Bed height not appropriate . e. An Office of Long Term Care (OLTC) Witness Statement Form dated 1/7/18 and signed by Registered Nurse (RN) #1 documented, .CNAs notified me (Resident #4) was on the floor. Res (Resident) was lying face down. Found laceration and bump to L (left) side of head. Staff assisted res (Resident) to bed. Blood on floor was red and wet. CNAs had been checking on res (Resident). I noticed his brief was dry. I did a peg tube feeding (at) 0000 (12:00 a.m.). I had been doing freq (frequent) room checks on res q (every) 30 min (minutes) to 1 hr (hour). Res had gotten [MEDICATION NAME](hypnotic medication) (at) 2000 (8:00 p.m.) . called ambulance and was told it would be apx. (approximately) 45 min. (minutes). Cleaned wound, applied drsg (dressing). Staff stayed with res until ambulance arrived . f. An OLTC Witness Statement Form dated 1/7/18 and signed by CNA #2 documented, .During rounds the night of Jan. (January) 6 to Jan. 7 (11:00 p.m. to 7:00 a.m. shift) around 3:30 a.m., (CNA #1) and I were doing our rounds on South Hall. As we began to start our rounds on North Hall, we started with (Resident #4) and found him on the floor. He (Resident #4) was face down and his entire body was at the footboard of his bed. His feet were also touching the closet. There was blood in the floor by his head. (CNA #1) and I noticed the (resident's) bed was raised to about shoulder height of us. (CNA #1) then goes on to ask (RN #1), our nurse, if she left the bed raised when she went in to do his (the resident's) feeding. She replied, 'Oh I must have forgotten'. (CNA #1) and I then gown up with Iso (isolation) precautions and walk into the room with (Resident #4). (CNA #1) and I asked our nurse, (RN #1), what she wanted us to do. So, she wanted us to pick him up and put him back on the bed, and get his vitals and she would call EMS (emergency medical services). (RN #1) asked me to stay in the room with (Resident #4) until EMS arrived. (CNA #1) started neuro (neurological) checks and I done (sic) them every 15 mins (minutes). I asked the nurse what was taking so long for the ambulance, and she said that it wasn't that emergent, so they called transport, not 911. As I stood there by (Resident #4's) side, my leg was getting wet and I noticed that the nurse had spilled tube feeding all over his bed and floor. She also never even told (CNA #1) or myself about it so we could go in immediately to clean him up . g. An OLTC Witness Statement Form dated 1/7/18 and signed by CNA #1 documented, .During rounds, (CNA #2) and I was (sic) doing our rounds on South Hall. When we went to start the rounds on North, (CNA #2) and I looked in on (Resident #4) face first on the floor. His head was at the end of the footboard, his feet was (sic) touching the closet. (Resident #4's) bed was raised up to about shoulder length (height) with me. So, the bed was about 4 1/2 ft (feet) high. There was tube feeding all over the floor and mattress. Before I entered the room, I asked my nurse, (RN #1), if she left the bed raised. She replied, 'Oh, I must've forgotten.' (CNA #2) and I gowned up and went to make sure the resident was ok (okay) and stable. Once (RN #1), myself and (CNA #2) carefully transferred him onto his bed, (CNA #2) got his vital signs as I went to get the neuro (neurological check) sheet. (RN #1) called for an EMT (emergency medical transport). Until the EMT arrived, (CNA #2) stayed with (Resident #4) doing (every) 15 minute vitals. The nurse asked me to write witness statement . h. A Neurological Assessment Form dated 1/7/18 documented, .Time . 2:45 (a.m.) .B/P (blood pressure) . 152/98 . Pulse . 78 . Respiration . 22 . Temperature . 98.2 A (axillary) . Initials . (CNA #1) . The neurological assessment information was documented by a CNA, rather than a licensed nurse, and did not include a complete description of the resident's neurological status. i. The Hospital #1 Medical Transfer Form dated 1/7/18 documented, .Received .0246 (2:46 a.m.) . Dispatched . 0248 (2:48 a.m.) . Enroute . 0250 (2:50 a.m.) . On Scene . 0326 (3:26 a.m.) . At Patient . 0330 (3:30 a.m.) . Depart Scene . 0337 (3:37 a.m.) . Arrive Hospital . 0345 (3:45 a.m.) . Medical Dx (diagnoses) . Intracranial inj (injury) (with) L(NAME) (loss of consciousness) . [MEDICAL CONDITIONS] .[MEDICAL CONDITION](hypertension) . Chr (chronic) Hep C ([MEDICAL CONDITION]) . Agitation . (and) restlessness . The Nursing Home to Hospital Transfer form dated 1/7/18 and signed by RN #1 did not document the resident's use of anticoagulation medications. The section titled Risk Alerts on the transfer form listed anticoagulation as one of the possible risk alerts, but this was not checked as being applicable to this resident. Other items which were checked in the Risk Alert section were, .Falls . Aspiration . [MEDICAL CONDITION] . j. The Hospital #1 Patient Registration Form dated 1/7/18 documented, .admitted / Time . 1/7/18 . 03:47 (3:47 a.m.) .Diagnosis . 1: fall head lac (laceration) .Rationale . he (Resident) presented after a fall at the nursing facility . Laceration was irrigated and closed at bedside. Head CT (computed tomography) shows a left parafalcine hemorrhage, with maximum thickness of 7 (to) 8 millimeters extending from the left frontal to left parietal region. He also has a left frontal subdural hematoma with maximum thickness of 1 cm (centimeter). There is no midline shift . 5:49 a.m. Initially we were told that he was not on anticoagulants, but the nursing facility now informed us that he does receive [MEDICATION NAME] injections daily . I discussed this case with (Hospital #2 Physician) at (Hospital #2). (Hospital #2) has accepted the patient transfer, given that we do not have neurosurgical coverage at our facility this weekend . k. The Hospital #2 History and Physical Report dated 1/7/18 documented, .Result Date . January 7, 2018 . 16:05 (4:05 p.m.) . Apparently, he (Resident) was at a skilled nursing facility at (location) when got out of bed and had a fall and hit his head. He was apparently taken to an outside hospital. The patient was seen at (Hospital #1) in (City). He had imaging of the brain that apparently revealed a subdural. He had a repeat CT done here at (Hospital #2) that shows an acute left frontal subdural measuring 7 (to) 8 mm (millimeters) in thickness. Evidence of his previous craniotomies also noted . Result Date . January 12, 2018 (at) 14:29 (2:29 p.m.). Preoperative Diagnosis . Acquired Post Traumatic [DIAGNOSES REDACTED] . Procedure . 1. Ventricular peritoneal shunt . 2. Diagnostic laparoscopy . The Hospital #2 Final Report / Discharge Summary dated 1/21/18, documented the resident was discharged back to the facility on [DATE], 14 days after the incident. l. On 1/23/18 at 4:20 p.m., RN #1 was asked about Resident #4's fall on 1/7/18. RN #1 stated, I took care of him for two days. The first night, he just laid there. The second night, he was more alert and fighting. I went to wash my hands, totally was distracted, his bed was higher than I normally did. I had 3 feeding tube patients that night. I was standing by the nursing station, and one of the CNAs came out and said, 'Did you leave his bed up?', and I said, 'Yes, I did.' She said, 'He has fallen and is laying (sic) face down.' Three of us went in there. He (the resident) was down at the foot of the bed on his stomach. The right side of his head had a laceration on his right temple. He was on [MEDICATION NAME] (anticoagnulant medication). We shipped him right out. I was told by the hospital staff that they had sent him to another hospital. They didn't treat neurological issues at (Hospital #1). The RN was asked if the resident's bed should have been placed in a lower position before leaving the room and stated, Common sense said it (the bed height) should have been lowered. I should have had the bed lowered. I always raise the bed because of my back. The first night I did lower the bed back. The RN was asked to describe how she and the CNAs responded to the resident's incident and injury and stated, We slowly turned him around. I looked at his injuries. He was hard to assess. We had to get him up into the bed. We lifted him into bed, he was very thin. He had bolus feedings, he was not continuous. I told one of the CNAs to stay with him, she was in panic mode. I put a bandage on him. I assessed him, he was restless in the bed. We lifted his whole body into the bed. The RN was asked if an assessment was conducted prior to moving the resident off of the floor and into the bed and stated, I did an assessment on the floor and in bed. I did vital signs. They (the CNAs) started neuro checks. The RN was asked what was included in the assessment she conducted while the resident was on the floor and stated, I made sure he could bend when he was on the floor, his extremities. He could not answer any questions due to his neurological condition. He wasn't talking, wasn't groaning. He was moving more the second night, he was moving on the floor. m. On 1/23/18 at 5:50 p.m., CNA #1 was asked about Resident #4's fall on 1/7/18. The CNA stated, (CNA #2) quit. She works at (another facility). We were doing our rounds. We had gowned up. We noticed right away that the bed was in a high position. (CNA #2) asked (RN #1) if she left the bed up, and she said, 'Oh, my goodness. I must have forgot'. He (the resident) was on the floor; he was bed bound. It was strange where he was at. He was on his belly, face down, he was at the end of his foot board. I know his bed was all the way up when we started rounds. The CNA was asked if the resident was at risk for falls and stated, He was a fall risk, because (RN #2) told me. She is very specific when we start our shift. He did have a fall mat - it was not by his bed - it may have been underneath his bed. The CNA was asked to describe the staff response to the resident's incident and injury and stated, (RN #1) came in and looked at him. I put my hand under his head. You could tell he had hit the side of his head. The CNA was asked if the resident was bleeding and stated, Yes, he was bleeding. The CNA was asked approximately what time the resident was initially discovered to have fallen on the floor and stated, It was like 1:30 a.m.; you could tell she (RN #1) had just got done with him. (CNA #2) stayed with him in the room. (CNA #2) stayed in the room for 30 minutes, at least. He was moaning, really badly. He looked like he was in pain. It sounded like he was in a lot of pain. I got down in front of him. He moaned more when I put my hand under his head. (RN #1) just stood there. We asked her if she wanted us to put him back in the bed. The CNA was asked if the RN assessed the resident prior to having the CNAs pick him up off of the floor and stated, (CNA #2) and I were the only ones that got on the floor. (RN #1) did not touch him when I was in the room. The CNA was asked if the RN assessed the resident when he was back in bed and stated, I'm not sure, once I helped him transfer to the bed. (RN #1) had walked out before I had left. The CNA was asked how the resident was transferred back to bed and stated, I grabbed him underneath his arms and (CNA #2) grabbed him around his knees. He was not very mobile. He was completely naked. His hospital gown was by his bed. We did lower his bed. I have only worked weekends 3 to 4 times. I did incontinent care with him, and he was like dead weight. n. On 1/24/18 at 11:10 a.m., Licensed Practical Nurse (LPN) #1 was asked if Resident #4 was a fall risk. LPN #1 stated, I worked with him a short period of time. He was alert, but very confused, fidgety, and restless. The LPN was asked if the resident had ever attempted to climb out of bed, prior to the incident, and stated, He did attempt to get out of bed once. He tried to stand up, he sat up right in bed. I redirected him and he just laid back down. The LPN was asked about providing care with the bed elevated and stated, I raised his bed and lowered it back down (when care was completed). He was a fall risk. The LPN was asked if staff were aware that the resident was at risk for falls and stated, Yes, because I put it in his care plan to lower his bed after care. The LPN was asked if the resident had a fall mat in place and stated, I don't think there was a fall mat in there. o. On 1/24/18 at 11:28 a.m., CNA #3 was asked if Resident #4 was a fall risk. CNA #3 stated, I worked with (Resident #4) a couple of days. His bed was always lowered, or in its lowest position, at all times. The CNA was asked if the resident moved around or attempted to climb out of bed and stated, Yes, at times he was moving around in bed. The nurse (RN #1) knew. He did have a fall mat. One time, he was trying to get out of bed. We got him up in a high-back wheelchair. p. On 1/24/18 at 11:37 a.m., CNA #4 was asked if Resident #4 was a fall risk. CNA #4 stated that on one occasion, (Resident #4) was sitting on the side of the bed. He had pulled his call light out of the wall. His bed was in the lowest position. I don't believe he had a fall mat. He was a fall risk. He wanted changed, he said he was wet. Maybe, I asked him if he was wet. q. On 1/24/18 at 1:42 p.m., RN #2 was asked about Resident #4's fall on 1/7/18. RN #2 stated, I didn't read a care plan. I keep all of my residents safe. Some of the beds don't go as low as the others. He was not mine; there were 3 (staff members) in his room when I first became aware (of the incident). I handed (RN #1) a bandage from the doorway. (Resident #4) was in isolation, no need for me to go in there. I called (Medical Transport Company). I did not see the area on his head. I saw him moving around on the floor making noises and trying to get up. I was just trying to assist her. (RN #1) was not in there (the resident's room) terribly long. I did see that they got him up out of the floor and into bed. The RN was asked if it was appropriate to move the resident when there was an apparent head injury and the resident was groaning and / or exhibiting other signs of pain. The RN stated, Anytime a resident is in pain, I would not get (them) up. I don't touch them. The RN was asked about the height of the resident's bed at the time of the incident and stated, The bed was in a high position; I did see that. I know (RN #1) told me that next time, she would need assistance when feeding (Resident #4). I know when she came out of his room (after the incident), she went down the hall and lowered the beds of her two other tube feeding residents. r. The facility removed the immediate jeopardy and corrected the failed practices on 1/8/18, prior to the survey, as evidenced by the following: 1.) An In-service Education Report dated 1/8/18 documented, .Topic(s) . Resident in (Resident #4's Room Number) is to be returned to lowest position after care has been provided . Fall mat at bedside . The in-service sign-in sheet was signed by 22 staff members. 2.) A facility Action Plan dated 1/8/18 documented, .Supervisor Signature . (Director of Nursing (DON)) . Date . 1/8/18 . Issue .1. Neuro (neurological) checks not being completed by licensed nurse per policy . Goal to be obtained . 1. Neuro checks to be completed by licensed nurse as per policy . Plan of Action (POA) . 1. In-service with staff that neuro checks are to be performed by licensed nurse as per policy . 2. Monitoring neuro checks are done as per policy 5 (times) (per) week (times) 2 weeks . 1/8/18 . In-service began . Issue . 1. Residents' beds not being kept in a low position when occupied per resident . Goal to be obtained . 1. Beds to be in low position when occupied per residents as resident will allow . Plan of Action . 1. In-service staff to keep beds in low / safe position when occupied per resident . 2. Monitor beds are in low position when occupied per residents 5 (times) (per) wk (week) (times) 2 weeks . Issue . 1. Residents with apparent head injury not sent out timely . Goal to be Obtained . 1. All residents with apparent / suspected injury to be sent out (to hospital) timely . Plan of Action . 1. In-service staff to send residents out with apparent suspected injury timely via 911 (emergency transport) . 2. Monitor residents requiring emergent transfer are sent out timely 5 (times per) week (times) 2 weeks . 3.) On 1/23/18 at 9:31 a.m., the Administrator was asked if Registered Nurse (RN) #1 was still employed at facility. The Administrator stated, She does not work here anymore. Some CNAs had made some statements about the (resident's) bed being left up in a high position and she (RN #1) would not come in. The DON texted her to come in and she texted back, 'Are you going to fire me?' She never did come in. (Resident #4) had fallen and they had moved him back to bed. The DON had called (RN #1) and asked her why the CNAs had moved (Resident #4) when having a head injury. (RN #1) self-terminated by not coming in. 4.) On 1/24/18 at 2:06 p.m., the DON was asked about (RN #1). The DON stated, I texted her on 1/8/18 that she needed to come in. She didn't respond. Then, she sent me a text that said, 'Are you going to fire me?' I texted her back that I had some concerns that I wanted to discuss with her and to let me know when available. She texted me back, 'You never answered my question about being fired'. She never came in again. We wanted to talk to her about leaving the bed up. She self-terminated herself, because she never returned to her work. She came in yesterday, because she wanted her check. 5.) On 1/24/18 at 2:30 p.m., the facility's monitoring forms, provided by the DON, documented the following: i.) .Beds in low positions when occupied . This monitoring form documented that rounds were made 5 times weekly by the DON from 1/8/18 to 1/24/18, and ongoing, to randomly check the height of residents' beds on various shifts. There were no negative findings documented in the monitoring. ii.) .Emergent Transfers Timely . This form documented monitoring for any hospital transfers was conducted by the DON 5 times weekly from 1/8/18 to 1/24/18, and ongoing, to ensure any emergent transfers were conducted promptly, with no negative findings. iii.) .Neuros (neurological checks) performed per policy . This monitoring form documented any neurological assessment documentation was audited by the DON 5 times weekly from 1/8/18 to 1/24/18, ongoing, with 1 negative outcome on 1/10/18. The response to the one negative finding was, .Neuros initiated, not completed. Disciplinary (action) (with) staff .

Based on observation, record review and interview, the facility failed to ensure licensed nursing staff provided necessary care and services to address a significant change in medical condition, as evidenced by failure to assess and monitor the condition and oxygen saturation levels of a resident who was newly diagnosed with [REDACTED].#1) of 1 case mix resident who was recently hospitalized . The failed practices resulted in immediate jeopardy, which caused or could have caused serious injury, harm or death for Resident #1, who experienced severe shortness of breath and subsequent respiratory arrest after staff failed to administer the ordered oxygen, and had the potential to cause more than minimal harm to 12 residents with physician orders [REDACTED]. 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 7/14/16 documented the resdient scored 4 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status, was independent with bed mobility, transfers, ambulation, eating and toilet use, required limited assistance or supervision with dressing, hygiene and bathing, was continent of bowel and bladder, had no shortness of breath and did not receive oxygen while a resident, since his last assessment. a. Nurses Note dated 7/31/16 for the 7:00 a.m. to 3:00 p.m. shift documented, .At (approximately) (2:00 p.m.) res (resident) c/o (complained of) SOB (shortness of breath). Resp (respirations) labored. Daughter was here and expressed concern of his SOB and difficulty walking. Res also c/o pain to (right) side of chest. Received N.O. (New Order) for CBC (complete blood count) / BMP (basic metabolic panel) stat (immediately), chest and lung x-ray 2 view stat and PT (Physical Therapy) to eval (evaluate), family in house and aware. Notified (laboratory service provider) for labs (laboratory tests) and onsite imaging for stat xrays. This note was signed by Licensed Practical Nurse (LPN) #2. b. Nurses' Notes dated 7/31/16 at 6:30 p.m. documented, Aides (Certified Nursing Assistants (CNAs)) went to help res (resident) with care after having a BM (bowel movement). When aides went to stand res. up he passed out. They lowered him to the floor and notified this Nurse (LPN #3). Assessment: pale, alert and responsive. Resp. labored and was grunting with each breath. Pulse Ox: 90%. N.O. (new order) Send res. to (Local Hospital) ER (emergency room ) to eval (evaluate) / treat as indicated. Called 911 at approx. 6:40 p.m. Res. left via stretcher. This note was signed by LPN #2. c. The Hospital Discharge Notes dated 8/2/16 documented, Primary Diagnoses: [REDACTED]. Start: [MEDICATION NAME] 40 mg Q (every) Day, KCL (Potassium Chloride)10 meq (milli-equivalents) ER (extended release) Q Day, Oxygen, nasal cannula 2 L (liters) per NC (nasal cannula) if gets SOB (short of breath) with activity and O2 (oxygen) Sat (saturation) less than 90%, Daily weights, 2 Liters Fluid Restriction if he can tolerate this. BMP for Creatinine and K+ (Potassium) 8/5/16. d. Physician order [REDACTED].Dx: (diagnosis) [MEDICAL CONDITION] Exacerbation, [MEDICAL CONDITION] . [MEDICATION NAME] 40 mg (milligrams) 1 po (by mouth) daily. Dx: [MEDICAL CONDITION] . Potassium Chloride 10 meq (milli-equivalents) 1 po daily . Dx: [MEDICAL CONDITION] . Laboratory per facility policy: BMP for [MEDICATION NAME] and Potassium on 8/5/16 . O2 (Oxygen) (at) 2 L/NC (liters per nasal cannula) if SOB (short of breath) (with) Activity or 92 Sat (saturation) (less than) 90% (percent) . 2 Liter Fluid Restriction in 24 (hours) . e. Nurses' Notes dated 8/4/16 at 6:35 a.m. documented, CNA reported Res. appeared to be having difficulty breathing. Res. O2 Sats between 91 -93% at rest. Oncoming LPN notified and this LPN offered assist 7 - 3 (7:00 a.m. to 3:00 p.m. shift) . Started O2. Will cont. (continue) to observe. This note was signed by LPN #3. f. Nurses' Notes dated 8/4/16 (not timed) documented, This a.m. (morning) res. appeared to be having difficulty breathing on previous shift. This Nurse went to assess res. Res. was in bed resting. O2 was at 98% on RA (room air). Res. stated he has difficulty breathing when up, but as long as he is laying down he can breathe pretty good. Res. will need O2 with activity. Res. will move off unit while on O2. This note was signed by LPN #2. g. Nurses' Notes dated 8/4/16 at 8:40 p.m. documented, Resident moved to (C-Hall South) and O2 at 2 L/min (liters per minute) via nasal cannula applied. Resident having some shortness of breath. Will cont. to observe. This note was signed by LPN #4. There was no documentation the resident's oxygen saturation was checked or that a respiratory assessment was conducted at this time. h. Nurses' Notes dated 8/5/16 at 1:20 p.m. documented, Resident alert (without) SOB O2 95% on room air, no chest pain. To bath assist (times) 2 tolerated fair. To bed noted SOB return to 2 Liter O2 per nasal cannula states heaviness of chest. MD (Medical Doctor) notified. N.O. for ER visit, daughter here. This note was signed by the Director of Nursing (DON). On 9/21/16 at 11:05 a.m., the DON reviewed her documentation from 8/5/16 at 1:20 p.m. then stated, I forgot to put a word 'prior' in front of the word to. Should have read resident alert without shortness of breath; O2 95% on room air, no chest pain prior to bath. Assist x (times) 2 tolerated fair. She was asked what assist x 2 tolerated fair meant. She said, he had been changed from assist x 1 to assist x 2. He had tolerated being fed that morning and being transferred. She was asked if she had observed any of this and stated, No. She was then asked what the 1320 time that she documented meant and stated, I can't tell you why I documented 1320; I saw him before stand up around 9:00 a.m. I just wanted to show that I had looked at him earlier and he was fine. It seems he got tired, used up all his oxygen and should have had oxygen on. I probably should have carried it further and went to (LPN #1) and told him to make sure he (Resident #1) had O2 on when he went to the shower. i. Nurses' Notes dated 8/5/16 at 2:20 p.m. documented, N.O. Pt. (Patient) to hospital (at) (2:17 p.m.) to (local hospital) .Pt. family member stated he had chest pain and stated he could not breathe . was SOB, RR (respiratory rate) 26 with O2 at 75%. MD notified to send to ER. Pt. is DNR (Do Not Resuscitate). This note was signed by LPN #1. j. The hospital Emergency Department Report dated 8/5/16 at 2:58 p.m. documented, .Chief Complaint: Loss of Consciousness .Diagnoses: [REDACTED]. HPI (History of Present Illness) comments: .Pt. with decreased responsiveness at the nursing home .Pt daughter was with him all day .daughter reported that when he got back from the shower he was not acting right. She said that the NH (Nursing Home) staff treated her like she did not know what she was talking about and ignored him until he became unresponsive. When they found him unresponsive, they called 911. Upon arrival, he had agonal respirations. His breathing continued to slow and stop. His heart rate slowed and stopped . k. As of 9/20/16, there was no documentation in the Nurses' Notes, or elsewhere in the clinical record, of scheduled or routine monitoring of the resident's oxygen saturation between 8/2/16 - 8/5/16. On 9/21/16 at 11:05 a.m., the DON was asked how often the resident's oxygen saturation should have been checked and stated it should have been monitored at least once per shift. l. On 9/20/16 at 2:30 p.m., LPN #2 was asked if she was aware that Resident #1 required oxygen. She stated, Yes, it all started just shortly before he was hospitalized at the end of July. His daughter was here and brought him back to the unit after an activity out in the general population. He was short of breath. I took his O2 Sat and it was fine, so I thought it must be anxiety and did not think he needed O2. At that time, he did not have an order for [REDACTED]. They lowered him to the floor and called me for help. At that time, I thought this was more than anxiety and had him shipped out to be assessed. When he returned, he required oxygen, especially with any activity. m. On 9/20/16 at 2:40 p.m., the DON was asked if she was familiar with Resident #1 and, if so, what she remembered about the last day he was at the facility, on 8/5/16. She stated, Yes, he was on the Men's Unit. Shortly before his death, he started having some cardiac issues. We got a chest film and lab work. I'm pretty sure we sent him to the hospital before we got results, because he stood up and passed out. He was diagnosed with [REDACTED]. We moved him to the general population on C-Hall (South). Our guidelines for the units are that they only require 1 person assist with ADLs and not require oxygen. He was doing better. He wanted a bath so we got him a bath. He wasn't wearing oxygen, because it was prn (as needed), and he did not have any signs / symptoms of distress. I talked to him that day to see if he was up to a bath and he told me 'yeah', thought it would feel good. I wasn't around during the bath but was called to his room later. He had taken a decline; excessively weak, SOB, chest discomfort. At that time, he had oxygen on, don't remember the liters. We called the Doctor, got orders to transfer. It took less than a half hour before he left with 911. His daughter was here. (Registered Nurse (RN)) #1) and (LPN #1) were working with him that day. He looked extremely pale when I got in there. I documented on his chart after (LPN #1) documented because I wasn't able to get to it until after 5 p.m. that day. I only documented my last observation of him that started at (1:20 p.m.). I did document that the MD was notified and the new order to send to ER, but I wasn't the one that did it. (LPN #1) and (RN #1) did; not sure which one. (RN #1) no longer works here. n. On 9/20/16 at 3:18 p.m., LPN #1 was asked if he was familiar with Resident #1. He stated, I vaguely remember him. After reviewing his Nurses' Notes dated 8/5/16, LPN #1 stated, .I don't remember anything about this situation . I was told by his daughter that he needed checked. He's having trouble breathing. I was at the Nurses' desk near my med (medication) cart when she told me that. He was in a room down the South Hall. I followed her immediately to his room to assess him. He couldn't breathe well. He had O2 on via N/C. His O2 Sat was 75%, don't remember the O2 liters. I went to get my Supervisor, (RN #1), to get a second set of eyes on him. She came immediately. She's the one that had me send him to the hospital. I then called 911; he left at 2:17 p.m From the time his daughter asked me to check on him until the time he left out to the hospital, it was less than 5 minutes. My DON was not present during any of this. o. On 9/20/16 at 3:40 p.m., Resident #1's daughter, who was documented to have been present at the facility on the date of the resident's death, was interviewed via telephone and was asked to describe the events that occurred at the facility on 8/5/16. She stated, I thought he needed a shower because he had a BM and it was everywhere. I told them it would be difficult because he needed his oxygen. The little aide took the oxygen out with them but she walked him down the hall and to the shower without his oxygen. When he got back to his room he had no oxygen on when he returned from the shower. He was fine prior to the shower; I had been there all day. I got there around 11:00 a.m., so I could feed him his lunch. No one came in prior to the shower to check his pulse ox. After the shower he was in such bad shape, he had collapsed on the girl who gave the shower and I was lifting him off of her. She went and got (LPN #1). After he checked my dad he went and got the lady with the red hair. The 20 minutes was from the time he got shower until the red head came into the room. When the paramedics arrived at the facility, my dad was just laying there he was not really breathing. I heard one of them say that his heart was very weak; he was not responsive at all. He was like that 15 - 20 minutes before the Paramedics arrived. I feel bad that I allowed them to walk him to the shower without oxygen. I know one person took him in there and the same person took him out. He was without oxygen the whole time. I told them he would need his oxygen. A blonde woman told me that would be no problem and that they could get him into the shower with his oxygen. So he got his shower without his oxygen and he walked all the way down there and back. And that's when he collapsed. Prior to the shower he was the same as he had been since Sunday. He would get short of breath with any activity. I know my dad was 91 and was recently diagnosed with [REDACTED]. p. On 9/20/16 at 4:44 p.m., CNA #1 was asked if she was familiar with Resident #1. She said, Yes, but I never took care of him. I wasn't aware what happened that day until (CNA #2) told me, when she took him to the shower and back, he became pale and weak. He was sent to the hospital not long after that. I don't know if he had oxygen on or not. q. On 9/20/16 at 5:02 p.m., RN #1, who is no longer employed by the facility, was contacted via telephone and was asked if she was familiar with Resident #1 and the events of 8/5/16. She said, Yes, (LPN #1) motioned for me to come here. I told him just a minute, I'm checking in these stat meds. He then said that his (Resident #1's) daughter was in his room. I then asked him what does she want him to do. He said I don't know. She's in there. I thought it was something she was upset about, so I signed the drugs in real fast and went to his room and he looked like he was already dead; his head was hanging off the pillow. I first repositioned his head. He had O2 on, but the machine (oxygen concentrator) was not running. I tried turning it on, but it would not. I took his O2 sat and it was low. I ran and got another concentrator and hooked him up to oxygen at 2 L per nasal canula; he did not respond. His eyes were open and fixed and he was unresponsive. (LPN #1) was out of the room during this time. He returned right after I got the oxygen going and I told him to go call 911 and tell them that I need them here now; I need them here before now. I told (DON) about (LPN #1) not letting me know the urgency of me coming to assess this man, but I'm not aware if anything was ever done. When asked if she was aware that the resident had a shower just before this episode without his oxygen, the RN stated she was not. r. On 9/21/16 at 10:14 a.m., the hospital emergency room physician, who was on duty on 8/5/16 when the resident was transported to the hospital, was asked if she remembered Resident #1. She stated, I remember talking to the daughter. Him being taken to the shower without his oxygen could have definitely led to his Respiratory Arrest. He did not seem cardiac at all when he arrived. The exertion of walking, and especially without the oxygen, probably led to this event with his recent [DIAGNOSES REDACTED]. s. On 9/21/16 at 1:49 p.m., CNA #2 (who was identified by the facility as the CNA who took the resident to the shower on 8/5/16) was asked if she was familiar with Resident #1. She stated, Yes, his daughter was here. They just moved him from the unit back to the South Hall. She was complaining that he was filty and needed a shower and his clothes changed. I was the one aide that showered him that day. I did not receive any special instructions on how to care for him or anything about his oxygen. He had on oxygen per the machine prior to the shower. I took it off of him right before taking him to the shower because I could not plug it up in the shower. I did not get a portable tank either. I've never taken anyone that is on oxygen to the shower with any form of oxygen. I have at other places, but not here. I walked him to the shower and it wasn't until bout halfway through the shower he started getting short of breath. I finished his shower real quick, walked him back to his room, and he became much more short of breath while walking back. When we got into the room, he tripped on his daughter's purse and toppled onto the bed on top of me. He was gasping for air. His daughter had to help get him off of me and help me get him to bed. He was blue around his lips. At this time, I ran and got a nurse; they got to his room in approximately 1 minute and applied oxygen. I don't remember what happened after that. t. The immediate jeopardy was removed and the scope / severity reduced to G 9/21/16 at 5:19 p.m., when the facility implemented the plan of removal, which documented: Failure to adequately monitor and intervene for serious medical condition . There were no other residents at risk for the same failed practice, by review of current physicians orders. No other residents with orders for O2 with activity . On 9/21/2016 at 4:15 p.m. DON/Designee began assessments on all residents for any change of condition, respiratory symptoms and any new diagnosis. This will be completed by 8 p.m. on 9/21/2016. Any negative findings will be reported to MD immediately. On 9/21/16 at 4:00 pm DON/Designee began obtaining O2 Sats on residents with orders for oxygen. This will be completed by 6 pm on 9/21/16. Any negative findings will be reported to MD immediately. On 9/21/16 at 4:45 pm Respiratory Therapist began asssessments on residents with [DIAGNOSES REDACTED]. This will be completed by 8 pm on 9/21/16. Any negative findings will be immediately reported to MD. In-Service began for all nursing staff on the application of oxygen per physician orders, on 9/21/16 beginning at 3:58 pm and will continue prior to staff starting their next shift until all staff have been in-serviced. Training will be done by DON/Designee. In-Service began to all nursing staff related to responding and assessing any residents change of condition, on 9/21/16 beginning at 3:58 pm and will continue prior to staff starting their next mshift until all staff have been in-serviced. Training will be done by DON/Designee. DON and 2 RN unit managers will review every physician order [REDACTED]. Any negative findings will be immediately addressed and brought to QAA (Quality Assessment and Assurance Committee). Administrator will review every physician order [REDACTED]. Any negative findings will be immediately addressed and brought to QAA.

Complaint # (AR 599) was substantiated (all or in part) in these findings. A. Based on record review and interview, the facility failed to ensure a disinfectant for equipment and non-porous hard medical surfaces was not used as a wound cleanser for 1 (Resident #4) of 6 (Residents #3, #4, #16, #19, #31, and #32) case mix residents who had pressure ulcers. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death for Resident #4 and had the potential to cause more than minimal harm for 7 residents who had pressure ulcers as documented on a list provided by the Administrator on 11/6/14 at 11:45 a.m. On 11/6/14 at 4:40 a.m., the Administrator was informed of the Immediate Jeopardy. The findings are: Resident #4 had [DIAGNOSES REDACTED]. Varicose Veins of Lower Extremities with Ulcer, and Senile Dementia. The Quarterly Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 7/28/14 documented the resident had a problem with short term and long term memory per staff assessment and was moderately impaired for cognitive skills for daily decision making, and had 1 Stage 3 Pressure Ulcer. a. The Care Plan dated 5/1/14 documented, "Resident is at risk for skin breakdown and pressure ulcers r/t (related to) incontinence, Decreased Mobility, Decreased sensation, [MEDICAL CONDITIONS], hx (history) pressure and vascular ulcer... Assess and record changes in skin status. Report pertinent changes to physician...Resident has Stage 3 ulcer (L) (left) heel... Goal: Ulcer will exhibit evidence of healing as indicated on pressure report (decrease in size, improved appearance, absence of drainage, etc.) through next review... Interventions: Administer/monitor effectiveness of/response to treatment(s) as ordered... Assess/record changes in skin status and report changes to physician... Report improvement and decline to MD (Medical Doctor) and family ... Resident to be seen by wound care clinic every two weeks ..." b. On 11/6/14 at 4:10 a.m., Licensed Practical Nurse (LPN) #1 performed wound care to the Resident's left heel and left lower leg. The LPN stated that the resident had gone to the wound clinic Monday and had measurements there. She also stated, "The wound on the lower leg is larger but looks healthier. The wound on the heel is larger and worse." At 4:30 a.m. after completion of the wound, the LPN was asked if she was aware of anyone using something on a wound that was not to be used on wounds. LPN #1 stated, "I did. I wouldn't ever mean any harm to a resident. I used this. (The LPN showed the surveyor a spray bottle of Clorox Brand Hydrogen Peroxide Cleaner Disinfectant for hard surfaces and equipment). " The LPN continued, "(Resident #4) won't let anyone but me and (LPN #2), another LPN that works nights, change his dressing. We were gone about 6 days and his dressing had not been changed for the 6 days. I was trying to find something that would help his wounds. They were draining yellow drainage and looked awful. So, I started using that." The LPN was asked if she was aware the cleaner was not for wounds. She stated, "Yes, but it does not have bleach in it." The LPN was asked if she had gotten physician orders [REDACTED]." The LPN also stated that she thought the wound had gotten better with this treatment and that it had not hurt the resident. She was asked how long she used it on the resident and she stated, "About 2 weeks (10/6/14 - 10/20/14)." She stated that the last time she used it on the resident was the day the resident went to the hospital (10/20/14) and had not used it on any other residents. The LPN was asked if anyone else was aware of her use of the cleaner on Resident #4. She stated, "Yes, the Treatment Nurse." 1) The October 2014 TAR documented, "L medial posterior foot. (Change dressing (every) d (day) (and) PRN. [MEDICATION NAME] (and) Santyl, wet to dry dressing. Kerlix (and) Tape. 10/1/14. L (lower) leg, Change dressing (every) day (and) PRN. [MEDICATION NAME] (and) Santyl wet to dry dressing. Kerlix (and) tape. 10/1/14." LPN #1 initialed 10/9/14, 10/10/14, 10/11/14, 10/15/14, 10/16/14, and 10/19/14 to indicate the treatments to both areas were performed as prescribed by the physician each of these days. The resident went to the hospital on [DATE]. 2) The label on the bottle of disinfectant read: "Kills bacteria [MEDICAL CONDITION] in 30 seconds ...Clorox ... Hydrogen Peroxide, Cleaner Disinfectant ... Compatible with Equipment Surfaces ... Non Bleach ... Keep out of the reach of children ... Directions For Use: It is a violation of Federal law to use the product in a manner inconsistent with its labeling. To operate: To open, Turn nozzle. Spray 6-8 inches from surface. Wipe with cloth. Do not breathe spray or mist. ... Precautionary statements: Hazards to Humans and Domestic Animals. Caution: Causes moderate eye irritation. Avoid contact with eyes or clothing. Wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, chewing tobacco, or using the toilet. First Aid: If in eyes: Hold eye open and rinse slowly and gently with water for 15-20 minutes. Remove contact lenses, if present, after the first 5 minutes, then continue rinsing. Call the poison control center at [PHONE NUMBER] or doctor for treatment advice... This product is not to be used as a terminal sterilant/high level disinfectant on any surface or instrument that (1) is introduced directly into the human body, either into or in contact with the bloodstream, or normally sterile areas of the body, or (2) contact intact mucous membranes, but which does not penetrate the blood barrier or otherwise enter normally sterile areas of the body. ... Disinfection: ... This product cleans, disinfects and deodorizes hard, nonporous medical surfaces in one step with no rinsing required..." 3) On 11/6/14 at 5:55 a.m., the Treatment Nurse was asked if she was aware of anyone using anything other than what was ordered on wounds. She stated, "Yep" then changed her answer to "No." The Treatment Nurse was told that LPN #1 had stated that she had told the treatment nurse what she was using on Resident #4, and showed the Treatment Nurse the bottle of cleaner. She stated, "I just thought she was using the wound cleanser that had peroxide in it in the cart. I never looked at what she said she was using. ... I did not tell the Director of Nursing (DON) or anyone else that she was using something not ordered ... I've never used anything like that on any resident's wounds. It (the wound) looked cleaner when (Resident #4) came back from the hospital. I thought they must have debrided it... I just thought anything in the cart we could use without an order." The Treatment Nurse was shown the bottle of equipment cleaner. She confirmed she was not aware that anyone had been using that on wounds. 4) On 11/6/14 at 6:08 a.m., the DON was asked if she was aware that (LPN #1) was using the cleaner on wounds. She stated, "I was told about 9/30/14 by a nurse, (LPN #2), via text that a CNA (Certified Nurse Assistant) had reported to her that (LPN #1) had been using Peroxide that they had used to clean beds. I sent copies of the text to the nurse consultant and Administrator as soon as I got the text. I was told to interview (LPN #1) and find out what she had been using. I called to find out how the wound was looking and exactly what the treatment was. She (LPN #1) said the wound was looking good and was cleaning with wound cleanser and Santyl. I said, so you're using the wound cleanser in the bottom of the cart. She said, yes. This morning I asked her if she was using this when I called her, she said no, I didn't start using that until approximately 6 times before the resident went to the hospital..." 5) On 11/6/14 at 10:49 a.m. by telephone, LPN #2 was asked if she was aware of anyone using the cleaner on wounds. She stated, "The Treatment Nurse told me one of the nurses had been using a Hydrogen Peroxide Cleaner for equipment and that she thought it was ok." She stated the cleaner was used on Resident #4. The LPN did not know if it was painful to the resident, but did say the wound got worse. She stated, "I voiced my concerns to the DON and asked if the wound care orders could be taken off of our shift. She said she would deal with it. The last time I worked, it was off the night shift." c. On 11/6/14 at 11:00 a.m., the Director of Nursing provided documentation of wound assessments/measurements for September and October 2014: 9/5/14: "L (left) heel, acquired 9/15/12." There were no measurements or wound descriptions documented. 9/18/14: "PU (Pressure Ulcer) Stage III, L heel: 1x7.5x3.5 ... PU, Stage III, L calf 3x3.5." There were no wound descriptions documented. 9/25/14: "PU, L shin, 3.7x2.6, Stage III, Avoidable, improved, Treatment Santyl/wet to dry, ... PU, L heel, Stage III." There were no additional measurements or wound descriptions documented. 10/9/14: "PU L shin, 3.7x2.6, Stage III, Avoidable, ... Stasis Ulcer, L heel." There were no additional measurements or wound descriptions documented. (Resident #4 was in the hospital from 10/20/14 until 10/30/14.) 10/31/14: "... L heel, ... Stage III, 5x2x0.2." There were no additional measurements or wound descriptions documented. d. The Wound Clinic's documentation included the following assessments and measurements: " 9/30/14: (There were no measurements or assessments.) " 10/14/14: #29 L heel: 4.0x2.0x0.2 ... #31 LLE (left lower extremity); 2.4x4.0x0.2 ... " " 11/3/14: (There were no measurements or assessments)." e. On 11/6/14 at 12:20 p.m., the Immediate Jeopardy was removed and the scope/severity reduced to "E" when the facility implemented the following plan of removal: 1) Nurse was immediately removed from the hall and suspended pending investigation by Administrator on 11/6/14 at 5:00 a.m. Resident's wounds were assessed by DON and treatment nurse and documented on a skin audit sheet on 11/6/14 at 8:30 a.m. At that time treatment was provided following correct physician orders. No deterioration was noted. Physician was notified on 11/6/14 at 7:00 a.m. with no new orders noted. 2) There were 7 residents found to be at risk for deficient practice based on a list of residents with pressure ulcers provided by treatment nurse on 11/6/14 at 6:00 a.m. All 7 residents will have wounds assessed by treatment nurse for any deterioration by 1:00 p.m. on 11/6/14 using a skin audit sheet. Any negative findings will be corrected immediately and reported to the Administrator. 3) All nurses will be re-educated by DON/Designee beginning 11/6/14 at 7:00 a.m.on reporting abuse, following physician orders, wounds must be assessed, measured, and documented weekly using inservice sign-in sheets that include content trained on and this will be included in orientation packet for all new hires. Nurses will be removed from the schedule and not allowed to work until they complete this re-education. 4) Nurses will be interviewed in regards to anybody using household cleaners for wound care by DON/Designee beginning 11/6/14 at 5:30 a.m. and will be completed by 11/6/14 at 4:00 p.m. using OLTC (Office of Long Term Care) witness forms. Nurses will be removed from the schedule and not allowed to work until they complete an interview form. Any negative findings will be investigated immediately by Administrator/Designee. 5) Cognitive residents will be interviewed in regards to anybody using household cleaners for care by DON/Designee beginning 11/6/14 at 8:00 a.m. and completed by 11/6/14 at 12:00 p.m. using OLTC witness forms. Any negative findings will be investigated immediately by Administrator/Designee. 6) DON/Designee will complete nurse competency checklist for all nurses beginning 11/6/14 at 10:00 a.m. and for all new hires prior to working on their own. Nurses will be removed from the schedule and not allowed to work until they complete a competency checklist. 7) DON/Designee will monitor wound care and wound care documentation of pressure ulcers for proper protocol and treatment on all residents with pressure ulcers 5 times per week for 2 weeks, then 3 times per week for 2 weeks, then 2 times per week thereafter until substantial compliance achieved. Any negative findings will be corrected immediately and taken to QA (Quality Assurance) meeting by Administrator/Designee." B. Based on observations, record review and interview, the facility failed to ensure assessments that included measurements and wound descriptions were consistently completed and documented for pressure ulcers to determine the healing or failure to heal to ensure prompt changes in treatment and failed to ensure wound treatments and intervals for wound treatments were implemented and performed according to physician orders [REDACTED].#4); and to ensure the physician was immediately notified so appropriate treatment could be initiated to expedite healing of a newly identified wound prior to treatment without a physician order [REDACTED]. 1. The facility's Skin Program Policy received from the Administrator on 11/7/14 at 9:20 a.m. documented: "... 3. A licensed nurse will complete a total body assessment on each resident on admission and weekly... 5. All open areas will be identified and documented on the appropriate forms ... 6. Resident(s) with wounds will have appropriate treatment. If there is deterioration or no change in a wound within 2 weeks, the treatment will be changed. 7. Resident(s) with wound acquired in the facility will be assessed to determine if pressure ulcers are unavoidable... 8. Resident's discharged /transferred to hospital will have a skin assessment completed prior to discharge/transfer... 9. All skin conditions will be assessed weekly with documentation of: a. Date, b. Stage, c. Length X width X Depth, d. Drainage, e. Odor, f. Progress / Remarks, g. Current Treatment Plan ..." 2. Resident #4 had [DIAGNOSES REDACTED]. Varicose Veins of Lower Extremities with Ulcer, and Senile Dementia. The Quarterly Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 7/28/14 documented the resident had a problem with short term and long term memory per staff assessment and was moderately impaired for cognitive skills for daily decision making, and had 1 Stage 3 Pressure Ulcer. a. The Care Plan dated 5/1/14 documented, "Resident is at risk for skin breakdown and pressure ulcers r/t (related to) incontinence, Decreased Mobility, Decreased sensation, [MEDICAL CONDITIONS], hx (history) pressure and vascular ulcer... Assess and record changes in skin status. Report pertinent changes to physician. .. Weekly skin assessments by nurse... Wound care consult as ordered... Resident has Stage 3 ulcer (L) (left) heel... Goal: Ulcer will exhibit evidence of healing as indicated on pressure report (decrease in size, improved appearance, abscence of drainage, etc.) through next review... Interventions: Administer/monitor effectiveness of/response to treatment(s) as ordered... Assess/record changes in skin status and report changes to physician... Measure and document condition of skin condition weekly. ... Monitor site for s/sx (signs and symptoms) of infection. ... Assess, record and monitor wound healing weekly. Measure length width and depth. Assess and document wound perimeter, wound bed and healing process. Report improvement and decline to MD (Medical Doctor) and family ... Resident to be seen by wound care clinic every two weeks ..." b. A physician order [REDACTED].#29 Left, Medial, Posterior Foot: Change dressing every day or as needed for excessive drainage. Wound #31 Left Lower Leg: Change dressing every day or as needed for excessive drainage ... Primary Wound Dressing: Wound #29 Left, Medial, Posterior Foot: Apply [MEDICATION NAME] ointment to wound bed. Apply thin layer of Santyl Ointment to wound bed only. Other: - WTD (wet to dry). Wound #31 Left Lower Leg: Apply [MEDICATION NAME] ointment to wound bed. Apply thin layer of Santyl Ointment to wound bed only. Other: - WTD. ... Secondary Dressing: Wound #29 Left, Medial, Posterior Foot: Secure with rolled gauze (conform or Kerlix). Secure with tape. Wound #31 Left Lower Leg: Secure with rolled gauze (conform or Kerlix). Secure with tape ..." 1) On 11/6/14 at 4:10 a.m., Licensed Practical Nurse (LPN) #1 performed wound care to the Resident's left heel and left lower leg. Both wounds were cleansed using wound cleanser and then dried. [MEDICATION NAME] was applied with a sterile Q-tip. Collagen was applied, then foam, then the wounds were wrapped with gauze and taped. The LPN stated that the resident had gone to the wound clinic Monday and had measurements there. She also stated, "The wound on the lower leg is larger but looks healthier. The wound on the heel is larger and worse." The Santyl ointment and the WTD dressings were not applied as per the 11/3/14 physician orders. 2) The November 2014 Treatment Administration Record (TAR) documented, "Cleanse left heel with wound cleanser, pat dry, apply [MEDICATION NAME] Ointment, then collagen, foam, & (and) secure with Kerlix. Change Mon (Monday), Wed (Wednesday), and Fri (Friday) & PRN (as needed) until resolved. One time a day every Mon, Wed, Fri - Start date - 10/31/14 2300 (11:00 p.m.), Cleanse wound to left lower leg with wound cleanser, pat dry, apply [MEDICATION NAME] Ointment, then collagen, foam, & (and) secure with Kerlix. Change Mon, Wed, and Fri & PRN until resolved. One time a day every Mon, Wed, Fri - Start date - 10/31/14 2300." There were initials by the Treatment Nurse on Monday, 11/3/14, indicating the treatments to both areas was done, and on Wednesday, 11/5/14, the Treatment Nurse's initials were circled to indicate the treatments were not done. The TAR documented, "11/5/14 , Res (resident) yelling (and) screaming. Refused to let this nurse do treatment." The new physician orders [REDACTED]. 3) On 11/6/14 at 10:00 a.m., the DON was asked to review the physician orders [REDACTED]. After the review, the DON was asked who was responsible for noting treatment orders from the wound clinic. She stated, "The Treatment Nurse." She was asked if she saw any problem with the comparison. She stated, "Yes, the order was not changed on the TAR nor noted by the Treatment Nurse." c. On 11/6/14 at 11:00 a.m., the Director of Nursing provided documentation of wound assessments/measurements for September and October 2014: 9/5/14: "L (left) heel, acquired 9/15/12." There were no measurements or wound descriptions documented. 9/18/14: "PU (Pressure Ulcer) Stage III, L heel: 1x7.5x3.5 ... PU, Stage III, L calf 3x3.5." There were no wound descriptions documented. 9/25/14: "PU, L shin, 3.7x2.6, Stage III, Avoidable, improved, Treatment Santyl/wet to dry, ... PU, L heel, Stage III." There were no additional measurements or wound descriptions documented. 10/9/14: "PU L shin, 3.7x2.6, Stage III, Avoidable, ... Stasis Ulcer, L heel." There were no additional measurements or wound descriptions documented. (Resident #4 was in the hospital from 10/20/14 until 10/30/14.) 10/31/14: "... L heel, ... Stage III, 5x2x0.2." There were no additional measurements or wound descriptions documented. d. The Wound Clinic's documentation included the following assessments and measurements: " 6/26/14, ... L heel ... 4.0x2.0x0.2. " 7/17/14: Heel 4.6x2.0x0.2. " 7/31/14: (There were no measurements or assessments.) 8/28/14: (There were no measurements or assessments.) " 9/30/14: (There were no measurements or assessments.) " 10/14/14: #29 L heel: 4.0x2.0x0.2 ... #31 LLE (left lower extremity); 2.4x4.0x0.2 ... " " 11/3/14: (There were no measurements or assessments)." d. The Nurses' Notes from 09/22/14 - 11/06/14 were reviewed: "10/6/14 @ (at) 2300 (11:00 p.m.) NO (New Order): 1. Tylenol 500 mg (milligrams) PO (by mouth) q (every) a.m. ...". (The resident was in the hospital from 10/20/14 and re-admitted [DATE].) "10/31/14: Wound assessment complete. L lower leg 3x3x (less than) 0.1 wound bed beefy red (no) slough noted. Wound edges dark purple/black, Surrounding tissue pink intact. L heel 5x2x0.2 wound bed beefy red. Scant amount of serosang (serosanguinous) drainage noted to both wounds ... " " 11/2/14 0115 (1:15 a.m.) Resting in bed ... CNA (Certified Nurse Assistant) notified this nurse @ approx (approximately) 2000 (8:00 p.m.) that resident needed something for pain. Resident unable to tell this nurse where his pain was located. PRN pain med given (with) effective results noted within one hour... " " 11/3/14 1800 (6:00 p.m.) ...Wound to heel cont (continues) to worsen - wound clinic appt (appointment) today... " " 11/4/14 0100 (1:00 a.m.) Has Dressings on Lt (left) (and) rt (right) lower legs. Does have some pain of legs @ times... " " 11/5/14 1000 (10:00 a.m.) ... Periodically c/o (complains of) pain to L foot. Medicated per orders..." 3. Resident #3 had a [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date of 9/29/14 documented the resident was severely impaired in cognitive skills for daily decision making per staff assessment; needed extensive assistance of one person for bed mobility; had an indwelling Foley catheter; was always incontinent of bowel; was at risk for developing pressure ulcers; and had 1 stage 2 Pressure ulcer. a. A physician's order [REDACTED]. b. A Care Plan dated 10/2/14 documented, " ... Resident has Stage 2 ulcer and Excoriation to Coccyx and peri-area related to incontinence, decreased mobility, fragile skin ... Administer/monitor effectiveness of/response to treatment (s) as ordered ... Assess/record changes in skin status and then report changes to physician..." c. On 11/5/14 at 10:15 a.m., Certified Nursing Assistant (CNA) #1 and CNA # 2 were observed providing incontinent care to Resident #3. When incontinent care was completed CNA # 2 stated that she was going to get the Treatment Nurse to look at Resident #3 since she had not worked with resident for a while and was unaware of current skin condition. The Treatment Nurse entered room, assessed resident and stated, " The area to the sacral crease is now open; it wasn't open this morning, I will notify Hospice." The Treatment Nurse then left the room. d. On 11/5/14 at 10:38 a.m., the Treatment Nurse returned to Resident #3 ' s room, wiped area around sacral crease with skin prep, cleansed wound, applied hydrogel and covered area with a [MEDICATION NAME] Border Dressing. She stated, "This is a new area; it was not here this morning when I did the body audit." e. On 11/5/14 at 10:50 a.m., the Treatment Nurse was asked for the physician's order [REDACTED]. She stated, "It is a standing order from the formulary that I am allowed to use." She was then asked for a copy of the standing order but was unable to provide it. f. On 11/5/14 at 10:55 a.m., the DON was asked if there was a standing order for wound treatments and a wound formulary they used. She stated, "No, we do not have standing orders, the Doctor has to be called each time a wound is discovered to get an order to treat."

Complaint # (AR 599) was substantiated (all or in part) in this finding. Based on record review and interview, Nursing Administration failed to thoroughly investigate allegations that LPN #1 was using a disinfectant for equipment and non-porous hard medical surfaces as a wound cleanser in order to prevent further infection/breakdown in wounds for 1 (Resident #4) of 6 (Residents #3, #4, #16, #19, #31, and #32) case mix residents who had pressure ulcers. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death for Resident #4 and had the potential to cause more than minimal harm for 7 residents who had pressure ulcers as documented on a list provided by the Administrator on 11/6/14 at 11:45 a.m. On 11/6/14 at 4:40 a.m., the Administrator was informed of the Immediate Jeopardy. The findings are: 1. The Job Description of the Director of Nursing documented: "... Summary: As our Director of Nursing you will be responsible for overall direction, coordination, and evaluation of nursing care services provided to the residents, as well as assuming daily operations of the facility in Administrator's absence as necessary ... Essential Duties and Responsibilities: This list is subject to individual facility policies, procedures and practices, which may require additional duties and responsibilities... Engaging in recruiting, interviewing, counseling, evaluating and retention of staff, Ensuring appropriate review, interpretation, and analysis of records and reports, Scheduling, monitoring and follow-up on all non-nursing resident care services, ... conducting facility-wide in-service education programs, ... Ensuring compliance with all state and federal guidelines, ..." 2. Resident #4 had [DIAGNOSES REDACTED]. Varicose Veins of Lower Extremities with Ulcer, and Senile Dementia. The Quarterly Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 7/28/14 documented the resident had a problem with short term and long term memory per staff assessment and was moderately impaired for cognitive skills for daily decision making, and had 1 Stage 3 Pressure Ulcer. a. The Care Plan dated 5/1/14 documented, "Resident is at risk for skin breakdown and pressure ulcers r/t (related to) incontinence, Decreased Mobility, Decreased sensation, [MEDICAL CONDITIONS], hx (history) pressure and vascular ulcer... Assess and record changes in skin status. Report pertinent changes to physician. .. .Resident has Stage 3 ulcer (L) (left) heel... Goal: Ulcer will exhibit evidence of healing as indicated on pressure report (decrease in size, improved appearance, abscence of drainage, etc.) through next review... Interventions: Administer/monitor effectiveness of/response to treatment(s) as ordered... Assess/record changes in skin status and report changes to physician... Report improvement and decline to MD (Medical Doctor) and family ... Resident to be seen by wound care clinic every two weeks ..." b. On 11/6/14 at 4:10 a.m., Licensed Practical Nurse (LPN) #1 performed wound care to the Resident's left heel and left lower leg. The LPN stated that the resident had gone to the wound clinic Monday and had measurements there. She also stated, "The wound on the lower leg is larger but looks healthier. The wound on the heel is larger and worse." At 4:30 a.m. after completion of the wound, the LPN was asked if she was aware of anyone using something on a wound that was not to be used on wounds. LPN #1 stated, "I did. I wouldn't ever mean any harm to a resident. I used this. (The LPN showed the surveyor a spray bottle of Clorox Brand Hydrogen Peroxide Cleaner Disinfectant for hard surfaces and equipment). " The LPN continued, "(Resident #4) won't let anyone but me and (LPN #2), another LPN that works nights, change his dressing. We were gone about 6 days and his dressing had not been changed for the 6 days. I was trying to find something that would help his wounds. They were draining yellow drainage and looked awful. So, I started using that." The LPN was asked if she was aware the cleaner was not for wounds. She stated, "Yes, but it does not have bleach in it." The LPN was asked if she had gotten physician orders [REDACTED]." The LPN also stated that she thought the wound had gotten better with this treatment and that it had not hurt the resident. She was asked how long she used it on the resident and she stated, "About 2 weeks (10/6/14 - 10/20/14)." She stated that the last time she used it on the resident was the day the resident went to the hospital (10/20/14) and had not used it on any other residents. The LPN was asked if anyone else was aware of her use of the cleaner on Resident #4. She stated, "Yes, the Treatment Nurse." 1) The October 2014 TAR documented, "L medial posterior foot. (Change dressing (every) d (day) (and) PRN. [MEDICATION NAME] (and) Santyl, wet to dry dressing. Kerlix (and) Tape. 10/1/14. L (lower) leg, Change dressing (every) day (and) PRN. [MEDICATION NAME] (and) Santyl wet to dry dressing. Kerlix (and) tape. 10/1/14." LPN #1 initialed 10/9/14, 10/10/14, 10/11/14, 10/15/14, 10/16/14, and 10/19/14 to indicate the treatments to both areas were performed as prescribed by the physician each of these days. The resident went to the hospital on [DATE]. 2) The label on the bottle of disinfectant read: "Kills bacteria [MEDICAL CONDITION] in 30 seconds ...Clorox ... Hydrogen Peroxide, Cleaner Disinfectant ... Compatible with Equipment Surfaces ... Non Bleach ... Keep out of the reach of children ... Directions For Use: It is a violation of Federal law to use the product in a manner inconsistent with its labeling. To operate: To open, Turn nozzle. Spray 6-8 inches from surface. Wipe with cloth. Do not breathe spray or mist. ... Precautionary statements: Hazards to Humans and Domestic Animals. Caution: Causes moderate eye irritation. Avoid contact with eyes or clothing. Wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, chewing tobacco, or using the toilet. First Aid: If in eyes: Hold eye open and rinse slowly and gently with water for 15-20 minutes. Remove contact lenses, if present, after the first 5 minutes, then continue rinsing. Call the poison control center at [PHONE NUMBER] or doctor for treatment advice... This product is not to be used as a terminal sterilant/high level disinfectant on any surface or instrument that (1) is introduced directly into the human body, either into or in contact with the bloodstream, or normally sterile areas of the body, or (2) contact intact mucous membranes, but which does not penetrate the blood barrier or otherwise enter normally sterile areas of the body. ... Disinfection: ... This product cleans, disinfects and deodorizes hard, nonporous medical surfaces in one step with no rinsing required..." 3) On 11/6/14 at 5:55 a.m., the Treatment Nurse was asked if she was aware of anyone using anything other than what was ordered on wounds. She stated, "Yep" then changed her answer to "No." The Treatment Nurse was told that LPN #1 had stated that she had told the treatment nurse what she was using on Resident #4, and showed the Treatment Nurse the bottle of cleaner. She stated, "I just thought she was using the wound cleanser that had peroxide in it in the cart. I never looked at what she said she was using. ... I did not tell the Director of Nursing (DON) or anyone else that she was using something not ordered ... I've never used anything like that on any resident's wounds. It (the wound) looked cleaner when (Resident #4) came back from the hospital. I thought they must have debrided it... I just thought anything in the cart we could use without an order." The Treatment Nurse was shown the bottle of equipment cleaner. She confirmed she was not aware that anyone had been using that on wounds. 4) On 11/6/14 at 6:08 a.m., the DON was asked if she was aware that (LPN #1) was using the cleaner on wounds. She stated, "I was told about 9/30/14 by a nurse, (LPN #2), via text that a CNA (Certified Nurse Assistant) had reported to her that (LPN #1) had been using Peroxide that they had used to clean beds. I sent copies of the text to the nurse consultant and Administrator as soon as I got the text. I was told to interview (LPN #1) and find out what she had been using. I called to find out how the wound was looking and exactly what the treatment was. She (LPN #1) said the wound was looking good and was cleaning with wound cleanser and Santyl. I said, so you're using the wound cleanser in the bottom of the cart. She said, yes. This morning I asked her if she was using this when I called her, she said no, I didn't start using that until approximately 6 times before the resident went to the hospital..." 5) On 11/6/14 at 10:49 a.m. by telephone, LPN #2 was asked if she was aware of anyone using the cleaner on wounds. She stated, "The Treatment Nurse told me one of the nurses had been using a Hydrogen Peroxide Cleaner for equipment and that she thought it was ok." She stated the cleaner was used on Resident #4. The LPN did not know if it was painful to the resident, but did say the wound got worse. She stated, "I voiced my concerns to the DON and asked if the wound care orders could be taken off of our shift. She said she would deal with it. The last time I worked, it was off the night shift." c. On 11/6/14 at 11:00 a.m., the Director of Nursing provided documentation of wound assessments/measurements for September and October 2014: 9/5/14: "L (left) heel, acquired 9/15/12." There were no measurements or wound descriptions documented. 9/18/14: "PU (Pressure Ulcer) Stage III, L heel: 1x7.5x3.5 ... PU, Stage III, L calf 3x3.5." There were no wound descriptions documented. 9/25/14: "PU, L shin, 3.7x2.6, Stage III, Avoidable, improved, Treatment Santyl/wet to dry, ... PU, L heel, Stage III." There were no additional measurements or wound descriptions documented. 10/9/14: "PU L shin, 3.7x2.6, Stage III, Avoidable, ... Stasis Ulcer, L heel." There were no additional measurements or wound descriptions documented. (Resident #4 was in the hospital from 10/20/14 until 10/30/14.) 10/31/14: "... L heel, ... Stage III, 5x2x0.2." There were no additional measurements or wound descriptions documented. d. The Wound Clinic's documentation included the following assessments and measurements: " 9/30/14: (There were no measurements or assessments.) " 10/14/14: #29 L heel: 4.0x2.0x0.2 ... #31 LLE (left lower extremity); 2.4x4.0x0.2 ... " " 11/3/14: (There were no measurements or assessments)." e. On 11/6/14 at 8:30 a.m., the personnel record of LPN #1 was reviewed and the "Core Competency Review Checklist" documented a self-evaluation by LPN #1. Under the topic of Skin and Wound Prevention the LPN had scored herself a "1" (1 indicates minimal experience) on Non-decub measurement and tracking, decubitus measurement/staging/tracking, Skin Formulary (Treatments, devices), and Nutritional interventions. The Review Dates, Return Demonstration, and Evaluation Signature columns were blank. At 9:00 a.m., the RN/Treatment Nurse (Date of Hire: 8/28/14) had no Competency Evaluation form in her personnel records. At 9:10 a.m., the DON was asked where the Competency Checklists were kept. She stated, "In their personnel records." She was asked if there wasn't one in there does it mean one was not done. She stated, "Who do you have because I've already pulled all charts and have them working on getting that done for the ones I found did not have one in their record." The DON was shown the personnel records of LPN #3, #7, and RN/Treatment Nurse. The DON said she would check on this because she did not do their evaluations. The DON was asked about the Checklist Evaluation on LPN #6 and she stated, "Most of it was verbal. I did watch her do a treatment, since that was what she was orginally hired for. Since then she is now not doing treatments she is passing meds, but I have not went back and re-evaluated competency." At 12:15 p.m. the DON stated that no further Competency Checklists were found, but they were working on getting them up to date. f. On 11/6/14 at 12:20 p.m., the Immediate Jeopardy was removed and the scope/severity reduced to " E " when the facility implemented the following plan of removal: 1) Nurse was immediately removed from the hall and suspended pending investigation by Administrator on 11/6/14 at 5:00 a.m. Resident's wounds were assessed by DON and treatment nurse and documented on a skin audit sheet on 11/6/14 at 8:30 a.m. At that time treatment was provided following correct physician orders. No deterioration was noted. Physician was notified on 11/6/14 at 7:00 a.m. with no new orders noted. 2) There were 7 residents found to be at risk for deficient practice based on a list of residents with pressure ulcers provided by treatment nurse on 11/6/14 at 6:00 a.m. All 7 residents will have wounds assessed by treatment nurse for any deterioration by 1:00 p.m. on 11/6/14 using a skin audit sheet. Any negative findings will be corrected immediately and reported to the Administrator. 3) All nurses will be re-educated by DON/Designee beginning 11/6/14 at 7:00 a.m.on reporting abuse, following physician orders, wounds must be assessed, measured, and documented weekly using inservice sign-in sheets that include content trained on and this will be included in orientation packet for all new hires. Nurses will be removed from the schedule and not allowed to work until they complete this re-education. 4) Nurses will be interviewed in regards to anybody using household cleaners for wound care by DON/Designee beginning 11/6/14 at 5:30 a.m. and will be completed by 11/6/14 at 4:00 p.m. using OLTC (Office of Long Term Care) witness forms. Nurses will be removed from the schedule and not allowed to work until they complete an interview form. Any negative findings will be investigated immediately by Administrator/Designee. 5) Cognitive residents will be interviewed in regards to anybody using household cleaners for care by DON/Designee beginning 11/6/14 at 8:00 a.m. and completed by 11/6/14 at 12:00 p.m. using OLTC witness forms. Any negative findings will be investigated immediately by Administrator/Designee. 6) DON/Designee will complete nurse competency checklist for all nurses beginning 11/6/14 at 10:00 a.m. and for all new hires prior to working on their own. Nurses will be removed from the schedule and not allowed to work until they complete a competency checklist. 7) DON/Designee will monitor wound care and wound care documentation of pressure ulcers for proper protocol and treatment on all residents with pressure ulcers 5 times per week for 2 weeks, then 3 times per week for 2 weeks, then 2 times per week thereafter until substantial compliance achieved. Any negative findings will be corrected immediately and taken to QA (Quality Assurance) meeting by Administrator/Designee."

Complaint # (AR 372) was substantiated, all or in part, Based on observation, record review and interview, the facility failed to ensure resident aggressive behaviors were thoroughly assessed for causative factors with interventions developed and implemented based on results of assessment; interventions were re-evaluated for effectiveness; a communication system for staff on the secure unit to use in emergency situations and sufficient numbers of staff were on duty on the male secure unit to ensure aggressive behaviors were monitored closely and to enable staff to quickly intervene for 1 of 1 (Resident #7) case mix resident who had a history of [REDACTED].#6) who was twice the victim of resident to resident physical aggression. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious injury, harm or death for Resident #6, who was hit in the abdomen on two occasions, and had the potential to affect 6 other male residents who resided on the secure male unit according to the list received from the Administrator on [DATE]. The facility was informed of the Immediate Jeopardy on [DATE] at 12:40 p.m. The findings are: 1. The Secure Unit Policy and Procedure received from the Administrator on [DATE] documented, "Secure Unit (Memory Care Unit), Admit modify the admit policy for the unit, Green light: [DIAGNOSES REDACTED]. Red Light: Mental Retardation who require active treatment, acute or chronic mental illness such as Schizophrenia, Manic Depression, Bi Polar, Psychosis. Brain injury or Acute Alcohol/Drug Withdrawal. Must be at least [AGE] years old unless approved by RDCO. Medically stable with no suicidal or homicidal ideation. Resident who is deemed to be a danger to themselves or others will not be admitted . Must be ambulatory." On [DATE] the Men's Secure Unit had 7 male residents. There were 2 residents confined to wheelchairs (Resident #2 and #9), 4 ambulatory residents (Residents #1, #8, #10 and #11), and 1 resident in a geri-psychiatric unit (Resident #7). 2. Resident #6 was admitted to the facility on [DATE] per the Admission Record. and resided on the Men's Secure Unit and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, had no documentation of behaviors, required supervision with ambulation in the room or corridors, extensive assistance with dressing, supervision with meals and was totally dependent with personal hygiene. a. An Incident Report Investigation Behavioral Outburst-Assault of Another Resident or Staff Member dated [DATE] at 9:00 p.m. documented, "This res (resident) was hit by another res (Resident #7)... was hit in the stomach." A witness statement dated [DATE] and signed by Licensed Practical Nurse (LPN #2) documented, "This res (Resident #6) was struck by another res as he was walking by in unit hallway-he was hit 2 x (times) in stomach (with) closed fist from other res before Nurse et (and) CNA (Certified Nursing Assistant) could intervene/get between both... No bruising is noted. Res shows no s/s (signs/symptoms) of distress." b. An Incident Report Investigation Behavioral Outburst-Assault of Another Resident or Staff Member dated [DATE] at 7:45 a.m. documented, "(Resident #6) was walking in the hall (and) was attacked by (Resident #7)... Res denies abd (abdominal) pain, no redness, swelling, or tenderness noted BS (bowel sounds) x 4 (all four quadrants) will monitor res." A witness statement dated [DATE] at 7:45 a.m. and signed by CNA #2 documented, "(Resident #7) was hitting (Resident #6) in stomach..." c. Nurses Notes dated [DATE] at 8:20 a.m. documented, "Experiencing loose stools and vomiting. New order received Phenergan 25 mg (milligrams) IM (intramuscularly) now. Imodium 2 mg after each loose stool max (maximum) 16 mg daily. Clear liquid diet 24 hours. Chem (chemistry lab) 8 am of [DATE]. Family notified of order." Nurses Notes dated [DATE] at 3:00 p.m. documented, "Resident still experiencing loose stools received new order for Lomotil 5 mg QID (four times daily) PRN (as needed) faxed to pharmacy. Call and requested stat order. Mucous membranes moist, no tenting of skin. Resident is able to keep down fluids." Nurses Notes dated [DATE] at 3:30 p.m. documented, "Resident's daughters without notifying staff call EMS (Emergency Medical System). Resident transferred via ambulance. Given copy of MAR (Medication Administration Record), Face Sheet. DON (Director of Nurses) notified." Nurses Notes dated [DATE] documented, "D/C (discharged ) from Heritage Park per family request." d. The Emergency Department GI (Gastrointestinal) Assessment documented, "[DATE] at 1628 (4:28 p.m.) the abdominal appearance- flat appearance, bowel sounds all quadrants. [DATE] at 1810 (6:10 p.m.) the abdominal appearance was rounded Symmetric audible bowel sounds soft non-tender incontinent of large amount of stool liquid brown." The Hospital Inpatient H&P (History and Physical) documented, "The... (Resident #6) presents for evaluation of AMS (altered mental status) and diarrhea for 2 days ...This is a new problem. This current episode started ,[DATE] hours ago. This problem has not changed since onset. Associated symptoms include somnolence and weakness. They stated that yesterday when wife visited he was sleeping. Today he would not wake up and had runny diarrhea about every 30 minutes. No documentation of fever. In ED (Emergency Department) pt (patient) was found to have elevated WBC (white blood count) 15.4 (range 3XXX,[DATE].0)." The Hospital Course documented, "After evaluating pt initially, I was called by RN (Registered Nurse) that pt started vomiting. Concerned about possibility of ischemic bowel. ordered CT (computerized tomography) abd (abdomen) stat. When I went back up to evaluate pt he had just vomited again and aspirated a large amount. Suctioned out fecal looking/smelling emesis. Pt likely does have ischemic bowel Discussed case with wife who has stayed the night. She states that she wants him to be comfortable and understands that there is likely nothing that can be done for him. Pt became hypoxic on 6 L (oxygen at 6 L) appears pale and dyspnea. Lungs have very coarse rales throughout. Will stop all medications other than those for pt comfort. Cancel labs, cancel CT abd. Morphine and Ativan prn. Pt's wife understands that pt's prognosis is very poor. Pt died at 2:14 a.m. Cause of death, Respiratory failure secondary to Aspiration Pneumonia secondary to Presumed ischemic bowel." 3. Resident #7 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. A History & Physical dated [DATE] and signed by the medical doctor documented, "...admitted to (Geri-Psychiatric unit) ,[DATE] (secondary to) sexually explicit behaviors at previous nursing facility. Psych meds were not changed. Received milieu therapy. Decided he (Resident #7) needed a locked down mens unit." b. A history and physical examination [REDACTED]. Refusal of ADLs (activities of daily living). Labile mood - from smile to combative in seconds..." The Psychiatric Evaluation dated [DATE] documented under Mental Status Evaluation, "Attitude is poorly cooperative... Delusions, paranoid type appear to be present and as manifest in patient with defensive aggression, especially with essential care. He is having prominent anxiety again pacing, talking to unseen people... While there is no frank suicidal ideation, intent or plan, his proclivity for aggression given his severe confusion and delusional thought can contribute to morbidity and mortality to himself and others... Prognosis: Guarded given severity of dementia syndrome and underlying chronic and acute psychiatric and medical conditions..." c. The Geri-Psychiatric Unit Continuing Care/Discharge Planning dated [DATE] documented, "...Psychosis NOS (not otherwise specified) CAD (coronary artery disease) Dementia (with) delusions..." d. The Social Services Progress Notes dated [DATE] documented, "Res (Resident) returned to (facility) on [DATE] from (Geri-Psychiatric Unit). Upon return Res swung at staff..." e. The Interdisciplinary Care Plan Conference Record dated [DATE] documented, "...Cont (continues) to have some agitation... Action Plan: cont. to observe for behaviors..." The care plan itself did not document any new interventions at this conference for monitoring and intervening when behaviors escalate. f. The Care Plan documented, "...Focus Resident has impaired cognitive skills AEB/RT (as evidenced by/related to) BIMS (Brief Interview for Mental Status) (less than) 13, impaired memory, disorientation to person, poor or unsafe decision making, dementia Created on: [DATE]..XXX[DATE] (handwritten) N.O. (new order) Risperdal (antipsychotic) 0.25 mg BID (twice daily)..." g. A Fall Investigation dated [DATE] documented the resident fell when he wandered into another resident's bedroom and tripped over a fall mat. Nurses Notes dated [DATE] at 10:00 a.m. documented a physician order [REDACTED]. Nurses Notes dated [DATE] at 6:10 a.m. and at 8:15 a.m. documented the resident fell twice while ambulating. Nurses Notes dated [DATE] documented the resident was seen in the emergency room due to the falls and returned to the facility at 6 p.m. and that new orders were received to discontinue the Risperdal. Nurses Notes dated [DATE] at 2:30 a.m. documented, "Reported to refuse all help (with) ADLs and will become aggressively agitated..." The Nurses Progress note dated for [DATE] documented, "Resident was mildly combative this a.m. able to be redirected." As of [DATE], the care plan did not document any new behavior interventions despite the discontinuation of the antipsychotic medication on [DATE]. The Nurses Notes did not document anything other than attempts to redirect. h. The Quarterly MDS with an ARD of [DATE] documented the resident scored 5 (,[DATE] indicated severely impaired) on a Brief Interview for Mental Status for daily decision making; was ambulatory and required extensive assistance of 1 person for dressing and totally dependent of 1 person for personal hygiene; exhibited wandering behavior with no other behavioral issues checked; had a history of [REDACTED]. i. The Nurses Notes documented, "[DATE] at 2100 (9:00 a.m.) This Nurse witnessed res (resident) walk out of his room et (and) hit another res in the stomach twice with his fist. This Nurse ran to intervene et (and) was hit as well. Res was distracted while the other res was moved out of the way ...Res was re-directed back to room where he got back into bed. (The Physician) was notified et no N.O. (new orders) were received at this time. The DON notified. Family wife notified. Q (every) 15 minute checks started to monitor res (resident)." The Incident Report Investigation Behavioral Outburst-Assault of Another Resident or Staff Member dated [DATE] at 9:00 p.m. documented, "Res (resident) came out of room et struck another res. (Resident #6) who was walking by (punched him in the stomach) x 2. ...Has a similar type of incident occurred in the past? (circle only one choice below)... (d circled) At least one other time within the past week... Who or what do you think might have precipitated this incident (triggers): Other resident (up) by room making noise et trying to get in his room most likely was why he got (up) and was agitated... Could the incident have been anticipated or avoided? If so how? ...Unknown. Res has hx (history) of these behaviors et can act out (at) any given moment... Could such an incident be avoided in the future? If so how?... Yes monitor this resident closely when ambulating in hall (with) other residents when agitated..." The witness statement dated [DATE] at 9:00 p.m. and signed by CNA #1 documented, "(Resident #7) walk up to (Resident #6) and punched him in the stomach. Then he walked towards me and trying to hit me and anybody that he came close too." As of [DATE], the care plan did not document any new interventions related to the triggers documented on the Incident Report Investigation. j. Nurses Notes dated [DATE] at 10:00 a.m. documented, "Res showing aggressive behavior et being combative (with) staff. Physician notified et N.O. received for Risperdal 0.25 mg po (by mouth) ..." k. The Incident Report Investigation Behavioral Outburst-Assault of Another Resident or Staff Member dated [DATE] at 7:45 a.m. documented, "Resident became combative (and) began hitting CNAs (and) another Resident (Resident #6)... Res 1:1 (one on one supervision)." Nurses Notes dated [DATE] at 6:00 p.m. documented, "(Incident occurred at 7:45 a.m.) Resident became combative (and) aggressive. While walking down the hallway he hit another resident (Resident #6) in the stomach. He also attacked the CNA hitting the CNA(CNA #2) in the face leaving a black eye. The CNA called for help. Upon entering the unit RN (Registered Nurse #1) attempted to give Resident po (by mouth) pain med (medication) and was attacked by resident. Dr. (Doctor) notified and orders given for Ativan IM 1 mg. Med was given. Resd (resident) calmed a little but remained combative against staff. (Physician) Ordered Psych Eval (Evaluation)(Geri-Psych) came and evaluated resident and accepted him in the program. Waiting for POA (Power of Attorney) to consent that Resd (resident) will be transported to (Geri-Psych)..." There was no indication that resident was still receiving one-on-one supervision. There was no documentation in the Nurses Notes until the next day. Nurses Notes dated [DATE] at 6:30 a.m. documented, "Resident calm (and) cooperative this morning (no) further behavior issues this shift..." There was no indication that resident was still receiving one-on-one supervision. Nurses Notes dated [DATE] at 11:05 a.m. and 1:06 p.m. did not mention one-on-one supervision. Nurses Notes at 3:25 p.m. documented the resident was taken to the Geri-Psychiatric Unit. l. The Resident Safety Check Form dated [DATE] documented, "7:45 (a.m.) One on One (checked)... Q (every) 15 minute check (checked)... 11:00 (a.m.) Q 30 min (minutes) check (checked), (1:00 p.m.) Q 1 hour check (checked)*Please initial below at the time the check was completed. By initialing you are verifying that the safety check was completed. Please note a one-on-one indicates that the assigned person is with the resident constantly..." The Resident Safety Check was initialed as completed with last hourly initial at 3:00 p.m. There was no further documentation of frequent monitoring. There was no documented Resident Safety Check form for [DATE]. m. Staff interviews were conducted regarding the Men's Secure Unit: 1) On [DATE] at 4:05 p.m., CNA #1 was asked if she had worked the Secure Unit. The CNA stated, "Yes, I have worked on the Men's Unit." The CNA was asked if she was aware of any incidents regarding resident to resident aggression. The CNA stated, "Yes, (Resident #7) came out of his room and hit (Resident #6) repeatedly in the abdomen, 2 or 3 times." The CNA was asked when the incident occurred. The CNA stated, "Right after breakfast ([DATE]) I told him not to hit (Resident #6). (Resident #7) stated it's not hurting him. Then (Resident #7) hit me in the face. He slapped me 3 times that day." The CNA was asked how she got help. The CNA stated, "I didn't leave the unit but I had to go to the door (the door is located at the end of the hall) and open the door and yell for help." The CNA was asked if they had anything other than yelling for help on the secure unit. The CNA stated that they had walky talkies but they weren't working and they had not worked for some time. The CNA stated, "The Nurse came in and attempted to give (Resident #7) medication and he slapped it out of her hand and bent her hand back and slapped her in the face." The CNA was asked how she protected (Resident #6). The CNA stated that the nurse gave (Resident #7) medication that calmed him down. The CNA was asked if (Resident #7) had been aggressive and hit before. The CNA stated, "Yes, he had hit staff but not residents as far as I know." The CNA was asked how many staff worked on the Men's Secure Unit. The CNA stated, "One, there is a float that also works the Women's Secure Unit, (the census for the Women's secure unit is 13)." The CNA was asked how often the float came to help. The CNA stated that it varied. The CNA was asked, "If you are in a room caring for a resident, how do you know what is going on with the other residents." The CNA stated, "You listen for them." 2) On [DATE] at 10:00 a.m., CNA #3 stated that she worked at the facility for 1 year and had been working on the Women's Secure Unit. The CNA was asked if she had worked the Men's Secure Unit. The CNA stated, "Yes." The CNA was asked, "Did you have any problems with aggressive residents?" The CNA stated, "Yes with (Resident #7). He came out of his room and slapped me and then went back in his room." She was asked when this occurred. The CNA stated, "It's been a while." The CNA was asked if she had seen any resident hit another resident. The CNA stated, "No." 3) On [DATE] at 12:20 p.m., CNA #4 and #5 both stated that (Resident #7) was aggressive at times and had hit a resident in the stomach, but had not witnessed the incident. CNA #5 stated that (Resident #7) did raise his hand to hit her, but CNA talked to him and he put his hand down. 4) On [DATE] at 4:05 p.m., Licensed Practical Nurse (LPN) #1 stated, "I have worked at the facility for 5 years." The LPN stated that she had not witnessed (Resident #7) hit a resident, but had heard of the resident hitting staff and (Resident #6). The LPN stated, "It was in May or June can't remember the exact date, but I assessed (Resident #6) and there was no redness or pain. The LPN was asked what the procedure was for the secure unit with an aggressive resident. The LPN stated, "The residents are monitored 1-on-1 until one hour after they receive medication." 5) On [DATE] at 11:20 a.m., RN #2 stated that he was the weekend supervisor and worked one day a week on the cart (medication). RN #2 was asked if he had observed any incident with aggressive residents on the secure unit. RN #2 stated, "Yes, (Resident #7) has been known to hit staff and I was told he hit a resident. I have not witnessed him hitting another resident." RN #2 was asked if there were any other residents that were aggressive on the Men's Secure Unit. The RN stated, "(Resident #11) had a history of [REDACTED]." RN #2 was asked how the staff get help when they are on the unit. RN #2 stated, "We have walky talkies but they haven't worked for over a couple of weeks." The RN was asked if the Administrator was aware. The RN stated, "I don't know, the former DON was (aware)." At 11:30 a.m., the RN received a phone call and stated that (Resident #7) was coming back to the facility. 6) On [DATE] at 10:22 a.m., the Administrator and DON were asked how the staff communicated on the Secure Units when they needed help. The DON stated that they have a button that they can push. When told that interviews with staff indicated they go to the door and yell for help and that on [DATE] with the resident-to-resident incident CNA #2 had to go to the door and yell for help which meant that she had to walk away from the residents, the Administrator stated, "I was not aware the walky talkies were not functioning." o. On [DATE] at 10:36 a.m., the Administrator was asked when she started working at the facility. The Administrator stated, "The afternoon of [DATE]." The Administrator was asked if she was aware of the incident that occurred with Resident #7. She stated, "I was not told that day, I was told the next day on [DATE]." The Administrator was asked what steps did the facility take to protect the resident. The Administrator stated, "I would have to check that was my first day." The Administrator was asked if she had checked to see if there had been any other incidents regarding Resident #7. The Administrator stated, "No." The Administrator was asked if there were any other incidents regarding Resident-to-Resident altercation. The Administrator stated, "I didn't know he had hit a resident, I was aware of him hitting a CNA." The Administrator was asked if she had read the Incident report. The Administrator stated, "No." The Administrator was shown a copy of the Incident report dated [DATE]. The Administrator was asked if Resident #7 was going to be coming back to the facility. The Administrator stated, " Eventually he will. The Administrator was asked if she had checked the other incidents regarding Resident #7. The Administrator stated, "No." p. Resident #7 was readmitted to the facility on [DATE] at 12:30 p.m. At 12:45 p.m., the Surveyor entered the Men's Secure Unit. There was only one staff member on the Men's Secure Unit. The resident was sitting on the couch covered with a blanket. CNA #6 went to the door to the secure until and yelled for someone to bring the resident his lunch tray. At 12:47 p.m. the resident's lunch tray was brought to the secure unit. The resident was not placed on 1-on-1 as soon as he was admitted . The Resident Safety Check form dated [DATE] was checked, there were initials on the 12:30 p.m. and the 12:45 p.m. slots the Resident #7 was on 1-on-1 starting at 12:30 p.m. RN #2 was asked whose initials were in the 12:30 slot indicating that Resident #7 had been on 1-on-1 starting at 12:30 p.m. The RN stated, "I signed it when I admitted him back to the unit." The RN was asked if he stayed with the resident for the first 15 minutes. The RN stated, "No." The RN was asked, "When you signed the form are you saying that you stayed with the resident for the first 15 minutes?" The RN stated, "I shouldn't have signed the form." The RN was asked when did the 1-on-1 actually start as there was only one CNA on the Men's Secure Unit at 12:47 p.m. The RN stated, "CNA #5 was supposed to be back there." There was an initial in the 12:45 p.m. slot and the RN was asked if the CNA was on the unit at 12:45 p.m. The RN stated that the CNA did not get to the Men's Secure Unit around 12:55 p.m. On [DATE] At 1:15 p.m., the Administrator and the Director of Nurses were asked what plans had been developed related to Resident #7's aggressive behaviors toward staff/residents when he returned to the facility. The DON stated, "I was not aware that (Resident #7) was returning to the facility until he was already in the facility." The DON stated, "We will get a Psych consult with (agency) and will have q 15 minutes checks to check the level of function and we plan on initiating a Plan of Care for Behaviors, see if we can find what the triggers are, we can't restrain him." The DON stated, "We are still working on our plans." 4. The facility removed the Immediate Jeopardy on [DATE] at 4:36 p.m. and reduced the scope/severity to "H" when the following plan of removal was implemented: 1. The resident in question, upon his return to the facility, was immediately placed on one-on-one supervision by a certified staff member for seven days and then the Director of Nursing will reassess the further need for one-on-one intervention. 2. A new order of Zyprexa was initiated for the resident in question during his recent geri-psych hospitalization . 3. New walkie-talkies were purchased on [DATE] at 3:15 p.m. by facility for staff members working on the dementia units. The new walkie-talkies were given immediately to the staff members working on the dementia units and the B-Hall and C-Hall nurse upon arrival at 3:30 p.m. on [DATE]. A front office staff member went to buy new batteries to replace the old batteries in the walkie-talkies not working on [DATE]. 4. Charts and care plans of residents with behaviors were reviewed by the MDS Coordinator on [DATE] to ensure appropriate interventions were in place. 5. Re-education initiated by Director of Nursing/Designee on [DATE] with staff members prior to coming to work the designated shift and with staff members returning back to work from vacation or leave of absence on the following: a. Separate residents involved in altercation immediately. b. Place residents on on-on-one supervision immediately following an altercation. c. Document the one-on-one supervision on the approved facility form. d. Continue the one-on-one supervision until a more permanent intervention is in place and the DON directs to remove the one-on-one supervision e. One-on-one refers to staff being placed with resident for close observation. 6. The Plan of Action will be monitored for on-going compliance by the Director of Nursing/Designee daily for seven days and then will be re-reviewed by the Interdisciplinary Team for further monitoring.

Complaint # , was substantiated (all or in part) in these findings. A. Based on observation, record review, and interview, the facility failed to ensure falls were fully investigated to determine the cause of falls and to ensure new interventions were developed and implemented to prevent further falls and to reduce risk of injury from falls for 3 (Residents Resident #3, # 5, and #6) of 4 (Residents # 2, #3, #5 and #6) case mix residents who had fallen since 1/17/14. The facility failed to ensure fall mats were used as care planned instead of full mattresses placed on the floor for 1 of 1 (Resident # 3) case mix residents with a full mattress on the floor next to the bed to decrease the potential for falls and injury. The facility failed to ensure beds were in low position as care planned for 1 (Resident # 6) of 4 (Residents # 2, #3, #5, and #6) case mix residents care planned for bed in lowest position. The facility failed to ensure Dycem pads were present in the wheel chairs as care planned to decrease the potential for falls for 1 (Resident # 6) of 3 (Residents # 5, #6, and #7) case mix residents care planned for Dycem pads. This failed practice resulted in a pattern of actual harm for Resident # 3, who fell on [DATE] which resulted in a fracture and who had a second fall on 2/16/14 which resulted in a second fracture. These failed practices had the potential to cause more than minimal harm for 22 residents in the facility who had falls since 1/17/14, 2 residents in the facility with full mattresses on the floor next to the bed, 13 residents in the facility care planned for bed in lowest position, and 5 residents in the facility care planned for Dycem pads according to the listings received from the MDS Coordinator on 3/14/14. The findings are: 1. The facility's Fall Prevention Program documented: "Fall Risk Assessment: All new admissions will have a complete Fall Risk Assessment on each resident. Reassessments are done quarterly ...The Fall Risk assessment includes condition parameters that utilized as indicators as to whether a resident is at risk for falls. If a resident scores a 10 or greater, the interdisciplinary Falls Committee will discuss the resident's risk and may put interventions into place to prevent falls ..., Nursing Care Plan: If the Resident is identified as being at risk for falls, it is noted in the care plan as problem ...Preventive interventions should be listed on the care plan. The Falls Care Plan must be revised following each fall. Safety Interventions as Needed: A fall preventions intervention should minimize the Resident's risk for falling and maintain functional independence and mobility...., Falling Star Program: Develop a visible system for all Employees to recognize each Resident at very high risk for falls. A star is placed on the Resident's nameplate outside the room, on all assistive devices and on his/her medical record if he/she is at very high risk for falls. This alerts employees that specific interventions are in the care plan. A list of residents at risk is placed in the nurse's station, CNA (Certified Nurse's Assistant) assignment books, and in Activities. The goal of the program is to raise awareness throughout the facility, not only with nursing staff but also with all employees ..., Fall Investigation: All residents found on the floor, witnessed or not are assessed as a fall. After the resident is cared for, an Incident Report with a Fall Investigation is completed by the nurse. This includes details on the circumstances surrounding the fall ...A full investigation of the fall is a fact-finding mission to uncover the cause and remove it if possible. The goal is to prevent future falls ..., Documentation of Falls: All falls are documented in the Resident's medical record. A detailed nurse's note and new immediate interventions should be noted in the care plan/fall action plan ..., Nursing will notify Rehab (Rehabilitation) of all falls and a fall screening will be completed in a timely manner ..., Interdisciplinary Falls Committee: The Falls Committee meets daily and weekly. The falls with immediate interventions are reviewed daily in the morning meeting. The Falls Committee meets once a week on a designated date/time. The Director of Nurses is the chairperson. Residents reviewed include 1) new residents who have fallen since last meeting and resident who have had a fall in last 60 days. 2) Appropriateness of intervention and care plan ... Education: To maintain a successful Falls Prevention Program, it requires frequent attentions and monitoring. It is not enough to implement it and let it go ... Key Fall Interventions: ...DO NOT LEAVE RESIDENTS UNATTENDED IN THE BATHROOM ..." 2. Resident # 3 had [DIAGNOSES REDACTED]. The resident's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/6/13 documented the resident scored 15 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status, required extensive assistance of 2 staff for transfers, required limited assistance of one staff when walking in room, had balance that was not steady, only able to stabilize with staff assistance, when moving from seated to standing, walking, turning around, moving on and off toilet, and surface to surface transfer, and had falls since the prior assessment with 1 fall with no injury. a. The resident's Fall Risk assessment dated [DATE] documented, "... Total Score above 10 represents HIGH RISK ..." The resident's total score was documented as "11." The Quarterly Data Collection Tool dated 8/2/13 and signed by the MDS Coordinator documented the Risk for Falls assessment as "Blank." On 3/14/14 at 11:07 a.m., the MDS Coordinator was asked, "Do you do quarterly assessments on skin, falls, etc." The MDS Coordinator stated, "Yes." The MDS Coordinator was asked, "For (Resident # 3) when was her last quarterly assessment done?" The MDS Coordinator stated, "Looks like 8/2/13." The MDS Coordinator was asked, "On that quarterly assessment what was her fall risk score?" The MDS Coordinator stated, "Oh my gosh, I missed that page completely. On her readmission assessment on 2/17/14 her fall risk score is 18." The MDS Coordinator was asked, "How did you miss the November 2013 quarterly assessment?" The MDS Coordinator stated, "I'm working 2 facilities here and (name of another long term care facility) doing MDSs and things fall through the cracks." b. The Resident Care Plan initiated on 8/15/12 with a review date of 8/26/13 documented, "Focus: Resident is at risk for falls/injuries (related to) Medication usage, Previous or History of Falls, Poor safety awareness from Dementia, Unsteady gait ... Interventions: ... Encourage resident to wait for CNA (Certified Nurse's Assistant) to respond to call light ... Offer to take resident to bathroom when giving 6:00 a.m. medication ... Pressure alarm to bed to alert staff of unsafe/unassisted transfers ... Provide assistance that is needed with mobility ... Pull alarm at all times when in chair or recliner to alert staff on unsafe/unassisted transfers ... Remind resident and reinforce safety awareness by: Educating and reminding resident to request assistance prior to ambulation/transfers ..." A Care Conference summary that was not dated, documented, "... Summary: ... Poor safety awareness which has resulted in falls - no injury ..." On 3/14/14 at 11:07 a.m., the MDS Coordinator was asked, "When was the undated care plan conference done?" The MDS Coordinator stated, "November 2013. I forgot to date it." The Certified Nursing Assistant (CNA) care plan that was not dated, documented, "... Safety: Encourage resident to wait for CNA to respond to call light. Offer to take resident to bathroom when giving 6:00 a.m. medication. Pressure alarm to bed to alert staff of unsafe/unassisted transfers ... Pull alarm at all times when in chair or recliner to alert staff of unsafe/unassisted transfers ..." c. Nurse's Notes dated 2/13/14, with no time noted, documented, "Resident found sitting on floor. Stated she wanted to sit on floor. She said she didn't fall. No injuries noted ..." This entry was signed by Licensed Practical Nurse (LPN) # 1. 1) The Resident Care Plan for falls was updated on 2/13/14. The care plan documented, "2/13/14 fall - no injury ... Intervention: 2/13/14 Personal alarm to chair to alert staff to assist." 2) Nurse's Notes dated 2/14/14 at 8:30 a.m., documented, "Resident leaning to (right) side, (complained of) pain in (right) shoulder (and) rib area when assisted to sit up. Resident fell on [DATE] (at) 11:00 a.m. X-ray ordered this a.m. ..." The radiology report dated 2/14/14 at 10:57 a.m. documented, "... Clinical History: Right chest pain ... Technique: Right ribs, 2 views ... Impression: Minimally displaced fracture of the right 4th rib." 3) The CNA care plan was updated on 2/14/14. The CNA care plan documented, "2/14/14. Fall (with) injury 2/13/14. (Fractured) 4th (right) rib. 2/14/14 Personal alarm ..." 4) The Fall Investigation form dated 2/13/14 documented, "... The primary purpose is to determine the facts surrounding the fall. This information will help determine the trends that may be present, as well as the factors, which may help prevent falls in the future ... 3). What is the resident's cognition? ... confused ... 9). Is assistance required to transfer/ambulate? Yes ... 12). What was resident doing prior to fall? Sitting in (wheelchair) ... Equipment: please check yes or no (if question doesn't apply check N/A (not applicable) ... 6). Was a walker near them? Yes. 7). Does the resident remember to use the walker? No. 8). Did they have on appropriate footwear? N/A ... 13). Is bed check/chair alarm used? No ... Physician notified. Date: 2/13/14. Time: 11:50 a.m. ... 1). What intervention was implemented after the fall? Personal alarm on chair. 2). Care plan must be updated with a new intervention 'Yes'. Conclusion (indicate what may have caused the accident). Resident (with) (increased) confusion. Signature of person completing form: (Blank). Date: (Blank). Supervisor Report. 1). Did resident sustain injury? No...4). Have falls been care planned? Yes. 5). Was Care Plan updated after fall? Yes...11). Was resident referred to (Physical Therapy)? No. 12). Was resident referred to (Occupational Therapy)? No. Signature of Supervisor: (Blank). Date: (Blank). Fall Committee Review/Recommendations: Personal alarm on chair to alert staff to assist." 5) On 3/14/14 at 10:00 a.m., CNA # 3, who was assigned to the resident's hall on 2/13/14 from 7:00 a.m. to 3:00 p.m. per the Daily Assignment Sheet, was asked, "Did you see (Resident # 3) fall?" CNA # 3 stated, "She fell 2 or 3 times that day. I came around the corner and I was walking down the hall and she was on the floor and she was saying, 'Help me.' I said what are you doing on the floor and she said, 'I was trying to take care of those kids.' She was delusional that day." CNA # 3 was asked, "Did you see her before the fall?" CNA # 3 stated, "She was in the wheel chair in her room and she would transfer from the wheel chair to the recliner on her own. She had wheeled up the door by her dresser and was trying to dress those kids and looking for kitty cats. She wasn't talking right." CNA # 3 was asked, "You said she fell more than once that day?" CNA # 3 stated, "Yes and I called (Interim Director of Nurses (DON)) when she fell in the room. Then she was out in the hall 20 minutes later and she was standing up with her alarm going off and I caught her and after I left work at 3:00 p.m. that day she fell again." CNA # 3 was asked, "Did she have any alarms prior to her fall?" CNA # 3 stated, "I can't say 100% if she did or didn't. Seems like I was clipping the personal alarm on her before her fall." CNA # 3 was asked, "Was her alarm going off when she was on the floor?" CNA # 3 stated, "No. I just heard her calling out help me." 6) On 3/14/14 at 10:20 a.m., LPN # 1 was asked, "Have you been working when she (Resident #3) fell ?" LPN # 1 stated, "Yes, on the (February) 13th." LPN # 1 was asked, "When was the fall and what happened?" LPN # 1 stated, "She fell around 11:30 a.m., she was in the dining room." LPN # 1 was asked, "In the dining room, the CNA who found her stated she was in her room?" LPN # 1 stated, "I thought she was in the dining room. I didn't chart it." LPN # 1 was asked, "What was she doing before the fall?" LPN # 1 stated, "She was sitting in her chair ..." LPN # 1 was asked, "Did she have an alarm?" LPN # 1 stated, "I don't remember it going off when I got to her." LPN # 1 was asked, "Have you reviewed the resident's care plan?" LPN # 1 stated, "No." LPN # 1 was asked, "How many falls did she have that day?" LPN # 1 stated, "Only 1." LPN # 1 was asked, "Did you fill out the (Fall Investigation form) for 2/13/14. LPN # 1 stated, "Yes but I didn't sign it, did I?" LPN # 1 was asked, "Did you assess the resident after the fall?" LPN # 1 stated, "No (Interim DON) did that." 7) On 3/14/14 at 10:37 a.m. , the Assistant Director of Nursing (ADON), who was interim Director of Nursing in February 2013, was asked: "On the (Fall Investigation form) dated 2/13/14, whose writing is on the supervisor's part?" The ADON stated, "That is mine." The ADON was asked to review the resident ' s care plan on falls. The ADON was then asked, "What was the date the wheel chair alarm was initiated?" The ADON stated, "8/5/12 initiated." The ADON was asked, "Did you know the resident had a care plan for a personal alarm before her fall on 2/13/14?" The ADON stated, "No. I know we put it on the chair on 2/13/14." The ADON was asked, "Were you involved in her fall on 2/13/14?" The ADON stated, "I believe I was there because I helped them put her back in her chair." The ADON was asked, "Where was she when she fell on [DATE]?" The ADON stated, "She was in her room close to the bathroom door." d. Nurse's Notes dated 2/16/14 at 5:55 a.m. and signed by LPN #2 documented, "CNA (initials of CNA) made this nurse aware that resident was in her room on floor. Upon entering room resident was observed on floor in middle of room lying on her (right) side (complained of) pain to (right) hip and stated she bumped her head. During assessment resident stated 'My head is okay, my (right) hip hurts. I want to go to (the) hospital' ..." The (hospital name) ED (Emergency Department) Provider Notes documented, "... Note time: 2/16/14 7:27 a.m... Clinical Impression: Final Diagnoses: [REDACTED]. XR (x-ray) hip 2 = (plus) (views) right ... Impression: 1. Osteopenia. 2. Cortical irregularity involving the inferior pubic ramus and pubis on the right which could represent an acute or healed fracture ... XR pelvis ... Impression: 1. Osteopenia. 2. Moderately displaced fracture involving the body of the right ilium extending into the hip joint with medical displacement of the fracture fragments. The ileal pectineal line is displaced approximately 1.5 cm (centimeters). Non-displaced fracture involving the right pubis and inferior pubic ramus ... CT Pelvis ... Impression: 1. Osteopenia. 2. Markedly comminuted and displaced fracture involving the right acetabulum with fracture lines extending through the anterior and posterior column of acetabulum and medial wall of acetabulum. Fracture lines also involve the far lateral portion of the superior pubic ramus and mid portion of the inferior pubic ramus. The femoral head and ischium are displaced medially and superiorly... Discharge Summary ... Note Time: 2/17/14 9:58 a.m ... Consults: Orthopedic surgery ... Hospital Course: Orthopedics was consulted, who recommended conservative management and follow-up with (name, orthopedic surgeon) in 6 weeks ... She was monitored overnight and deemed appropriate for discharge ..." 1) The Fall Investigation form dated 2/16/14 documented, "... The primary purpose is to determine the facts surrounding the fall. This information will help determine the trends that may be present, as well as the factors, which may help prevent falls in the future ... 3. What is the resident's cognition? (Alert and oriented times) 3 ... 7. When was last toileting time? Prior to fall. 8. How many falls has the resident had in the last 30 days? 2 ... 9. Is assistance required to transfer/ambulate? (At) times ... 12. What was resident doing prior to fall? (Blank) ... Equipment please check yes or no (if question doesn't apply check N/A (not applicable) ... 3. Do (wheelchair) brakes work? Yes. 4. Can resident operate the brakes? Yes. 5. Were the brakes on? No. 6. Was a walker near them? NA (not applicable). 7. Does the resident remember to use the walker? NA. 8. Did they have on appropriate footwear? Yes ... 11. Is bed check/chair alarm used? No ... 12. Was a call bell in place? Yes. Can resident use it? Yes. How long did it take to answer it? 3 (minutes). 13. Is bed check/chair alarm used? Yes. Did staff verify it was working before resident placed in bed or chair? Yes. Did it function properly? Yes. How long did it take to respond? Right away ... Physician notified. Date: 2/16/14. Time: 06:00 a.m. ... 1. What intervention was implemented after the fall? Encouraged to use call light for assistance. ... Conclusion (indicate what may have caused the accident). Resident (became impatient, tends to want things to happen immediately. Signature of person completing form: (LPN # 2). Date: 2/16/17. Supervisor Report. 1. Did resident sustain injury? Yes. 2. If so, what was the injury and how was it treated? (Fractured) pelvis, (diagnoses) upon x-ray (at) hospital. 4. Have falls been care planned? Yes. 5. Was Care Plan updated after fall? Yes. ... 11. Was resident referred to (Physical Therapy)? No. 12. Was resident referred to (Occupational Therapy)? No. Signature of Supervisor: (MDS Coordinator). Date: (2/16/14). Fall Committee Review/Recommendations: Reassess upon return from hospital." 2) On 3/14/14 at 11:40 a.m. LPN # 2 was asked, "Were you working on 2/16/14 when (Resident # 3) fell ?" LPN # 2 stated, "Yes." LPN # 2 was asked, "Was she up in a chair or in bed?" LPN # 2 stated, "She was toileting herself independently the last time I saw her before her fall. That was about 10 minutes before she fell . I saw her on the toilet." LPN # 2 was asked, "Did you send anyone to be in with her or stay with her yourself?" LPN # 2 stated, "The CNA was in the next room and she knew she was in the bathroom. Before her fall she was always able to toilet herself." LPN # 2 was asked, "Were you aware the resident had fallen on 2/13/14 and had fractured a rib?" LPN # 2 stated, "No. I found that out later." LPN # 2 was asked, "When you found her after the fall, what was her position?" LPN # 2 stated, "On her right side but not fully on the right, on the floor. Her head was toward her bed and her feet were toward the bathroom door, close to the bathroom." LPN # 2 was asked, "How did you find out the resident was on the floor?" LPN # 2 stated, "I heard her screaming and the CNA called me to tell me she on the floor." 3) On 3/14/14 at 2:00 p.m., CNA # 10 stated she had worked in the facility for 2 years on the 11:00 p.m. to 7:00 a.m. shift. CNA # 10 was asked, "Have you worked with (Resident # 3)?" CNA # 10 stated, "Yes." CNA # 10 was asked, "Is she (Resident #3) at risk for falls?" The CNA stated, "Yes." CNA # 10 was asked, "Did you see or know about the resident's fall on 2/16/14?" CNA # 10 stated, "I was in another room and I heard her yelling and went in to check and she was on the floor and I told the nurse." CNA # 10 was asked, "Did you hear an alarm going off?" CNA # 10 stated, "No, she was yelling that's why I checked her and the nurse said she'd went in there and found the resident on the toilet. She said she was on the toilet and by the time I got there she was out of the bathroom and she fell ." CNA # 10 was asked, "Did you help her to the bathroom before her fall?" CNA # 10 stated, "No." CNA # 10 was asked, "Was her alarm on earlier that shift?" CNA # 10 stated, "Yes but she could take it off and she did that a lot." 4) On 3/13/14 at 3:45 p.m., CNA # 5 stated she had worked in the facility since August 2013 on the 3:00 p.m. to 11:00 p.m. shift. CNA # 5 was asked, "Have you worked with (Resident # 3)?" CNA # 5 stated, "Yes." CNA # 5 was asked, "Is she at risk for falls?" CNA # 5 stated, "Yes." CNA # 5 was asked, "Did she have anything for fall/safety interventions before the fall in February?" CNA # 5 stated, "Yes a wheel chair alarm but it wasn't used much because she could help herself." 5) On 3/14/14 at 9:05 a.m., CNA # 9 stated she had worked in the facility for 6 months on the 7:00 a.m. to 3:00 p.m. shift. CNA # 9 was asked, "Have you worked with (Resident # 3)?" CNA # 9 stated, "Yes." CNA # 9 was asked, "Is she at risk for falls?" CNA # 9 stated, "Yes." CNA # 9 was asked, "Before her falls were any safety interventions in place?" CNA # 9 stated, "No. She could transfer on her own. She's had a personal alarm for as long as I can remember because she was trying to transfer and she was a 1 person assist. We moved it from the chair to the recliner." 6) The Resident Care Plan was updated on 2/16/14 and 2/17/14. The care plan documented, "2/16/14 (Telephone Order) send (resident) to (name) hospital for x-ray of (right) hip (related to) fall. 2/17/14 Risk for fall ... Intervention: Low bed, pressure alarm to alert staff, mat by bed." The CNA care plan was updated on 2/17/14. The CNA care plan documented, "2/16/14. Fall (with) injury to (hospital). (Fractured) pelvis.... 2/17/14 low bed (with) landing strip to (decrease) degree of injury should fall occur. 2/17/14 Pressure sensitive device to bed. 2/17/14 Personal alarm to chair when up ..." e. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/25/14 documented the resident scored 14 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), was totally dependent for transfers, and had falls since the prior assessment with 2 major injuries. f. The Resident Care Plan initiated on 8/15/12 with a review date of 2/17/14 documented, "Focus: Resident is at risk for falls/injuries (related to) Medication usage, Previous or History of Falls, Poor safety awareness from Dementia, Unsteady gait ... Interventions: ... 2/17/14 Low bed, pressure alarm to alert staff, mat by bed ..." On 3/12/14 at 5:46 a.m., 6:45 a.m., and 7:25 a.m., the resident was in bed with the bed low to the floor, approximately 15 inches from the top of the mattress to the floor. The left of the bed was against the wall and a full mattress was noted to the right of the bed. The full mattress next to the bed could cause the resident to trip if attempting to get out of bed or if stood on by the resident could increase the risk for falls. g. On 3/14/14 at 10:37 a.m. the Assistant Director of Nursing (ADON), who was interim Director of Nursing in February 2013, was asked, "Does the facility have a fall program?" The ADON stated, "I believe there is a falling star program. For resident's who have fallen or are at risk, there is a star system on the door and they are care planned with interventions to avoid falls." The ADON was asked, "Do you have a system where there is a list of residents with alarms and where they are checked?" The ADON stated, "I don't believe there is. CNAs do walking rounds when they first come on and check the alarms to see if they work." The ADON was asked, "Did you know the resident was already care planned for a personal alarm when she fell on [DATE]?" The ADON stated, "I don't believe she had one other wise I would not have put it on there (care plan)." The ADON was asked, "Who updated the CNA care plan and care plan in the chart?" The ADON stated, "I did. I didn't see an alarm on the chair so that was my intervention to put one on there." The ADON was asked, "Do you have interventions for safety on the MARs?" The ADON stated, "No." On 3/14/14 at 11:32 a.m., the Restorative Nursing Assistant (RNA) was asked, "Do you do anything with checking for or keeping a list of residents with alarms?" The RNA stated, "No. I'm usually told who needs one and I get it and put it on. We tried to keep a list once but with all the putting on and taking off it was too hard so we don't do that anymore." On 3/14/14 at 12:50 p.m., the Director of Nursing (DON) and Administrator were interviewed. The DON stated she had worked in the facility for 10 days. The DON and Administrator were asked, "Do you get witness statements from staff whenever a resident falls?" The Administrator stated, "No." The DON and Administrator were asked, "What are you doing to check alarms?" The DON stated, "The department heads do rounds and check if they function." The DON and Administrator were asked, "Do you have a list of residents who are supposed to have alarms, checking what's there is one thing, but how do they know who is supposed to have an alarm?" The DON stated, "No but we will have." The DON and Administrator were asked, "Were you aware (Resident # 3) was left unattended on the toilet when she fell and fractured her pelvis on 2/16/14?" The DON and Administrator stated, "No." h. On 3/14/14 at 7:45 a.m., LPN # 3 stated she had worked in the facility since January 2014 on the 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. shifts. LPN # 3 stated she usually worked as the resident's (Resident #3) charge nurse. LPN # 3 was asked, "How do you know what residents are at risk for falls?" LPN # 3 stated, "I consider all residents a fall risk." LPN # 3 was asked, "How do you know what safety interventions are to be in place for those residents?" LPN # 3 stated, "Care plan." LPN # 3 was asked, "Have you worked with (Resident # 3)?" LPN # 3 stated, "Yes." LPN # 3 was asked, "Is she at risk for falls?" LPN # 3 stated, "Yes." LPN # 3 was asked, "What new interventions were started after her fall?" LPN # 3 stated, "Before the fall she didn't have an alarm. She rolled around and transferred herself on and off the toilet." LPN # 3 was asked, "Did she have a personal alarm prior to her fall?" LPN # 3 stated, "I don't know." LPN # 3 was asked to review Resident # 3's Medication Administration Record (MAR). LPN # 3 was asked, "Do you see any safety interventions on the MAR?" LPN # 3 stated, "No." LPN # 3 was asked, "Do you review her care plan and how often?" LPN # 3 stated, "I haven't." On 3/14/14 at 10:20 a.m., LPN # 1 stated she had worked in the facility for 6 weeks and was Resident # 3's charge nurse on the 7:00 a.m. to 7:00 p.m. shift. LPN # 1 was asked, "How do you know which residents are at risk for falls?" LPN # 1 stated, "It's on the MAR (Medication Administration Record) and in the chart, on the care plan." LPN # 1 was asked to show this surveyor where it was on the MAR for (Resident # 3). LPN # 1 stated, "It's not there." LPN # 1 was asked, "How do you know what safety interventions are to be in place for those residents who are at risk for falls?" LPN # 1 stated, "In the care plan in the chart." LPN # 1 was asked, "Have you worked with (Resident # 3)?" LPN # 1 stated, "Yes." LPN # 1 was asked, "Is she at risk for falls?" LPN # 1 stated, "Yes." 3. Resident #5 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/13 documented the resident was moderately impaired in cognitive skills for daily decision making per a staff assessment for mental status, required limited assistance of one person for transfers/toilet use, required extensive assistance of one person for personal hygiene and was non-ambulatory. a. A resident Fall Risk assessment dated [DATE] documented, " ...Total score above 10 represents High Risk ..." The resident's total score was documented as "17." b. Nurse's Notes dated 2/8/14 at 0225 (2:25 a.m.) documented, "CNA (Certified Nursing Assistant) (initials)-made this nurse aware that resident had fallen this nurse immediately went to unit upon entering resident's rm (room) res. (resident) was observed lying flat on his back outside of wash room door, resident responsive denies pain." An OLTC (Office of Long Term Care) Witness Statement Form dated 2/8/14 at 2:30 a.m. and signed by CNA #7 documented, "I was walking down the hall and heard (Resident #5) yelling help, I went in his room and seen him on his back on the floor by bathroom door. I told him I was gonna get help and I would be right back." A Fall investigation dated 2/8/14 documented, "What is the resident's cognition? Impaired ... When was last toileting time? Fall occurred during unassisted toileting ... What intervention was implemented after the fall? Encouraged (Resident #5) to request assistance with transfers. Conclusion (Indicate what may have caused the accident) Resident continues to try and maintain independence, Fall Committee Review/Recommendations: Re-educate staff to offer toileting before/after meals and q (every) 2 hours during night-(Inservice). c. Nurse's Notes dated 2/16/14 at 0700 (7:00 a.m.) documented, "CNA made this nurse aware that resident was on floor NOC(night nurse) and am (morning) nurse went to resident's rm, upon entering rm resident observed in a sitting position with his back rested on bed "B", when asked resident what happen resident didn't respond-head to toe assessment attempted resident snatched away refusing to be touched, as far as we could see no new injuries-were observed at this time, assist x 3 to bed resident with no indication of pain-discomfort VS (vital signs) 97.9-76-20-138/72 resident encouraged to use call light for assistance ..." An OLTC Witness Statement Form dated 2/16/14 at 2:45 a.m., and signed by CNA #11 documented, "I had helped (Resident #5) to the bathroom stood by the door and he came out and I watched him walk towards his bed. He stumbled and before I could get to him and stop him he went down hitting his head on the wall. I called (name deleted) as soon as it happened." A Fall Investigation dated 2/17/14 documented, "What is the resident's cognition? Impaired; How many falls have they had in the last 30 days? 4; What interventions was implemented after the fall? In-service staff on toileting before and after meals as res. (resident) will allow; Did resident sustain injury? yes; If so, what was the injury and how was it treated? 2.5 cm (centimeter) abrasion to the R (right) side of top of head-very superficial-scant bleeding." There was nothing listed after Fall Committee Review/Recommendations. There was no intervention initiated to prevent further falls. d. Nurse's Notes dated 2/17/14 at 0245 (2:45 a.m.) documented, "CNA #11 made co-worker aware that resident had fallen this writer immediately went to unit upon entering rm resident was observed sitting in middle of floor with his pants partially down, resident was very agitated with CNA-resident unable to verbalize exactly what happened he made it clear that he wanted to get off floor back to his bed, assist x 2 to bed resident able to use extremities x 4 without difficulty ..." An OLTC Witness Statement Form dated 2/16/14 at 6:50 a.m. and signed by CNA # 11 documented, "I was cleaning up in the hall and I heard someone calling for help. I walked into (Resident #5's) room and found him on the floor on his right side." A Fall Investigation dated 2/17/14 documented, "What is the resident's cognition? Impaired; What intervention was implemented after the fall? In-service staff to toilet q 2 hours during noc (hour of sleep) and before and after meals." There was nothing listed after Fall Committee Review/Recommendations. There were no new interventions initiated to prevent further falls.

Complaint # , was substantiated (all or in part) in these findings. Based on record review, and interview nursing administration failed to ensure falls were fully investigated to determine the cause of falls and to ensure new interventions were developed or that plan interventions (fall mats; beds in low positions, and Dycem pads) were implemented to prevent further falls and to reduce risk of injury from falls for 3 (Residents Resident #3, # 5, and #6) of 4 (Residents # 2, #3, #5 and #6) case mix residents who had fallen since 1/17/14. This failed practice resulted in a pattern of actual harm for Resident # 3, who fell on [DATE] which resulted in a fracture and who had a second fall on 2/16/14 which resulted in a second fracture. These failed practices had the potential to cause more than minimal harm for 22 residents in the facility who had falls since 1/17/14, 2 residents in the facility with full mattresses on the floor next to the bed, 13 residents in the facility care planned for bed in lowest position, and 5 residents in the facility care planned for Dycem pads according to the listings received from the MDS Coordinator on 3/14/14. The findings are: 1. The facility's Job Description for the Director of Nursing documented, "... Summary: Responsible for organizing, planning, directing and evaluating nursing and other resident care services ... Essential Duties and Responsibilities: Ensures and oversees implementation of all (company name) nursing services and standards. Directs continuous evaluation of quality of care and resident education by nursing services ...Reviews and interprets records and reports to ascertain compliance with established policies and procedures ...Responsible for the development of and maintenance of nursing service objectives and standards of nursing practice ...Conducts and performs rounds to monitor and evaluate the quality and appropriateness of nursing care ...Oversee and ensures that all task and responsibilities of the Nursing Services Department are in compliance with State and Federal guidelines. Maintains current knowledge and understanding of the same ..." 2. The facility's Fall Prevention Program documented: "Fall Risk Assessment: All new admissions will have a complete Fall Risk Assessment on each resident. Reassessments are done quarterly ...The Fall Risk assessment includes condition parameters that utilized as indicators as to whether a resident is at risk for falls. If a resident scores a 10 or greater, the interdisciplinary Falls Committee will discuss the resident's risk and may put interventions into place to prevent falls ... Nursing Care Plan: If the Resident is identified as being at risk for falls, it is noted in the care plan as problem ...Preventive interventions should be listed on the care plan. The Falls Care Plan must be revised following each fall. Safety Interventions as Needed: A fall preventions intervention should minimize the Resident's risk for falling and maintain functional independence and mobility.... Falling Star Program: Develop a visible system for all Employees to recognize each Resident at very high risk for falls. A star is placed on the Resident's nameplate outside the room, on all assistive devices and on his/her medical record if he/she is at very high risk for falls. This alerts employees that specific interventions are in the care plan. A list of residents at risk is placed in the nurse's station, CNA (Certified Nurse's Assistant) assignment books, and in Activities. The goal of the program is to raise awareness throughout the facility, not only with nursing staff but also with all employees ... Fall Investigation: All residents found on the floor, witnessed or not are assessed as a fall. After the resident is cared for, an Incident Report with a Fall Investigation is completed by the nurse. This includes details on the circumstances surrounding the fall ...A full investigation of the fall is a fact-finding mission to uncover the cause and remove it if possible. The goal is to prevent future falls ... Documentation of Falls: All falls are documented in the Resident's medical record. A detailed nurse's note and new immediate interventions should be noted in the care plan/fall action plan ... Nursing will notify Rehab (Rehabilitation) of all falls and a fall screening will be completed in a timely manner ... Interdisciplinary Falls Committee: The Falls Committee meets daily and weekly. The falls with immediate interventions are reviewed daily in the morning meeting. The Falls Committee meets once a week on a designated date/time. The Director of Nurses is the chairperson. Residents reviewed include 1) new residents who have fallen since last meeting and resident who have had a fall in last 60 days. 2) Appropriateness of intervention and care plan ... Education: To maintain a successful Falls Prevention Program, it requires frequent attentions and monitoring. It is not enough to implement it and let it go ... Key Fall Interventions: ...DO NOT LEAVE RESIDENTS UNATTENDED IN THE BATHROOM ..." 3. Resident # 3 had [DIAGNOSES REDACTED]. The resident's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/6/13 documented the resident scored 15 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status, required extensive assistance of 2 staff for transfers, required limited assistance of one staff when walking in room, had balance that was not steady, only able to stabilize with staff assistance, when moving from seated to standing, walking, turning around, moving on and off toilet, and surface to surface transfer, and had falls since the prior assessment with 1 fall with no injury. a. The resident's Fall Risk assessment dated [DATE] documented, "... Total Score above 10 represents HIGH RISK ..." The resident's total score was documented as "11." The Quarterly Data Collection Tool dated 8/2/13 and signed by the MDS Coordinator documented the Risk for Falls assessment as "Blank." On 3/14/14 at 11:07 a.m., the MDS Coordinator was asked, "Do you do quarterly assessments on skin, falls, etc." The MDS Coordinator stated, "Yes." The MDS Coordinator was asked, "For (Resident # 3) when was her last quarterly assessment done?" The MDS Coordinator stated, "Looks like 8/2/13." The MDS Coordinator was asked, "On that quarterly assessment what was her fall risk score?" The MDS Coordinator stated, "Oh my gosh, I missed that page completely. On her readmission assessment on 2/17/14 her fall risk score is 18." The MDS Coordinator was asked, "How did you miss the November 2013 quarterly assessment?" The MDS Coordinator stated, "I'm working 2 facilities here and (name of another long term care facility) doing MDSs and things fall through the cracks." b. The Resident Care Plan initiated on 8/15/12 with a review date of 8/26/13 documented, "Focus: Resident is at risk for falls/injuries (related to) Medication usage, Previous or History of Falls, Poor safety awareness from Dementia, Unsteady gait ... Interventions: ... Encourage resident to wait for CNA (Certified Nurse's Assistant) to respond to call light ... Offer to take resident to bathroom when giving 6:00 a.m. medication ... Pressure alarm to bed to alert staff of unsafe/unassisted transfers ... Provide assistance that is needed with mobility ... Pull alarm at all times when in chair or recliner to alert staff on unsafe/unassisted transfers ... Remind resident and reinforce safety awareness by: Educating and reminding resident to request assistance prior to ambulation/transfers ..." A Care Conference summary that was not dated, documented, "... Summary: ... Poor safety awareness which has resulted in falls - no injury ..." On 3/14/14 at 11:07 a.m., the MDS Coordinator was asked, "When was the undated care plan conference done?" The MDS Coordinator stated, "November 2013. I forgot to date it." The Certified Nursing Assistant (CNA) care plan that was not dated, documented, "... Safety: Encourage resident to wait for CNA to respond to call light. Offer to take resident to bathroom when giving 6:00 a.m. medication. Pressure alarm to bed to alert staff of unsafe/unassisted transfers ... Pull alarm at all times when in chair or recliner to alert staff of unsafe/unassisted transfers ..." c. Nurse's Notes dated 2/13/14, with no time noted, documented, "Resident found sitting on floor. Stated she wanted to sit on floor. She said she didn't fall. No injuries noted ..." This entry was signed by Licensed Practical Nurse (LPN) # 1. 1) The Resident Care Plan for falls was updated on 2/13/14. The care plan documented, "2/13/14 fall - no injury ... Intervention: 2/13/14 Personal alarm to chair to alert staff to assist." 2) Nurse's Notes dated 2/14/14 at 8:30 a.m., documented, "Resident leaning to (right) side, (complained of) pain in (right) shoulder (and) rib area when assisted to sit up. Resident fell on [DATE] (at) 11:00 a.m. X-ray ordered this a.m. ..." The radiology report dated 2/14/14 at 10:57 a.m. documented, "... Clinical History: Right chest pain ... Technique: Right ribs, 2 views ... Impression: Minimally displaced [MEDICAL CONDITION] 4th rib." 3) The CNA care plan was updated on 2/14/14. The CNA care plan documented, "2/14/14. Fall (with) injury 2/13/14. (Fractured) 4th (right) rib. 2/14/14 Personal alarm ..." 4) The Fall Investigation form dated 2/13/14 documented, "... The primary purpose is to determine the facts surrounding the fall. This information will help determine the trends that may be present, as well as the factors, which may help prevent falls in the future ... 3). What is the resident's cognition? ... confused ... 9). Is assistance required to transfer/ambulate? Yes ... 12). What was resident doing prior to fall? Sitting in (wheelchair) ... Equipment: please check yes or no (if question doesn't apply check N/A (not applicable) ... 6). Was a walker near them? Yes. 7). Does the resident remember to use the walker? No. 8). Did they have on appropriate footwear? N/A ... 13). Is bed check/chair alarm used? No ... Physician notified. Date: 2/13/14. Time: 11:50 a.m. ... 1). What intervention was implemented after the fall? Personal alarm on chair. 2). Care plan must be updated with a new intervention 'Yes'. Conclusion (indicate what may have caused the accident). Resident (with) (increased) confusion. Signature of person completing form: (Blank). Date: (Blank). Supervisor Report. 1). Did resident sustain injury? No...4). Have falls been care planned? Yes. 5). Was Care Plan updated after fall? Yes...11). Was resident referred to (Physical Therapy)? No. 12). Was resident referred to (Occupational Therapy)? No. Signature of Supervisor: (Blank). Date: (Blank). Fall Committee Review/Recommendations: Personal alarm on chair to alert staff to assist." 5) On 3/14/14 at 10:00 a.m., CNA # 3, who was assigned to the resident's hall on 2/13/14 from 7:00 a.m. to 3:00 p.m. per the Daily Assignment Sheet, was asked, "Did you see (Resident # 3) fall?" CNA # 3 stated, "She fell 2 or 3 times that day. I came around the corner and I was walking down the hall and she was on the floor and she was saying, 'Help me.' I said what are you doing on the floor and she said, 'I was trying to take care of those kids.' She was delusional that day." CNA # 3 was asked, "Did you see her before the fall?" CNA # 3 stated, "She was in the wheel chair in her room and she would transfer from the wheel chair to the recliner on her own. She had wheeled up the door by her dresser and was trying to dress those kids and looking for kitty cats. She wasn't talking right." CNA # 3 was asked, "You said she fell more than once that day?" CNA # 3 stated, "Yes and I called (Interim Director of Nurses (DON)) when she fell in the room. Then she was out in the hall 20 minutes later and she was standing up with her alarm going off and I caught her and after I left work at 3:00 p.m. that day she fell again." CNA # 3 was asked, "Did she have any alarms prior to her fall?" CNA # 3 stated, "I can't say 100% if she did or didn't. Seems like I was clipping the personal alarm on her before her fall." CNA # 3 was asked, "Was her alarm going off when she was on the floor?" CNA # 3 stated, "No. I just heard her calling out help me." 6) On 3/14/14 at 10:20 a.m., LPN # 1 was asked, "Have you been working when she (Resident #3) fell ?" LPN # 1 stated, "Yes, on the (February) 13th." LPN # 1 was asked, "When was the fall and what happened?" LPN # 1 stated, "She fell around 11:30 a.m., she was in the dining room." LPN # 1 was asked, "In the dining room, the CNA who found her stated she was in her room?" LPN # 1 stated, "I thought she was in the dining room. I didn't chart it." LPN # 1 was asked, "What was she doing before the fall?" LPN # 1 stated, "She was sitting in her chair ..." LPN # 1 was asked, "Did she have an alarm?" LPN # 1 stated, "I don't remember it going off when I got to her." LPN # 1 was asked, "Have you reviewed the resident's care plan?" LPN # 1 stated, "No." LPN # 1 was asked, "How many falls did she have that day?" LPN # 1 stated, "Only 1." LPN # 1 was asked, "Did you fill out the (Fall Investigation form) for 2/13/14. LPN # 1 stated, "Yes but I didn't sign it, did I?" LPN # 1 was asked, "Did you assess the resident after the fall?" LPN # 1 stated, "No (Interim DON) did that." 7) On 3/14/14 at 10:37 a.m. , the Assistant Director of Nursing (ADON), who was interim Director of Nursing in February 2013, was asked: "On the (Fall Investigation form) dated 2/13/14, whose writing is on the supervisor's part?" The ADON stated, "That is mine." The ADON was asked to review the resident ' s care plan on falls. The ADON was then asked, "What was the date the wheel chair alarm was initiated?" The ADON stated, "8/5/12 initiated." The ADON was asked, "Did you know the resident had a care plan for a personal alarm before her fall on 2/13/14?" The ADON stated, "No. I know we put it on the chair on 2/13/14." The ADON was asked, "Were you involved in her fall on 2/13/14?" The ADON stated, "I believe I was there because I helped them put her back in her chair." The ADON was asked, "Where was she when she fell on [DATE]?" The ADON stated, "She was in her room close to the bathroom door." d. Nurse's Notes dated 2/16/14 at 5:55 a.m. and signed by LPN #2 documented, "CNA (initials of CNA) made this nurse aware that resident was in her room on floor. Upon entering room resident was observed on floor in middle of room lying on her (right) side (complained of) pain to (right) hip and stated she bumped her head. During assessment resident stated 'My head is okay, my (right) hip hurts. I want to go to (the) hospital' ..." The (hospital name) ED (Emergency Department) Provider Notes documented, "... Note time: 2/16/14 7:27 a.m.,.. Clinical Impression: Final Diagnoses: [REDACTED]. XR (x-ray) hip 2 = (plus) (views) right ... Impression: 1. Osteopenia. 2. Cortical irregularity involving the inferior pubic ramus and pubis on the right which could represent an acute or healed fracture ... XR pelvis ... Impression: 1. Osteopenia. 2. Moderately displaced fracture involving the body of the right ilium extending into the hip joint with medical displacement of the fracture fragments. The ileal pectineal line is displaced approximately 1.5 cm (centimeters). Non-displaced fracture involving the right pubis and inferior pubic ramus ... CT Pelvis ... Impression: 1. Osteopenia. 2. Markedly comminuted and displaced fracture involving the right acetabulum with fracture lines extending through the anterior and posterior column of acetabulum and medial wall of acetabulum. Fracture lines also involve the far lateral portion of the superior pubic ramus and mid portion of the inferior pubic ramus. The femoral head and ischium are displaced medially and superiorly ... Discharge Summary ... Note Time: 2/17/14 9:58 a.m. ... Consults: Orthopedic surgery ... Hospital Course: Orthopedics was consulted, who recommended conservative management and follow-up with (name, orthopedic surgeon) in 6 weeks ... She was monitored overnight and deemed appropriate for discharge ..." 1) The Fall Investigation form dated 2/16/14 documented, "... The primary purpose is to determine the facts surrounding the fall. This information will help determine the trends that may be present, as well as the factors, which may help prevent falls in the future ... 3. What is the resident's cognition? (Alert and oriented times) 3 ... 7. When was last toileting time? Prior to fall. 8. How many falls has the resident had in the last 30 days? 2 ... 9. Is assistance required to transfer/ambulate? (At) times ... 12. What was resident doing prior to fall? (Blank) ... Equipment please check yes or no (if question doesn't apply check N/A (not applicable) ... 3. Do (wheelchair) brakes work? Yes. 4. Can resident operate the brakes? Yes. 5. Were the brakes on? No. 6. Was a walker near them? NA (not applicable). 7. Does the resident remember to use the walker? NA. 8. Did they have on appropriate footwear? Yes ... 11. Is bed check/chair alarm used? No ... 12. Was a call bell in place? Yes. Can resident use it? Yes. How long did it take to answer it? 3 (minutes). 13. Is bed check/chair alarm used? Yes. Did staff verify it was working before resident placed in bed or chair? Yes. Did it function properly? Yes. How long did it take to respond? Right away ... Physician notified. Date: 2/16/14. Time: 06:00 a.m. ... 1. What intervention was implemented after the fall? Encouraged to use call light for assistance. ... Conclusion (indicate what may have caused the accident). Resident (became impatient, tends to want things to happen immediately. Signature of person completing form: (LPN # 2). Date: 2/16/17. Supervisor Report. 1. Did resident sustain injury? Yes. 2. If so, what was the injury and how was it treated? (Fractured) pelvis, (diagnoses) upon x-ray (at) hospital. 4. Have falls been care planned? Yes. 5. Was Care Plan updated after fall? Yes. ... 11. Was resident referred to (Physical Therapy)? No. 12. Was resident referred to (Occupational Therapy)? No. Signature of Supervisor: (MDS Coordinator). Date: (2/16/14). Fall Committee Review/Recommendations: Reassess upon return from hospital." 2) On 3/14/14 at 11:40 a.m. LPN # 2 was asked, "Were you working on 2/16/14 when (Resident # 3) fell ?" LPN # 2 stated, "Yes." LPN # 2 was asked, "Was she up in a chair or in bed?" LPN # 2 stated, "She was toileting herself independently the last time I saw her before her fall. That was about 10 minutes before she fell . I saw her on the toilet." LPN # 2 was asked, "Did you send anyone to be in with her or stay with her yourself?" LPN # 2 stated, "The CNA was in the next room and she knew she was in the bathroom. Before her fall she was always able to toilet herself." LPN # 2 was asked, "Were you aware the resident had fallen on 2/13/14 and had fractured a rib?" LPN # 2 stated, "No. I found that out later." LPN # 2 was asked, "When you found her after the fall, what was her position?" LPN # 2 stated, "On her right side but not fully on the right, on the floor. Her head was toward her bed and her feet were toward the bathroom door, close to the bathroom." LPN # 2 was asked, "How did you find out the resident was on the floor?" LPN # 2 stated, "I heard her screaming and the CNA called me to tell me she on the floor." 3) On 3/14/14 at 2:00 p.m., CNA # 10 stated she had worked in the facility for 2 years on the 11:00 p.m. to 7:00 a.m. shift. CNA # 10 was asked, "Have you worked with (Resident # 3)?" CNA # 10 stated, "Yes." CNA # 10 was asked, "Is she (Resident #3) at risk for falls?" The CNA stated, "Yes." CNA # 10 was asked, "Did you see or know about the resident's fall on 2/16/14?" CNA # 10 stated, "I was in another room and I heard her yelling and went in to check and she was on the floor and I told the nurse." CNA # 10 was asked, "Did you hear an alarm going off?" CNA # 10 stated, "No, she was yelling that's why I checked her and the nurse said she'd went in there and found the resident on the toilet. She said she was on the toilet and by the time I got there she was out of the bathroom and she fell ." CNA # 10 was asked, "Did you help her to the bathroom before her fall?" CNA # 10 stated, "No." CNA # 10 was asked, "Was her alarm on earlier that shift?" CNA # 10 stated, "Yes but she could take it off and she did that a lot." 4) On 3/13/14 at 3:45 p.m., CNA # 5 stated she had worked in the facility since August 2013 on the 3:00 p.m. to 11:00 p.m. shift. CNA # 5 was asked, "Have you worked with (Resident # 3)?" CNA # 5 stated, "Yes." CNA # 5 was asked, "Is she at risk for falls?" CNA # 5 stated, "Yes." CNA # 5 was asked, "Did she have anything for fall/safety interventions before the fall in February?" CNA # 5 stated, "Yes a wheel chair alarm but it wasn't used much because she could help herself." 5) On 3/14/14 at 9:05 a.m., CNA # 9 stated she had worked in the facility for 6 months on the 7:00 a.m. to 3:00 p.m. shift. CNA # 9 was asked, "Have you worked with (Resident # 3)?" CNA # 9 stated, "Yes." CNA # 9 was asked, "Is she at risk for falls?" CNA # 9 stated, "Yes." CNA # 9 was asked, "Before her falls were any safety interventions in place?" CNA # 9 stated, "No. She could transfer on her own. She's had a personal alarm for as long as I can remember because she was trying to transfer and she was a 1 person assist. We moved it from the chair to the recliner." 6) The Resident Care Plan was updated on 2/16/14 and 2/17/14. The care plan documented, "2/16/14 (Telephone Order) send (resident) to (name) hospital for x-ray of (right) hip (related to) fall. 2/17/14 Risk for fall ... Intervention: Low bed, pressure alarm to alert staff, mat by bed." The CNA care plan was updated on 2/17/14. The CNA care plan documented, "2/16/14. Fall (with) injury to (hospital). (Fractured) pelvis.... 2/17/14 low bed (with) landing strip to (decrease) degree of injury should fall occur. 2/17/14 Pressure sensitive device to bed. 2/17/14 Personal alarm to chair when up ..." e. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/25/14 documented the resident scored 14 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), was totally dependent for transfers, and had falls since the prior assessment with 2 major injuries. f. The Resident Care Plan initiated on 8/15/12 with a review date of 2/17/14 documented, "Focus: Resident is at risk for falls/injuries (related to) Medication usage, Previous or History of Falls, Poor safety awareness from Dementia, Unsteady gait ... Interventions: ... 2/17/14 Low bed, pressure alarm to alert staff, mat by bed ..." On 3/12/14 at 5:46 a.m., 6:45 a.m., and 7:25 a.m., the resident was in bed with the bed low to the floor, approximately 15 inches from the top of the mattress to the floor. The left of the bed was against the wall and a full mattress was noted to the right of the bed. The full mattress next to the bed could cause the resident to trip if attempting to get out of bed or if stood on by the resident could increase the risk for falls. g. On 3/14/14 at 10:37 a.m. the Assistant Director of Nursing (ADON), who was interim Director of Nursing in February 2013, was asked, "Does the facility have a fall program?" The ADON stated, "I believe there is a falling star program. For resident's who have fallen or are at risk, there is a star system on the door and they are care planned with interventions to avoid falls." The ADON was asked, "Do you have a system where there is a list of residents with alarms and where they are checked?" The ADON stated, "I don't believe there is. CNAs do walking rounds when they first come on and check the alarms to see if they work." The ADON was asked, "Did you know the resident was already care planned for a personal alarm when she fell on [DATE]?" The ADON stated, "I don't believe she had one other wise I would not have put it on there (care plan)." The ADON was asked, "Who updated the CNA care plan and care plan in the chart?" The ADON stated, "I did. I didn't see an alarm on the chair so that was my intervention to put one on there." The ADON was asked, "Do you have interventions for safety on the MARs?" The ADON stated, "No." On 3/14/14 at 11:32 a.m., the Restorative Nursing Assistant (RNA) was asked, "Do you do anything with checking for or keeping a list of residents with alarms?" The RNA stated, "No. I'm usually told who needs one and I get it and put it on. We tried to keep a list once but with all the putting on and taking off it was too hard so we don't do that anymore." On 3/14/14 at 12:50 p.m., the Director of Nursing (DON) and Administrator were interviewed. The DON stated she had worked in the facility for 10 days. The DON and Administrator were asked, "Do you get witness statements from staff whenever a resident falls?" The Administrator stated, "No." The DON and Administrator were asked, "What are you doing to check alarms?" The DON stated, "The department heads do rounds and check if they function." The DON and Administrator were asked, "Do you have a list of residents who are supposed to have alarms, checking what's there is one thing, but how do they know who is supposed to have an alarm?" The DON stated, "No but we will have." The DON and Administrator were asked, "Were you aware (Resident # 3) was left unattended on the toilet when she fell and fractured her pelvis on 2/16/14?" The DON and Administrator stated, "No." h. On 3/14/14 at 7:45 a.m., LPN # 3 stated she had worked in the facility since January 2014 on the 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. shifts. LPN # 3 stated she usually worked as the resident's (Resident #3) charge nurse. LPN # 3 was asked, "How do you know what residents are at risk for falls?" LPN # 3 stated, "I consider all residents a fall risk." LPN # 3 was asked, "How do you know what safety interventions are to be in place for those residents?" LPN # 3 stated, "Care plan." LPN # 3 was asked, "Have you worked with (Resident # 3)?" LPN # 3 stated, "Yes." LPN # 3 was asked, "Is she at risk for falls?" LPN # 3 stated, "Yes." LPN # 3 was asked, "What new interventions were started after her fall?" LPN # 3 stated, "Before the fall she didn't have an alarm. She rolled around and transferred herself on and off the toilet." LPN # 3 was asked, "Did she have a personal alarm prior to her fall?" LPN # 3 stated, "I don't know." LPN # 3 was asked to review Resident # 3's Medication Administration Record [REDACTED]?" LPN # 3 stated, "No." LPN # 3 was asked, "Do you review her care plan and how often?" LPN # 3 stated, "I haven't." On 3/14/14 at 10:20 a.m., LPN # 1 stated she had worked in the facility for 6 weeks and was Resident # 3's charge nurse on the 7:00 a.m. to 7:00 p.m. shift. LPN # 1 was asked, "How do you know which residents are at risk for falls?" LPN # 1 stated, "It's on the MAR (Medication Administration Record) and in the chart, on the care plan." LPN # 1 was asked to show this surveyor where it was on the MAR for (Resident # 3). LPN # 1 stated, "It's not there." LPN # 1 was asked, "How do you know what safety interventions are to be in place for those residents who are at risk for falls?" LPN # 1 stated, "In the care plan in the chart." LPN # 1 was asked, "Have you worked with (Resident # 3)?" LPN # 1 stated, "Yes." LPN # 1 was asked, "Is she at risk for falls?" LPN # 1 stated, "Yes." 4. Resident #5 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/13 documented the resident was moderately impaired in cognitive skills for daily decision making per a staff assessment for mental status, required limited assistance of one person for transfers/toilet use, required extensive assistance of one person for personal hygiene and was non-ambulatory. a. A resident Fall Risk assessment dated [DATE] documented, " ...Total score above 10 represents High Risk ..." The resident's total score was documented as "17." b. Nurse's Notes dated 2/8/14 at 0225 (2:25 a.m.) documented, "CNA (Certified Nursing Assistant) (initials)-made this nurse aware that resident had fallen this nurse immediately went to unit upon entering resident's rm (room) res. (resident) was observed lying flat on his back outside of wash room door, resident responsive denies pain." An OLTC (Office of Long Term Care) Witness Statement Form dated 2/8/14 at 2:30 a.m. and signed by CNA #7 documented, "I was walking down the hall and heard (Resident #5) yelling help, I went in his room and seen him on his back on the floor by bathroom door. I told him I was gonna get help and I would be right back." A Fall investigation dated 2/8/14 documented, "What is the resident's cognition? Impaired ... When was last toileting time? Fall occurred during unassisted toileting ... What intervention was implemented after the fall? Encouraged (Resident #5) to request assistance with transfers. Conclusion (Indicate what may have caused the accident) Resident continues to try and maintain independence, Fall Committee Review/Recommendations: Re-educate staff to offer toileting before/after meals and q (every) 2 hours during night-(Inservice). c. Nurse's Notes dated 2/16/14 at 0700 (7:00 a.m.) documented, "CNA made this nurse aware that resident was on floor NOC(night nurse) and am (morning) nurse went to resident's rm, upon entering rm resident observed in a sitting position with his back rested on bed "B", when asked resident what happen resident didn't respond-head to toe assessment attempted resident snatched away refusing to be touched, as far as we could see no new injuries-were observed at this time, assist x 3 to bed resident with no indication of pain-discomfort VS (vital signs) 97.9-76-20-138/72 resident encouraged to use call light for assistance ..." An OLTC Witness Statement Form dated 2/16/14 at 2:45 a.m. and signed by CNA #11 documented, "I had helped (Resident #5) to the bathroom stood by the door and he came out and I watched him walk towards his bed. He stumbled and before I could get to him and stop him he went down hitting his head on the wall. I called (name deleted) as soon as it happened." A Fall Investigation dated 2/17/14 documented, "What is the resident's cognition? Impaired; How many falls have they had in the last 30 days? 4; What interventions was implemented after the fall? In-service staff on toileting before and after meals as res. (resident) will allow; Did resident sustain injury? yes; If so, what was the injury and how was it treated? 2.5 cm (centimeter) abrasion to the R (right) side of top of head-very superficial-scant bleeding." There was nothing listed after Fall Committee Review/Recommendations. There was no intervention initiated to prevent further falls. d. Nurse's Notes dated 2/17/14 at 0245 (2:45 a.m.) documented, "CNA #11 made co-worker aware that resident had fallen this writer immediately went to unit upon entering rm resident was observed sitting in middle of floor with his pants partially down, resident was very agitated with CNA-resident unable to verbalize exactly what happened he made it clear that he wanted to get off floor back to his bed, assist x 2 to bed resident able to use extremities x 4 without difficulty ..." An OLTC Witness Statement Form dated 2/16/14 at 6:60 a.m. and signed by CNA #11 documented, "I was cleaning up in the hall and I heard someone calling for help. I walked into (Resident #5's) room and found him on the floor on his right side." A Fall Investigation dated 2/17

Complaint # was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure the physician was notified of the unresponsiveness and lack of fluid consumption for 1 (Resident #6) of 1 case mix resident with physician orders [REDACTED]. The failed practice resulted in actual harm to Resident #6, who became unarousable, did not drink any fluids for over 15 hours, exhibited signs of decreased urine output and subsequently was found without vital signs after receiving a PRN dose of intramuscular [MEDICATION NAME]. The facility also failed to notify the resident's family of the resident's change in condition for 1 (Resident #6) of 1 case mix resident with physician orders [REDACTED]. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial Minimum Data Set with an assessment reference date of 3/9/12 documented the resident was severely impaired in cognitive skills for daily decision-making per a staff assessment of mental status, totally dependent on two plus persons for all activities of daily living, was not ambulatory and had physical and verbal behavioral symptoms directed toward others that occured every 1 to 3 days. a. The (geriatric psychiatric care provider) Discharge Summary dated 3/8/12 documented the resident was admitted there on 1/31/12 and, "Program of care: The patient was titrated on Clonzepam to decrease severity of aggression due to severe anxiety. It was felt that antipsychoic medications that were tried during this hospitalization contributed more to an akathisia and extrapyramidal side effects and more misery and suffering and subsequently these were discontinued". b. The Nurse's Note dated 3/9/12 at 12:01 a.m. documented, "Resident increase agitated and restless - climbing out of bed and geri chair-combative with staff - APN (Advance Practice Nurse) notified, received order for [MEDICATION NAME] 10 mg (milligrams) IM (intramuscular) now x (times) 1 related to agitation - order written and noted medications given." The March 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The next Nurse's Note on 3/9/12 at 2:30 p.m. documented, "Res (Resident) cont. (continues) to be sleeping since IM [MEDICATION NAME] given on last shift. Res meds (medications) held for entire shift d/t (due to) drowsiness. Res T & (and) R (turned and repositoned) per staff. Incont (incontinent) care provided per staff. Res without s/s (signs and symptoms) of distress at this time." There was no documentation the physician was consulted regarding the drowsiness and medications being held. The Nurse's Note dated 3/9/12 at 3:00 p.m. documented, "Res son here & unaware that IM [MEDICATION NAME] was given during 11-7 (11:00 p.m. - 7:00 a.m.) shift resulting in drowsiness. Son requests to be notified immediately of all new orders regardless of time of day." The Nurse's Note dated 3/9/12 at 4:30 p.m. documented, "At approx (approximately) 4:30 p.m., this nurse sent CNA (Certified Nursing Assistant) to prepare res for dinner. CNA immediately came to get this nurse. Upon entering room, this nurse then paged for LPN (Licensed Practical Nurse #1) and DON (Director of Nursing) to room stat (immediately) and got the emergency cart. (LPN #1) called 911, the DON & this nurse began compressions. 911 EMS (Emergency Medical Services) arrived at approx 4:40 p.m. Called res son & informed that res had a sudden change in condition and was going to be transported to (hospital) via 911. At approx 5:00 p.m., EMS exited building with resident for transport to (hosptial) ER (emergency room )." The Nurse's Notes dated 3/9/12 at 6:30 p.m. documented, "(LPN #1) called ER to check res. status. ER nurse reported res did not make it out of ER, Admin (Administrator) and DON notified." c. On 6/4/12 at 10:45 a.m, the surveyor asked CNA #1, who was on duty at the facility during the 7:00 a.m. - 3:00 p.m. shift on 3/9/12, "What was your assessment of the resident when you came on (duty)?" CNA #1 stated, "He was sleeping." The surveyor asked, "Could you arouse him?" The CNA stated, "No. I touched his shoulder and called his name and he just snored." The surveyor asked, "Did the resident eat or drink anything during your shift?" The CNA stated, "No." The surveyor asked, "Did you report it to anyone?" The CNA stated, "Yes, my charge nurse (LPN #3)". d. On 6/4/12 at 11:27 a.m., CNA #2, who was on duty at the facility during the 7:00 a.m. - 3:00 p.m. shift on 3/9/12, stated that the resident was very sleepy and she was told that he had been up all night. She stated they (the two CNA's) tried to wake him up but he would not arouse. She stated that she reported it to the charge Nurse, LPN #3, who went down and checked him. She stated that the resident did not eat or drink during her shift and his brief was barely wet when they changed him. e. On 6/4/12 at 6:00 p.m., LPN #3 stated that she could not get the resident awake to give him his medications. She stated that the resident's respirations changed when she touched him, so she thought he was sleeping. She stated she knew that he didn't eat or drink anything and went and got the DON, who looked back and saw that he got the [MEDICATION NAME] and that he needed to sleep. She stated the CNAs had told her that he would not wake up to eat or drink. The surveyor asked, "Did you notify the physician of the resident's unresponsiveness?" The LPN stated, "No, we thought he was just sleeping." f. On 6/4/12 at 6:10 p.m., the DON stated, "the son was upset because no one called him" and stated she in-serviced the staff immediately about that. The surveyor asked, "Is it a policy of this facility that the physician be notified if a resident does not eat or drink for 2 meals?" The DON stated, "Yes, it is." g. An Internal Investigation/Review Report dated 6/3/12 was provided by the DON on 6/4/12. The report documented, "Upon having state in our building (Name of facility), and questioning the [MEDICATION NAME]/[MEDICATION NAME] ...I started this internal investigation... "The investigation did not address failure to notify the physician or the family of the resident's change in condition. The resident did not arouse enough for fluid consumption for approximately 15 and 1/2 hours and the facility did not notify the physician or the resident's family of the resident's condition.

Complaint # was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure necessary care and services were provided to identify and address complications of antipsychotic medication administration, as evidenced by failure to conduct assessments and frequent monitoring after administration of an as-needed (PRN) injection of [MEDICATION NAME] and failure to consult with the physician regarding unresponsiveness that resulted in an inability to consume food, fluid or medications for several hours after the medication was administered for 1 (Resident #6) of 1 case mix resident with physician orders [REDACTED].#6, who became unarousable, did not drink any fluids for over 15 hours, exhibited signs of decreased urine output and subsequently was found without vital signs after receiving a PRN dose of intramuscular [MEDICATION NAME]. The failed practices had the potential to cause more than minimal harm to 6 residents with physician orders [REDACTED]. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Initial Minimum Data Set with an assessment reference date of 3/9/12 documented the resident was severely impaired in cognitive skills for daily decision-making per a staff assessment of mental status, totally dependent on two plus persons for all activities of daily living, was not ambulatory and had physical and verbal behavioral symptoms directed toward others that occured every 1 to 3 days. a. The (geriatric psychiatric care provider) Discharge Summary dated 3/8/12 documented the resident was admitted there on 1/31/12 and, "Program of care: The patient was titrated on Clonzepam to decrease severity of aggression due to severe anxiety. It was felt that antipsychoic medications that were tried during this hospitalization contributed more to an akathisia and extrapyramidal side effects and more misery and suffering and subsequently these were discontinued." b. The Nurse's Note dated 3/9/12 at 12:01 a.m. documented, "Resident increase agitated and restless - climbing out of bed and geri chair-combative with staff - APN (Advance Practice Nurse) notified, received order for [MEDICATION NAME] 10 mg (milligrams) IM (intramuscular) now x (times) 1 related to agitation - order written and noted medications given." The March 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The next Nurse's Note on 3/9/12 at 2:30 p.m. documented, "Res (Resident) cont. (continues) to be sleeping since IM [MEDICATION NAME] give on last shift. Res meds (medications) held for entire shift d/t (due to) drowsiness. Res T & (and) R (turned and repositoned) per staff. Incont (incontinent) care provided per staff. Res without s/s (signs and symptoms) of distress at this time." The Nurse's Note dated 3/9/12 at 3:00 p.m. documented, "Res son here & unaware that IM [MEDICATION NAME] was given during 11-7 (11:00 p.m. - 7:00 a.m.) shift resulting in drowsiness. Son requests to be notified immediately of all new orders regardless of time of day." The Nurse's Note dated 3/9/12 at 4:30 p.m. documented, "At approx (approximately) 4:30 p.m., this nurse sent CNA (Certified Nursing Assistant) to prepare res for dinner. CNA immediately came to get this nurse. Upon entering room, this nurse then paged for LPN (Licensed Practical Nurse #1) and DON (Director of Nursing) to room stat (immediately) and got the emergency cart. (LPN #1) called 911, the DON & this nurse began compressions . 911 EMS (Emergency Medical Services) arrived at approx 4:40 p.m. Called res son & informed that res had a sudden change in condition and was going to be transported to (hospital) via 911. At approx 5:00 p.m., EMS exited building with resident for transport to (hosptial) ER (emergency room )." The Nurse's Notes dated 3/9/12 at 6:30 p.m. documented, "(LPN #1) called ER to check res. status. ER nurse reported res did not make it out of ER, Admin (Administrator) and DON notified." c. On 6/4/12 at 6:16 p.m., the surveyor asked LPN #2, who was on duty at the facility during the 11-7 shift on 3/8/12 - 3/9/12, "Was the [MEDICATION NAME] Effective?" The LPN replied, "Yes, it was." He stated that he had taken the resident to the secure wing to visit with another spanish speaking man and that the resident got sleepy and they put him to bed. The surveyor asked, "How often did you check on him (the resident)?" The LPN stated, "I was mostly up in the front myself . I told the C NAs to check him often." The surveyor asked, "Did you go see him?" He stated, "Around 2:00 a.m. and 5:00 a.m., to give him some medication but, I could not arouse him to give him his 6:00 a.m. medications. The surveyor asked, "What was your assessment of the resident when you went home?" He replied, "Resting comfortably, respirations normal, skin warm and dry and no distress noted." The surveyor asked, "Where did you document your assessments?" The LPN stated, "I'm afraid my documentation was not very good." d. On 6/4/12 at 10:45 a.m, the surveyor asked CNA #1, who was on duty at the facility during the 7:00 a.m. - 3:00 p.m. shift on 3/9/12, "What was your assessment of the resident when you came on (duty)?" CNA #1 stated, "He was sleeping." The surveyor asked, "Could you arouse him?" The CNA stated, "No. I touched his shoulder and called his name and he just snored." The surveyor asked, "Did the resident eat or drink anything during your shift?" The CNA stated, "No." The surveyor asked, "Did you report it to anyone?" The CNA stated, "Yes. My charge nurse (LPN #3)." The surveyor asked, "Do you know if she (LPN #3) checked on the resident?" The CNA stated, "I don't know if she checked on him. I didn't see it happen." The surveyor asked, "Who worked with you that day?" The CNA stated, "Either (LPN #3 or #4)." The surveyor asked, "Did you turn him and check him during your shift and did he arouse?" The CNA stated, "Yes. We turned him and checked him and he would only snore." The surveyor asked, "Did you think it was strange that the resident slept the entire 8 hours?" The CNA stated, "Yes. I told the nurse and she said he had been up all night and needed to sleep." The surveyor asked, "Did you check his vital signs during your shift?" The CNA stated, "No, I did not." The surveyor asked, "Did the resident drink any fluids during your shift?" The CNA stated, "No." e. On 6/4/12 at 11:27 a.m., CNA #2, who was on duty at the facility during the 7:00 a.m. - 3:00 p.m. shift on 3/9/12, stated that the resident was very sleepy and she was told that he had been up all night. She stated they (the two CNA's) tried to wake him up but he would not arouse. She stated that she reported it to the charge Nurse, LPN #3, who went down and checked him. She stated that the resident did not eat or drink during her shift and his brief was barely wet when they changed him. f. On 6/4/12 at 6:00 p.m., LPN #3 stated that she could not get the resident awake to give him his medications. She stated that the resident's respirations changed when she touched him, so she thought he was sleeping. She stated she knew that he didn't eat or drink anything and went and got the DON, who looked back and saw that he got the [MEDICATION NAME] and that he needed to sleep. She stated the CNA's had told her that he would not wake up to eat or drink. The surveyor asked, "Did you notify the physician of the resident's unresponsiveness?" The LPN stated, "No, we thought he was just sleeping." g. On 6/4/12 at 6:10 p.m., the DON stated that she did not recall LPN #3 talking with her about the resident being unresponsive because she would have checked on him. She stated that the son was upset because no one called him and she inserviced the staff immediately about that. The surveyor asked, "Is it a policy of this facility that the physician be notified if a resident does not eat or drink for 2 meals?" The DON stated, "Yes, it is." h. An Internal Investigation/Review Report dated 6/3/12 was provided by the DON on 6/4/12. The report documented, "Upon having state in our building (Name of facility), and questioning the [MEDICATION NAME]/[MEDICATION NAME] ...I started this internal investigation... "The investigation did not address failure to notify the physician or the family of the resident's change in condition. The resident did not arouse enough for fluid consumption for approximately 15 and 1/2 hours and the facility did not notify the physician or the resident's family of the resident's condition.