Every finding on record at The Springs of El Dorado

Based on observations, interview, record review, and facility policy review, it was determined the facility failed to ensure provider orders were completed for one resident (Resident #2) of three residents reviewed for wound care. The findings include: Review of Resident #2's admission Record revealed the facility admitted Resident #2 on 01/07/2025 with diagnoses that included peripheral vascular disease, acquired absence of a right toe, and malnutrition. Review of Resident #2's Progress Notes from 03/31/2025 at 2:58 PM, revealed the resident was alert and oriented to person, place, and time. The Progress Note also revealed Resident #2 was cognitively intact and went to the Wound Care Clinic for wound care. Review of a Wound Care Clinic Order for Resident #2 dated 03/18/2025, revealed the following order for dressing wound #2 (right lower leg), wound #3 (left lower leg), and wound #4 (right lower leg): -Wound to be cleansed with normal saline every other day for 30 days. -Primary Dressing of transfer foam to be applied every other day for 30 days. -Secured with soft cloth surgical tape every other day for 30 days.-Secured with sterile roll gauze bandages every other day for 30 days. -Add-on of gauze sponge, non-sterile every other day for 30 days. Review of a Wound Care Clinic Order for Resident #2 dated 03/25/2025, revealed an additional wound identified as Wound #5 (right lower leg) and new orders for Wound #2 (right lower leg) as follows:-Wound to be cleansed with normal saline every other day for 30 days. -Primary Dressing of an autolytic debridement gel every other day for 30 days.-Secondary Dressing of an auto debridement dressing every other day for 30 days, to be applied over the primary dressing.-Secured with soft cloth surgical tape every other day for 30 days.-Secured with sterile roll gauze bandage every other day for 30 days. -Compression stockings (generic elasticated tubular bandage) right leg compression. -Add-on of gauze sponge, non-sterile every other day for 30 days. Review of the Wound Care Clinic Order for Resident #2 dated 03/25/2025, also revealed wounds #3, #4, and #5 were to have the same dressing as documented above, but without the compression stocking. Review of the facility's Treatment Administration Record (TAR) dated March 2025, revealed the following treatments were completed for Resident #2: Cleanse left lower leg with normal saline, pat dry, secure with soft cloth surgical tape, apply gauze to wound bed, apply self-adherent wrap, apply from toes to bend of leg with 50% overlap 1x a week for 30 days. Every day shift, every Tue, Thu, Sat for venous ulcer with a start date of 03/18/2025. Resident #2 received the treatment, per the TAR on 03/18/2025, 03/20/2025, 03/22/2025, 03/25/2025, 03/27/2025, and 03/29/2025. Cleanse right lower leg with normal saline, pat dry, secure with soft cloth surgical tape, apply gauze to wound bed, apply self-adherent wrap, apply from toes to bend of leg with 50% overlap 1x a week for 30 days. Every day shift, every Tue, Thu, Sat for venous ulcer with a start date of 03/18/2025. Resident #2 received the treatment, per the TAR on 03/18/2025, 03/20/2025, 03/22/2025, 03/25/2025, 03/27/2025, and 03/29/2025. Cleanse right bilateral extremity with normal saline, pat dry, apply autolytic debridement gel, apply auto debridement dressing, cover with soft surgical tape wrap with sterile gauze, apply elasticated tubular bandage for 30 days as needed for arterial ulcer, with a start date of 03/29/2025. Resident #2 had documentation of receiving this treatment on 03/29/2025 and 03/31/2025. Cleanse left bilateral extremity with normal saline pat dry, apply autolytic debridement gel, apply auto debridement dressing, cover with soft surgical tape wrap with sterile gauze, apply elasticated tubular bandage for 30 days every day shift every other day for arterial ulcer, with a start date of 03/29/2025. Resident #2 had documentation of receiving this treatment on 03/29/2025 and 03/31/2025. After comparison of the Wound Care Clinic Orders and the facility's TAR this surveyor noted incongruencies from the provider's orders to the documented treatments as follows:-No distinction made on the TAR to ensure both wounds were treated on the right lower leg (Wound #2 and #4), for the date of 03/18/2025.-No distinction on the TAR of Resident #2 receiving the transfer foam as ordered on 03/18/2025 to wounds #2, #3, and #4.-The frequency of dressing changes completed were not congruent with the provider's orders, performed on Tuesday, Thursday, and Saturday versus every other day as ordered.-Resident #2 received self-adherent wrap to both lower legs that was not ordered by the provider, during the dressing changes documented on 03/18/2025, 03/20/2025, 03/22/2025, 03/25/2025, 03/27/2025, and 03/29/2025.-No documentation of the compression stocking being applied to Wound #2 (right lower leg) as ordered on 03/25/2025 During an interview on 04/29/2026 at 11:30 AM, the Treatment Nurse (TN) stated the process for completing orders from a Wound Care Clinic was that the Wound Clinic faxed orders to the facility after a resident had a clinic visit. Orders were then compiled and given to the TN during the facility leadership meetings held Monday – Friday at 9:30 AM. Resident orders were then updated by the TN to the TAR as soon as the TN received them, or at the end of the business day. During an interview on 04/29/2026 at 12:25 PM, the Director of Nursing (DON) indicated that it was the responsibility of the TN to ensure that provider orders from a Wound Care Clinic were completed. The DON also indicated that if wounds were not treated per the provider's order, wounds could deteriorate. During an interview on 04/29/2026 at 1:53 PM, the DON, Administrator, and the Nurse Consultant were not able to provide any documentation that Resident #2 received the treatment of the transfer foam as ordered on 03/18/2025, nor documentation as to why the orders written for every other day were performed on a Tuesday, Thursday, Saturday schedule as ordered on 03/1/2025. Review of a facility policy titled Medication and Treatment Orders, revised in July 2016, revealed that medications shall be administered per the written order of a licensed provider.

Based on record review, interview, and facility document review, the facility failed to provide a safe care environment by placing one (Resident #1) of five residents reviewed for Quality of Care, at risk. Specifically, Resident #1 consumed alcohol brought in by Certified Nursing Assistant (CNA) #3 and became intoxicated in the facility. The findings include: A review of Resident #1's admission Record revealed an admission date of 05/22/2024, with which included diagnoses of Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, mild protein-calorie malnutrition, and alcohol abuse (in remission). A review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/2026, revealed a Brief Interview of Mental Status score of 15, which indicated the resident was cognitively intact. Resident #1's MDS further revealed the resident's history of alcohol abuse (in remission), anxiety disorder, COPD, and malnutrition. A review of Resident #1's Care Plan did not reveal an allowance for consumption of alcohol. Resident #1's Care Plan indicated an intervention which revealed the resident was using anti-anxiety medications, with the following warning statement: Abuse, misuse, and addition. The use of benzodiazepines, including [generic anti-anxiety medication], exposes users to risks of abuse, misuse, and addiction, which can lead to overdose or death. Abuse and misuse of benzodiazepines commonly involve concomitant use of other mediations, alcohol, and/or illicit substances, which is associated with an increased frequency of serious adverse outcomes. A review of Resident #1's Order Summary did not reveal a provider's order for consuming alcohol. A review of Resident #1's Progress Notes from 03/08/2026, revealed an entry at 3:48 PM, by Licensed Practical Nurse (LPN) #1, which indicated there were four empty alcohol bottles found under Resident #1's sink by the CNAs on the shift. A review of Resident #1's Progress Notes from 03/08/2026 revealed an entry at 10:00 PM, by LPN #2, which indicated LPN #2 witnessed Resident #1 drinking from an alcohol bottle. The same entry also revealed LPN #2 searched the resident's room and found two more bottles of alcohol, at that time. A review of Resident #1's Provider Note from 03/10/2026, revealed the resident was taking anti-anxiety medications as follows: [Generic Anti-anxiety] Oral Tablet 0.5 mg (one tablet by mouth at bedtime). [Generic Anti-anxiety] Oral Tablet (one tablet by mouth one time a day). A review of Resident #1's Advanced Practice Registered Nurse (APRN) Note from 03/11/2026 at 6:57 AM, indicated, Today [Resident #1] is not [their] normal self and seems significantly more drowsy than normal. A review of Resident #1's APRN Note, with an effective date of 03/14/2026 at 11:00 PM, indicated [Resident #1's] roommate reports that patient has had trouble walking and has been showing irritation behavior, which is out of the ordinary. [Resident #1's roommate] reports that [they] knew [Resident #1] had alcohol and wasn't going to rat [Resident #1] out but also voices concern and would like to keep [Resident #1] safe. A review of Resident #1's Progress Notes from 03/15/2026 revealed an entry at 10:12 AM, by LPN #1, which indicated Resident #1 was moved to the secure unit and nine more pints of alcohol were found in Resident #1's previous room. A review of Resident #1's Progress Note by the APRN, with a service date of 03/15/2026, revealed Today [Resident #1] is sitting in [their] chair. [Resident #1] is lethargic, slurring words, and does not recall me seeing [them] yesterday and having a 45-minute-long conversation with me. When initially asked about sneaking alcohol, [Resident #1] reported an old friend brought me some half pints and would not give specific answer as to how many or how often. [Resident #1] did not report how much [they] drank. Today when I asked [Resident #1] about it, [Resident #1] stated, what are you talking about? and appeared to be confused/incoherent. [Resident #1] is grimacing and reports that everything is echoing in [their] ears and it sounds like [they are] screaming when [they] whisper. During an interview on 04/15/2026 at 10:25 AM, LPN #1 indicated she first found Resident #1 seemingly drunk on Saturday [03/07/2026] and the CNAs found some alcohol bottles [in the resident's room]. LPN #1 stated they did not do a room search at that time because the Director of Nursing (DON) instructed them not to. LPN #1 confirmed to have also found Resident #1 drinking alcohol in the bathroom on 03/08/2026. During an interview on 04/15/2026 at 11:15 AM, LPN #2 indicated on the evening of 03/08/2026, she witnessed Resident #1 drinking alcohol. LPN #2 then revealed to have worked a day or two after that incident and described Resident #1 as groggy and a little confused, during that time. During an interview on 04/15/2026 at 1:40 PM, the APRN indicated that a few days prior to the first time Resident #1 was found drinking, it was decided Resident #1 could have had an equilibrium [state of physical balance] problem. Resident #1 was slurring words, and their speech was getting delayed. The APRN also indicated that the equilibrium issues started a couple of days before the alcohol was first found on 03/08/2026, they were not sure what all was going on with Resident #1, but they now knew Resident #1 became intoxicated. The APRN also mentioned that the (generic anti-anxiety) medication had been increased at one time, since Resident #1 mentioned being more depressed, but ordered the medication to be held when she knew the resident had become intoxicated. During an interview on 04/15/2026 at 3:40 PM, the DON indicated Resident #1 admitted to her and the APRN, that it was CNA #3 that had been supplying the alcohol to Resident #1. This information was discovered on 03/16/2026, after Resident #1 was moved to the secure unit on 03/15/2026. During an interview on 04/16/2026 at 9:45 AM, the Administrator indicated that staff contacted her on 03/08/2026 and explained that Resident #1 appeared intoxicated. The Administrator indicated that Resident #1 agreed to an alcohol-recovery program and did an initial visit via telemedicine on 03/12/2026. The Administrator also indicated that she received a phone call from staff the following weekend on 03/15/2026, indicating to the Administrator Resident #1 appeared intoxicated and was hallucinating, and trying to exit out the back door. As a result, on 03/15/2026, the Interdisciplinary Team decided to place Resident #1 on the secure unit and instructed every staff member to watch Resident #1around the clock. The Administrator indicated that after Resident #1 was moved to the secure unit, a room search was completed that revealed more alcohol bottles like the ones found on the previous weekend. The Administrator added that it was the next day, 03/16/2026, that Resident #1 confessed to the APRN that it was CNA #3 that had been providing them with alcohol. In addition, the Administrator indicated that CNA #3 confessed to bringing Resident #1 alcohol on 03/16/2026, because Resident #1 told CNA #3 they just wanted a taste. A review of CNA #3's Termination Record, signed by CNA #3, had nature of infraction as follows: CNA was bringing alcohol to a resident that didn't have a doctor's order. Resident consumed large amount of alcohol on two different occasions and was intoxicated in facility. Termination date 03/16/2026. A review of an article titled, Drinking alcohol and getting older – What do I need to know? dated 05/29/2024, from the Mayo Clinic Press, revealed that as people age, alcohol tolerance can be significantly diminished, effects of alcohol can be exacerbated, and drinking while taking medications across a host of drug classes (like anxiety medication) can cause serious side effects. In addition, the article indicated alcohol consumption in adults 55 and older could contribute to falls, and alcohol contributes to 65% of falling deaths.

Based on interview, record review, and facility policy review, it was determined the facility failed to notify the resident, and/or the resident's representative, in writing and provide written information regarding the facility's bed-hold policy when a resident was transferred to the hospital for three (Residents #40, #61, and #45) of four sampled residents, reviewed for hospitalization . 1. Review of Resident #40's Medicare-5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/22/2025, revealed a Brief Interview for Mental Status (BIMS) score of 10 (indicated the resident had moderate cognitive impairment). Resident #40 ' s MDS also revealed the resident had active medical diagnoses which included: diabetes mellitus, non-Alzheimer ' s dementia, and respiratory failure. a. Review of Resident #40 ' s Progress Notes on 04/30/2025 at 11:12 AM, revealed on 03/14/2025 at 10:43 PM, indicated Licensed Practical Nurse (LPN) #3 was doing rounds and noticed Resident #40 sounded very congested. LPN #3 tried to wake the resident, but the resident was unarousable. LPN #3 took the resident ' s vital signs and recorded the resident ' s oxygen saturation as 50 percent. LPN #3 notified the Advanced Practice Registered Nurse (APRN), who ordered oxygen to be delivered to the resident at 2 liters per minute by nasal cannula with an updraft treatment. Resident #40 ' s oxygen saturation rose to 98 percent, but the resident was still lethargic and unable to arouse. The APRN ordered LPN #3 to send Resident #40 to the emergency room for further evaluation. b. Review of Resident #40 ' s Progress Note, on 04/30/25 at 11:17 AM, revealed LPN #4 called the hospital for and update on Resident #40 and was informed that the resident had been admitted to the hospital with a diagnosis of acute respiratory distress. c. During an interview on 04/30/2025 at 3:01 PM, with the Director of Nursing (DON), this surveyor asked for the Notice of Transfer/Bed Hold sent for Resident #40 ' s 03/14/2025 hospitalization . d. On 04/30/2025 at 3:28 PM, the Administrator notified this surveyor that no Notice of Transfer/Bed Hold for Resident #40 ' s 03/14/2025 hospitalization had been sent. e. On 05/01/2025 at 8:45 AM, the Administrator provided a policy titled Transfer or Discharge Notice which revealed the residents and representatives were to be notified, in writing, of the following information: .reason for transfer, date of transfer, location of resident . f. On 05/01/2025 at 8:45 AM, the Administrator provided a policy titled Bed-Holds and Returns which revealed, prior to transfer, resident representatives will be informed in writing of the bed-hold and return policy. g. During an interview on 05/01/2025 at 9:40 AM, the Business Office Manager (BOM) indicated they was responsible for sending Notices of Transfer/Bed Holds, the notice should be sent out within two days, and there was not Notice of Transfer/Bed Hold for Resident #40. h. During an interview on 05/01/2025 at 4:35 PM, Registered Nurse (RN) #2 indicated frontline staff did not have any role in initiating documentation that would contain the resident's appeal rights, the Ombudsman contact information, or the contact information for protection and advocacy agencies pertaining to nursing facility residents with intellectual/developmental/mental disabilities. RN# 2 added that the role of the Charge Nurse was to notify the DON when a resident was going to the hospital, and the DON was the one who would notify the BOM. i. During an interview on 05/01/2025 at 4:47 PM, this surveyor asked the DON how the BOM would be notified that a resident and/or resident's representative needed Notice of Transfer/Bed Hold. The DON indicated the Nurse transferring the resident out should do 3 things: 1) automatic discharge transfer (ADT) out, 2) computer generated change of condition, 3) and computer-generated transfer. When ADT was completed, a bed hold would be triggered. The nurse must click ADT and then the Notice of Transfer/Bed Hold. For the resident representatives that did not get the notices, the nurse must not have completed the ADT form. j. During an interview on 05/01/2025 at 4:47 PM, the DON indicated that when a resident was being transferred to the hospital, the Charge Nurse should have completed a document titled Automatic Discharge Transfer (ADT) form in the Electronic Health Record (EHR), which then prompted the BOM to provide the information listed above to the appropriate parties. The DON added the reason that Residents #45 and #61 did not receive the information listed above was because the nurses responsible did not select the ADT document to complete in the EHR. 2) A review of the MDS with an ARD of 03/05/2025, indicated Resident #45 had a BIMS score of 09 (indicating the resident had moderate cognitive impairment). The MDS also indicated Resident #45 had active diagnoses which included: cerebral palsy, schizophrenia, and unspecified intellectual disabilities. a. A review Resident #45's Medical Record revealed a document titled SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form that indicated the resident was transferred to the hospital on 12/30/2024. b. During an interview on 05/01/2025 at 8:47AM, the Administrator indicated Resident #45 did go to the hospital on 12/30/2024. The facility could not provide evidence that Resident #45 and the resident's representative received complete information for the 12/30/2024 hospitalization . The missing information included: resident appeal rights, contact information for the Ombudsman, and the contact information of the agency responsible for the protection and advocacy of the residents with intellectual/developmental disabilities/mental disorder or related disabilities. 3) A review of the MDS with an ARD of 02/10/2025, indicated Resident #61 had a BIMS score of 01 (indicating the resident was severely cognitively impaired). The MDS also indicated Resident #61 had active diagnoses, which included: stroke, hemiplegia, dysphagia, and chronic pancreatitis. a. A review of Resident #61's Medical Record revealed a document titled SNF/NF to Hospital Transfer Form indicated the resident was transferred to the hospital on 01/03/2025. b. During an interview on 05/01/2025 at 8:47 AM, the Administrator indicated Resident #61 did go to the hospital on 01/03/2025. The facility could not provide evidence that Resident #61, and the resident's representative, received complete information for the 01/03/2025 hospitalization . The missing information included: resident appeal rights, contact information for the Ombudsman, and the contact information of the agency responsible for the protection and advocacy of the residents with intellectual/developmental disabilities/mental disorder or related disabilities. 4. A review of the facility ' s Transfer Policy titled Transfer or Discharge Notice, revised March 2021, indicated that when a resident was being transferred or discharged , a written notice should have been given to the resident and representative that contained: a. Appeal rights after transfer or discharge. b. Contact information of the Ombudsman, the contact information of the agency responsible for the protection and advocacy of residents with intellectual and developmental disabilities. c. Contact information of the agency responsible for the protection and advocacy of the agency responsible for residents with a mental disorder or related disabilities. d. Contact information of the state health department agency that has been designated to handle appeals of transfers and discharge notices. 51381

Based on observation, interview, record review, and facility policy review, the facility failed to ensure food items in the refrigerator, freezer and storage room were covered or sealed; one (1) of one (1) ice machine was maintained in clean and sanitary condition; dietary staff washed their hands before handling food or clean equipment; ceiling tiles, air vents, dish washer wall, kitchen door frames were free of, debris, dirt, rust, stains; baseboards were secured for one (1) of two (2) meals observed. The findings are: 1. During an observation on [DATE] at 10:22 AM, an opened box of sausage patties was on a cart in the walk-in the refrigerator. The box was not covered or sealed. 2. During an observation on [DATE] at 10:26 AM, an opened box of fish was observed on a shelf in the freezer. The box was not covered or sealed. 3. During an interview on [DATE] at 10:29 AM, with the Dietary Manager, she was asked what the concerns of not storing food in the freezer or refrigerator properly were, and she stated it could lead to freezer burn. 4. During an observation on [DATE] at 10:33 AM, one opened box of crackers was observed on a shelf in the storage room, which had a best used by date of [DATE] on it. The Dietary Manager stated it had expired, and she would go ahead and throw it away. 5. During an observation on [DATE] at 10:56 AM, one (1) opened box of salt was on a shelf, above the food preparation counter, the box was not covered. The Dietary Manager stated it was open, and she would put it in a sealed container. She was asked what could happen if food was left open, and she stated bugs could crawl in. 6. During an observation on [DATE] at 10:59 AM, the following observation was made in the kitchen area: a. The floor between the deep fryer and the oven had an accumulation of grease built up on it. 7. During an observation, on [DATE] at 11:11 AM, of the inside corners of the ice machine, in a room on the 100-hall, where ice formed before dropping into the ice collector had a wet, blackish residue on it. The areas were pointed out to the Maintenance Supervisor, with the Dietary Manager present. During an interview, the Maintenance Supervisor was asked if the residue build up could be wiped off, how often he cleaned the ice machine, and who used the ice from the machine. He used tissue papers and wiped the wet residue off. The wet residue easily transferred to the tissue. The Maintenance Director stated the area had scum from the water, which could have dripped into the ice. He stated that he had been cleaning the area once a month, but began to clean it once a week, because the dirt built up quickly. The Maintenance Director also stated he had last cleaned the area on [DATE] 8. During an observation on [DATE] at 11:38 AM, Dietary Aide (DA) #1 used a rag to wipe up food items that spilled onto the counter. She then picked up the water hose with her bare hand and used it to spray leftover food from inside of the dishes, contaminating her hands. She placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, DA #1 moved to the clean side of the dishwasher area, picked up the clean blade and attached it to the base of the blender, then used a rag to dry inside of the blender bowl. As DA #1 was about to use the blender to puree food items to be served to the residents on pureed diets, this surveyor asked DA #1 what she should have done after she touched dirty objects, or before she handled clean equipment. DA #1 stated she should have washed her hands. 9. On [DATE] at 1:24 PM, the following observations were made on a shelf in the refrigerator in the Medicare wing nourishment room, on the 100 -Hall. a. One (1) unopened carton of whole milk, with an expiration date of [DATE]. b. One (1) unopened box of whole milk, with an expiration date of [DATE]. 10. A review of facility policy titled, Quick Resources Tool QRT Hand Washing indicated hands should be washed before starting work with food and before putting on gloves and as often as needed during food preparation and when changing tasks. 11. A review of facility policy titled, Quick Resources Tool QRT Food Storage reviewed indicated all foods should be stored wrapped or in covered containers and arranged in a manner to prevent cross contamination.

Based on observation, record review and interview, the facility failed to ensure dented cans were discarded to prevent bacteria growth; food items had opened and/or received dates; shelves were clean of debris; and contaminated pan covers were not placed on food to be served. These practices had the potential to affect 80 (total census 81) residents who resided in the facility. The findings are: 1. On 2/26/2024 at 11:30 AM, one 50 ounce can of Tomato Soup did not have received date and had a dent near the seal. The Surveyor asked the Dietary Manager, why should dented cans not be used? The Dietary Manager confirmed dented cans bent at rim may not be safe, may be contaminated. 2. On 2/27/2024 at 12:00 PM, the following spices on the spice shelf were opened and did not have an open date: Parsley Flakes - 11 ounces; Chopped Onions 3 pounds; Ground Cumin Seed 15 ounces; Poppy Seeds 2.37 ounces; Mild Chili Powder 16 ounces; Ground Nutmeg 16 ounces; Taco Season 21 ounces; Italian Seasoning 7 ounces; [NAME] Leaf 6 ounces; Ground Mustard 14 ounces; Leaf Basil 5.5 ounces; Ground Mustard 14 ounces; Onion Powder 19 ounces; Leaf Thyme 6 ounces; Ground Cinnamon 15 ounces; Paprika 16 ounces; Fine Ground Sage 8 ounces; Chicken Base 16 ounces; Original Creole Seasoning. The Surveyor asked the Dietary Manager what should have been done when the spice containers were opened. The Dietary Manager confirmed the open date should have been written on the container. 4. On 2/28/2024 at 10:38 AM, the Dietary Manager picked up a pan cover that had the handle facing upward and placed the pan cover on top of the beef stew that was to be served for lunch. The Surveyor asked why would you not want to lay the lid handle side up and return the lid to the pan containing food. The Dietary Manager confirmed there was different stuff on the stove and could contaminate the food. 3. On 2/28/2024 at 12:02 PM, the shelf where the seasoning was kept had debris on. The Dietary Manager cleaned the shelving prior to returning seasoning containers. The Surveyor asked the Dietary Manager why do you want shelving units containing food items to be free from debris. The Dietary Manager confirmed we don't want bacteria or cross-contamination to occur. On 2/29/2024 at 8:35 AM, the Surveyor asked Dietary Manager why you want to date food items when they are opened. The Dietary Manager confirmed so we know when it was first opened. 5. 2/29/2024 at 10:50 AM, the Nurse Consultant provided a policy titled, Quick Resource Tool: Cleaning and Sanitizing and Proper Hair Restraints, which documented, Standard: Food contact surfaces are properly cleaned and sanitized before and after use, in order to help prevent food-borne illness and minimize bacterial growth . with Guidelines .1. Food contact surfaces (i.e. countertops and other food preparation areas) are washed and sanitized before use 5. Non-food contact surfaces are washed with soapy water per frequency identified on the facility cleaning schedule - or as visually necessary. These are then wiped down with sanitizer solution . 6. 2/29/2024 at 10:50 AM, the Nurse Consultant provided a policy titled, Quick Resource Tool: Safe Storage of Food, which documented, Standard: All time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code.5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. 9. All packaged and canned food items will be kept clean, dry, and properly sealed . 10. Storage areas will be neat, arranged for easy identification, and date marked as appropriate .

Based on record review and interview, the facility failed to ensure that resident laundry was transported in a way to prevent the spread of infection. This failed practice had the potential to affect 81 residents residing in the facility. The findings are: 1. On 02/26/24 at 3:43 PM, Laundry Worker #1 was putting clothes away in room [ROOM NUMBER]. The laundry cart was sitting outside in the hall, uncovered, with clean clothing laying on it. 2. On 02/29/24 at 2:35 PM, the Housekeeping Supervisor [HS] was asked, How is clean laundry supposed to be transported back to a resident's room? The HS stated, The laundry is supposed to be on a cart and covered with a sheet. 3. On 02/29/24 at 3:06 PM, the Director of Nursing [DON] was asked, How is resident laundry supposed to be transported back to a resident's room? The DON stated, Residents clean laundry is supposed to be on a cart and covered. 4. Laundry Worker (LW) #1 was asked how resident's clean laundry is supposed to be transported back to the resident ' s room. LW #1 stated, That she puts it in a rolling basket and takes it back to the residents room. LW #1 was asked if there was anything else she did when she transported the basket back to the hall. LW #1 stated I sanitize my hands before and after I go into and out of a resident's room, and cover the basket with a clean sheet, so the clothes are covered.

Based on observation, record review and interview, the facility failed to ensure residents on the secured unit were supervised while smoking to decrease the potential for injury for 2 (Residents #37 and #71) of 2 sampled residents who were smoking without supervision. The findings are: 1. Resident #37 had diagnoses of Alcohol-Induced Persisting Dementia. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/23/23 documented the resident scored 14 (13-15 cognitively intact) on a Brief Interview for Mental Status (BIMS). a. A Care Plan with a revision date of 12/13/23 documented, .I smoke cigarettes and am at risk for injury . Resident requires supervision with smoking . b. A Smoking Safety Screen dated 12/07/23 documented, .Category: safe to smoke with supervision . c. On 2/27/24 at 3:25 PM, Certified Nursing Assistant (CNA) #2 opened the door to the smoking area on the secured unit, gave Resident #37 and one male resident a cigarette, lit it with a lighter and allowed those two residents and another male resident who did not have cigarette, to go outside to the smoking area. CNA #2 re-entered the building leaving 2 residents smoking and a third resident just sitting, and all were unattended in the smoking area. 2. Resident #71 had diagnoses of Suicidal Ideations, Seizures or Convulsions and Bipolar Disease. A Quarterly MDS with an ARD of 12/06/23 documented resident #71 had a BIMS score of 15. a. A Care Plan with a revision date of 01/03/24 documented, . I smoke cigarettes . Resident requires supervision with smoking . b. A Smoking Safety Screen dated 1/11/24 documented, .Category: safe to smoke with supervision . c. On 2/27/24 at 3:26 PM, CNA #2 left the smoking area, went down the hall and returned with Resident #71 following her to the smoking area. At 3:27 PM, CNA #2 gave Resident #71 a cigarette, lit it with a lighter, allowed Resident #71 to go out to the smoking area with 3 other residents, 2 who were smoking, and she re-entered the building. There was a female resident sitting in a wheelchair and CNA #2 propelled this resident down the hall, away from the smoking area, leaving 4 residents, 3 of whom were smoking cigarettes. No residents were wearing smoking aprons. At 3:38 PM, CNA #2 did go to the door and looked outside, where Resident #37 was the only resident outside, yet smoking a lit cigarette, as the other residents came in on their own. CNA #2 then went back down the hallway, leaving Resident #37 unattended. At 3:39 PM, Resident #37 finished smoking, placed the used cigarette in the smoking receptacle and re-entered the building. d. On 2/27/24 at 3:44 PM, CNA #2 was asked if she was familiar with [Resident #37]'s plan of care. CNA #2 stated, No ma'am I'm not. The Surveyor asked if [Resident #37] was able to smoke without supervision. CNA #2 stated, Yes, [Resident #37] is. CNA #2 was asked if the other residents were able to smoke without supervision. CNA #2 stated, It's usually two people back here and one would be out with the resident's that smoke, and the other one would stay in here. It's usually two CNAs back here and sometimes the other CNA is late. CNA #2 confirmed that if a resident's clothing caught fire with no staff there, that the resident could burn holes in their clothing or burn up. e. On 2/28/24 at 11:40 AM, the Director of Nursing (DON) confirmed residents on the secured unit were not allowed to smoke without supervision. f. A Smoking Policy provided by the Director of Operations on 2/26/24 documented, .Purpose To permit residents who smoke the right to do so within the limits designated by the smoking policy to ensure safety and comfort for the smokers and for the others in the environment . g. A Smoking Procedure Admission Packet provided by the Director of Operations on 2/26/24 documented, .Resident's will be supervised while smoking at the facility during designated smoking times .

Based on observation, record review and interview, the facility failed to ensure physicians orders were followed to maintain a medication error rate of less than 5% to prevent potential complications for 1 (Residents #45) of 5 sampled residents. The findings are: 1.Resident # 45 had diagnoses of Allergic Rhinitis, Osteoarthritis and Hypertension. a. A Physician Order dated 12/08/21 documented, Aspirin EC [Enteric Coated] Tablet Delayed Release 81 MG [milligram] (Aspirin) Give 1 tablet by mouth one time a day . Do Not Crush . b. A Physician Order dated 02/08/22 documented, [Nasal Allergy Spray] Suspension 2 sprays in both nostrils one-time a day . c. The Medication Administration Record (MAR) documented, [Nasal Allergy Spray] Suspension . 2 spray in both nostrils one time a day . wait one minute between sprays in same nostril . c. On 2/27/24 at 09:10 AM, Licensed Practical Nurse (LPN) #1 gave medications to Resident # 45, then signed them off. LPN #1 failed to give the Aspirin EC Tablet. LPN #1 gave [Nasal Allergy Spray] 2 sprays to each nostril. LPN #1 failed to wait 1 minute between sprays to same nostril. According to the Medication Administration Record (MAR) the Aspirin was not signed off after the medication pass by LPN #1. d. On 2/29/24 at 11:15 AM, LPN# 1 was asked if she was aware of any medications that she did not give. LPN #1 stated, I didn't give the aspirin. I got nervous and put the bottle back up. LPN #1 was asked how long she should wait between squirts of [Nasal Allergy Spray] in the same nostril. LPN #1 stated, One minute. LPN #1 stated, But I didn't wait one minute. I squirted it back to back. e. On 3/1/24 at 10:39 AM, the Director of Nursing (DON) was asked how she expected the nurses to conduct a medication pass. The DON stated, By the rights of medication administration. The DON was asked to explain why a physician's order should be followed. The DON stated, They should be followed because it's in the best interest of the resident and the plan of care. f. On 2/29/24 at 09:52AM, a policy provided by the Nurse Consultant titled, Administering Medications documented, .Medications are administered in a safe and timely manner, and as prescribed . Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .The individual administering the medication checks the label THREE (3) times to verify .right dosage, right method of administration before giving the medication . 48630

Based on observation and interview, the facility failed to ensure the refrigerated narcotic medications were stored in a permanently affixed compartment to prevent the potential of misappropriation of resident property. The findings are: 1. On 2/27/24 at 3:40 PM, the Medication room was inspected with the Licensed Practical Nurse (LPN) #3. Inside the refrigerator was a locked narcotic box containing narcotics, but it was not permanently affixed. 2. The narcotic box contained Lorazepam 30 milliliters. 3. On 02/27/24 At 03:43 PM, LPN #3 was asked what the process was for securing refrigerated narcotics. LPN # 3 stated, It must be locked up behind two locks. LPN # 3 was asked, Who has a key to the refrigerator? LPN #3 stated, I do. LPN #3 was asked, How should the box be kept, and can anyone take it currently? LPN #3 stated, It is usually attached to the inside of the refrigerator. Yes, they could take it. 4. On 03/01/24 at 11:57 AM, the Director of Nursing (DON) was asked what the process was for securing refrigerated narcotics. The DON stated, It's double locked in the refrigerator. The Surveyor asked, How should the box be stored in the refrigerator? The DON replied, Glued or chained in the refrigerator. The Surveyor asked, What could happen if it is not secured? The DON stated, It could be taken. 5. On 2/29/24 at 09:52 AM, a policy provided by the Administrator titled, Storage of Medications documented, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner .Schedule 2-5 controlled medications are stored in separately locked, permanently affixed compartments .

Based on observation, record review and interview, the facility failed ensure fingernails were cleaned, trimmed, smooth and free of jagged edges to promote good personal hygiene and grooming for 1 (Resident #15) of 1 sampled resident who was dependent for nail care. The findings are: 1. On 02/26/24 at 10:48 AM, Resident #15's left hand had long jagged fingernails. The right hand had long fingernails with a dark brown substance packed under the nails. 2. On 02/26/24 at 04:09 PM, Resident #15's fingernails had long jagged fingernails on both hands with a dark brown substance packed under the fingernails on the right hand. 3. On 02/27/24 at 08:57 AM, Resident #15 was sitting up in bed eating breakfast and was holding a piece of bread in his right hand. The fingernails on his right hand were long, jagged, and had a dark brown substance packed under them. The left had long jagged nails. 4. A Care Plan dated 1/18/23 documented, .I have an ADL [activities of daily living] self-care performance deficit r/t [related to] Dementia. Revision on: 01/18/2023 . I will be clean and well-groomed daily throughout the review date. Date Initiated: 01/18/2023. Revision on: 02/12/2024 .Nail Care: Check nail length and trim and clean as necessary. Date Initiated: 01/18/2023 . I am at risk for Impaired Skin Integrity. Date Initiated: 08/19/2022 Revision on: 02/16/2023 . My risk for impaired skin integrity will be minimized through plan of care Date Initiated: 08/19/2022 Revision on: 02/12/2024 .Nails trimmed Date Initiated: 03/09/2023 Revision on: 03/09/2023 . Keep nails trimmed / filed to minimize jagged edges Date Initiated: 01/18/2023 . 5. On 02/28/24 at 08:10 AM, the Surveyor accompanied Certified Nursing Assistant (CNA) #1 to Resident #15's room and was asked to describe the resident's fingernails. CNA #1 stated, It looks like food but I'm not sure and they are long and jagged. CNA #1 was asked who could trim, cut, clean and file Resident #15's nails. CNA #1 stated, CNAs can if they aren't diabetic otherwise the nurse cuts those. CNA #1 was asked when nails were to be cut, cleaned, and filed. CNA #1 stated, Every day especially during showers. CNA #1 was asked when Resident #15's shower was scheduled. CNA #1 stated, Tuesday, Thursday and Saturdays. They need to be clean to prevent infections and fungus. 6. Resident #15's Bathing task sheet documented the resident received a sponge bath on 02/24/24 and 02/27/24. 7. 02/28/24 08:19 AM, the Surveyor accompanied the Assistant Director of Nursing (ADON) to Resident #15's room and observed the resident's fingernails. The ADON stated, It's probably food. That can make him sick. 8. On 2/29/24 at 09:50 AM, the Nurse Consultant provided a policy titled, Fingernails/Toenails, Care of, which documented, .Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . Nail care includes daily cleaning and regular trimming .

Based on observation, record review and interview, the facility failed to ensure parameters were put in place to ensure the correct dosage of oxygen was administered to enable the Physician to determine the dosage needed for 1 (Resident #27) sampled resident. The findings are: 1.On 02/26/24 at 11:24 AM, Resident #27 was lying in bed with oxygen on via nasal cannula (NC) at 2 liters per minute (LPM). a. On 02/26/24 at 04:11 PM, Resident #27 was lying in bed with oxygen on via NC at 2 LPM. b. On 02/27/24 at 09:03 AM, Resident #27 was lying in bed receiving oxygen via nasal cannula at 2 LPM. c. A Physicians Order dated 6/30/23 documented, Oxygen on at 2 liters via NC to keep sats at 90% or above, every shift for shortness of breath . d. A Care Plan with an initiated date of 4/13/22 documented, [Resident #27] uses oxygen therapy r/t [related to] SOB [shortness of breath]. Revision date 09/29/2022 .Oxygen via NC @ 2 liters to keep sats [saturations (oxygen level)] above 90% - May self-remove for ADL's [activities of daily living] Date Initiated: 09/29/202 Revision on: 12/11/202 . e. The February 2024 Medication Administration Record (MAR) did not address monitoring Resident #27's oxygen levels to allow the physician to determine the correct dosage of oxygen administration. f. On 02/29/24 at 08:45 AM, Licensed Practical Nurse (LPN) #2 was asked how do you know when to increase or decrease the oxygen on Resident #27 to keep his oxygen saturation greater than 90%. LPN #27 said they checked Resident #27's pulse ox [oximetry (an electronic device that measures the saturation of oxygen carried in your red blood cells)] weekly. LPN #2 was asked if there was an order to check the pulse oximetry. LPN #2 stated, No. LPN #2 was asked how he/she knew Resident #27's oxygen saturation was above 90% per physician's orders. LPN #2 stated, I don't know. g. On 3/01/24 at 10:43 AM, the Director of Nursing (DON) was asked to explain how she expected the nurses to determine what an oxygen flow rate should be. The DON stated that there should be an O2 [oxygen] check per shift and PRN [as needed]. The DON was asked to look at the electronic record and read the current physician's order. The DON stated, There are no parameters and should be. The DON was asked the importance of setting parameters. The DON stated, To alert the nurses and doctor the need to increase or decrease the amount of oxygen needed. h. On 2/29/24 at 09:50 AM, the DON provided a policy titled, Oxygen Administration, which documented, The purpose of this procedure is to provide guidelines for safe oxygen administration . Preparation .Review the Physicians order . Assessment Before administering oxygen, and while the resident is receiving oxygen therapy, assess, for the following: .oxygen saturation .

Based on record review and interview, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 (Resident #52) of 1 sampled resident who fell during transport in the facility van. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #52 who fell out of the wheelchair in the facility van during transport on 11/22/22. The failed practice had the potential to affect all 63 residents who resided in the facility as documented on the Daily Census Report provided by the Administrator on 12/27/22 at 10:27 a.m. The Administrator was notified of the Immediate Jeopardy on 12/27/22 at 3:50 PM. The findings are: 1. Resident #52 had diagnoses of Functional Quadriplegia, Pressure Ulcer Right Buttock Stage 4, Acquired Absence of Left Leg, and Acquired Absence of Right Leg. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/03/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance from two staff members for transfers and had impaired range of motion on both sides of the lower extremities. He had one fall with no injury since the last assessment. He had one stage 4 pressure ulcer that was not present on admission. a. The Physician's Order dated 2/18/22 documented, .Send resident to the wound care center for evaluation of wounds and treat as indicated . b. The Care Plan dated 10/28/22 documented, .I have a stage IV (4) pressure ulcer to my right hip . c. The Nursing I&A (Incident and Accident) Note dated 11/22/22 documented, .Wound clinic reported to facility that they were informing us that resident just had a fall while on our facility van. And they were sending resident to ER [emergency room ] to get checked out. Upon return to facility resident stated that when van came to a stop at wound clinic parking lot, he started feeling himself sliding down in his wheelchair, so he tried repositioning himself while van driver was headed back to help him and fell forward out of the wheelchair. He states he hit his head on the back of front passenger side. Staff from the medical building assisted getting the resident up, then wound clinic sent me to the ER to get checked out. Immediate Intervention (to prevent reoccurrence): Changed wheelchair out and added non-skid pad to w/c [wheelchair] seat. Immediate Intervention: Driver and medical building staff including a doctor assessed resident then got him up from van floor. Wound clinic called ambulance and had resident sent to ER for evaluation. Neuro checks will be continued at facility since resident states he hit his head on seat. CT [computerized tomography] of head and spine, clear. X-ray of left shoulder mild AC [Acromioclavicular] joint arthropathy, no fracture . d. The One on One Inservice dated 11/22/22 documented, .Anytime an incident happen on the van notify DON [Director of Nursing] and Administrator immediately. Do not attempt to get resident up just call ambulance for assistance . The document was signed by the DON and the Van Driver. e. On 12/27/22 at 10:30 a.m., Resident #52 reported to the Surveyor that he was in the van going to the wound clinic and the driver put on the breaks and he slid forward out of the chair. He stated he injured his shoulder. He stated he was not strapped into the chair. f. On 12/27/22 at 2:40 p.m., the Administrator was asked to provide the last 4 reportables. A Review of the last 4 reportables did not reveal a reportable that documented an incident with Resident #52 on 11/22/22. g. The OLTC (Office of Long Term Care) Witness Statement Form provided by the Administrator on 12/27/22 at 5:53 p.m. and signed by the Van Driver documented, .11/22/22 .Transporting resident to wound care. At wound care van stop as I was stopping resident said he was falling out of chair. Got off van open side door. Resident sitting in floor. Resident states he hit his head. Stop first person I seen to help with putting him back in chair. Couldn't get resident back in chair. I went to get the Wound Clinic Nurse from wound care to assist me. Myself, Wound Clinic Nurse and Doctor put him into chair. Wound Clinic Nurse and I went in to building to wound clinic. h. The Medical Record provided by the Administrator on 12/27/22 at 3:50 PM documented, .Fall from non-moving wheelchair - Pain in left shoulder Pain . i. The Incident and Accident Report (I&A) dated 11/22/22, provided by the DON on 12/28/22 at 9:05 a.m. documented, .Wound clinic reported to facility that they were informing us that resident just had a fall while on our facility van and they were sending him to the ER to get checked out . He states he hit his head . j. The Transportation Policy and Procedure Staff Acknowledgement Form dated 7/15/22 and signed by the Van Driver and provided by the DON on 12/28/22 at 11:55 a.m. documented, .By signing below, I agree to abide by the policies and procedures set forth in the facility transport manual . Review of transport policy and procedure manual . Ensuring resident is buckled properly in transport vehicle . reporting any problems or unusual occurrences to administrator . handling of resident injuries during a transport . k. On 12/27/22 at 2:50 p.m., the Surveyor asked the Administrator, Did you do a reportable on the incident that occurred with [Resident #52] in the van on November 22nd? She answered, No. It was a fall with no injury. There was no reason to do a reportable. He went to the emergency room after it happened, and we added Dycem to the wheelchair when he came back. l. On 12/27/22 at 3:15 p.m., the Surveyor asked the Administrator to provide the investigation documentation about the incident for Resident #52's fall in the van, any staff in-service training that was done after the incident, and name of all witnesses. She stated the Van Driver was the only witness. m. On 12/27/22 at 3:29 p.m., the Surveyor asked the Administrator to provide a policy for the transport van and the use of seat belts, a policy for reporting incidents, and policy for conducting investigations. n. On 12/27/22 at 3:39 p.m., during a telephone interview with the Advance Practice Nurse (APN) at the Wound Care Center, the Surveyor asked the APN, Are you aware of an incident on 11/22/22 that involved [Resident #53] falling in the facility van? She stated, No one here was a witness to the incident. The van driver called to say she needed help. It happened in the van. We didn't take him to an exam room. He told the staff he was dizzy, and we sent him to the ER. o. As of 12/27/22 at 5:45 p.m., the Administrator had not provided a policy for reporting incidents or a policy for conducting investigations. p. On 12/28/22 at 9:05 a.m., the Surveyor asked the DON if the Van Driver was present. She stated, She was actually the backup van driver. Our full time van driver was on vacation that week. q. On 12/28/22 at 9:11 a.m., the Surveyor asked the Van Driver, Do you remember the day when [Resident #52] fell in the van? She answered, Yes. I was driving and we had made it to the clinic. I parked and he said he was sliding. He was trying to reposition himself in the chair. He had gained weight and he was uncomfortable in that chair. The Surveyor asked, Did he have any kind of seatbelt in use? She answered, Yes. He had a shoulder strap, and it also went across his waist. He doesn't have any legs and he is top heavy. The Surveyor asked, Did you see him fall? She answered, No. I opened the van door, and he was sitting on his bottom. The Surveyor asked, Did he fall over the seatbelt, or did he slide under the seatbelt? She answered, I am not real sure. The straps were not fastened when I opened the door to the van. The Surveyor asked, What happened after he fell ? She answered, I saw a doctor coming out of the building and I asked him to help me. We couldn't get him back in the chair, so the doctor stayed with the patient, and I went in the building to get the guy from the wound clinic to come help. All three of us got him up in the chair. The Surveyor asked, Did you notify anyone when it happened? She answered, I talked to the DON. I told her I had a doctor here with us. The Surveyor asked, Prior to the day that happened, had you had any training on van transports? She answered, I've been trained quite frequently in the eight to nine months I have been here. The Surveyor asked, Do you know what the facility policy says about incidents in the van? She answered, It says to call the facility. The Surveyor asked, What does the policy say about moving the resident if they fall? She answered, I'm not sure. r. On 12/28/22 at 9:20 a.m., the Surveyor asked the DON, When were you notified about [Resident #52's] fall in the van? She answered, First the wound clinic called to let us know. Later the van driver called. The Surveyor asked, What was the van driver advised to do? She answered, She said the first person she saw was a doctor. Then she got an employee of the wound clinic to come help. It took three people to get him up in the chair. That's why I did that one on one training with her. s. On 12/28/22 at 11:30 a.m. the Surveyor asked the DON, Did anyone check to see if the resident was strapped in correctly to prevent the fall? She answered, Maintenance did. The Surveyor asked, What did the facility do about the chair, was it the right size for the resident? She answered, On the day of the incident, he told me that his chair was too little, and I immediately ordered a larger chair and some Dycem for the seat. The Surveyor asked, Did anyone investigate why he was not wearing a seatbelt? She answered, When he returned to the facility, we asked him if he was strapped in, and he said he was. He told me the reason he fell was because of the chair. The Surveyor asked, Did you inservice any other van drivers on 11/22/22? She answered, I didn't. I didn't think it was an issue with transfers. I thought it was just that one driver. The Surveyor asked, Did you check the straps on the van? She answered, I did not. t. A handwritten document provided by the Administrator on 12/28/22 at 11:50 a.m. documented, This is documentation of the conversation we had with the resident when he returned to the facility on [DATE]. We did not do an official investigation that day. u. The facility policy titled, Transportation Policy and Procedure Manual - [Facility Name], provided by the Administrator on 12/27/22 at 3:53 p.m. documented, .If a resident fall occurs at any time during transport, call administrator for further guidance. Do not move the resident or transport resident yourself . If you accomplish any of the above listed items, call your DON (Director of Nursing), ADON (Assistant Director of Nursing), or Administrator immediately . 2. The Immediate Jeopardy was removed on 12/27/22 at 5:40 p.m., when the facility implemented the following Plan of Removal: Step #1: Corrective Action: A. Upon notification to the facility on [DATE], the facility administrator, per surveyor's directive ceased all facility van transports and began immediate in-service regarding staff education and performance competencies to demonstrate safe van transports. The facility van driver was previously educated on 11/22/2022 at the time of the incident by facility administrator. B. Upon notification to the facility on [DATE], the facility administrator reported the alleged incident to the office of long term care utilizing 7734 reporting form. The incident had been previously investigated on 11/22/2022 and determined per resident interview that the resident had fallen out of the wheelchair while adjusting himself unrelated to the van securement system. C. Resident #52 was immediately assessed on 11/22/2022 by medical provider. Resident #52 was provided with a new wheelchair and nonskid pad was added to the wheelchair seat on 11/22/2022. Step #2: identification of others with the potential to be affected: A. On 12/27/2022, the facility administrator initiated an in-service regarding staff education and performance competencies to demonstrate safe van transports. The facility has not had any alleged van incidents since the date of the alleged deficient practice on 11/22/2022. B. On 12/27/2022, the facility administrator began reviewing incidents 11/22/22-current to verify all incidents that met the regulatory requirements for reporting were investigated and reported per regulations. Step 3: To ensure deficient practice does not occur: A. On 12/27/2022, the facility administrator initiated an in-service regarding staff education and performance competencies to demonstrate safe van transports. B. On 12/27/2022, the facility administrator initiated an in-service on the procedure for reporting and investigating incidents. Step 4: Monitoring: A. Beginning 12/27/2022, the facility administrator will review incidents 5x [times] weekly until compliance verified by OLTC during morning stand up to verify all incidents that meet the regulatory requirements for reporting are investigated and reported per regulations. B. Beginning 12/27/2022, the facility maintenance director will observe staff securing residents in the facility van to ensure competency 3x weekly until compliance verified by OLTC. Monitoring will be documented on monitoring calendar and negative findings will be corrected immediately by Administrator/designee. Step 5: QA [Quality Assurance]: Administrator/designee will present findings to the monthly QA committee x1 quarter for further review and recommendations.

Based on observation and interview, the facility failed to ensure dietary staff washed their hands between clean and dirty tasks, foods were utilized prior to their use by dates, containers were sealed to prevent the potential for food borne illness for residents who received meals from 1 of 1 kitchen and the kitchen and equipment was cleaned to prevent cross contamination. These failed practices had the potential to affect 62 residents (Total Census: 63) who obtained their meals from 1 of 1 kitchen according to a list provided by the Administrator on 12/29/22 at 1:18 PM. The findings are: 1. On 12/27/22 at 10:32 AM, the following observations were made in the Dry Storage Area: a. On a shelf was a 25 pound box of graham cracker crumbs was on a shelf. Upon opening the box, the bag of graham cracker crumbs was opened to air and contaminants. b. Located in the same area was a one pound, 8 ounce bag of Fried Onions with a use by date of 12/13/21. c. In the same area was a five pound container of baking powder with a use by date 12/17/20. d. On a rolling cart, there was a clear plastic bin. The top of the bin was covered in a white film of dust and was opened approximately 1 inch allowing for the entrance of air and contaminants. 2. On 12/27/22 at 11:27 AM, the sink and cabinet unit adjacent to the deep fryer was covered in dust, grime, food particles and areas of rust. The floor and wall had areas of grime, and what appeared to be dried food debris/spills. The floor next to and under the deep fryer was discolored with broken tile. The side and front of the deep fryer was covered with a greasy film, in which dust and food particles had adhered. The top of the deep fryer was covered with a large baking tray which was covered in a greasy film that contained multiple food particles. 3. On 12/27/22 at 11:29 AM, on a shelf in the kitchen was one pound containers of Onion Powder, Ground Cinnamon, Garlic Powder and Paprika. The top of each container was opened exposing the contents to air and contaminants. 4. On 12/27/22 at 12:01 PM, the hood suspended over the dishwasher loading and unloading area was covered in a layer of grime and dust. 5. On 12/27/22 at 12:03 PM, Dietary Employee (DE) #2 opened the kitchen door, obtained the chain that is used to secure the door open and hooked the chain to the wall. DE #2 then retrieved an insulated cart and positioned the cart for loading. DE #2 did not wash her hands prior to serving on the tray line. 6. On 12/27/22 at 12:09 PM, DE #1 was serving the tray line when her cell phone began ringing in her pocket. DE #1 used her hand to silence the phone through the cloth of her pocket. DE #1 did not wash her hands after contact with clothing and continued to serve the tray line. 7. On 12/27/22 at 12:21 PM, DE #1 left the tray line. She obtained hot pads, opened the oven door, and retrieved a pan of lasagna from the oven. DE #1 removed the aluminum foil from the top of the pan and proceeded to carry the pan to the steam table. Without washing her hands, she continued to serve the tray line. 8. The facility policy titled, Hand Washing, provided by the Administrator on 12/29/22 at 1:30 PM documented, .Employees shall keep their hands and exposed portions of arms clean. 1. When to wash hands: Immediately before engaging in food preparation including working with exposed food, clean equipment, or service utensils and: After touching any part of the body or clothing other than clean hands or clean exposed portions of arms. After handling soiled equipment or utensils. During food preparations, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks .

Based on record review and interview, the facility failed to notify residents, their representatives, and families of those residing in facilities by 5:00 p.m. the next calendar day following the occurrence of a single confirmed infection of COVID-19 for 4 (Residents #1, #3, #36 and #52) sampled residents whose records were reviewed. The findings are: 1. The Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes dated 05/06/2020 documented, .COVID-19 Reporting. The facility must . (3) Inform residents, their representatives, and families of those residing in facilities by 5 p.m. 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 . 2. The list of the most recent COVID positive residents and staff provided by the Administrator on 12/29/22 at 1:40 PM documented: Positive Residents on 09/12/22, 09/15/22, 10/25/22 and Positive Staff on 09/08/22, 09/09/22, 09/19/22 and 09/20/22. 3. The facility's [Communication Software] messages for Resident #52 documented notifications on 09/09/22 and 09/12/22. There were no notifications for 09/15/22, 09/19/22, 09/20/22 or 10/25/22. Resident #52's Progress Notes did not reveal documentation of any notifications. 4. The facility's [Communication Software] messages for Resident #3 documented notifications on 09/12/22 and 09/9/22. There were no notifications for 09/15/22, 09/19/22, 09/20/22 or 10/25/22. Resident #3's Progress Notes did not reveal documentation of any notifications. 5. The facility's [Communication Software] messages for Resident #1 documented the last notification was on 08/02/22. Resident #1's Progress Notes did not reveal documentation of any notifications. 6. The facility's [Communication Software] messages for Resident #36 documented notifications on 09/09/22 and 09/12/22. There were no notifications for 09/15/22, 09/19/22, 09/20/22 or 10/25/22. Resident #36's Progress Notes did not reveal documentation of any notifications. 7. On 12/29/22 at 2:30 PM, the Surveyor asked the Administrator to please look at Resident #3's [Communication Software] notifications. Does she have a notification from 10/25/22? She answered, I don't see it at all. The Surveyor asked, Does she have one from 09/15/22? She answered, No. I see one for 9/12 and 9/9, but I know I did them. The Surveyor asked, Do you only use [Communication Software] or do you ever call or use another method? She answered, We just use [Communication Software]. The Surveyor asked, Is there a report that you can run or a log that you keep when you send out those notifications? She answered, I will check about the report. I don't keep a log. The Surveyor asked, Do you have a staff member who is the relative of a resident who may have received the notifications? She answered, No. 8. On 12/30/22 at 8:10 AM, the Surveyor asked the Administrator if she was able to pull a report from [Communication Software]. She stated, No. The Surveyor asked, How is [Resident #1] notified of any covid positive residents or staff members? She answered, When she had a phone, she got the [Communication Software] notifications, but now that she does not have a phone that works, I'm not sure. 9. On 12/30/22 at 8:20 AM, the Surveyor asked Resident #1 (who is self-responsible), How are you notified of any covid positive residents or positive staff members? She answered, The Infection Control nurse puts a sign on the entry doors that lets visitors know there has been a positive result and that we need to wear masks. 10. On 12/30/22 at 8:37 AM, Resident #52's responsible party/family member was contacted by phone. The Surveyor asked, Does the facility notify you when there is a positive COVID in the building? He answered, Yes. I get phone calls. The Surveyor asked, Do you recall when the last time you got a phone call about positive covid? He answered, It's been a while. I'm not sure when it was. The Surveyor asked, Could it have been October? He answered I'm just not sure. It's been a while. 11. On 12/30/22 at 8:41 AM, the Surveyor attempted to contact Resident #3's responsible party/family member. The call could not be completed as dialed. 12. On 12/30/22 at 8:51 AM, the Surveyor asked Resident #36, (who is self-responsible), How are you notified when there is a positive covid result in the building? He answered, The nurse comes in and tells me. The Surveyor asked, Do you ever get a phone call or a text message? He answered, No. The nurse tells me. The Surveyor asked, Does the nurse tell you the day of the positive result? He answered, As far as I know. 13. On 12/30/22 at 9:20 AM, the Administrator stated, I did not notify on 10/25/22 because the way I read the guidance, you only have to notify if there are 3 or more. 14. On 12/30/22 at 9:26 AM, the Administrator provided print outs dated 9/12/22 and 9/9/22 of the [Communication Software] notifications that were sent to the families. The Surveyor asked, Do you have a print out of the notifications that went out on 9/15 and 9/19 and 9/20? She stated, No, I grouped them all together. The Surveyor asked, Please explain to me why you did not send out notifications of the 2 residents who were admitted with covid on 10/25/22? She answered, We don't have to notify families if we admit a positive resident, or if there are less than 3 positives. The Surveyor asked the Administrator to provide the guidance. 15. The guidance provided by the Administrator on 12/30/22 at 10:00 AM documented, .The facility must . Inform residents, their representatives, and families of those residing in facilities by 5 p.m. 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 Surveyor asked, Would the two residents who were admitted with covid not count as a confirmed infection? She answered, They didn't test positive here. The Surveyor asked, Did you treat them as confirmed positive when they admitted ? She answered, Yes.

Based on observation, record review, and interview, the facility failed to ensure a label was placed on the formula bottle to identify the type of formula the resident was receiving for 1 (Resident #6) of 3 (Residents #6, #26 and #171) sampled residents who received continuous enteral feedings according to the list provided by the Administrator on 12/30/2022 at 10:24 AM. The findings are: 1. Resident #6 had diagnoses of Gastrostomy Status and Cerebrovascular Accident (CVA). The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/22 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and received tube feedings. a. The Plan of Care dated 12/01/22 documented, .NPO [Nothing by mouth], She receives all nutrition/hydration via PEG [Percutaneous Endoscopic Gastrostomy] Tube . b. The Physician's Order dated 12/27/22 documented, .Enteral Feed Order every 24 hours *JEVITY 1.5 - Infuse 35 ml/hr [milliliters/hour] attempt to increase by 5mls q [every] 12h [hours] until reaches 50 ml/hr. Flush with 50 ml/hr ***MONITOR CLOSELY FOR FLUID OVERLOAD*** Start date 5/4/22 . c. On 12/27/22 at 11:20 AM, Resident #6 was lying in bed, asleep receiving a tube feeding via a pump. The feeding bag did not have a label to specify the formula or the rate it was to be delivered. d. On 12/27/22 at 2:25 PM, Resident #6 was lying in bed, receiving a tube feeding. The feeding bag remained not labeled. e. On 12/30/2022 at 11:20 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2, Should an enteral feeding bag have a label and type of formula on it? She stated, Yes, it should.

Based on observation, record review, and interview, the facility failed to administer oxygen at the correct flow rate for 1 (Resident #171) of 3 (Residents #6, #171 and #221) sampled residents who had physician orders for oxygen. This failed practice had the potential to affect 6 residents who had a physician's order for oxygen according to a list provided by the Administrator on 12/30/2022 at 10:24 AM. The findings are: 1. Resident #171 had diagnoses of Pneumonia and Cerebrovascular Accident. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/22 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview Mental Status (BIMS) and did not receive oxygen therapy. a. The Plan of Care dated 12/02/2022, did not address oxygen therapy. b. The Physician's Order dated 12/15/22 documented, .O2 [oxygen] at 2L [liters] via N/C [nasal cannula] . c. On 12/27/22 at 11:37 AM, Resident #171 was lying in bed, asleep, O2 in place at 3 LPM/NC (liters per minute). c. On 12/30/2022 at 11:20 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2, What can be done to ensure that the oxygen setting stays at the ordered rate? She stated, Do frequent checks.

Based on observation, record review, and interview, the facility failed to ensure the written menu was followed to ensure the nutritional needs of the residents were met. The failed practice had the ability to effect 3 sampled residents who had physician orders for a pureed diet as documented on a list provided by the Administrator on 12/29/22 at 1:20 PM. The findings are: 1. The [Facility] Menu Extension, provided by the Dietary Manager on 12/27/22 at 11:00 AM documented the residents with a physician's order for a pureed diet were to receive Pureed Lasagna, two #8 scoops, one 2 ounce extra sauce, 4 ounces of pureed Green Beans and a #16 scoop of pureed Dinner Roll and Lemon Pudding. 2. On 12/27/22 at 12:10 PM, a pureed lunch tray being filled on the tray line contained pureed Lasagna and pureed Green Beans. The Lemon Pudding was in a bowl. 3. On 12/28/22 at 11:30 AM, the Lunch Menu for the residents who had physician orders for a pureed diet documented they were to receive a #10 scoop of Roast Beef, a #8 scoop of Noodles Au Gratin, #8 scoop of pureed Cauliflower, #8 scoop of Mandarin Oranges and a #16 scoop of pureed Dinner Roll. 4. On 12/28/22 at 11:55 AM, a pureed lunch tray contained pureed Roast Beef, pureed Noodles Au Gratin, and pureed Cauliflower. A separate bowl contained fruit. 5. On 12/29/22 at approximately 10:45 AM, the Dietary Manager (DM) was shown a pureed tray that was served for lunch on 12/28/22. The Surveyor asked the DM to identify the items on the tray. She identified pureed roast beef, pureed noodles, and pureed cauliflower. The Surveyor asked the DM to identify the bread. She stated, Well that must be it. See that looks like a piece of bread on top. The Surveyor asked what the concern would be if there was a piece of bread on the tray that was large enough to identify as bread. She stated, Then they could choke. Because the bread could not readily be identified Dietary Aide #1 was asked if she prepared pureed bread for the lunch meal. She stated, I guess I forgot. To the DM, she stated, You know I said something to you about that. Concerning the lunch meal on Tuesday 12/27/22, she said, I guess I forgot that too. The Surveyor asked for clarification concerning the use of bread crumbs as a substitution for pureed bread. Dietary Aide #1 obtained a plastic container that was sitting on a shelf above the steam table. The DM described that the bread crumbs were sprinkled on top of other pureed items. The Surveyor asked the DM what could take place when bread crumbs were added to an item that had already been pureed to the correct consistency. She stated, It could mess up the texture. She continued to discuss how she felt the addition of the bread crumbs worked better for their residents. The Surveyor asked the DM what should take place if a menu requirement did not work well within the facility. She stated, I should talk to my dietitian and get it changed.

Based on observation, interview, and record review, the facility failed to ensure a water pitcher was provided to ensure water was assessable at the bedside to prevent the potential for dehydration for 1 (Resident #170) of 3 (Residents #61, #170 and #171) sampled residents who were recently admitted to the facility according to the list provided by the Business Office Manager on 12/30/2022 at 10:34 AM, and 1 (Resident #170) of 1 sampled resident who had a Urinary Tract Infection (UTI) on admission according to the list provided by the Director of Nursing (DON) on 12/30/2022 at 11:10 AM. The findings are: 1. Resident #170 was admitted to the nursing facility on 11/10/2022 and had diagnoses of Urinary Tract Infection and Edema. The Medicare 5 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/22 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) a Brief Interview Mental Status (BIMS) and requires total assistance of one person with eating and drinking. a. The Plan of Care with an initiated date of 12/19/22 documented, .Resident has a Urinary Tract Infection . Encourage adequate fluid intake . b. On 12/27/22 at 11:30 AM, Resident #170 was sitting on the bedside in her room, alert oriented, well groomed, and swelling in her lower extremities (LE's). Resident #170 stated, She has had that a long time. The resident had no water pitcher in her room. The Surveyor asked, Where is your water pitcher? Resident #170 stated, I don't have one. The Surveyor asked, Have you had one since you've been here? She stated, No. The Surveyor asked, How long have you been here? Resident #170 stated, A few days now. c. On 12/28/22 at 10:34 AM, Resident #170 still had no water pitcher. She stated, I've been here for a few days now. The Surveyor asked the Assistant Director of Nursing (ADON) at this time if Resident #170 could get a water pitcher. She stated, I will get her one. d. On 12/30/2022 at 11:20 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2, How soon should a resident have a water pitcher in their room if they were admitted on [DATE]? She stated, They should be given one the same day.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate to facilitate the ability to plan and provide necessary care and services for 1 (Resident #3) of 14 (Residents #1, #3, #6, #24, #26, #27, #29, #33, #49, #52, #55, #61, #67 and #171) sampled residents whose MDS were reviewed. The findings are: 1. The RAI (Resident Assessment Instrument) Manual documented, .Section 1 .The RAI process has multiple regulatory requirements . the assessment accurately reflects the resident status . (Resident Assessment Instrument Manual Minimum Data Set 3.0 Resident Assessment Instrument Manual V1.17.1 October 2019) 2. Resident #3 had a diagnosis of Schizoaffective Disorder, Bipolar Type, Bipolar Disorder, Current Episode Manic without Psychotic Features, Moderate, and Unspecified Convulsion. The Quarterly MDS with an Assessment Reference Date (ARD) of 10/14/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was totally dependent of two plus persons physical assistance for bed mobility, transfers, and did not use antianxiety medications during the 7 day look back period. a. The Care Plan dated 10/28/20 documented, .uses psychotropic medications R/T [related to] Bipolar disorder, Anxiety, and Schizoaffective disorder . b. The Physician's Order dated 8/18/22 documented, Clonazepam Tablet Disintegrating 0.25 MG [milligrams] Give 1 tablet by mouth two times a day related to UNSPECIFIED CONVULSIONS . c. The facility policy titled, MDS Completion and Submission Timeframes, provided by the Administrator on 12/29/22 at 1:20 PM did not address the deficient practice. d. On 12/29/22 at 9:30 AM, the Surveyor asked the Minimum Data Set Coordinator (MDSC), What type of antianxiety medication was [Resident #3] receiving? She looked in Resident #3's medical record and stated, She's on Clonazepam. The Surveyor asked her to check her medication record for October for documentation of Resident #3's clonazepam. She reviewed the resident's medication record and stated, Yes she received it. The Surveyor asked, Should it have been captured on her Minimum Data Set? She stated, No, it's used for a convulsant. The surveyor then showed her information from the Resident Assessment Instrument Manual Minimum Data Set 3.0 Resident Assessment Instrument Manual V1.17.1 October 2019 Page .472, Code medications in Item N0410 according to the medication's therapeutic category and/or pharmacological classification, not how it is used. For example, although oxazepam may be prescribed for use as a hypnotic, it is categorized as an antianxiety medication. Therefore, in this section, it would be coded as an antianxiety medication and not as a hypnotic. Medications that have more than one therapeutic category and/or pharmacological classification should be coded in all categories/classifications assigned to the medication, regardless of how it is being used. For example, prochlorperazine is dually classified as an antipsychotic and an antiemetic. Therefore, in this section, it would be coded as an antipsychotic, regardless of how it is used . The MDSC stated, I'll have to read up on this and get back to you. e. On 12/29/22 at 10:44 AM, the MDSC stated, You are correct. I should have coded the clonazepam on the MDS as an antianxiety. I have submitted a modification.

Based on observation, interview, and record review, the facility failed to ensure the baseline care plan was completed within 48 hours of admission for 1 (Resident #61) of 1 sampled resident whose baseline care plan was reviewed. The failed practice had the potential to affect all 63 residents who resided in the facility according to the Census and Conditions of Residents provided by the Administrator on 12/27/22 at 1:00 PM. The findings are: 1. Resident #61 had diagnoses of Unspecified Dementia with other Behavioral Disturbance, and Early Onset Alzheimer's Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/11/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required supervision for bed mobility and transfers, limited physical assistance with dressing, toilet use, and personal hygiene and set up assistance only with eating. a. The Resident Assessment Instrument (RAI) S483.21(b)(1) documented, .The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . b. Resident #61's Medical Record documented the resident was admitted on [DATE]. c. On 12/29/22 at 10:40 AM, the Surveyor asked the Administrator to provide a baseline care plan for Resident #61. At 10:48 AM, the Director of Nursing (DON) presented this surveyor with a copy of a comprehensive care plan with an initiated of 11/29/22. The DON stated, We didn't have a baseline care plan. I asked and this is what she gave me. The Surveyor asked the DON to clarify that there was no baseline care plan. At 10:55 AM, the DON returned and said, That is correct, we do not have a baseline care plan. d. The facility policy titled, Care Plans - Baseline, provided by the MDS Coordinator on 12/29/22 at 1:45 PM documented, .A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .

Complaint # (AR 279) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure the necessary assessments, monitoring, treatment and services were provided for the management of bowel incontinence for Resident #1, as evidenced by: failure to ensure that before a rectal tube with fecal bag (Flexi-seal system) was initiated, the staff responsible for managing the device were knowledgeable and fully competent with doing so; failure to ensure nursing staff monitored the Flexi-seal system and fecal output, promptly addressed leakage of fecal material, kinks or blockage of the tubing, evaluated the positioning of the rectal tube for correct positioning in the rectum when the system continued to experience leakage of fecal material on an ongoing basis, and consulted the physician when the Flexi-seal system continued to be unsuccessful in preventing a Stage IV pressure ulcer from being repeatedly contaminated with fecal material, to prevent further infection and / or exacerbation of the pressure ulcer; and, failure to ensure all nursing staff involved with the resident's care were aware of when to change the Flexi-seal bag and who was responsible for doing so, to ensure fecal material could evacuate from the bowel into the collection bag without impediment for 1 (Resident #1) of 1 case mix resident who had a Flexi-seal system in place. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who had a large Stage 4 pressure ulcer to the coccyx that deteriorated, developed maceration of the surrounding tissue. The failed practices also had the potential to cause more than minimal harm for 4 residents who had pressure ulcers, according to a list provided by the Administrator on 4/23/18. The Administrator and the Director of Nursing were informed of the Immediate Jeopardy condition on 4/20/18 at 4:10 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date (ARD) of 3/30/18 documented the resident had severely impaired cognitive skills for daily decision-making per a Staff Assessment for Mental Status, was totally dependent for personal hygiene, had a feeding tube, was incontinent of bowel and had an indwelling urinary catheter, was at risk for the development of pressure ulcers, had a Stage 1 or higher pressure ulcer, had a Stage IV pressure ulcer measuring 3.0 cm (centimeters) (length) by 2.7 cm (width) by 1.2 cm (depth with slough, required pressure ulcer care, and required pressure reducing device for chair. a. A Hospital Progress Note dated 1/20/18 documented, .Admit 1/13/18 . Subjective . she came in with elevated white blood cell count of 27,000 . She has positive urine culture that grew Proteus Mirabilis . Her wound culture grew Providencis stuartii. She is on [MEDICATION NAME] and Meropenem for UTI (Urinary Tract Infection) and the wound . The hospital documentation indicated the resident was admitted to the hospital on [DATE] and discharged on [DATE]. b. The monthly Wound Clinic Notes dated 1/29/18 documented, .(length) 3 cm (centimeters) (by) (width) 3.2 cm (by) (depth) 0.6 cm, area 7.54 cm, volume 4.524 cm, 0% tunneling or undermining and the peri wound had no abnormalities . c. A Hospital Antimicrobial Susceptibility and Organism Identification Report dated admit 1/29/18, discharged [DATE], documented, . CULT (culture) Wound (and) Gram Stain . Identity . Proteus mirabilis . d. A Physician's Telephone Order dated 2/1/18 documented, .[MEDICATION NAME] 825/125 mg (milligrams) one tab BID (twice daily) (times) 10 days for wound . e. The facility's Weekly Wound Assessments documented the following: .2/13/18 .(length) 3.0 cm (centimeters) (by) (width) 2.5 cm (by) (depth) 1.5 cm . peri wound clear . moderate amount serosanguinous exudate . no odor . Specific wound dressing challenges . urine /fecal incontinence soils dressing intermittently . .2/19/18 . (length) 2.9 cm (by) width) 2.6 cm (by) (depth) 1 cm and tunneling at 1.2 cm at 10 o'clock and peri wound denuded . moderate amount serosanguinous exudate . no odor . Specific wound dressing challenges . urine /fecal incontinence soils dressing intermittently . .2/26/18 . (length) 3.0 cm (by) (width) 2.9 cm (by) (depth) 0.5 cm and 10 o'clock tunneling . peri wound the same . moderate amount serosanguinous exudate . no odor . Specific wound dressing challenges . urine /fecal incontinence soils dressing intermittently . The Monthly Wound Clinic Notes for the same date documented, .(length) 3 cm (by) (width) 2.9 cm (by) (depth) 0.5 cm, area 6.833 cm, volume 3.416 cm, 0% tunneling and undermining and the peri wound has scarring . moderate amount serosanguinous exudate . no odor . Specific wound dressing challenges . urine /fecal incontinence soils dressing intermittently . The area of the pressure ulcer had decreased by 0.7 cm from the previous month, and the volume had decreased by 1.108 cm. .3/5/18 . (length) 3.0 cm (by) (length) 3.1 cm (by) (depth) 0.6 cm . 0.5 cm at 10 o'clock tunneling . moderate amount serosanguinous exudate . no odor . Specific wound dressing challenges . urine /fecal incontinence soils dressing intermittently . .3/12/18 . (length) 3.0 cm (by) (width) 3.4 cm (by) (depth) 1.9 cm . 0.5 cm at 10 o'clock and 1.3 cm at 3 o'clock tunneling . peri wound macerated, [DIAGNOSES REDACTED]tous . peri wound open . moderate amount serosanguinous exudate . no odor . Specific wound dressing challenges . urine /fecal incontinence soils dressing intermittently . .3/19/18 . (length) 3.0 cm (by) (width) 3.2 cm (by) (depth) 1.4 cm . 1 cm at 10 o'clock tunneling . peri wound same . moderate amount serosanguinous exudate . no odor . Specific wound dressing challenges . urine /fecal incontinence soils dressing intermittently . f. A Physician's Telephone order dated 3/23/18 documented, .T.O. (Telephone Order) flex seal per rectum. RE (regarding) wound healing . The Flexi-seal manufacturer's instructions, obtained from the manufacturer's website, documented, .Is designed for managing acute fecal incontinence and is not indicated for chronic incontinence . When fecal incontinence with liquid stool is present, the patient will receive anti-diarrhea therapy . 5 Small amounts of moisture or seepage around the catheter is anticipated.Sometimes during the course of using Flexi-seal, the retention balloon may slide deeper inside the rectum and no longer provide an effective seal, thus leaking feces around the catheter. Alternatively, in a patient with a weak rectal sphincter, the balloon may slide out and also lead to leakage 6. How can leakage be prevented? . The best way to prevent leakage is to ensure that the retention balloon is adequately inflated and properly positioned in the rectum at all times during the flexi-seal. make sure that all the instructions for proper insertion are followed. After ensuring that the balloon is properly positioned, take note of the position indicator line relative to the patient's anus. Observe changes in the location of the position indicator line to determine movement of the balloon in the rectum. If the position indicator line moves up (i.e. (such as) closer to the anus), this may indicate that there is a need for gently pulling the catheter to bring the balloon where it should be. If the position indicator line moves down (i.e. away from the anus), this may indicate that the device may expel. In such cases, the balloon should be deflated, removed and re-inserted . 7.Proper positioning, and maintenance of proper positioning, of the retention balloon are key to prevention of expulsion. Maintenance of proper positioning can be achieved by observing changes in the location of the position indicator line to determine movement of the balloon in the rectum.9.Ensure unobstructed flow of stool through the catheter into the collection bag. If the catheter becomes blocked with solid particles, it can be rinsed with water .periodically, 'milk' the catheter to facilitate the flow. Change the collection bag frequently, or before it becomes too full . we recommend changing the bag between 600 ml (milliliters) and 800 ml 10. Can flex-seal be used for formed stool? . No, it cannot. Formed stool cannot pass through the catheter and will obstruct the opening . g. A monthly Wound Clinic Note dated 3/26/18 (3 days after the rectal tube was initiated) documented, .wound measured (length) 3.1 cm (increase of 0.1 cm from previous month's measurement) (by) (width) 2.6 cm (by) (depth) 0.7 cm (increase of 0.2 cm from previous month's measurement), area 6.33 cm upper, and 4.431 cm lower, volume 3 cm . There is no tunneling, or undermining noted. The peri wound skin appearance exhibited excoriation, scarring, maceration . This was the first documented reference in the Wound Clinic Notes regarding the skin surrounding the pressure ulcer being excoriated and macerated. h. The facility's Weekly Wound Assessments documented the following: .3/26/18 . (length) 2.9 cm (by) (width) 3.2 cm (by) (depth) 1.2 cm . 1.0 cm tunneling at 10 to 11 o'clock . peri wound same . .4/2/18 . (length) 3.0 cm (by) (width) 2.7 cm (by) (depth) 1.2 cm . 1.0 cm tunneling at 10 o'clock . peri wound same . .4/9/18 . (length) 3.0 cm (by) (width) 3.2 cm (by) (depth) 1.2 cm . (1.0 cm) tunneling at 10 o'clock . peri wound same . .4/16/18 . (length) 2.8 cm (by) (width) 3.2 cm (by) (depth) 1.4 cm . tunneling 1.0 cm at 10 to 11 o'clock . peri wound same . i. A physician's orders [REDACTED].Treatment . cleanse stage IV sacral wound with Dakin's solution, Pat dry, apply silver calcium alginate, cover with ABD (abdominal) Pad, secure with tape every other day (and) PRN (as needed) . j. A Care Plan with a revised date of 4/3/18 documented, .3/24/18 flexi-seal per manufacturer guidelines . monitor skin around tubing, monitor for s/s (signs / symptoms) of closed tubing, flush per guidelines . NSG (Nursing) staff to provide all ADL (activities of daily living) care to ensure daily needs are met . k. A Physician's Telephone order dated 4/12/18 documented, .T.O. (Telephone Order) . culture stage IV wound sacrum for any indications of infection . l. A Hospital Antimicrobial Susceptibility and Organism Identification Report dated 4/12/18 (with an admission and discharge date of [DATE]) documented, .Culture wound (and) Gram Stain . wound infection . Identity . Providencia stuartii and Staphylococcus aureus . m. A Physician's Telephone Order dated 4/16/18 documented, . T.O (Telephone Order) .[MEDICATION NAME] mg (milligrams) one tab BID (twice daily) (times) 10 days for wound infection per [DEVICE] (gastrostomy tube) . n. On 4/18/18 at 2:00 p.m., Resident #1 was lying in bed. Certified Nursing Assistant (CNA) #1 was called to the resident's room by the surveyor. CNA #1 was asked to check the resident for incontinence. CNA #1 removed the linens from over the resident. There was a dressing on the resident's coccyx wound that was soiled with brown and greenish stool that was liquid in some areas and dried in others. The incontinence brief, which was not fastened, appeared clean with the exception of some soiling caused by the soiled dressing, indicating a clean brief had been applied without changing the heavily soiled dressing. CNA #1 exited the resident's room in order to get supplies and assistance from other staff members to provide care for the resident. o. On 4/18/18 at 2:25 p.m., CNAs #1 and #2, and Licensed Practical Nurse (LPN) #1 entered the resident's room. The resident was lying in bed with the head of the bed elevated. The CNAs started to provide incontinent care for the resident and a tube coming from the resident's rectal area was visible. The soiled dressing on the resident's coccyx was dated 4/18/18. LPN #1 was asked what type of tube was coming from the rectal area and stated, Fecal tube. The rectal tube was attached to a collection bag, which was full to capacity with fecal material, and the rectal tubing was packed with solid feces, from the resident's buttocks to the collection bag opening. LPN #1 was asked if anyone had reported the soiled dressing earlier in the shift and stated, No. The staff provided incontinent and wound care for the resident. The staff exited the resident's room without changing the collection bag and checking the position of the rectal tube. p. On 4/18/18 at 3:15 p.m., CNA #1 was asked if the resident was soiled and if the rectal tube was leaking. She stated, I just got to work, and this is my first time in her room. She was asked, how long has the resident's rectal tube been leaking? She stated, About a week. q. On 4/18/18 CNA #1 and LPN #1 were asked who was responsible for emptying the resident's rectal bag, and how long had it been leaking. They were also asked, should it leak, and has the leakage been reported to the doctor or the nurse. Their responses were as follows: 1.) At 2:25 p.m. CNA #1 stated the rectal tube had been leaking for about 1 week and that the bag should be emptied every 2 hours, as needed, and after every shift. CNA #1 was asked when the bag was last emptied and stated, I don't know; I didn't know I was supposed to empty the bag. CNA #1 was asked if she had been trained in how to care for the rectal tube. She stated, No. She was asked, should you report to the nurse when the resident is soiled and that the stool is not draining into the fecal bag? She stated, Yes, and they knew the stool wasn't going in the bag. 2.) At 3:00 p.m., LPN #1 stated the facility staff had already been aware that the stool was not flowing through the bag. r. On 4/19/18 at 1:10 p.m., LPN #1 was asked who was responsible for emptying the fecal bag and how often. She stated, Nurses and CNAs can empty the bag and it should be emptied every shift. She was also asked what the purpose was for the fecal tube. She stated, To help wound healing. s. On 4/19/18 at 1:30 p.m., the Director of Nursing (DON) was asked, who is responsible for emptying the fecal bag and how often. She stated, The nurses are responsible for changing the bag, not emptying it! That's why I bought so many collection bags. The CNAs should report to the nurse when the collection bag needs emptying (changing). The flex-seal is used to promote wound healing. t. On 4/19/18 at 3:00 p.m., LPN #1, #3 and CNA #1 were at the resident's bedside. They were asked what they were doing for the resident. CNA # 1 stated, She was like this when I came into her room, and I told the nurse. The resident was lying on her right side. There was a soiled draw sheet and pad under the resident that had brown, loose stool on them, and they were rolled under the resident. The inserted fecal tube had stool in it, and the bag contained 100 milliliters (ml) of loose stool. The stool was still oozing from the resident's rectal area, around the rectal tube, onto the resident's skin. The Stage IV pressure ulcer was visibly soiled with fecal material. LPN #1 had the bedside table set up with 4 by 4's, wound cleanser, white strip (calcium alginate), and ABD (abdominal) pads. No Dakin's solution was available in the room. LPN #1 was asked what she was using for the treatments. She stated, while providing the treatment, Clean with wound cleanser, put on calcium alginate, ABD pad, and tape. LPN #1 was asked to measure the wound. The position the resident was lying in prevented the wound from accessibility for correct measurements. LPN #4 tried to reposition the resident so the entire pressure ulcer could be measured. LPN #1 measured the pressure ulcer, which was partially mashed together by the resident's buttocks, and stated, 2.8 cm (l) (by) 3 cm (w). The staff was asked to position the resident's buttocks so the entire wound was visible. After doing so, LPN #1's measurements of the wound were 3.0 (l) (by) 3.7 (w) (by) 1.6 (d), with 11:00 and 12:00 o'clock tunneling. The Stage IV pressure ulcer had a dark red area to the center of the wound bed, and the remainder of the wound bed was pale red. The peri wound had several opened areas that were pink / red. The peri wound was pale, wet and boggy in an area measuring approximately 3.0 cm (length) by 3.7 cm (width) by 1.6 cm (depth) with 11:00 - 12:00 tunneling. There was an opened red area approximately 1 (by) 1 cm on the left leg, close to the bottom of the buttock. The LPN covered this opened 1 (by) 1 cm area with an ABD pad. She did not measure the area or provide treatment. The fecal bag tubing was kinked at the end closest to the collection bag and was not allowing feces to empty from the rectum into the bag. After the care was completed, the staff left the room without removing the kink from the tubing or evaluating whether the rectal tube was positioned correctly to minimize leakage. u. On 4/19/18 at 3:45 p.m., LPN #1 was asked if they were finished with the resident's care. She stated, Yes. She was asked if the resident had any new skin breakdown on her buttocks. She stated, No. She was asked, how often she had to change the feces soiled dressing on her shift and stated, Three to four times. She was asked how long the peri wound had been pale, boggy and with open areas, and how long the opened area on the left leg near the buttocks had been present. She stated, It's macerated. She was asked if the peri area was getting better or worse. She stated, Since the stool stays on her, it's gotten worse. She was asked if the doctor was notified of the deterioration in the coccyx wound since the fecal bag had been in place and stated, He knows. She was asked, where do you document the fecal tube output. She stated, We did at first, but what for? v. On 4/20/18, staff were asked multiple questions, including: Are you familiar with the resident's care? When did the buttocks become macerated? What was done to prevent further skin breakdown? How often is the flexi seal changed during the day? Was the leaking of the fecal tube reported to the doctor? Do you notify the nurse of the fecal soilage? Has the leaking fecal tube been examined? Should measurements be accurate and the entire wound be measured? Should you report changes in skin breakdown to the physician? Should the fecal tube output be measured? Should the care plan document the resident has a flex seal tube? Was the physician notified of skin irritation on the resident's upper middle thighs? What are the resident's current physician's orders [REDACTED].? Was the doctor notified of the changes in the coccyx? Who is responsible for emptying or changing the rectal tube collection bag? Who trained you on the flexi-seal? Their responses were as follows: 1.) At 1:35 p.m., CNA #3 stated, Yes, I am familiar with the resident's care. The pressure ulcer started to worsen about 2 weeks ago . We were told the purpose of the flex seal tube was to keep stool out of the pressure ulcer and we should be emptying and checking the fecal bag often. She is soiled about 3 or 4 times a day. The dressing has to be changed, and I report the soilage to the nurse. The fecal tube has been leaking about 1 week. I reported the leaking tube to the nurse. She said she would observe the tube. Later on in the day, it would leak again. The leakage wasn't coming from the tube, but from the rectal area. Nurses and aides empty the fecal bag as soon as it is halfway full. We empty the bag, and the nurse changes the bag . When asked about the Flexi-Seal training she had received, she stated, I was told to empty the fecal bag. 2.) At 2:00 p.m., the Treatment Nurse, (LPN #1), stated, Yes, I am aware of her plan of care. The wound on her coccyx was present when I started working about 2 months ago. It gets better, then worse, depending on how many stools she has. Sometimes the peri wound has opened areas in it, and sometimes it doesn't. We used to measure the open areas on the peri wound, but we stopped. I have measured the open areas on the peri wound once. I call and report drastic changes of the wound to the physician, like odors, and if it gets worse or better. I just called him on Monday (4/16/18) to give him an update that there were no changes in the wound. I use Dakin's solution to clean the wound, silver calcium alginate, and ABD dressing. The Flexi-seal is to keep stool out of the wound. I empty the bag prn (as needed). We don't have an order to change the bag, but I have changed it before. (Physician #1) ordered the Flexi-seal and I reported the leakage to the wound care doctor (Physician #2). I left a message with (Physician #1), but she hasn't got back with me. We inserted the tube in the facility. It's been leaking for a few weeks. I didn't document that the fecal tube was leaking, and I didn't document I called the physician. I didn't notify the physician (#2) of the measurement changes yesterday, because I didn't write them down yesterday. If you tell me the measurements, I will notify him. The opened area on the left upper leg has always been there. The Flexi-seal is to prevent stool from getting into the wound. If it doesn't work, we will try something else. I only document that the peri wound is denuded or macerated, not other changes in the peri wound . 3.) At 4:50 p.m., the Medical Director was contacted via telephone. She stated, I communicate closely with administration at the facility. I was aware of the stool coming from the Flexi-seal. I believe it was mentioned to me about two weeks ago. I believe the rectal tube was being repositioned. I was notified once of the stool expelling from the tube. I wasn't aware that stool was expelling from the tube daily. I was notified on Tuesday (4/17/18) of this week that the pressure ulcer was deteriorating. I received a call on Wednesday (4/18/18) that she (the resident) was placed on an antibiotic for a wound infection. 4.) At 5:10 p.m., the Director of Nursing stated, I'm not sure of all of her plan of care. She admitted in (MONTH) (YEAR) with the pressure ulcer on her coccyx, and I have not noticed a deterioration in the wound on her coccyx. The Flexi-seal tube was to prevent some of bowel movement from getting in the pressure ulcer. Only the nurses can change the fecal bag, not empty it. No one should be emptying the bag. Staff should report when the bag needs changing to the Treatment Nurse. I wasn't aware that the dressing was soiled with stool that frequently. I didn't report to the physician that fecal matter was coming from the tube. Yes, if we notice changes in the pressure ulcer, we should notify the physician. We were not recording the output of the fecal tube, because it wasn't required. Yes, the care plan and MDS should include the Flexi-seal. Yes, physician's orders [REDACTED]. I trained the Nurses that work on that end (where resident resides) about the Flexi-seal tubing. w. On 4/23/18 at 9:00 a.m., the Director of Nursing (DON) was asked if staff had received training for the Flexi-seal device. At 2:25 p.m. the DON provided an in-service dated 3/27/18 titled, Fecal Tube Irrigation. The in-service documented, .Nurses . Flexi-seal signal fecal management system . To irrigate the device . repeat the irrigation procedure as often as necessary to maintain proper functioning of the device . If repeated flushing with water does not return the flow of stool through the catheter, the device should be inspected to ascertain that there is no external obstruction . If no source of obstruction of the device is detected, use of the device should be discontinued . Maintenance of device . Change the collection bag as needed. Discard used bag . Observe the device frequently for obstructions from kinks, solid fecal particles or external pressure . The in-service was signed by 12 Licensed Practical Nurses. LPN #1 was in attendance of the in-service. The in-service training did not contain documentation to indicate information related to the evaluation of the fecal tube's position to minimize leakage was included in the training. x. The Immediate Jeopardy was removed, and the scope and severity lowered to H on 4/20/18 at 6:00 p.m., when the facility implemented the following Plan of Removal: 1.) On 4/20/18 prior to 9:00 a.m., the rectal tube was removed for Resident #1 by the Director of Nursing, per the manufacturer's guidelines of leave in no more than 29 days. 2.) On 4/20/18 at 3:30 p.m., the MD (medical doctor) was notified of the change on condition of Resident #1's wound. 3.) On 4/20/18 at 3:30 p.m. the Treatment Nurse was in-serviced on proper wound measurements and documentation by the Director of Nursing. 4.) On 4/20/18 the Treatment Nurse completed a new body audit and recorded the findings for Resident #1. 5.) On 4/20/18 at 3:30 p.m., the Treatment Nurse was in-serviced on following physician's orders [REDACTED]. 6.) Starting 4/20/18 all nurses will be in-serviced on immediate notification of resident's change in condition to the resident's physician. 7.) Other Affected residents: 8.) All other residents with pressure wounds will have a body audit completed on 4/20/18 by the nursing staff, and notification to the MD of any negative findings. 9.) There are no other residents with rectal tubes. 10.) All residents' charts will be reviewed by the Administrator on 4/20/18 to ensure physicians have been notified of any change in conditions. 11.) Systemic Changes: 12.) All nursing staff will be in-serviced to report any change in condition to the physician promptly beginning 4/20/18 by the DON. 13.) QA Monitoring: 14.) The Administrator will monitor all resident's body audits weekly to ensure proper documentation of wounds for 8 weeks or until compliance is verified by the Office of Long Term Care. 15.) The Administrator will monitor all resident charts 2 times per week to ensure resident's change in condition is reported promptly to the physician for 8 weeks or until compliance is verified by the Office of Long Term Care. 16.) The DON will monitor treatments of residents with pressure wounds to verify that Physician order [REDACTED].

Complaint # (AR 869) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure necessary treatment and services were provided for management of existing pressure ulcers, as evidenced by failure to ensure wounds were assessed and measured weekly with the results documented, to include the type / stage of the wound, measurements, condition of the surrounding tissue and the presence or absence of drainage / odor to enable accurate tracking of healing progress or prompt identification of deterioration; failure to accurately identify and document the pressure ulcer as a Stage 4 wound; failure to ensure physician-ordered pressure ulcer treatments were consistently provided and documented to promote healing and prevent potential infection; failure to ensure a severe, Stage 4 pressure ulcer was reported to the resident's wound specialist physician, which resulted in a delay in providing appropriate treatment measures; and, failure to ensure loose or missing wound dressings were promptly replaced to prevent potential infection for 1 (Resident #6) of 2 (Residents #1 and #6) case mix residents who had pressure ulcers. These failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #6, who developed a large, severe, infected, Stage 4 pressure ulcer to the buttock, with necrotic tissue and foul-smelling drainage, and had the potential to cause more than minimal harm to 19 residents who had pressure ulcers, according to a list provided by the Administrator on 1/26/18. The Administrator was informed of the Immediate Jeopardy condition on 1/25/18 at 4:10 p.m. The findings are: 1. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/21/18 documented 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, was totally dependent on two-plus persons for transfer and toilet use, was always incontinent of bladder and of bowel, was at risk for pressure ulcers, had a stage 3 pressure ulcer, and had an unstageable pressure ulcer with slough or eschar present with measurements of 4.0 centimeter (cm) in length, 7.0 cm in width, and depth 0.1 cm. a. A Braden Scale for Predicting Pressure Sore Risk form dated 6/19/17 documented a score of 14, Moderate Risk. There was no documentation of any Pressure Sore Risk assessments dated more recently than 6/19/17. b. A physician order [REDACTED]. c. The Skin Wound Log dated 1/4/18 documented, .Left Buttock . onset . 1/2/18 . facility acquired . Stage 3 pressure . There was no documentation this facility-acquired pressure ulcer was identified until it was a Stage 3 wound. The initial entry regarding this pressure ulcer did not document any measurements, information regarding the condition of the surrounding tissue, description of the wound bed, presence or absence of odor or drainage, or whether any signs/symptoms of infection were present. d. The Treatment Administration Record dated January 2018 documented, .Cleanse left heel with NS (normal saline), apply Calcium Alginate with Silver, cover with rolled gauze QOD (every other day) . e. The Skin Wound Log dated 1/9/18 documented, . stage 3 pressure . This entry did not document any measurements, information regarding the condition of the surrounding tissue, description of the wound bed, presence or absence of odor or drainage, or whether any signs/symptoms of infection were present. The Skin Wound Log contained no documentation of an assessment of the Stage 3 left buttock wound between 1/9/18 and 1/22/18, a 13-day period. f. A physician order [REDACTED]. The January 2018 Treatment Administration Record (TAR) documented nurses' initials to indicate the wound care was provided to the left buttock on Friday, 1/12/18 and Monday 1/15/18; however, there was no documentation to indicate the wound care was provided on Wednesday 1/17/18. The TAR documented the Monday, Wednesday and Friday treatments were continued through Monday, 1/22/18. g. The Skin Wound Log dated 1/22/18 documented the Stage 3 pressure ulcer to the left buttock measured 4 by (x) 7 centimeters (cm). There was no documented information regarding the condition of the surrounding tissue, description of the wound bed, presence or absence of odor or drainage, or whether any signs/symptoms of infection were present. This was the first entry that documented any measurements of this wound, and no depth was documented, at this time. h. A Wound Clinic Note dated 1/24/18 documented, .Left calcaneous (pressure ulcer) . Weeks in Treatment: 41; Date acquired 3/24/17 . Left Gluteal fold . date acquired 1/2/2018 . Weeks of treatment .0 .wound status . open . measurements . 5.6 x 5.5 x 2.7 . area . 24.19 cm (centimeters) . volume . 65.314 cm . % (percentage) of reduction in area and reduction in volume . 0.00% . stage IV (4) . Exudate amount .Large . Exudate .Purulent . Exudate color . yellow, brown, green . foul odor after cleaning . yes . wound margin .Distinct, outline attached . granulation amount .None Present .(0) % . Necrotic tissue .Eschar, adherent slough . muscle (involved) .yes . tissue exposed .fat layer (subcutaneous tissue) . Wound preparation . Ulcer cleaning . Rinsed / irrigated with saline . Patient was finished with wound #1 (pressure ulcer to heel) when CNA (Certified Nursing Assistant from facility) asked if we would look at the wound to the bottom. Wound Center staff had no knowledge of wound in that location . patient transferred out of wheelchair into bed to assess new wound . Wound with very foul odor, wound with no dressing upon assessment . drainage had drained through pants . Wound debrided per MD (physician) . tissue liquefied under top dry layer . The physician order [REDACTED]. i. The Plan of Care with a revised date of 1/24/18 documented, .At risk for developing skin issues / skin breakdown d/t (due to) decreased mobility, w/c (wheelchair) used for mobility. sits in w/c most of the day, receives daily diuretic, has history of falls, has OA ([MEDICAL CONDITION]) . Goal . Resident will have intact skin, free of redness, blisters or discoloration over a bony prominence . Approaches . Measure weekly and as needed . Monitor for signs / symptoms of infection . Complete Braden scale quarterly . Skin Assessments . Report changes in skin status to MD (medical doctor) . Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care . unstageable wound to left buttock . treatment as ordered . j. A laboratory culture final report dated 1/25/18 documented, .culture of wound / abscess . heavy growth Proteus mirabilis . k. On 1/25/18 at 9:20 p.m., wound care was provided by Licensed Practical Nurse (LPN) #1 with Certified Nursing Assistant (CNA) #9 assisting. The dressing on the left buttock was removed, revealing a large, necrotic, foul-smelling pressure ulcer. The old dressing was removed per LPN #1 and she proceeded to clean the ulcer. The area measured 5.8 cm long X 6.8 cm wide X 2.4 cm deep. The drainage was black in color, liquified and oozing from the area. The LPN placed Santyl in the wound bed and covered it with a dry dressing. The Nurse was asked how long she had been doing the treatments and stated, It has been 4 years since I did treatments, but they told me I will be doing treatments. The LPN was asked if yesterday was the first time the left buttock wound had been evaluated or treated by the physician at the wound clinic. She stated, Yes. l. On 1/25/18 at 9:20 a.m., LPN #3 was asked if the resident had been to the wound clinic for the pressure sore to left buttocks before 1/24/18. She stated, No. m. On 1/25/18, CNAs were asked, Does the resident get dressing changes daily to his pressure ulcers? and, Have you noticed if his dressings are changed? Their responses were as follows: At 10:45 a.m., CNA #2 stated, Yesterday, I asked (LPN #6) if she was going to change the dressing. She said, 'No, he's going to wound care (clinic)', and when I was getting him dressed for wound care, it (dressing) had come off. I told (LPN #6), and she said 'he's going to wound care (clinic).' She didn't stay all day. She left the facility. The resident didn't get another dressing put on. She does treatments on the weekends . I had noticed his dressing go unchanged. I have seen nurses on the weekend changing the dressings, yes, but only some weekends. At 11:00 a.m., CNA #10 stated, When I have him, they are changed daily. We rotate every other day. On the 6 to 2 shift, I have noticed dressings going unchanged, or having no dressing on it. At 11:05 a.m., CNA #9 stated, I have to go to the nurse and tell her (to change the dressing) during peri-care. n. On 1/26/18 at 1:37 p.m., the physician from the wound care clinic was interviewed via telephone. He was asked about the pressure ulcer to the resident's left buttock and stated, We did a little debridement on it the other day and cleaned it out some to get some of that dead tissue out of it. If they keep it clean and apply Santyl to the wound bed, I think it will heal fine. He was asked if he knew about the decubitus on the resident's buttocks prior to 1/24/18 and stated, No, I did not. That was the first time I knew about it. When I finished his other treatment, the person who brought him here asked 'What about his other wound, the one on the bottom?' I looked at it; it was a bad one and had a bad smell. I asked here in the clinic if any of staff knew about it, and they all stated 'no'. o. On 1/26/18 at 2:20 p.m., CNA #10 was asked, Are you the one who does transportation? She stated, Yes. She was asked if she was the one who took the resident to the wound clinic on 1/24/18 and stated, Yes, I do the transportation here. She was asked if she knew whether the wound clinic physician had ever checked the wound on the resident's left buttock before 1/24/18 and stated, No, they had not. When I went in, they had him sitting in the chair, and I asked, 'what about the sore on his bottom?' I could smell it, so I asked them to look at the sore on his bottom. The nurse stated, 'We didn't know he had a sore on the left buttock, I thought that smell was BM (bowel movement)' . p. The Immediate Jeopardy was removed, and the scope and severity lowered to H on 1/26/18 a 12:40 p.m., when the facility implemented the following Plan of Removal: a. All residents with wounds received new body audits by staff nurses on 1/25/18. Pressure wounds were assessed and measured in a manner to include a description of the wound bed and surrounding tissue, documented descriptions also were made of any wound drainage odor or S/S (signs / symptoms) of infection. Resident pressure ulcers were assessed by the ADON on 1/25/18 and correct staging, measurements and a thorough description of bed, surrounding tissue, any drainage, odor or S/S of infection were obtained and documented in the clinical record and communicated to the attending physician as appropriate. Body audits on other residents were checked by the DON (Director of Nursing) / Designee to ensure they were completely and accurately documented. Licensed Nursing staff will be in-serviced by ADON with regards to assessing wounds, documenting wound condition, following physician orders [REDACTED]. b. The DON or ADON will monitor 2 random treatments weekly to assure treatments are being consistently documented per physician orders [REDACTED]. c. Information from these body audits will be forwarded to the wound doctor for his review and recommendation. DON / Designee will review skin audits weekly to verify any new pressure ulcers, worsening pressure ulcers, or ulcers that are failing to heal are promptly reported to the physician. d. On 1/25/18 licensed nursing staff assessed all residents with wound dressings to assure the dressing was in place. Wound dressing monitoring sheets will be placed with the MARs (Medication Administration Records) on the Nurses' carts. Each shift, the medication nurse will check the dressing and check off it is in place or replace the dressing and indicate it was replaced. RN (Registered Nurse) nursing staff will monitor dressings 3 times weekly to assure the dressings are in place and check monitoring sheets to ensure dressings are being consistently documented with any negative findings being corrected immediately.

Complaint # (AR 869) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure Resident #1, who had a [MEDICAL CONDITION], received proper treatment and services to prevent potential respiratory complications, as evidenced by failure to ensure licensed nurses promptly and competently responded to signs of respiratory distress and need for tracheal suctioning (excessive coughing, gurgling, visible copious secretions, and deep flushing of the face) during [MEDICAL CONDITION] care; failure to ensure licensed nursing staff received adequate training, with return demonstration, to assure competency with [MEDICAL CONDITION] care and suctioning to facilitate maintenance of a patent airway and minimize the potential for complications; failure to immediately inform the physician of the presence of blood in the resident's respiratory secretions to enable the physician to determine if any diagnostic or treatment measures were necessary; and failure to ensure the proper emergency equipment was maintained at the bedside to enable staff to quickly address potential accidental extubation or occlusion of the [MEDICAL CONDITION] for 1 (Resident #1) of 1 case mix resident who had a [MEDICAL CONDITION] (trach). The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who was observed gurgling, gasping for air and with copious thick respiratory secretions in her [MEDICAL CONDITION] and mouth [MEDICAL CONDITION] and was not suctioned by the licensed nurse. The failed practices had the potential to affect only this resident (the only resident in the facility with a [MEDICAL CONDITION]), as documented on the Resident Census and Conditions of Residents form dated 1/23/18. The facility Administrator was informed of the Immediate Jeopardy condition on 1/25/18 at 12:10 p.m. The findings are: 1. The facility's policy and procedure titled, Patient Care Instructions / [MEDICAL CONDITION] Care (and) Suctioning, received from the Administrator on 1/26/18, documented, .[MEDICAL CONDITION] Care . Equipment Needed . Ambu (artificial manual breathing unit) bag . Procedure . Suction the patient if needed . Early Warning Signs . It is very important for you to know the signs and symptoms of infection or other problems. Signs of infection . Changes in sputum color, volume, odor, and consistency . Breathing Symptoms . Increased shortness of breath, Increased coughing, Increased accessory muscle use . Sputum changes . Color change (yellow, green, tan or brown) . Change consistency, Increase in quantity, Bloody . Page 10 . Suctioning . Secretions can obstruct the airway making it difficult for lungs to get the oxygen they need. Suctioning removes the secretions from the airway which will allow the patient to breathe better .When a patient needs suctioned they will begin to breathe noisily, cough . Notify the physician if you notice an increase in sputum production or blood in sputum . Page 13 . Emergency Equipment to be kept in Room at All Times .[MEDICAL CONDITION] of the same size,[MEDICAL CONDITION] one size smaller, Ambu bag with mask, [MEDICATION NAME] Suction, Hemostats . When to suction . Clinical Indicators . Course Breathing sounds, Noisy Breathing, Increased or decreased rate of respirations, Decreased oxygen saturation, Copious secretions, Patient attempting to cough . Respiratory Distress and [MEDICAL CONDITION] Obstruction . Mucus plugs are the most common cause of respiratory distress for patients with tracheostomies . Symptoms of Respiratory Distress . Grunting, noisy breathing, sweaty, clammy skin, more comfortable with head elevated or sitting up . 2. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date (ARD) of 12/31/18 documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment of Mental Status, was totally dependent on two-plus person physical assistance for bed mobility and transfer, did not have shortness of breath, had a feeding tube through which she received 51 percent or more of daily caloric and fluid intake, had a [MEDICAL CONDITION] and required oxygen therapy and suctioning. a. A physician's orders [REDACTED].Suction As Needed .[MEDICAL CONDITION] . [MEDICAL CONDITION]. Pat Dry (and) Cover with Split Dry Dressing QD (every day) (and) PRN (as needed) .Treatment . Remove Inner Cannula [MEDICAL CONDITION] (and) replace with new disposable inner cannula daily . b. A Care Plan with a review date of 1/3/18 documented, .Monitor for changes in / development of signs (and) symptoms of breathing difficulty and report to nurse if noted . SOB (shortness of breath), Cough (productive or non- productive) . [MEDICAL CONDITION] care daily using sterile technique . c. An (Emergency Medical Services EMS) patient record dated 11/30/17 at 14:10 (2:10 p.m.) documented, .M2 (Medical 2) was dispatched to the above location for a female patient with shortness of breath. Upon arrival we found the patient lying in bed. The patient was diaphoretic and was having obvious difficulty breathing. The patient had a [MEDICAL CONDITION]. The patient was making gurgling noises coming from the [MEDICAL CONDITION] opening .The nursing home stated that the patient had suddenly started experiencing the diaphoresis and shortness of breath . The patient [MEDICAL CONDITION] was suctioned with a 12 Fr (French) catheter. Thick secretions were suctioned out. The patient began to breathe easier . There was no indication that the facility staff attempted to suction the resident'[MEDICAL CONDITION]. d. Hospital #1's Emergency Department Nurse Documentation sheet dated 11/30/17 at 19:32 (7:32) p.m. documented, .(Physician) was informed about pt's (patient's) condition and the wait time for ground ambulance transfer. He agreed that pt should be flown to (Large Metropolitan Hospital) if possible. Air Medical Transport has been contacted and will call back . e. The Hospital #1 Emergency Department (ED) Physician's Documentation sheet dated 11/30/17 at 19:39 (7:39) p.m. documented, .ED (Emergency Department) course . respiratory reports not able to [MEDICAL CONDITION], rec (recommend) surgical eval (evaluation) for change, believe to have granulation tissue around tube, surgery rec transfer for ENT (endotracheal) back up. Seen in ED by hospitalists who agreed and also rec transfer . Resident's [MEDICAL CONDITION] was unable to be replaced because granulation tissue had attached to [MEDICAL CONDITION]. f. On 1/12/17 at 11:23 a.m., there were several licensed and certified staff at the resident's bedside. Resident #1 was lying in bed with the head of the bed (HOB) elevated. The resident's facial expression was anxious and the skin on her face was moist. The staff were asked what was going on and stated, She's going to the hospital. The resident had a pulse oximeter on a finger of her right hand, indicating onscreen that her oxygen saturation was 93%. Her heart rate was 108. Certified Nursing Assistant (CNA) #11 loudly stated, Blood Pressure 187/117 and axillary temperature 99.6 degrees. Registered Nurse (RN) #1 was standing at the resident's bedside with an [MEDICAL CONDITION]. RN #1 stated, We've been calling the doctor all day for her temperature and cough. RN #1 was asked if she had just changed the resident'[MEDICAL CONDITION]. She stated, Yes. She was asked by the surveyor to open [MEDICAL CONDITION]. [MEDICAL CONDITION] contained an inner cannula that was filled with yellow, thick secretions. Upon observation of the equipment at the bedside, there was not a pair of hemostats at her bedside or in the multi-functional dresser. There was no Ambu bag at the resident's bedside. There was a suction machine at the resident's bedside. g. A Nurse's Note dated 1/13/18 documented, .Sent to the Emergency for panting, diminished lung sounds, and blood-tinged mucus [MEDICAL CONDITION]. h. A Hospital Discharge Record indicated the resident was transferred back to the facility on [DATE], after receiving, .[MEDICATION NAME] 500 mg (milligrams) one per peg tube QD (every day) (times) 10 days . Dx: (Diagnosis) UTI (Urinary Tract Infection) . [MEDICAL CONDITION], whether it was urosepsis or [MEDICAL CONDITION], I do not know . Chronic Sacral decubitus that grew out Providencia stuartii . There was no indication in the hospital record that the resident had experienced a respiratory infection. i. On 1/25/18 at 7:40 a.m., Licensed Practical Nurse (LPN) #1 and #2 were standing at the resident's bedside setting up supplies to [MEDICAL CONDITION]. LPN #1 placed a pulse oximeter on the resident's right index finger, and the display indicated the resident's oxygen saturation was 93% and heart rate was 110. LPN #2 paused the enteral tube feeding and LPN #1 lowered the head of the resident's bed to a flat position. The resident began to cough, and gurgling sounds were coming from the trach. The resident continued to cough and her face became flushed to a dark red color. The cough became more forceful and her cheeks and forehead began to perspire. The oxygen saturation readings were fluctuating between 93% and 97%. Without assessing the resident to determine if suctioning was needed, LPN #1 donned a pair of blue non-sterile gloves and began to clean around [MEDICAL CONDITIONS] area. The resident had visible, thick, clear, and bubbling secretions in her mouth and was gurgling and coughing continuously. LPN #1 raised the head of bed to about 15 to 20 degrees and the coughing became less frequent. The oxygen saturation held steady at 96% for several seconds. The resident began grinding her teeth as LPN #1 continued to [MEDICAL CONDITION]. The resident briefly stopped coughing, but started coughing again until she again became red in the face. LPN #1 raised the head of the bed to approximately 30 to 40 degrees and the coughing briefly stopped again. LPN #1 removed the non-sterile gloves, opened the [MEDICAL CONDITION], and donned the sterile gloves from the kit. The resident began coughing again, and the oxygen saturation again began fluctuating between 93% and 96%. LPN #1 removed the inner cannula from the resident'[MEDICAL CONDITION] inserted a new size 6 disposable inner cannula into the trach. The old inner cannula was filled with blood-tinged, thick yellow sputum. The thick secretions remained in the resident's mouth. After LPN #1 completed [MEDICAL CONDITION], LPN #2 restarted the tube feeding without checking placement of the PEG tube, LPN #1 exited the resident's room and went to her treatment cart, documented information on a chart, then sanitized her hands. While the LPN was still standing just outside the door to the room, the resident again began to cough continuously. LPN #1 entered the resident's room and asked the non-verbal resident if she needed to be suctioned. The resident did not respond, and the LPN left the room without suctioning the resident, who still had visible thick secretions in her mouth. The surveyor re-entered the room. The resident's face was red and diaphoretic, but the coughing had stopped. At 7:50 a.m., LPN #1 was asked how long she had been the Treatment Nurse, and when she was last trained on how to [MEDICAL CONDITION]. She stated, I have been the Treatment Nurse for 48 hours, and I [MEDICAL CONDITION] training about [AGE] years ago. I use [MEDICAL CONDITION] Manual at the nurses' desk and the policy and procedure manual. At 10:10 a.m., LPN #1 was asked, how often should you suction a resident with a trach, and when? She stated, As needed. She was asked, what are the signs and symptoms that [MEDICAL CONDITION] to be suctioned? She stated, Breathing sounds change, like something is blocking the airway, and if you hear gurgling sounds. j. On 1/25/18 at 9:20 a.m., LPN #2 was asked, when she had last [MEDICAL CONDITION] training. She stated, It was before (Resident #1) became a resident. (Respiratory Supply Company) provided the training, and the training was very brief. k. On 1/25/18 at 10:15 a.m., the Assistant Director of Nursing (ADON) was asked if the facility's nurses had received training [MEDICAL CONDITION]. At 10:30 a.m., she provided an in-service sheet dated 10/9/17, which documented,[MEDICAL CONDITION] review, plus multiple topics not related [MEDICAL CONDITION]. No written instructions or illustrations were included with the in-service documentation. The ADON stated, I can't find the original copy of the in-service. LPN #1 was not listed as one of the attendees for the in-service. l. On 1/25/18 at 10:50 a.m., LPN #3 was asked when she had last received training [MEDICAL CONDITION]. She stated, A guy came out a few months ago. He was an hour late, so I had to leave and only saw half of the presentation. I didn't sign the sign in-sheet. I feel I need more training on trachs. Only 3 people showed up for the training. (Respiratory Supply Company) did the training. m. On 1/25/18 at 12:35 p.m., the Assistant Director of Nursing was asked if she was aware the resident had blood-tinged mucus in inner cannula in this morning. She stated, No, not today. She had blood in [MEDICAL CONDITION] she went to the hospital, but not since she has been back. n. On 1/25/18 at 1:22 p.m., the Medical Director, who was the resident's attending physician, was asked if she was aware that the resident had blood-tinged sputum coming from [MEDICAL CONDITION] morning, and was also asked if the resident had issues with her trach. She stated she received a voice mail from the facility at 12:40 p.m. today and that the resident had no issues with her trach. o. The Immediate Jeopardy was removed and the scope and severity reduced to E on 1/25/18 at 3:45 p.m. when the facility implemented the following Plan of Removal: 1.) On 1/25/18 at 12:21 p.m., Respiratory Therapy was contacted to come to in-service all licensed nursing staff on [MEDICAL CONDITION] that will include return demonstration and assure that resident's room is set up per P&P (policy and procedure). Respiratory Therapist plans to arrive at the facility by 3:00 p.m. 2.) The ADON is contacting all licensed nursing staff to be here by 3:00 p.m. to receive training. Any that are unable to make training, will not return to work on the hall until they have completed competency training. 3.) Will monitor [MEDICAL CONDITION] competency three times weekly for four weeks then random thereafter. 4.) Respiratory Therapist will do competency check-off quarterly, and then as needed. 5.) Nurses noted (for Resident #1) resp. (respirations) (were) even and unlabored and v/s (vital signs) (were) stable at 10:25 a.m. on 1/25/18. No distress noted throughout the day as of 3:25 p.m.

Complaint # (AR 869) was substantiated, all or in part, with these findings: A. Based on observation, record review, and interview, the facility failed to ensure licensed nurses demonstrated competency with necessary care, treatment and services required by each resident, as evidenced by: failure to ensure pressure ulcers were assessed and measured weekly with the results documented, to include the type / stage of the wound, measurements, condition of the surrounding tissue and the presence or absence of drainage / odor to enable accurate tracking of healing progress or prompt identification of deterioration; failure to accurately identify and document the pressure ulcer as a Stage 4 wound; failure to ensure physician-ordered pressure ulcer treatments were consistently provided and documented to promote healing and prevent potential infection; failure to ensure a severe, Stage 4 pressure ulcer was reported to the resident's wound specialist physician, which resulted in a delay in providing appropriate treatment measures; and, failure to ensure loose or missing wound dressings were promptly replaced to prevent potential infection for 1 (Resident #6) of 2 (Residents #1 and #6) case mix residents who had pressure ulcers. These failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #6, who developed a large, severe, infected, Stage 4 pressure ulcer to the buttock, with necrotic tissue and foul-smelling drainage, and had the potential to cause more than minimal harm to 19 residents who had pressure ulcers, according to a list provided by the Administrator on 1/26/18. The Administrator was informed of this Immediate Jeopardy condition on 1/25/18 at 4:10 p.m.; failure to ensure licensed nurses promptly and competently responded to signs of respiratory distress and need for tracheal suctioning (excessive coughing, gurgling, visible copious secretions, and deep flushing of the face) during [MEDICAL CONDITION] care; failure to ensure licensed nursing staff received adequate training, with return demonstration, to assure competency with [MEDICAL CONDITION] care and suctioning to facilitate maintenance of a patent airway and minimize the potential for complications; failure to immediately inform the physician of the presence of blood in the resident's respiratory secretions to enable the physician to determine if any diagnostic or treatment measures were necessary; and failure to ensure the proper emergency equipment was maintained at the bedside to enable staff to quickly address potential accidental extubation or occlusion of the [MEDICAL CONDITION] for 1 (Resident #1) of 1 case mix resident who had a [MEDICAL CONDITION] (trach). The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who was observed gurgling, gasping for air and with copious thick respiratory secretions in her [MEDICAL CONDITION] and mouth [MEDICAL CONDITION] and was not suctioned by the licensed nurse. These failed practices had the potential to affect only this resident (the only resident in the facility with a [MEDICAL CONDITION]), as documented on the Resident Census and Conditions of Residents form dated 1/23/18. The facility Administrator was informed of this Immediate Jeopardy condition on 1/25/18 at 12:10 p.m.; The facility was informed that the above failures, collectively, constituted an Immediate Jeopardy condition in nurse competency on 1/25/18 at 4:10 p.m. The findings are: 1. The facility's policy and procedure titled, Patient Care Instructions / [MEDICAL CONDITION] Care (and) Suctioning, received from the Administrator on 1/26/18, documented, .[MEDICAL CONDITION] Care . Equipment Needed . Ambu (artificial manual breathing unit) bag . Procedure . Suction the patient if needed . Early Warning Signs . It is very important for you to know the signs and symptoms of infection or other problems. Signs of infection . Changes in sputum color, volume, odor, and consistency . Breathing Symptoms . Increased shortness of breath, Increased coughing, Increased accessory muscle use . Sputum changes . Color change (yellow, green, tan or brown) . Change consistency, Increase in quantity, Bloody . Page 10 . Suctioning . Secretions can obstruct the airway making it difficult for lungs to get the oxygen they need. Suctioning removes the secretions from the airway which will allow the patient to breathe better .When a patient needs suctioned they will begin to breathe noisily, cough . Notify the physician if you notice an increase in sputum production or blood in sputum . Page 13 . Emergency Equipment to be kept in Room at All Times .[MEDICAL CONDITION] of the same size,[MEDICAL CONDITION] one size smaller, Ambu bag with mask, [MEDICATION NAME] Suction, Hemostats . When to suction . Clinical Indicators . Course Breathing sounds, Noisy Breathing, Increased or decreased rate of respirations, Decreased oxygen saturation, Copious secretions, Patient attempting to cough . Respiratory Distress and [MEDICAL CONDITION] Obstruction . Mucus plugs are the most common cause of respiratory distress for patients with tracheostomies . Symptoms of Respiratory Distress . Grunting, noisy breathing, sweaty, clammy skin, more comfortable with head elevated or sitting up . 2. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date (ARD) of 12/31/18 documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment of Mental Status, was totally dependent on two-plus person physical assistance for bed mobility and transfer, did not have shortness of breath, had a feeding tube through which she received 51 percent or more of daily caloric and fluid intake, had a [MEDICAL CONDITION] and required oxygen therapy and suctioning. a. A physician's orders [REDACTED].Suction As Needed .[MEDICAL CONDITION] . [MEDICAL CONDITION]. Pat Dry (and) Cover with Split Dry Dressing QD (every day) (and) PRN (as needed) .Treatment . Remove Inner Cannula [MEDICAL CONDITION] (and) replace with new disposable inner cannula daily . b. A Care Plan with a review date of 1/3/18 documented, .Monitor for changes in / development of signs (and) symptoms of breathing difficulty and report to nurse if noted . SOB (shortness of breath), Cough (productive or non- productive) . [MEDICAL CONDITION] care daily using sterile technique . c. An Emergency Medical Services (EMS) patient record dated 11/30/17 at 14:10 (2:10 p.m.) documented, .M2 (Medical 2) was dispatched to the above location for a female patient with shortness of breath. Upon arrival we found the patient lying in bed. The patient was diaphoretic and was having obvious difficulty breathing. The patient had a [MEDICAL CONDITION]. The patient was making gurgling noises coming from the [MEDICAL CONDITION] opening .The nursing home stated that the patient had suddenly started experiencing the diaphoresis and shortness of breath . The patient [MEDICAL CONDITION] was suctioned with a 12 Fr (French) catheter. Thick secretions were suctioned out. The patient began to breathe easier . There was no indication that the facility staff attempted to suction the resident's trach. d. Hospital #1's Emergency Department Nurse Documentation sheet dated 11/30/17 at 19:32 (7:32) p.m. documented, .(Physician) was informed about pt's (patient's) condition and the wait time for ground ambulance transfer. He agreed that pt should be flown to (Large Metropolitan Hospital) if possible. Air Medical Transport has been contacted and will call back . e. The Hospital #1 Emergency Department (ED) Physician's Documentation sheet dated 11/30/17 at 19:39 (7:39) p.m. documented, .ED (Emergency Department) course . respiratory reports not able to [MEDICAL CONDITION], rec (recommend) surgical eval (evaluation) for change, believe to have granulation tissue around tube, surgery rec transfer for ENT (endotracheal) back up. Seen in ED by hospitalists who agreed and also rec transfer . Resident's [MEDICAL CONDITION] was unable to be replaced because granulation tissue had attached to [MEDICAL CONDITION]. f. On 1/12/17 at 11:23 a.m., there were several licensed and certified staff at the resident's bedside. Resident #1 was lying in bed with the head of the bed (HOB) elevated. The resident's facial expression was anxious and the skin on her face was moist. The staff were asked what was going on and stated, She's going to the hospital. The resident had a pulse oximeter on a finger of her right hand, indicating onscreen that her oxygen saturation was 93%. Her heart rate was 108. Certified Nursing Assistant (CNA) #11 loudly stated, Blood Pressure 187/117 and axillary temperature 99.6 degrees. Registered Nurse (RN) #1 was standing at the resident's bedside with an [MEDICAL CONDITION]. RN #1 stated, We've been calling the doctor all day for her temperature and cough. RN #1 was asked if she had just changed the resident'[MEDICAL CONDITION]. She stated, Yes. She was asked by the surveyor to open [MEDICAL CONDITION]. [MEDICAL CONDITION] contained an inner cannula that was filled with yellow, thick secretions. Upon observation of the equipment at the bedside, there was not a pair of hemostats at her bedside or in the multi-functional dresser. There was no Ambu bag at the resident's bedside. g. A Nurse's Note dated 1/13/18 documented, .Sent to the Emergency for panting, diminished lung sounds, and blood-tinged mucus [MEDICAL CONDITION]. h. A Hospital Discharge Record indicated the resident was transferred back to the facility on [DATE], after receiving, .[MEDICATION NAME] 500 mg (milligrams) one per peg tube QD (every day) (times) 10 days . Dx: (Diagnosis) UTI (Urinary Tract Infection) . [MEDICAL CONDITION], whether it was urosepsis or [MEDICAL CONDITION], I do not know . Chronic Sacral decubitus that grew out Providencia stuartii . There was no indication in the hospital record that the resident had experienced a respiratory infection or any respiratory distress after the EMTs i. On 1/25/18 at 7:40 a.m., Licensed Practical Nurse (LPN) #1 and #2 were standing at the resident's bedside setting up supplies to [MEDICAL CONDITION]. LPN #1 placed a pulse oximeter on the resident's right index finger, and the display indicated the resident's oxygen saturation was 93% and heart rate was 110. LPN #2 paused the enteral tube feeding and LPN #1 lowered the head of the resident's bed to a flat position. The resident began to cough, and gurgling sounds were coming from the trach. The resident continued to cough and her face became flushed to a dark red color. The cough became more forceful and her cheeks and forehead began to perspire. The oxygen saturation readings were fluctuating between 93% and 97%. Without assessing the resident to determine if suctioning was needed, LPN #1 donned a pair of blue non-sterile gloves and began to clean around [MEDICAL CONDITIONS] area. The resident had visible, thick, clear, and bubbling secretions in her mouth and was gurgling and coughing continuously. LPN #1 raised the head of bed to about 15 to 20 degrees and the coughing became less frequent. The oxygen saturation held steady at 96% for several seconds. The resident began grinding her teeth as LPN #1 continued to [MEDICAL CONDITION]. The resident briefly stopped coughing, but started coughing again until she again became red in the face. LPN #1 raised the head of the bed to approximately 30 to 40 degrees and the coughing briefly stopped again. LPN #1 removed the non-sterile gloves, opened the [MEDICAL CONDITION], and donned the sterile gloves from the kit. The resident began coughing again, and the oxygen saturation again began fluctuating between 93% and 96%. LPN #1 removed the inner cannula from the resident'[MEDICAL CONDITION] inserted a new size 6 disposable inner cannula into the trach. The old inner cannula was filled with blood-tinged, thick yellow sputum. The thick secretions remained in the resident's mouth. After LPN #1 completed [MEDICAL CONDITION], LPN #2 restarted the tube feeding without checking placement of the PEG tube. LPN #1 exited the resident's room and went to her treatment cart, documented information on a chart, then sanitized her hands. While the LPN was still standing just outside the door to the room, the resident again began to cough continuously. LPN #1 entered the resident's room and asked the non-verbal resident if she needed to be suctioned. The resident did not respond, and the LPN left the room without suctioning the resident, who still had visible thick secretions in her mouth. The surveyor re-entered the room. The resident's face was red and diaphoretic, but the coughing had stopped. At 7:50 a.m., LPN #1 was asked how long she had been the Treatment Nurse, and when she was last trained on how to [MEDICAL CONDITION]. She stated, I have been the Treatment Nurse for 48 hours, and I [MEDICAL CONDITION] training about [AGE] years ago. I use [MEDICAL CONDITION] Manual at the nurses' desk and the policy and procedure manual. At 10:10 a.m., LPN #1 was asked, how often should you suction a resident with a trach, and when? She stated, As needed. She was asked, what are the signs and symptoms that [MEDICAL CONDITION] to be suctioned? She stated, Breathing sounds change, like something is blocking the airway, and if you hear gurgling sounds. j. On 1/25/18 at 9:20 a.m., LPN #2 was asked, when she had last [MEDICAL CONDITION] training. She stated, It was before (Resident #1) became a resident. (Respiratory Supply Company) provided the training, and the training was very brief. k. On 1/25/18 at 10:15 a.m., the Assistant Director of Nursing (ADON) was asked if the facility's nurses had received training [MEDICAL CONDITION]. At 10:30 a.m., she provided an in-service sheet dated 10/9/17, which documented,[MEDICAL CONDITION] review, plus multiple topics not related [MEDICAL CONDITION]. No written instructions or illustrations were included with the in-service documentation. The ADON stated, I can't find the original copy of the in-service. LPN #1 was not listed as one of the attendees for the in-service. l. On 1/25/18 at 10:50 a.m., LPN #3 was asked when she had last received training [MEDICAL CONDITION]. She stated, A guy came out a few months ago. He was an hour late, so I had to leave and only saw half of the presentation. I didn't sign the sign in-sheet. I feel I need more training on trachs. Only 3 people showed up for the training. (Respiratory Supply Company) did the training. m. On 1/25/18 at 12:35 p.m., the Assistant Director of Nursing was asked if she was aware the resident had blood-tinged mucus in inner cannula in this morning. She stated, No, not today. She had blood in [MEDICAL CONDITION] she went to the hospital, but not since she has been back. n. On 1/25/18 at 1:22 p.m., the Medical Director, who was the resident's attending physician, was asked if she was aware that the resident had blood-tinged sputum coming from [MEDICAL CONDITION] morning, and was also asked if the resident had issues with her trach. She stated she received a voice mail from the facility at 12:40 p.m. today and that the resident had no issues with her trach. o. The Immediate Jeopardy was removed and the scope and severity reduced to E on 1/25/18 at 3:45 p.m. when the facility implemented the following Plan of Removal: a. On 1/25/18 at 12:21 p.m., Respiratory Therapy was contacted to come to in-service all licensed nursing staff on [MEDICAL CONDITION] that will include return demonstration and assure that resident's room is set up per P&P (policy and procedure). Respiratory Therapist plans to arrive at the facility by 3:00 p.m. b. The ADON is contacting all licensed nursing staff to be here by 3:00 p.m. to receive training. Any that are unable to make training, will not return to work on the hall until they have completed competency training. c. Will monitor [MEDICAL CONDITION] competency three times weekly for four weeks then random thereafter. d. Respiratory Therapist will do competency check-off quarterly, and then as needed. e. Nurses noted (for Resident #1) resp. (respirations) (were) even and unlabored and v/s (vital signs) (were) stable at 10:25 a.m. on 1/25/18. No distress noted throughout the day as of 3:25 p.m. 3. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/21/18 documented 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, was totally dependent on two-plus persons for transfer and toilet use, was always incontinent of bladder and of bowel, was at risk for pressure ulcers, had a stage 3 pressure ulcer, and had an unstageable pressure ulcer with slough or eschar present with measurements of 4.0 centimeter (cm) in length, 7.0 cm in width, and depth 0.1 cm. a. A Braden Scale for Predicting Pressure Sore Risk form dated 6/19/17 documented a score of 14, Moderate Risk. There was no documentation of any Pressure Sore Risk assessments dated more recently than 6/19/17. b. A physician order [REDACTED]. c. The Skin Wound Log dated 1/4/18 documented, .Left Buttock . onset . 1/2/18 . facility acquired . Stage 3 pressure . There was no documentation this facility-acquired pressure ulcer was identified until it was a Stage 3 wound. The initial entry regarding this pressure ulcer did not document any measurements, information regarding the condition of the surrounding tissue, description of the wound bed, presence or absence of odor or drainage, or whether any signs/symptoms of infection were present. d. The Treatment Administration Record dated January 2018 documented, .Cleanse left heel with NS (normal saline), apply Calcium Alginate with Silver, cover with rolled gauze QOD (every other day) . e. The Skin Wound Log dated 1/9/18 documented, . stage 3 pressure . This entry did not document any measurements, information regarding the condition of the surrounding tissue, description of the wound bed, presence or absence of odor or drainage, or whether any signs/symptoms of infection were present. The Skin Wound Log contained no documentation of an assessment of the Stage 3 left buttock wound between 1/9/18 and 1/22/18, a 13-day period. f. A physician order [REDACTED]. The January 2018 Treatment Administration Record (TAR) documented nurses' initials to indicate the wound care was provided to the left buttock on Friday, 1/12/18 and Monday 1/15/18; however, there was no documentation to indicate the wound care was provided on Wednesday 1/17/18. The TAR documented the Monday, Wednesday and Friday treatments were continued through Monday, 1/22/18. g. The Skin Wound Log dated 1/22/18 documented the Stage 3 pressure ulcer to the left buttock measured 4 by (x) 7 centimeters (cm). There was no documented information regarding the condition of the surrounding tissue, description of the wound bed, presence or absence of odor or drainage, or whether any signs/symptoms of infection were present. This was the first entry that documented any measurements of this wound, and no depth was documented, at this time. h. A Wound Clinic Note dated 1/24/18 documented, .Left calcaneous (pressure ulcer) . Weeks in Treatment: 41; Date acquired 3/24/17 . Left Gluteal fold . date acquired 1/2/2018 . Weeks of treatment .0 .wound status . open . measurements . 5.6 x 5.5 x 2.7 . area . 24.19 cm (centimeters) . volume . 65.314 cm . % (percentage) of reduction in area and reduction in volume . 0.00% . stage IV (4) . Exudate amount .Large . Exudate .Purulent . Exudate color . yellow, brown, green . foul odor after cleaning . yes . wound margin .Distinct, outline attached . granulation amount .None Present .(0) % . Necrotic tissue .Eschar, adherent slough . muscle (involved) .yes . tissue exposed .fat layer (subcutaneous tissue) . Wound preparation . Ulcer cleaning . Rinsed / irrigated with saline . Patient was finished with wound #1 (pressure ulcer to heel) when CNA (Certified Nursing Assistant from facility) asked if we would look at the wound to the bottom. Wound Center staff had no knowledge of wound in that location . patient transferred out of wheelchair into bed to assess new wound . Wound with very foul odor, wound with no dressing upon assessment . drainage had drained through pants . Wound debrided per MD (physician) . tissue liquefied under top dry layer . The physician order [REDACTED]. i. The Plan of Care with a revised date of 1/24/18 documented, .At risk for developing skin issues / skin breakdown d/t (due to) decreased mobility, w/c (wheelchair) used for mobility. sits in w/c most of the day, receives daily diuretic, has history of falls, has OA ([MEDICAL CONDITION]) . Goal . Resident will have intact skin, free of redness, blisters or discoloration over a bony prominence . Approaches . Measure weekly and as needed . Monitor for signs / symptoms of infection . Complete Braden scale quarterly . Skin Assessments . Report changes in skin status to MD (medical doctor) . Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care . unstageable wound to left buttock . treatment as ordered . j. A laboratory culture final report dated 1/25/18 documented, .culture of wound / abscess . heavy growth Proteus mirabilis . k. On 1/25/18 at 9:20 p.m., wound care was provided by Licensed Practical Nurse (LPN) #1 with Certified Nursing Assistant (CNA) #9 assisting. The dressing on the left buttock was removed, revealing a large, necrotic, foul-smelling pressure ulcer. The old dressing was removed per LPN #1 and she proceeded to clean the ulcer. The area measured 5.8 cm long X 6.8 cm wide X 2.4 cm deep. The drainage was black in color, liquified and oozing from the area. The LPN placed Santyl in the wound bed and covered it with a dry dressing. The Nurse was asked how long she had been doing the treatments and stated, It has been 4 years since I did treatments, but they told me I will be doing treatments. The LPN was asked if yesterday was the first time the left buttock wound had been evaluated or treated by the physician at the wound clinic. She stated, Yes. l. On 1/25/18 at 9:20 a.m., LPN #3 was asked if the resident had been to the wound clinic for the pressure sore to left buttocks before 1/24/18. She stated, No. m. On 1/25/18, CNAs were asked, Does the resident get dressing changes daily to his pressure ulcers? and, Have you noticed if his dressings are changed? Their responses were as follows: At 10:45 a.m., CNA #2 stated, Yesterday, I asked (LPN #6) if she was going to change the dressing. She said, 'No, he's going to wound care (clinic)', and when I was getting him dressed for wound care, it (dressing) had come off. I told (LPN #6), and she said 'he's going to wound care (clinic).' She didn't stay all day. She left the facility. The resident didn't get another dressing put on. She does treatments on the weekends . I had noticed his dressing go unchanged. I have seen nurses on the weekend changing the dressings, yes, but only some weekends. At 11:00 a.m., CNA #10 stated, When I have him, they are changed daily. We rotate every other day. On the 6 to 2 shift, I have noticed dressings going unchanged, or having no dressing on it. At 11:05 a.m., CNA #9 stated, I have to go to the nurse and tell her (to change the dressing) during peri-care. n. On 1/26/18 at 1:37 p.m., the physician from the wound care clinic was interviewed via telephone. He was asked about the pressure ulcer to the resident's left buttock and stated, We did a little debridement on it the other day and cleaned it out some to get some of that dead tissue out of it. If they keep it clean and apply Santyl to the wound bed, I think it will heal fine. He was asked if he knew about the decubitus on the resident's buttocks prior to 1/24/18 and stated, No, I did not. That was the first time I knew about it. When I finished his other treatment, the person who brought him here asked 'What about his other wound, the one on the bottom?' I looked at it; it was a bad one and had a bad smell. I asked here in the clinic if any of staff knew about it, and they all stated 'no'. o. On 1/26/18 at 2:20 p.m., CNA #10 was asked, Are you the one who does transportation? She stated, Yes. She was asked if she was the one who took the resident to the wound clinic on 1/24/18 and stated, Yes, I do the transportation here. She was asked if she knew whether the wound clinic physician had ever checked the wound on the resident's left buttock before 1/24/18 and stated, No, they had not. When I went in, they had him sitting in the chair, and I asked, 'what about the sore on his bottom?' I could smell it, so I asked them to look at the sore on his bottom. The nurse stated, 'We didn't know he had a sore on the left buttock, I thought that smell was BM (bowel movement)' . p. The Immediate Jeopardy was removed, and the scope and severity lowered to H on 1/26/18 a 12:40 p.m., when the facility implemented the following Plan of Removal: a. All residents with wounds received new body audits by staff nurses on 1/25/18. Pressure wounds were assessed and measured in a manner to include a description of the wound bed and surrounding tissue, documented descriptions also were made of any wound drainage odor or S/S (signs / symptoms) of infection. Resident pressure ulcers were assessed by the ADON on 1/25/18 and correct staging, measurements and a thorough description of bed, surrounding tissue, any drainage, odor or S/S of infection were obtained and documented in the clinical record and communicated to the attending physician as appropriate. Body audits on other residents were checked by the DON (Director of Nursing) / Designee to ensure they were completely and accurately documented. Licensed Nursing staff will be in-serviced by ADON with regards to assessing wounds, documenting wound condition, following physician orders [REDACTED]. b. The DON or ADON will monitor 2 random treatments weekly to assure treatments are being consistently documented per physician orders [REDACTED]. c. Information from these body audits will be forwarded to the wound doctor for his review and recommendation. DON / Designee will review skin audits weekly to verify any new pressure ulcers, worsening pressure ulcers, or ulcers that are failing to heal are promptly reported to the physician. d. On 1/25/18 licensed nursing staff assessed all residents with wound dressings to assure the dressing was in place. Wound dressing monitoring sheets will be placed with the MARs (Medication Administration Records) on the Nurses' carts. Each shift, the medication nurse will check the dressing and check off it is in place or replace the dressing and indicate it was replaced. RN (Registered Nurse) nursing staff will monitor dressings 3 times weekly to assure the dressings are in place and check monitoring sheets to ensure dressings are being consistently documented with any negative findings being corrected immediately. 4. The overall Immediate Jeopardy related to nurse competency was removed, and the scope and severity lowered to H on 1/26/18 a 12:40 p.m., when the final Plan of Removal for pressure ulcer care was accepted (see above). Refer to individual plans of removal above for details regarding planned competency training and monitoring for the facility's licensed nursing staff. B. Based on observation, record review and interview, the facility failed to ensure licensed nurses were competent with the provision of pain management, as evidenced by failure to ensure pain assessments were conducted before, during and after a wound care procedure, failure to ensure pain medication was offered / administered prior to a painful wound care procedure, and failure to stop the wound care and provide pain medication immediately when the resident exhibited obvious signs of severe pain in order to provide prompt pain relief and promote comfort and wellbeing for 1 (Resident #6) of 2 (Residents #1 and #6) case mix residents who required pain management. This failed practice resulted in a pattern of actual harm to Resident #6, who cried out in pain during treatment of [REDACTED]. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an Assessment Reference Date (ARD) of 1/21/18 documented the resident scored 14 (13-15 indicates cognition intact) on a Brief Interview for Mental Status (BIMS), required extensive two-plus person assistance for bed mobility, received as needed pain medication, pain was present occasionally at a severity numeric rating of 4 on a scale of 0 to 10, was at risk for pressure ulcers, had a stage 3 pressure ulcer, and had an unstageable pressure ulcer with slough or eschar present. a. The Plan of Care with a revised date of 1/24/18 documented, .Resident is at risk for pain / discomfort with decreased mobility due to [DIAGNOSES REDACTED]. Resident has complaints of pain bilateral heels related to pressure ulcers . Goal . Resident will have decreased pain / discomfort with decreased complications related to complaints of pain . Approaches . Monitor and report to nurse . Signs and symptoms of pain, worsening pain. Report changes in pain location/type, frequency/intensity to physician. Monitor for non-verbal signs and symptoms of pain/discomfort . at risk for .skin issues / skin breakdown due to decreased mobility . unstageable wound to left buttock . treatment as ordered . administer pain medications per orders prn (as needed) and prior to initiation of treatment . b. A physician's orders [REDACTED].[MEDICATION NAME] 325 mg (milligrams) oral tablet two tabs PO (by mouth) PRN (as needed) q (every) 4 Hrs (hours). Dx (diagnosis) . Other Chronic Pain . c. The January 2018 Medication Administration Record [REDACTED]. Dx: Chronic Pain . There was no documentation, as of 1/25/18, that this medication had been administered to the resident at any time between 1/1/18 and 1/25/18, nor was there any documentation of any other medication administered for pain during that timeframe. The MAR indicated [REDACTED]. Pain evaluations / assessments were not documented on the January 2018 MAR indicated [REDACTED]. d. A Pain Evaluation dated 1/3/18 documented, .Pain is relieved by medication, frequent position changes. Not on a scheduled pain regimen. Receives PRN medication, Tylenol . This was the most recent reference in the clinical record to an assessment or evaluation of the resident's pain. e. A Wound Clinic Note dated 1/24/18 documented, .Left Glutea (TRUNCATED)

Complaint # (AR 869) was substantiated, all or in part, with these findings: A. Based on observation, record review, and interview, the facility failed to ensure the facility's administration and nursing administration identified and promptly addressed deficient practices with regard to competency of licensed nursing staff, as evidence by: failure to ensure pressure ulcers were assessed and measured weekly with the results documented, to include the type / stage of the wound, measurements, condition of the surrounding tissue and the presence or absence of drainage / odor to enable accurate tracking of healing progress or prompt identification of deterioration; failure to accurately identify and document the pressure ulcer as a Stage 4 wound; failure to ensure physician-ordered pressure ulcer treatments were consistently provided and documented to promote healing and prevent potential infection; failure to ensure a severe, Stage 4 pressure ulcer was reported to the resident's wound specialist physician, which resulted in a delay in providing appropriate treatment measures; and, failure to ensure loose or missing wound dressings were promptly replaced to prevent potential infection for 1 (Resident #6) of 2 (Residents #1 and #6) case mix residents who had pressure ulcers. These failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #6, who developed a large, severe, infected, Stage 4 pressure ulcer to the buttock, with necrotic tissue and foul-smelling drainage, and had the potential to cause more than minimal harm to 19 residents who had pressure ulcers, according to a list provided by the Administrator on 1/26/18. The Administrator was informed of this Immediate Jeopardy condition on 1/25/18 at 4:10 p.m.; failure to ensure licensed nurses promptly and competently responded to signs of respiratory distress and need for tracheal suctioning (excessive coughing, gurgling, visible copious secretions, and deep flushing of the face) during [MEDICAL CONDITION] care; failure to ensure licensed nursing staff received adequate training, with return demonstration, to assure competency with [MEDICAL CONDITION] care and suctioning to facilitate maintenance of a patent airway and minimize the potential for complications; failure to immediately inform the physician of the presence of blood in the resident's respiratory secretions to enable the physician to determine if any diagnostic or treatment measures were necessary; and failure to ensure the proper emergency equipment was maintained at the bedside to enable staff to quickly address potential accidental extubation or occlusion of the [MEDICAL CONDITION] for 1 (Resident #1) of 1 case mix resident who had a [MEDICAL CONDITION] (trach). The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who was observed gurgling, gasping for air and with copious thick respiratory secretions in her [MEDICAL CONDITION] and mouth [MEDICAL CONDITION] and was not suctioned by the licensed nurse. These failed practices had the potential to affect only this resident (the only resident in the facility with a [MEDICAL CONDITION]), as documented on the Resident Census and Conditions of Residents form dated 1/23/18. The facility Administrator was informed of this Immediate Jeopardy condition on 1/25/18 at 12:10 p.m.; The facility was informed that the above failures, collectively, constituted an Immediate Jeopardy condition in facility and nursing administration on 1/25/18 at 4:10 p.m. The findings are: 1. The Administrator Job Function and Responsibilities Policy, received from the Administrator on 1/26/18, documented, . Purpose of Your Job Position . The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with the current Federal, State, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our residents at all times . 2. The Director of Nursing Services Job Function and Responsibilities Policy, received from the Administrator on 1/26/18, documented, .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Services Department in accordance with current Federal, State, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure the highest degree of quality care is maintained at all times . 3. The Assistant Director of Nursing Services Job Function and Responsibilities Policy, received from the Administrator on 1/26/18, documented, .The Primary purpose of your job position is to assist the Director of Nursing Services in planning, organizing, developing and directing the day to day functions of the Nursing Service Department in accordance with current Federal, State, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director to ensure the highest degree of quality care is maintained at all times . 4. The facility's policy and procedure titled, Patient Care Instructions / [MEDICAL CONDITION] Care (and) Suctioning, received from the Administrator on 1/26/18, documented, .[MEDICAL CONDITION] Care . Equipment Needed . Ambu (artificial manual breathing unit) bag . Procedure . Suction the patient if needed . Early Warning Signs . It is very important for you to know the signs and symptoms of infection or other problems. Signs of infection . Changes in sputum color, volume, odor, and consistency . Breathing Symptoms . Increased shortness of breath, Increased coughing, Increased accessory muscle use . Sputum changes . Color change (yellow, green, tan or brown) . Change consistency, Increase in quantity, Bloody . Page 10 . Suctioning . Secretions can obstruct the airway making it difficult for lungs to get the oxygen they need. Suctioning removes the secretions from the airway which will allow the patient to breathe better .When a patient needs suctioned they will begin to breathe noisily, cough . Notify the physician if you notice an increase in sputum production or blood in sputum . Page 13 . Emergency Equipment to be kept in Room at All Times .[MEDICAL CONDITION] of the same size,[MEDICAL CONDITION] one size smaller, Ambu bag with mask, [MEDICATION NAME] Suction, Hemostats . When to suction . Clinical Indicators . Course Breathing sounds, Noisy Breathing, Increased or decreased rate of respirations, Decreased oxygen saturation, Copious secretions, Patient attempting to cough . Respiratory Distress and [MEDICAL CONDITION] Obstruction . Mucus plugs are the most common cause of respiratory distress for patients with tracheostomies . Symptoms of Respiratory Distress . Grunting, noisy breathing, sweaty, clammy skin, more comfortable with head elevated or sitting up . 5. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date (ARD) of 12/31/18 documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment of Mental Status, was totally dependent on two-plus person physical assistance for bed mobility and transfer, did not have shortness of breath, had a feeding tube through which she received 51 percent or more of daily caloric and fluid intake, had a [MEDICAL CONDITION] and required oxygen therapy and suctioning. a. A physician's orders [REDACTED].Suction As Needed .[MEDICAL CONDITION] . [MEDICAL CONDITION]. Pat Dry (and) Cover with Split Dry Dressing QD (every day) (and) PRN (as needed) .Treatment . Remove Inner Cannula [MEDICAL CONDITION] (and) replace with new disposable inner cannula daily . b. A Care Plan with a review date of 1/3/18 documented, .Monitor for changes in / development of signs (and) symptoms of breathing difficulty and report to nurse if noted . SOB (shortness of breath), Cough (productive or non- productive) . [MEDICAL CONDITION] care daily using sterile technique . c. An Emergency Medical Services (EMS) patient record dated 11/30/17 at 14:10 (2:10 p.m.) documented, .M2 (Medical 2) was dispatched to the above location for a female patient with shortness of breath. Upon arrival we found the patient lying in bed. The patient was diaphoretic and was having obvious difficulty breathing. The patient had a [MEDICAL CONDITION]. The patient was making gurgling noises coming from the [MEDICAL CONDITION] opening .The nursing home stated that the patient had suddenly started experiencing the diaphoresis and shortness of breath . The patient [MEDICAL CONDITION] was suctioned with a 12 Fr (French) catheter. Thick secretions were suctioned out. The patient began to breathe easier . There was no indication that the facility staff attempted to suction the resident'[MEDICAL CONDITION]. d. Hospital #1's Emergency Department Nurse Documentation sheet dated 11/30/17 at 19:32 (7:32) p.m. documented, .(Physician) was informed about pt's (patient's) condition and the wait time for ground ambulance transfer. He agreed that pt should be flown to (Large Metropolitan Hospital) if possible. Air Medical Transport has been contacted and will call back . e. The Hospital #1 Emergency Department (ED) Physician's Documentation sheet dated 11/30/17 at 19:39 (7:39) p.m. documented, .ED (Emergency Department) course . respiratory reports not able to [MEDICAL CONDITION], rec (recommend) surgical eval (evaluation) for change, believe to have granulation tissue around tube, surgery rec transfer for ENT (endotracheal) back up. Seen in ED by hospitalists who agreed and also rec transfer . Resident's [MEDICAL CONDITION] was unable to be replaced because granulation tissue had attached to [MEDICAL CONDITION]. f. On 1/12/17 at 11:23 a.m., there were several licensed and certified staff at the resident's bedside. Resident #1 was lying in bed with the head of the bed (HOB) elevated. The resident's facial expression was anxious and the skin on her face was moist. The staff were asked what was going on and stated, She's going to the hospital. The resident had a pulse oximeter on a finger of her right hand, indicating onscreen that her oxygen saturation was 93%. Her heart rate was 108. Certified Nursing Assistant (CNA) #11 loudly stated, Blood Pressure 187/117 and axillary temperature 99.6 degrees. Registered Nurse (RN) #1 was standing at the resident's bedside with an [MEDICAL CONDITION]. RN #1 stated, We've been calling the doctor all day for her temperature and cough. RN #1 was asked if she had just changed the resident'[MEDICAL CONDITION]. She stated, Yes. She was asked by the surveyor to open [MEDICAL CONDITION]. [MEDICAL CONDITION] contained an inner cannula that was filled with yellow, thick secretions. Upon observation of the equipment at the bedside, there was not a pair of hemostats at her bedside or in the multi-functional dresser. There was no Ambu bag at the resident's bedside. There was a suction machine at the resident's bedside. g. A Nurse's Note dated 1/13/18 documented, .Sent to the Emergency for panting, diminished lung sounds, and blood-tinged mucus [MEDICAL CONDITION]. h. A Hospital Discharge Record indicated the resident was transferred back to the facility on [DATE], after receiving, .[MEDICATION NAME] 500 mg (milligrams) one per peg tube QD (every day) (times) 10 days . Dx: (Diagnosis) UTI (Urinary Tract Infection) . [MEDICAL CONDITION], whether it was urosepsis or [MEDICAL CONDITION], I do not know . Chronic Sacral decubitus that grew out Providencia stuartii . There was no indication in the hospital record that the resident had experienced a respiratory infection. i. On 1/25/18 at 7:40 a.m., Licensed Practical Nurse (LPN) #1 and #2 were standing at the resident's bedside setting up supplies to [MEDICAL CONDITION]. LPN #1 placed a pulse oximeter on the resident's right index finger, and the display indicated the resident's oxygen saturation was 93% and heart rate was 110. LPN #2 paused the enteral tube feeding and LPN #1 lowered the head of the resident's bed to a flat position. The resident began to cough, and gurgling sounds were coming from the trach. The resident continued to cough and her face became flushed to a dark red color. The cough became more forceful and her cheeks and forehead began to perspire. The oxygen saturation readings were fluctuating between 93% and 97%. Without assessing the resident to determine if suctioning was needed, LPN #1 donned a pair of blue non-sterile gloves and began to clean around [MEDICAL CONDITIONS] area. The resident had visible, thick, clear, and bubbling secretions in her mouth and was gurgling and coughing continuously. LPN #1 raised the head of bed to about 15 to 20 degrees and the coughing became less frequent. The oxygen saturation held steady at 96% for several seconds. The resident began grinding her teeth as LPN #1 continued to [MEDICAL CONDITION]. The resident briefly stopped coughing, but started coughing again until she again became red in the face. LPN #1 raised the head of the bed to approximately 30 to 40 degrees and the coughing briefly stopped again. LPN #1 removed the non-sterile gloves, opened the [MEDICAL CONDITION], and donned the sterile gloves from the kit. The resident began coughing again, and the oxygen saturation again began fluctuating between 93% and 96%. LPN #1 removed the inner cannula from the resident'[MEDICAL CONDITION] inserted a new size 6 disposable inner cannula into the trach. The old inner cannula was filled with blood-tinged, thick yellow sputum. The thick secretions remained in the resident's mouth. After LPN #1 completed [MEDICAL CONDITION], LPN #2 restarted the tube feeding without checking placement of the PEG tube. LPN #1 exited the resident's room and went to her treatment cart, documented information on a chart, then sanitized her hands. While the LPN was still standing just outside the door to the room, the resident again began to cough continuously. LPN #1 entered the resident's room and asked the non-verbal resident if she needed to be suctioned. The resident did not respond, and the LPN left the room without suctioning the resident, who still had visible thick secretions in her mouth. The surveyor re-entered the room. The resident's face was red and diaphoretic, but the coughing had stopped. At 7:50 a.m., LPN #1 was asked how long she had been the Treatment Nurse, and when she was last trained on how to [MEDICAL CONDITION]. She stated, I have been the Treatment Nurse for 48 hours, and I [MEDICAL CONDITION] training about [AGE] years ago. I use [MEDICAL CONDITION] Manual at the nurses' desk and the policy and procedure manual. At 10:10 a.m., LPN #1 was asked, how often should you suction a resident with a trach, and when? She stated, As needed. She was asked, what are the signs and symptoms that [MEDICAL CONDITION] to be suctioned? She stated, Breathing sounds change, like something is blocking the airway, and if you hear gurgling sounds. j. On 1/25/18 at 9:20 a.m., LPN #2 was asked, when she had last [MEDICAL CONDITION] training. She stated, It was before (Resident #1) became a resident. (Respiratory Supply Company) provided the training, and the training was very brief. k. On 1/25/18 at 10:15 a.m., the Assistant Director of Nursing (ADON) was asked if the facility's nurses had received training [MEDICAL CONDITION]. At 10:30 a.m., she provided an in-service sheet dated 10/9/17, which documented,[MEDICAL CONDITION] review, plus multiple topics not related [MEDICAL CONDITION]. No written instructions or illustrations were included with the in-service documentation. The ADON stated, I can't find the original copy of the in-service. LPN #1 was not listed as an attendee on the in-service. l. On 1/25/18 at 10:50 a.m., LPN #3 was asked when she had last received training [MEDICAL CONDITION]. She stated, A guy came out a few months ago. He was an hour late, so I had to leave and only saw half of the presentation. I didn't sign the sign in-sheet. I feel I need more training on trachs. Only 3 people showed up for the training. (Respiratory Supply Company) did the training. m. On 1/25/18 at 12:35 p.m., the Assistant Director of Nursing was asked if she was aware the resident had blood-tinged mucus in inner cannula in this morning. She stated, No, not today. She had blood in [MEDICAL CONDITION] she went to the hospital, but not since she has been back. n. On 1/25/18 at 1:22 p.m., the Medical Director, who was the resident's attending physician, was asked if she was aware that the resident had blood-tinged sputum coming from [MEDICAL CONDITION] morning, and was also asked if the resident had issues with her trach. She stated she received a voice mail from the facility at 12:40 p.m. today and that the resident had no issues with her trach. o. The Immediate Jeopardy was removed and the scope and severity reduced to E on 1/25/18 at 3:45 p.m. when the facility implemented the following Plan of Removal: a. On 1/25/18 at 12:21 p.m., Respiratory Therapy was contacted to come to in-service all licensed nursing staff on [MEDICAL CONDITION] that will include return demonstration and assure that resident's room is set up per P&P (policy and procedure). Respiratory Therapist plans to arrive at the facility by 3:00 p.m. b. The ADON is contacting all licensed nursing staff to be here by 3:00 p.m. to receive training. Any that are unable to make training, will not return to work on the hall until they have completed competency training. c. Will monitor [MEDICAL CONDITION] competency three times weekly for four weeks then random thereafter. d. Respiratory Therapist will do competency check-off quarterly, and then as needed. e. Nurses noted (for Resident #1) resp. (respirations) (were) even and unlabored and v/s (vital signs) (were) stable at 10:25 a.m. on 1/25/18. No distress noted throughout the day as of 3:25 p.m. 6. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/21/18 documented 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, was totally dependent on two-plus persons for transfer and toilet use, was always incontinent of bladder and of bowel, was at risk for pressure ulcers, had a stage 3 pressure ulcer, and had an unstageable pressure ulcer with slough or eschar present with measurements of 4.0 centimeter (cm) in length, 7.0 cm in width, and depth 0.1 cm. a. A Braden Scale for Predicting Pressure Sore Risk form dated 6/19/17 documented a score of 14, Moderate Risk. There was no documentation of any Pressure Sore Risk assessments dated more recently than 6/19/17. b. A physician order [REDACTED]. c. The Skin Wound Log dated 1/4/18 documented, .Left Buttock . onset . 1/2/18 . facility acquired . Stage 3 pressure . There was no documentation this facility-acquired pressure ulcer was identified until it was a Stage 3 wound. The initial entry regarding this pressure ulcer did not document any measurements, information regarding the condition of the surrounding tissue, description of the wound bed, presence or absence of odor or drainage, or whether any signs/symptoms of infection were present. d. The Treatment Administration Record dated January 2018 documented, .Cleanse left heel with NS (normal saline), apply Calcium Alginate with Silver, cover with rolled gauze QOD (every other day) . e. The Skin Wound Log dated 1/9/18 documented, . stage 3 pressure . This entry did not document any measurements, information regarding the condition of the surrounding tissue, description of the wound bed, presence or absence of odor or drainage, or whether any signs/symptoms of infection were present. The Skin Wound Log contained no documentation of an assessment of the Stage 3 left buttock wound between 1/9/18 and 1/22/18, a 13-day period. f. A physician order [REDACTED]. The January 2018 Treatment Administration Record (TAR) documented nurses' initials to indicate the wound care was provided to the left buttock on Friday, 1/12/18 and Monday 1/15/18; however, there was no documentation to indicate the wound care was provided on Wednesday 1/17/18. The TAR documented the Monday, Wednesday and Friday treatments were continued through Monday, 1/22/18. g. The Skin Wound Log dated 1/22/18 documented the Stage 3 pressure ulcer to the left buttock measured 4 by (x) 7 centimeters (cm). There was no documented information regarding the condition of the surrounding tissue, description of the wound bed, presence or absence of odor or drainage, or whether any signs/symptoms of infection were present. This was the first entry that documented any measurements of this wound, and no depth was documented, at this time. h. A Wound Clinic Note dated 1/24/18 documented, .Left calcaneous (pressure ulcer) . Weeks in Treatment: 41; Date acquired 3/24/17 . Left Gluteal fold . date acquired 1/2/2018 . Weeks of treatment .0 .wound status . open . measurements . 5.6 x 5.5 x 2.7 . area . 24.19 cm (centimeters) . volume . 65.314 cm . % (percentage) of reduction in area and reduction in volume . 0.00% . stage IV (4) . Exudate amount .Large . Exudate .Purulent . Exudate color . yellow, brown, green . foul odor after cleaning . yes . wound margin .Distinct, outline attached . granulation amount .None Present .(0) % . Necrotic tissue .Eschar, adherent slough . muscle (involved) .yes . tissue exposed .fat layer (subcutaneous tissue) . Wound preparation . Ulcer cleaning . Rinsed / irrigated with saline . Patient was finished with wound #1 (pressure ulcer to heel) when CNA (Certified Nursing Assistant from facility) asked if we would look at the wound to the bottom. Wound Center staff had no knowledge of wound in that location . patient transferred out of wheelchair into bed to assess new wound . Wound with very foul odor, wound with no dressing upon assessment . drainage had drained through pants . Wound debrided per MD (physician) . tissue liquefied under top dry layer . The physician order [REDACTED]. i. The Plan of Care with a revised date of 1/24/18 documented, .At risk for developing skin issues / skin breakdown d/t (due to) decreased mobility, w/c (wheelchair) used for mobility. sits in w/c most of the day, receives daily diuretic, has history of falls, has OA ([MEDICAL CONDITION]) . Goal . Resident will have intact skin, free of redness, blisters or discoloration over a bony prominence . Approaches . Measure weekly and as needed . Monitor for signs / symptoms of infection . Complete Braden scale quarterly . Skin Assessments . Report changes in skin status to MD (medical doctor) . Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care . unstageable wound to left buttock . treatment as ordered . j. A laboratory culture final report dated 1/25/18 documented, .culture of wound / abscess . heavy growth Proteus mirabilis . k. On 1/25/18 at 9:20 p.m., wound care was provided by Licensed Practical Nurse (LPN) #1 with Certified Nursing Assistant (CNA) #9 assisting. The dressing on the left buttock was removed, revealing a large, necrotic, foul-smelling pressure ulcer. The old dressing was removed per LPN #1 and she proceeded to clean the ulcer. The area measured 5.8 cm long X 6.8 cm wide X 2.4 cm deep. The drainage was black in color, liquified and oozing from the area. The LPN placed Santyl in the wound bed and covered it with a dry dressing. The Nurse was asked how long she had been doing the treatments and stated, It has been 4 years since I did treatments, but they told me I will be doing treatments. The LPN was asked if yesterday was the first time the left buttock wound had been evaluated or treated by the physician at the wound clinic. She stated, Yes. l. On 1/25/18 at 9:20 a.m., LPN #3 was asked if the resident had been to the wound clinic for the pressure sore to left buttocks before 1/24/18. She stated, No. m. On 1/25/18, CNAs were asked, Does the resident get dressing changes daily to his pressure ulcers? and, Have you noticed if his dressings are changed? Their responses were as follows: At 10:45 a.m., CNA #2 stated, Yesterday, I asked (LPN #6) if she was going to change the dressing. She said, 'No, he's going to wound care (clinic)', and when I was getting him dressed for wound care, it (dressing) had come off. I told (LPN #6), and she said 'he's going to wound care (clinic).' She didn't stay all day. She left the facility. The resident didn't get another dressing put on. She does treatments on the weekends . I had noticed his dressing go unchanged. I have seen nurses on the weekend changing the dressings, yes, but only some weekends. At 11:00 a.m., CNA #10 stated, When I have him, they are changed daily. We rotate every other day. On the 6 to 2 shift, I have noticed dressings going unchanged, or having no dressing on it. At 11:05 a.m., CNA #9 stated, I have to go to the nurse and tell her (to change the dressing) during peri-care. n. On 1/26/18 at 1:37 p.m., the physician from the wound care clinic was interviewed via telephone. He was asked about the pressure ulcer to the resident's left buttock and stated, We did a little debridement on it the other day and cleaned it out some to get some of that dead tissue out of it. If they keep it clean and apply Santyl to the wound bed, I think it will heal fine. He was asked if he knew about the decubitus on the resident's buttocks prior to 1/24/18 and stated, No, I did not. That was the first time I knew about it. When I finished his other treatment, the person who brought him here asked 'What about his other wound, the one on the bottom?' I looked at it; it was a bad one and had a bad smell. I asked here in the clinic if any of staff knew about it, and they all stated 'no'. o. On 1/26/18 at 2:20 p.m., CNA #10 was asked, Are you the one who does transportation? She stated, Yes. She was asked if she was the one who took the resident to the wound clinic on 1/24/18 and stated, Yes, I do the transportation here. She was asked if she knew whether the wound clinic physician had ever checked the wound on the resident's left buttock before 1/24/18 and stated, No, they had not. When I went in, they had him sitting in the chair, and I asked, 'what about the sore on his bottom?' I could smell it, so I asked them to look at the sore on his bottom. The nurse stated, 'We didn't know he had a sore on the left buttock, I thought that smell was BM (bowel movement)' . p. The Immediate Jeopardy was removed, and the scope and severity lowered to H on 1/26/18 a 12:40 p.m., when the facility implemented the following Plan of Removal: a. All residents with wounds received new body audits by staff nurses on 1/25/18. Pressure wounds were assessed and measured in a manner to include a description of the wound bed and surrounding tissue, documented descriptions also were made of any wound drainage odor or S/S (signs / symptoms) of infection. Resident pressure ulcers were assessed by the ADON on 1/25/18 and correct staging, measurements and a thorough description of bed, surrounding tissue, any drainage, odor or S/S of infection were obtained and documented in the clinical record and communicated to the attending physician as appropriate. Body audits on other residents were checked by the DON (Director of Nursing) / Designee to ensure they were completely and accurately documented. Licensed Nursing staff will be in-serviced by ADON with regards to assessing wounds, documenting wound condition, following physician orders [REDACTED]. b. The DON or ADON will monitor 2 random treatments weekly to assure treatments are being consistently documented per physician orders [REDACTED]. c. Information from these body audits will be forwarded to the wound doctor for his review and recommendation. DON / Designee will review skin audits weekly to verify any new pressure ulcers, worsening pressure ulcers, or ulcers that are failing to heal are promptly reported to the physician. d. On 1/25/18 licensed nursing staff assessed all residents with wound dressings to assure the dressing was in place. Wound dressing monitoring sheets will be placed with the MARs (Medication Administration Records) on the Nurses' carts. Each shift, the medication nurse will check the dressing and check off it is in place or replace the dressing and indicate it was replaced. RN (Registered Nurse) nursing staff will monitor dressings 3 times weekly to assure the dressings are in place and check monitoring sheets to ensure dressings are being consistently documented with any negative findings being corrected immediately. 7. The overall Immediate Jeopardy related to facility and nursing administration was removed, and the scope and severity lowered to H on 1/26/18 a 12:40 p.m., when the final Plan of Removal for pressure ulcer care was accepted (see above). B. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an Assessment Reference Date (ARD) of 1/21/18 documented the resident scored 14 (13-15 indicates cognition intact) on a Brief Interview for Mental Status (BIMS), required extensive two-plus person assistance for bed mobility, received as needed pain medication, pain was present occasionally at a severity rating of 4 on a numeric rating scale of 0 to 10, was at risk for pressure ulcers, had a stage 3 pressure ulcer, and had an unstageable pressure ulcer with slough or eschar present. a. The Plan of Care with a revised date of 1/24/18 documented, .Resident is at risk for pain / discomfort with decreased mobility due to [DIAGNOSES REDACTED]. Resident has complaints of pain bilateral heels related to pressure ulcers . Goal . Resident will have decreased pain / discomfort with decreased complications related to complaints of pain . Approaches . Monitor and report to nurse . Signs and symptoms of pain, worsening pain. Report changes in pain location/type, frequency/intensity to physician. Monitor for non-verbal signs and symptoms of pain/discomfort . at risk for .skin issues / skin breakdown due to decreased mobility . unstageable wound to left buttock . treatment as ordered . administer pain medications per orders prn (as needed) and prior to initiation of treatment . b. A physician's orders [REDACTED].[MEDICATION NAME] 325 mg (milligrams) oral tablet two tabs PO (by mouth) PRN (as needed) q (every) 4 Hrs (hours). Dx (diagnosis) . Other Chronic Pain . c. The January 2018 Medication Administration Record [REDACTED]. Dx: Chronic Pain . There was no documentation, as of 1/25/18, that this medication had been administered to the resident at any time between 1/1/18 and 1/25/18, nor was there any documentation of any other medication administered for pain during that timeframe. The MAR indicated [REDACTED]

Based on observation, record review, and interview, the facility failed to ensure pain assessments were conducted before, during and after a wound care procedure, failed to administer pain medication prior to a painful wound care procedure, and failed to stop the wound care and provide pain medication immediately when the resident exhibited obvious signs of severe pain in order to provide prompt pain relief and promote comfort and wellbeing for 1 (Resident #6) of 2 (Residents #1 and #6) case mix residents who required pain management. This failed practice resulted in a pattern of actual harm to Resident #6, who cried out in pain during treatment of [REDACTED]. The findings are: Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an Assessment Reference Date (ARD) of 1/21/18 documented the resident scored 14 (13-15 indicates cognition intact) on a Brief Interview for Mental Status (BIMS), required extensive two-plus person assistance for bed mobility, received as needed pain medication, pain was present occasionally at a severity rating of 4 on a numeric rating scale of 0 to 10, was at risk for pressure ulcers, had a stage 3 pressure ulcer, and had an unstageable pressure ulcer with slough or eschar present. a. The Plan of Care with a revised date of 1/24/18 documented, .Resident is at risk for pain / discomfort with decreased mobility due to [DIAGNOSES REDACTED]. Resident has complaints of pain bilateral heels related to pressure ulcers . Goal . Resident will have decreased pain / discomfort with decreased complications related to complaints of pain . Approaches . Monitor and report to nurse . Signs and symptoms of pain, worsening pain. Report changes in pain location/type, frequency/intensity to physician. Monitor for non-verbal signs and symptoms of pain/discomfort . at risk for .skin issues / skin breakdown due to decreased mobility . unstageable wound to left buttock . treatment as ordered . administer pain medications per orders prn (as needed) and prior to initiation of treatment . b. A physician's orders [REDACTED].[MEDICATION NAME] 325 mg (milligrams) oral tablet two tabs PO (by mouth) PRN (as needed) q (every) 4 Hrs (hours). Dx (diagnosis) . Other Chronic Pain . c. The January 2018 Medication Administration Record (MAR) documented, .[MEDICATION NAME] 325 mg oral tablet, two tabs po prn Q4hrs. Dx: Chronic Pain . There was no documentation, as of 1/25/18, that this medication had been administered to the resident at any time between 1/1/18 and 1/25/18, nor was there any documentation of any other medication administered for pain during that timeframe. The MAR contained no documentation of pain assessments performed by a licensed nurse. Pain evaluation / assessment was not documented on the January 2018 MAR or the January 2018 Treatment Administration Record (TAR) for this resident. d. A Pain Evaluation dated 1/3/18 documented, .Pain is relieved by medication, frequent position changes. Not on a scheduled pain regimen. Receives PRN medication, Tylenol . This was the most recent reference in the clinical record to an assessment or evaluation of the resident's pain. e. A Wound Clinic Note dated 1/24/18 documented, .Left Gluteal fold . date acquired 1/2/2018 . Weeks of treatment .0 .wound status . open . measurements . 5.6 x 5.5 x 2.7 . area . 24.19 cm (centimeters) . volume . 65.314 cm . % (percentage) of reduction in area and reduction in volume . 0.00% . stage IV (4) . Exudate amount .Large . Exudate .Purulent . Exudate color . yellow, brown, green . foul odor after cleaning . yes . wound margin .Distinct, outline attached . granulation amount .None Present . (0) % . Necrotic tissue .Eschar, adherent slough . muscle (involved) .yes . tissue exposed .fat layer (subcutaneous tissue) . Wound preparation . Ulcer cleaning . Rinsed / irrigated with saline . Patient was finished with wound #1 when CNA (Certified Nursing Assistant from facility) asked if we would look at the wound to the bottom. Wound Center staff had no knowledge of wound in that location . patient transferred out of wheelchair into bed to assess new wound . Wound with very foul odor, wound with no dressing upon assessment . drainage had drained through pants . Wound debrided per MD (physician) . tissue liquified under top dry layer . f. On 1/25/18 at 9:20 a.m., Licensed Practical Nurse (LPN #1) was assisted by Certified Nursing Assistant (CNA) #9 to perform wound care for the resident. The dressing on the left buttock was removed and revealed a large, necrotic, foul-smelling pressure ulcer. As the LPN began to cleanse the pressure ulcer, the resident grimaced in pain, with mouth open, then yelled and began to grunt and cry out loudly as the LPN continued to clean the wound. The nurse continued to perform the wound care until it was completed. LPN #1 was asked if the resident was medicated for pain prior to receiving the treatment to the ulcer. She stated, I will have to ask the medication nurse. She said earlier that she offered Tylenol earlier this morning, but he did not want it. She was asked, Do you think you should have stopped the treatment to get him something for pain, and then completed the treatment later? She stated, He went to the wound clinic yesterday and they did a little debridement on the ulcer, so that's why he's hurting. LPN #1 was asked how long she had been doing treatments / wound care. She stated, I used to do treatments 4 years ago, but they told me last week that I will be doing treatments, so I worked last night and stayed over to do treatments this morning. At 9:50 a.m., LPN #3 was asked if she had given the resident anything for pain prior to his wound treatment. She stated, No, earlier this morning, I offered Tylenol, but he did not want it. g. On 1/26/18 at 1:30 p.m., LPN #4 was asked about pain assessments for this resident and stated, I just did a pain assessment the other day. When asked where it was documented, she stated, On the MDS. h. On 1/26/18 at 11:50 p.m., LPN #2 was asked, would you look for a resident's pain assessment on the MDS? She stated, No, I would look in the medical record under assessments. i. On 1/26/18 at 12:00 p.m., the Assistant Director of Nursing (ADON) was asked, would you look for a resident's pain assessment on the MDS? She stated, No. I would look on the resident's chart under assessments. j. On 1/26/18 at 12:40 p.m., LPN #3 was asked, would you look for a resident's pain assessment on the MDS? She stated, No, I would go to the chart under assessments. k. On 1/26/18 at 2:10 p.m., LPN #4 was asked, would you look for a resident's pain assessment on the MDS? She stated, No, I would look in resident record under assessments. l. On 1/26/18 at 3:20 p.m., LPN #5 was asked, would you look for a resident's pain assessment on the MDS? She stated, No, I would look in resident record under assessments. m. The facility's policy titled Pain Assessment/Management, provided by the Administrator on 1/26/18, documented, .Evaluation per pain scale each resident will have a routine order for 'pain evaluation' per scale every shift and PRN (as needed). The results of evaluation will be documented on the MAR (Medication Administration Record). When a resident demonstrates pain, whether verbally or non-verbally, the nurse is to administer pain med (medication) per PRN orders. If the resident does not have an order for [REDACTED]. Breakthrough pain will be monitored for on all residents with routine pain medication dosing through the pain scale evaluation . General signs / symptoms of pain . [MEDICAL CONDITION] diaphoresis . words expressing pain, exclamations of protest . sighs, gasps, moans, groans . grimacing or wincing, clenched teeth .

Complaint # (AR 921) substantiated all or in part, with these findings. Based on observation, record review, and interview, the facility failed to ensure staff members who provided transportation in the facility van were trained and competent in application of the van's restraint system per manufacturer's instructions for securing residents in wheelchairs in the van, to prevent them from tipping over during transport and causing injury for 1 (Resident #1) of 5 (Residents # 1-5) case mix residents who required the use of a wheelchair during transport in the facility van. This failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, whose wheelchair and van restraints were not correctly secured during transport, resulting in the resident flipping backwards and sustaining a soft tissue injury to her right knee. The failed practice also had the potential to cause more than minimal harm to 31 residents who required the use of a wheelchair when being transported via the facility van, as documented on a list provided by the Director of Nursing (DON) on 4/13/17 at 4:12 p.m. via a fax. The Administrator was informed of the Immediate Jeopardy on 4/6/17 at 5:55 p.m. The findings are: 1. On 4/6/17 at 3:05 p.m. the Administrator provided a copy of manufacturer's instructions titled, Doing It Right, A Guide to the Proper Use of Sure-Lok Wheelchair Securement and Occupant Restraint Systems for the facility's van restraint system. The instructions documented, .Section 4: Securing the Wheelchair - Correctly securing a wheelchair is extremely important for the safety and comfort of the passenger . Injury or death may result from improper securement . If you're using an S-hook system, press the red release button and pull the web out of the Retraktor. Let go of the release button and attach the S-hook to a structural frame member of the wheelchair, as close to the corner junction of the seat cushion and seatback as possible. Then push the button on the Retraktor to remove the slack . Section 5: Securing the Occupant . Lap Belts Start by attaching the lap belt. Place the ends of the lap belt around the passenger. Thread them down through the opening between the side panel or the seat back and the seat cushion. Remember to position the lap belt around the occupant's pelvic zone near the hip, with the buckle of the lap belt placed opposite to the side where the shoulder belt is attached to the wall. Integrated Lap Belts - For Intregrated Lap Belts, take the Snap Hook end of the belt and attach it directly to the D-Ring on the rear securement strap assembly. Adjust the lap belt through the adjusters by pulling on the free end to make the fit firm yet comfortable. The Integrated Lap Belt attaches to the rear wheelchair tie-downs, making it a part of the wheelchair securement system. Because of this the Integrated Lap Belt can only be used with the heavy-duty FF600 Retraktor Series Systems or the FE500 Series Systems . Shoulder Belts - The last belt to attach before you're on your way is the shoulder belt. Bring the triangular fitting of the shoulder belt over the passenger's shoulder, past the collar bone, and diagonally across the upper chest. Attach it to the stud of the lap belt latch plate. Pull on the loose end through the adjuster to achieve firm yet comfortable tension. Pull on the belt to ensure that everything is properly attached. There are several types of shoulder belts that may be used . Section 7: Hands-On Training . Take the participants to a vehicle equipped with a Sure-Lok Wheelchair Securement and Occupant Restraint System. Then, take turns practicing the proper procedure of operation as demonstrated during the classroom session . 2. On 4/7/17 at 10:40 a.m., the Administrator was asked for the facility's policy and procedure for resident transportation in the facility van. The Administrator stated the facility did not have such a policy. 3. Arkansas Code, Title 27 - Transportation, Subtitle 3 - Motor Vehicles And Their Equipment, Chapter 37 - Equipment Regulations, Subchapter 7 - Mandatory Seat Belt Use (§ 27-37-702) documented, .(c) . each driver or passenger who is seated in a wheelchair in a motor vehicle shall: (1) Wear a properly adjusted and fastened seat belt properly secured to the wheelchair; and (2) Have the wheelchair properly secured in the motor vehicle. 4. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 3/12/17 documented the resident scored 12 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance of one to two persons for bed mobility and transfers, used a wheelchair for mobility, had no functional limitation in range of motion, and received dialysis treatments. a. An Incident Report dated 4/3/17 at 3:30 p.m. documented, .Describe exactly what was observed and what ACTIONS you took: (Location,Type of Incident, Area & (and) Type of Injury) When this nurse entered room to give medication, resident (R) stated that her legs hurt. When asked why they hurt, R stated that she had been 'thrown out of the chair' when she was coming back from dialysis. R stated the chair was tied down and locked properly. She stated that when they were going down the highway, then that changed to (avenue). She stated that chair flipped backwards and she flipped back and hit her knees. Type of Intervention initiated to prevent further injury . 1) Physician notified and orders received to x-ray bilateral knees. 2) Witness statement from CNA (Certified Nursing Assistant), environmental assessment, Right knee immobilizer . b. An Office Long Term Care (OLTC) Witness Statement Form dated 4/4/17 at 8:30 a.m. documented, Witness Full Name: (Resident #1) Job Title: resident. State in your own words what you witnessed (be very descriptive) and sign below. 'On the way back from dialysis the driver was driving. When she stopped, I went straight back and flipped out of the wheelchair. All the straps were in place. There was a strap around my waist. When the van stopped I went forward and then flipped backward out of the chair.' When asked if footrests were on chair 'What foot rests? I don't like them. They were not on my chair. I fell forward out of the chair. I hit my knees, my head and my feet. The driver kept driving til she could get pulled over and got me back in the chair. I think the name of the road is (road name). This happened after she crossed the tall bridge'. The statement was signed as taken by Registered Nurse (RN) #1. c. An OLTC Witness Statement Form dated 4/3/17 at 3:30 p.m. documented, Witness Full Name: (CNA #1) Job Title: CNA. I was transporting a resident from dialysis. After strapping her in we left dialysis turn on (street) went down the street turn onto (avenue) went all down turn on to (another street) and head to the nursing home. We was coming down (another street) turned onto (another street), I was coming up the hill make a stop at the stop sign and as I begin to take off from the stop sign the resident chair tilt back so I pulled over to check to make sure that the resident was o.k. I got back there and sit the chair back up into it right position that it was suppose to be in and the resident was still strapped in and hooked up so I reposition her to make sure she was ok. When I got back to the facility I took her straight to the nurse and told her what had happen and she check her out to make sure she did not have any bruises or skin tears after she checked her out I had the other aide assist me with putting her to bed. d. A Nurses Note dated 4/3/17 at 4:15 p.m. documented, Resident returned to facility @ (at) this time with transport CNA. CNA reported that resident's chair tilted slightly while they were on the van. She states resident did not fall, this nurse then asked resident did she fall, resident states no I'm good. Resident assessed @ this time denies pain @ present - resident assisted into bed by staff vs (vital signs) on return from dialysis 134/71, p (pulse) 78, r (respirations) 20, t (temperature) 97.6 . This note was signed by Licensed Practical Nurse (LPN) #1. A Nurses Note dated 4/4/17 at 5:30 a.m. documented, C/O (Complains of) both legs hurting @ this time. Norco 7.5/325 mg (2) po (per mouth) given @ this time. Tolerated well. Will monitor for effectiveness. e. A Nurses Note dated 4/4/17, late entry from 8:00 a.m., documented, When this nurse entered R room to administer morning medication R c/o pain to bilateral legs. When this nurse asked why legs were hurting R stated that she had been 'thrown out of the chair' when being transported back from dialysis yesterday. R then stated that the chair was locked and strapped down. She stated that when they 'were on the highway, I mean (avenue)' the chair flipped back and she flipped backwards out of the chair and hit her knees. X-ray order obtained, x-rays ordered, CNA witness statement taken (RN #1). f. A Nurses Note dated 4/4/17 at 11:30 a.m., documented, Received call from on-site imaging to critical x-ray. X-ray showed non-displaced fracture to right knee. X-rays faxed to (doctor) as well as placed call to alert to x-ray being faxed. Awaiting call back. (Signed by RN #1) . 3:30 p.m. Received call back from (doctor) regarding knee fracture received t.o. (telephone order) to 1) place knee immobilizer, 2) knee to be placed in full extension and 3) evaluation (eval) by PT (physical therapy). Orders written. Knee immobilizer ordered through (medical supply company) and delivered at 4:00 p.m. Physical Therapy applied knee immobilizer at 4:05 p.m. (Signed by PT tech). g. The X-ray reports dated 4/4/17 at 10:37 a.m. documented, .Knee (1-2V (views)) AP (anterior/posterior)/LAT (lateral) Right. Reason: Pain. Comparison: None. 2 images. The patient is rotated. There is subtle irregularity of the inferior patella, this is nonspecific; however a nondisplaced fracture cannot be excluded. Consider CT (computerized tomography) scan for further evaluation. The soft tissues appear edematous. The bones appear demineralized. No dislocation involving the knee is seen. There is moderate join effusion. There is multifocal osteophytosis and joint space narrowing notable involving the medial and patello femoral compartments, Atherosclerosis calcifications are noted. Impression: 1. Equivocal findings for nondisplaced patellar fracture 2. Moderate joint effusion . Note: On 4/7/17, the Director of Nursing (DON) provided results of a CT scan of the resident's right lower extremity. The report documented, .Findings: Bones/joints - No acute fracture. No dislocation. Joint effusion with fluid filled level suggesting hemarthrosis. Soft tissues: Mild prepatellar soft tissue swelling. Vasculature: Extensive atherosclerotic calcifications . h. A Nurses Note dated 4/4/17 at 6:50 p.m. documented, R yelling out 'OW', asked R what was wrong. R states her leg is hurting, asked to go to the (doctor). Advised R she was already x-rayed, results sent to (doctor) and orders received for tx (treatment). Right knee immobilized and extended out. Administered Norco 7/5/325 mg (milligrams) 1 prn (as needed) order for pain. Swallowed without difficulty, hydration provided no other needs. This note was signed by RN #2. i. A Nurses Note dated 4/4/17 at 8:00 p.m. documented, R continues to yell out 'OW' and 'OUCH' asked for pain pill again stating she hadn't had one since this am (morning). Advised R this nurse gave one to her an hour ago. R stated 'Oh, can I go to the (doctor)?' Advised R of same answer as previous. No other needs. This note was signed by RN #2. j. A nurses note dated 4/5/17 at 6:30 a.m. documented, R c/o pain asked for pain pill. Administered Norco 7.5/325 mg 1 po per PRN order for pain . k. On 4/6/17 at 12:15 p.m. the resident was asked, Can you tell me what happened on 4/3/17 when returning from dialysis? She stated, I was coming back from dialysis and the girl (CNA #1) strapped me in. With her hands, the resident demonstrated how the straps were placed around the wheels of the wheelchair, then stated, And then, they put this strap around the front of my chair and around my waist. But, when the girl stopped so fast, I went forward, and when my head came back, I fell out of my chair over the side of the chair. The resident was asked where she landed when she fell and stated, Between the chair and the back door. The girl said 'oh' and came back and helped me back in my chair. The resident was asked what happened next and stated, We came back here (to the facility), and I told the nurse my knee was hurting. The resident was asked, What did the nurse do? The resident stated, Nothing, didn't even give me some pain medicine, and my knee was really hurting. The resident was questioned multiple times about the incident and repeated the details the same way each time. l. On 4/6/17 at 1:35 p.m., RN #1 was asked, Who does your transports? She stated, (CNA #1), (CNA #2) is the main one, (CNA #3). She stated CNA #2 just returned to work on Wednesday from having knee surgery. She was asked, Who transported (Resident #1) on 4/3/17? She stated, (CNA # 1). She is usually our restorative aide. m. On 4/6/17 at 2:15 p.m., CNA #1 was asked, What time did the incident happen? She stated, About 3:30 p.m. The CNA was asked, What time did you get back to the facility? She stated, About 3:35 p.m. She was asked, What nurse did you tell about the incident? She stated, (LPN #1). She was asked, What did you tell her? She stated, I told her (Resident #1) had tilted in her wheelchair. She was asked to describe what happened and stated, I stopped at a stop sign, and when I took off, she tilted back. She was asked, The chair did not flip completely over? She stated, No, it was tilted sideways, still strapped in. I stopped and got back there and set the chair up straight. I asked the resident if she was okay and she stated 'yes'. We pulled into the courtyard, and I got the resident out of the van and took her to the nurses station and reported it to (LPN #1), the nurse on duty. She was asked, When you straightened (Resident #1) up, was any part of her body touching anything? She stated, She did not hit the van floor. She remained suspended in a tilted position until I repositioned her. She was asked, Was the chair flipped over? She stated, No,it was tilted to the side, like. n. On 4/6/17 at 2:33 p.m. LPN #1 was asked, What did the CNA tell you when she returned to the facility on [DATE]? She stated, She said when the resident was in the van her wheelchair tilted. I asked her did she fall and she told me no. I asked the resident if she fell and she said no ma'am. (CNA #1) was standing there with the resident. The LPN was asked, What did you do then? She stated, I checked her over; she said she was fine. She was asked, Was there any swelling or anything unusual about her knees? She stated, No. (Resident #1) agreed with (CNA #1) when she was telling me the wheelchair just tilted, that she did not fall. She was asked, Did you fill out an Incident & Accident Report? She stated, No, because they said nothing happened but tilting of the wheelchair. She was asked, Did the resident complain of pain to you? She stated, About 7 something (about 3 and a half hours later) she said her feet hurt. She said her feet hurt all the time and she asked for a pain pill. I gave her a Norco 7.5 milligram. o. On 4/6/17 at 2:50 p.m., CNA #1 and CNA #2 took the resident out to the van to transport her to a doctor's appointment. CNA #1 pushed the resident into the van. She began securing the back straps to the wheelchair, close to the wheels. CNA #2 instructed her that was not the correct placement of the straps and secured them to the wheelchair frame, where they crossed under the seat. CNA #2 took the seat belt and positioned it across the resident's lap area, took the strap down between the seat and the back of the wheelchair, then tightened the strap down, checking the tightness around the resident's waist. p. On 4/6/17 at 4:22 p.m., CNA #2 was asked to demonstrate securing a wheelchair in the van. She secured the back straps to the bar underneath the wheelchair. Then she secured the front straps to the bar underneath the wheelchair. She then demonstrated securing the seat belt. At no time did she attach a shoulder strap. Once she had tightened the straps down, the Surveyor standing behind the wheelchair was able to tilt the wheelchair backward up off the floor several inches. Another Surveyor then sat in the wheelchair and the other Surveyor was still able to tilt the wheelchair backwards off of the floor several inches. q. On 4/6/17 at 5:00 p.m., the Administrator asked, What have you done since the allegation? He stated, We spoke with the Nurse and Aide that did the transport. We talked with them several times. We had the aide demonstrate how she had secured the resident. We had the aide secure (RN #1) in the wheelchair to attempt to flip it backwards. She was unable to do this. We reexamined the x-ray report and questioned if it was an actual fracture and scheduled a bone density scan and CT of the right knee. We have had the regular transport aides in here going over everything about securing residents in a wheelchair in the van. The Administrator was asked, What were you going over? He stated, A copy of the instructions for the Secure Lok. We talked about it with them at that time. (RN #1) stated, We've had the staff do return demonstrations. RN #1 was asked, Who have you had do return demonstrations? She stated, The primary ones (CNA #2), (CNA #3), (CNA #1). RN #1 provided documentation that the CNAs had signed, indicating they were instructed on using the Sure-Lok Wheelchair Securement and Occupant Restraint System. Forms signed by CNA #3 and CNA #2 documented, I have read and understand the sure-lok, safe and secure DOING IT RIGHT a guide to the proper use of sure-loc wheelchair securement and occupant restraint systems. The forms were signed by Transport employee #2 on 4/4/16 and CNA #2 on 4/5/17. There was no documentation of return demonstrations. RN #1 was asked when the return demonstrations with CNAs #1, #2 and #3 were completed and stated, On 4/5/17, in the afternoon. r. On 4/6/17 at 5:35 p.m., CNA #1 was asked to demonstrate securing a wheelchair in the van. She secured the back straps to the frame of the wheelchair, close to the back wheels, secured the straps to the front of the wheelchair frame, next to the wheels, then took the seat belt and secured it through the arms of the wheelchair. She did not attach a shoulder strap. Once she was finished securing the wheelchair, she stated, That's the way I hook it. Everybody does it different; you know, (CNA #2) does hers different. This Surveyor sat in the wheelchair and was able to rock the chair back and forth. CNA #1 was asked, Do you use the shoulder strap to secure the residents when you transport them? She stated, I don't use the shoulder strap in this van. I've never used the shoulder strap part. s. On 4/7/17 at 10:05 a.m., RN #1 provided documentation of return demonstration by CNA #3 and CNA #2. A form signed on 4/4/17 by CNA #3 documented, I have read and understand the sure-lok, safe and secure DOING IT RIGHT a guide to the proper use of sure-loc wheelchair securement and occupant restraint systems. (CNA #3) Date- 4/4/16 Instructor- (Administrator). Hand written on the bottom of the form was Employee did a reverse demonstration of the secure-loc process (CNA #3) dated 4/4/17. A form signed on 4/5/17 by CNA #2 documented, I have read and understand the sure-lok, safe and secure DOING IT RIGHT a guide to the proper use of sure-loc wheelchair securement and occupant restraint systems. (CNA #2) Date - 4/4/16 Instructor- (Administrator). Hand written on the bottom of the form was Employee did a reverse demonstration of the secure-loc process Signature (CNA #2) dated 4/5/17. t. On 4/7/17 at 10:10 a.m., CNA #3 was asked, Did you do a return demonstration on how to secure a resident in the van prior to 4/6/17, when the Surveyor asked you to demonstrate it? She stated, No. She was asked, Have you been asked by anyone to demonstrate how you secure a resident in the van? She stated, No. She was asked, Did you receive any training on how to secure a resident in the van? She stated, When we first got the van, the Maintenance man showed us. She was asked, Did you do a return demonstration? She stated, We didn't do a return demonstration with him. u. On 4/7/17 at 10:10 a.m., CNA #2 was asked, Did you do a return demonstration on how to secure a resident in the van prior to 4/6/17, when the Surveyor asked you to demonstrate it? She stated, No. She was asked, Have you been asked by anyone to demonstrate how you secure a resident in the van? She stated, No. She was asked, Did you receive any training on how to secure a resident in the van? She stated, When we first got the van, the Maintenance man showed us. She was asked, Did you do a return demonstration? She stated, We didn't do a return demonstration with him. v. On 4/7/17 at 10:05 a.m., the Administrator was asked to provide the employee files for CNA #1, 2, 3 and maintenance #1 and 2 who drove the van for transports. The employee files of the 5 staff members who transported residents were reviewed. CNA #1 had signed the form, I have read and understand the sure-lok, safe and secure DOING IT RIGHT a guide to the proper use of the sure-loc wheelchair securement and occupant restraint system on 3/21/16. CNA #2 signed the form on 4/5/17, and CNA #3 signed the form on 4/5/17. There were no signed forms for training on the van sure-loc system in the employee records for Maintenance personnel #1 and #2 . w. On 4/7/17 at 11:15 a.m., the DON provided in-service records for 7/15/16 through 3/3/17. There were no in-services related to the van / transportation / securing wheelchairs in the van or application of seat belts to passengers in the van. 5. On 4/7/17 at 8:55 a.m., the Immediate Jeopardy was removed and the scope/severity reduced to an E when the facility implemented the following Plan of Removal: a. Corrective Action: On 4/6/17, upon notification of the deficient practice, the DON immediately called the three transport aides in to train through video and return demonstration. b. Protect residents affected: On 4/6/17, identified five residents in the last week who could have been affected by the non-compliant practice. DON/designee performed body audits on all five residents. No negative findings. c. Protect all residents: Administrator and DON in-service transport drivers with video of secure-loc wheelchair securement and restraint systems and perform return demonstration for proper operation before transporting residents on 4/6/17. The failed practice was explained to the drivers and they verbalized understanding, All new and alternative transport drivers will be trained before transporting residents beginning immediately. d. Monitoring: Administrator will monitor through observation the proper securing of residents in the facility van, 5 times a week for five weeks or until compliance is achieved. Any negative findings will be corrected immediately by the Administrator. e. QA (Quality Assurance): Administrator will present all findings to the monthly QA committee for further review.

Complaint # was substantiated all or in part with these findings. A. Based on observation, record review and interview, the facility failed to ensure roll belt restraints were not used when contraindicated for 3 of 3 (Residents #2, #5, #6) case mix residents who had a history of [REDACTED]. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious injury or death, for Resident #2, #5, and #6 and was likely to cause more than minimal harm for 6 residents in the facility with orders for roll belt restraints according to the list provided by the Director of Nursing on 10/4/11. The facility was informed of the Immediate Jeopardy on 10/4/11 at 4:45 p.m. The findings are: 1. The manufacturer's instructions for the use of a Skil-Care Roll-Belt provided by the Administrator on 10/4/11 documented, "Contraindications for use: Do not use this device: With a patient who has a history of easily removing restraints. With a patient who slides or moves down toward the foot of the bed..." 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 8/2/11 documented the resident had severely impaired cognitive skills for daily decision making per Staff Assessment of Mental Status, had fallen twice with no injury and once with injury since the last assessment, and used a trunk restraint on a daily basis. a. The Incident Report dated 6/24/11 at 3:15 p.m. documented, "Type of incident: Fall. If Fall what position was person found in? Standing in hall. Injury: Laceration, Swelling. Treatment: Examined at hospital. First Aid administered. ... Investigation: ...Why did this incident occur? Resident very confused (and) wanders. Crawled over bedrails. Family requests no restraints. What was done immediately? (to prevent reoccurrence): Placed in gerichair (with) a lap tray. Order for roll belt while in bed obtained." b. The Nurse's Notes dated 6/29/11 documented, "10 a (a.m.) N.O. (New Order) to DC (Discontinue) personal alarm while in bed d/t (due to) roll belt being used. 11 p (p.m.) In bed (with) roll belt intact. Both side rails up in place. Resp. (Respirations) even & (and) unlabored. Res. (Resident) is constantly moving around in bed as if he is trying to get O.O.B. (Out of Bed). Will monitor." c. The Nurse's Notes dated 6/30/11 at 4:00 p.m. documented, "... Roll belt tied to bed frame (with) 2-4 finger space between belt & resident. Resident able to roll from side to side easily when roll belt in place. Family expressed concern that belt was too tight. Showed family how 4 fingers were able to be inserted between roll belt & resident. Explained to family that purpose of roll belt was to keep resident from getting out of bed (without) assistance & hurting himself or falling. Roll belt is loose enough to allow resident to roll over & (change) positions (without) resistance, but will help keep resident safely in the bed." The Nurse's notes dated 6/30/11 at 5:00 p.m. documented, "Resident's family leaving facility. Resident in bed (with) roll belt tied only to one side of bed. Other strap untied & dangling off edge of bed. Resident sitting up (with) legs in between siderails & bed frame (at) the foot of the bed. Assisted X (times) 3 staff members to free resident's legs & move him back to top of bed. Roll belt secured to both sides of bed. 3 finger space in between belt & resident..." The Nurse's Notes dated 6/30/11 at 11:00 p.m. documented, "Res. in bed with roll belt intact. Res. moves around in bed often, moving from side to side sometimes (with) legs hanging over bed railing..." d. The Incident Report dated 7/19/11 at 5:00 a.m. documented, "Type of Incident: Behavior. If Fall, what position was person found in? : Sitting on the floor beside his bed (with) roll belt still intact... Investigation: ... Why did this incident occur? : Res. (Resident) was attempting to get out of bed. He let down R (right) side rail. What was done immediately? (to prevent reoccurrence): Reinforced roll belt once assisted back to bed." e. A Physical Restraint Elimination assessment dated [DATE] documented a total score of 26 (21-35 indicates a Good Candidate for reduction). The back narrative section of the form documented, "1. Candidate status as determined by TOTAL SCORE on reverse: Good. 2. Candidate for restraint reduction or elimination: No. If No, State specific reason or targeted behavior: DX (Diagnosis): Huntington's Chorea. 3. Additional Comments: uncontrollable involuntary movements of all extremities." f. The Plan of Care dated 8/5/11 documented, "Problem: At risk for falls and other injuries. Approaches: Maintain a safe, hazard free environment. Provide supportive device, gerichair with lap tray, to promote good posture & (and) prevent falls or injury ... Problem: At risk for complications R/T (related to) restraint use; is in gerichair every day with lap tray and roll belt is used in bed. Approaches: Document and report restraint related problems... Do restraint elimination evaluation quarterly and PRN (as needed). Obtain physical restraint informed consent from responsible party..." g. The Incident Report dated 8/28/11 at 11:25 p.m. documented, "Type of Incident: Fall. If fall what position was person found in?: Resident found sitting on floor (with) legs stretched out in front of him and upper body in upright position. Roll-belt remained around resident untied from L (left) side of bed... Investigation: Why did this incident occur? Blank. What was done immediately? (to prevent reoccurrence): Assessed and assisted back to bed. Roll belt resecured." There was no documented investigation into the cause of the incident. No additional interventions were documented. h. The September 2011 physician's orders [REDACTED]. Posture support in w/c (wheelchair). Continue roll belt in bed." i. A Pre-Restraining assessment dated [DATE] documented, "... Balance (when sitting): Falls forward: Yes. Falls/leans sideways: Yes. Both Left and Right. Slides down: Yes. Slumps: Yes ... Interdisciplinary Team Evaluation 9/12/11. Recommendations: Posture support in new wheelchair, continue roll belt in bed." j. Two Pre-Restraining Assessments dated 9/23/11 documented that the Resident's balance while sitting was: "Falls forward: Yes. Falls / leans sideways: Yes. Both Left and Right side. Slides down: Yes. Slumps: Yes." The Interdisciplinary Team Recommendations on 9/23/11 documented: "Pelvic support in W/C (wheelchair) - to maintain core body positioning r/t (related to) Huntington's Disease." There was no mention of the roll belt on the Interdisciplinary team recommendations. k. On 10/4/11 at 3:07 p.m., the resident was observed sitting up positioned toward the foot of the bed wearing a roll-belt restraint that was tied to the bed frame on both sides of the bed. Full padded side rails were elevated on both sides of the bed. The roll-belt restraint was around the abdomen and the straps were pulled taut. The resident's feet were off the bottom right side of the bed. The resident waved both arms around his body and jerked his head from side to side. The bed was of regular height and no fall mat was beside the bed and no alarm was on the bed or on the resident to alert the staff of the resident's attempt to get out of the bed wearing the belt restraint. At 3:15 p.m., the resident was observed sitting in the bed near the foot of the bed wearing the roll-belt restraint. The straps were pulled taut, and both feet were off the right side of the bed at the foot of the bed, and the resident's right foot was touching the floor. The resident was attempting to exit the bed at the foot of the bed while wearing a roll belt restraint around the abdomen, which had the potential to cause severe injury or death from restraint suffocation. At 3:25 p.m., Certified Nursing Assistant (CNA) #1 and CNA #2 performed incontinent care on the resident. CNA #1 and CNA #2 were asked, "Can he scoot down and get his feet and legs off the side of the bed (while wearing the roll-belt restraint)?" CNA #2 and CNA #1 stated, "Yes." l. On 10/4/11 at 3:45 p.m., the Administrator and Director of Nursing (DON) were interviewed and the surveyor called to their attention the fact that the resident tries to get out of bed at the foot of the bed with the roll belt on. The manufacturer's instructions documented that it is contraindicated in residents who have a history of removing restraints or moving to the foot of the bed. The Administrator and DON were asked, "Have you tried other methods such as low beds or fall mats?" The Director of Nursing stated, "No. We only have one low bed." 3. Resident # 6 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 7/24/11documented the resident was severely impaired in cognitive skills for daily decision making per Staff Assessment of Mental Status; required total dependence of one to two person assist for transfers and 1 person assist for locomotion on and off the unit, activity did not occur for walk in room or corridor, surface to surface transfer was not steady, only able to stabilize with human assistance, impairment on both sides in the upper and lower extremities; was always incontinent of bladder and bowel; had no falls since admission; and restraints were not used. a. The Nurse's Notes from 7/29/11 to 8/18/11 documented the following attempts to get out of bed, sliding down in bed/wheelchair, and/or incidences of resident being found in the floor: 1) The Nurse's Notes dated 7/29/11 at 10:15 p.m. documented, "...Resident bed rail on R (right) side was down and resident had both legs off bed..." 2) The Nurse's Notes dated 8/7/11 at 6:45 a.m. documented, "...Resident was found per CNA (Certified Nursing Assistant) at end of bed with legs hanging off the side of bed. Both side rails up and locked..." 3) The Nurse's Notes dated 8/8/11 at 3:30 p.m. documented, "Resident was found per CNA at end of bed with bilateral legs hanging off of bed. SR (Side Rails) up x 2... 8:00 p.m. Res. in high back wc sliding down and out of it... 8:30 p.m. Res. sliding down towards end of bed again. SR up x 2 and locked..." 4) The Nurse's Notes dated 8/9/11 at 2:15 p.m. documented, "Resident in bed restless, scoots and gets to end of bed with side rails up and hangs legs off side of bed. (Physician) notified and awaiting call back for request of soft roll belt for safety. 4:15 p.m. Res. in bed sliding down towards end of bed... Soft belt while in bed and soft belt while in wc TO (telephone order) per (Physician)... 9:00 p.m. ... Soft belt in place when put to bed..." 5) The Nurse's Notes dated 8/15/11 at 1:30 p.m. documented, "Heard noise coming from residents rm (room) Upon entering rm resident had leg hanging off bed and was shaking side rail..." 6) The Nurse's Notes dated 8/18/11 at 1:55 p.m. documented, "Entered residents rm and found her lying in the floor on lt (left) side. Resident moved self on to her back. Laceration above lt eye (left), hematoma noted Lt side above eye brow and hematoma Lt cheek... 5:20 p.m. ... roll belt on at this time wctm (will continue to monitor)." b. The Plan of Care dated 7/28/11 documented, "...8/18/11 At risk for complications r/t (related to) restraint use- Roll belt in bed - Soft belt while in w/c (wheelchair)... use restraints only as ordered, report any complications r/t restraint use, release restraints q (every) 2 h (hours)..." c. The Pre-Restraining assessment dated [DATE] documented, "... Balance (when sitting): falls forward yes checked, falls/leans sideways yes checked, slides down yes checked... Emotional, Environmental and Social Considerations: ...Does not understand what is being said yes checked ... Interdisciplinary Team Evaluation date 8/18/11 Recommendations: Soft belt in w/c and roll belt in bed. Alternatives to restraints (include length of time to be tried) have tried personal alarms..." d. Incident Reports and Nurses Notes from 8/19/11 to 09/28/11 documented the following attempts to get out of bed, sliding down in bed/wheelchair, falls and/or incidences of resident being found in the floor: 1) The Nurse's Notes dated 8/19/11 at 8:45 a.m. documented, "...Has soft belt on in w/c. Family requested restraint after fall on 8/18/11... 6:30 p.m. ...Resident roll belt is in place at this time. Resident did get out of roll belt earlier in shift. When this LPN (Licensed Practical Nurse) went in to give 4 pm meds, roll belt was in place and tied correctly. Back in resident room (at) 4:45 p and resident was lying on top of belt. Belt was still tied to bed, pulled back up in bed and roll belt back on..." 2) The Nurse's Notes dated 8/24/1 at 11:40 a.m. documented, "Alert with confusion, roll belt in place for safety continues to move around in bed. Legs hanging over side rails..." 3) The Incident Report dated 8/28/11 at 5:40 a.m. documented, "...type of incident fall...description of incident- R (resident) on floor bed rail up roll belt removed and tied to bed rail by R. Supine on floor head and upper back raised from floor pulling at bottom of gown, R stated, 'I am going to the bathroom'...Why did this occur- R removed restraint, no use of call light. What was done immediately- Advised and instructed on the use of call light..." 4) The Nurse's Notes dated 8/31/11 at 11:00 p.m. documented, "...upon entering room resident had roll belt removed and was holding it in her hand. Resident re-secured with roll belt... 11:10 p.m. Resident used call light upon entering room resident had roll belt removed and holding it in her hand. Again roll belt placed back on resident..." 5) The Incident Report dated 9/2/11 at 8:20 p.m. documented, "...type of incident fall...injury - skin tear to right hand...description of incident- res (resident) found in floor beside bed lying on lt side. Soft belt undone SR up times (x) 2 and locked...Why did this incident occur- Res took roll belt off and was attempting to get out of bed, What was done immediately - Res placed back in bed. Roll belt back in place..." The Nurse's Notes dated 9/2/11 at 8:30 p.m. documented, "Res. found by (CNA) in floor. Soft belt undone SR up x 2 and locked..." 6) The Nurse's Notes dated 9/14/11 at 10:15 a.m. documented, "...wears soft belt while up in wc for safety, res unties restraint several times a day monitored closely by staff..." 7) The Nurse's Notes dated 9/17/11 at 11:45 a.m. documented, "...Lap belt intact. Earlier res was attempting to stand up while restrained. Staff watching closely..." 8) The Incident Report dated 9/19/11 at 4:15 a.m. documented, "...type of incident - fall... If fall what position was person found in- aid found resident lying on back on the floor with roll belt around waist... Description of incident- Aid heard a thump in resident's room. Went to check it out and found resident on floor. Got on call light for assist. This nurse assisted... Why did this incident occur- Resident has history (hx) of undoing restraints and climbing out of bed, What was done immediately- Roll belt applied properly and monitor more frequently..." The Nurse's Notes dated 9/19/11 at 4:15 a.m. documented, "Call light answered. Aid in room ask for assistance in resident room. This nurse went to resident room to assist and saw resident lying on floor with restraint around waist. Side rail up x 2 ... Resident assisted back to bed with restraint in place properly ..." 9) The Nurse's Notes dated 9/20/11 at 11:30 p.m. documented, "Up in wc in dining room with aid at side. Soft belt restraint intact properly. Resident was trying to climb out of bed, so CNA got resident up..." 10) The Incident Report dated 9/23/11 at 1:37 p.m. documented, "...type of incident - fall... If fall what position was person found in - Sitting (with) back against side of bed. Resident used call light to let staff know she tried to transfer unassisted... Description of incident- resident stated, 'I wanted to see if I could transfer so that when I go home I will be good at it.'... Why did this incident occur - Resident was attempting to transfer self without assist to see if she could and she said she did, What was done immediately- Resident assessed for injuries with none noted ..." There was no documentation of new interventions being put into place after the incident. The Nurse's Notes dated 9/23/11 at 1:37 p.m. documented, "Resident sitting on floor beside bed... Resident untied roll belt and attempted to transfer unassisted when slid from bed to floor..." 11) The Nurse's Notes dated 9/28/11 at 11:30 a.m. documented, "Resident in bed with roll belt on and next time resident checked resident was up in chair. Transferred self. All staff denied helping with transfer..." e. The Physician order [REDACTED]. Restraint- soft belt while up in wheelchair..." f. On 10/4/11 at 4:23 p.m., CNA #3 was asked if she had ever seen the resident slide down in bed with the roll belt on. She stated, "Yeah, I done seen her slide down before." At 4:25 p.m., CNA #4 was asked if she had ever seen the resident slide down in bed with the roll belt on. She stated, "Yeah, had roll belt on." 4. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 7/18/11 documented the resident scored 5 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), scored 14 (indicates moderate depression) on a Patient Health Questionnaire (PHQ-9), had episodes of hallucinations, was independent in bed mobility, was non-ambulatory, and required limited assistance of 1 staff for transfers. a. As of 10/5/11 at 9:10 a.m., the Resident Plan of Care dated 4/25/11 through 7/23/11 did not address restraint use. b. The Nurse's Notes dated 7/10/11 at 2:00 p.m. documented, "Res (Resident) was crawling to edge of bed and attempting to crawl out...Res stated, 'I need to get up, I am at the office.' Hospice on call nurse paged after Ativan did not calm Res. 2:20 p.m. (Nurse) for Hospice called with order for soft belt in bed as needed." c. The Nurse's Notes dated 8/10/11 at 7:30 a.m. documented, "Res awake and very restless. Swinging legs over side rail. Both side rails up and locked." d. The Nurse's Notes dated 8/17/11 at 9:00 a.m. documented, "Res in bed with soft roll belt on for safety due to resident occasionally becomes agitated and swings both legs over the side rails." e. The Nurse's Notes dated 9/26/11 at 8:30 a.m. documented, "Soft roll belt in place for safety due to periods of extreme restlessness." f. On 10/4/11 at 4:15 p.m., LPN #2 was asked, "Have you ever seen residents on your hall with roll belts on moving around, sliding down in the bed?" and she stated, "Yes, (Resident #5) and (Resident #6), they become very restless and active sometimes." Then she was asked, "Have you ever seen any resident with a roll belt in the bed with their feet and legs hanging off of the bed?" and LPN #2 stated, "Yes (Resident #5) in the process of doing it, and with her legs hanging over the side rails." g. On 10/4/11 at 4:19 p.m., CNA #5 was asked, "Have you ever seen residents on your hall with roll belts on moving around, sliding down in the bed?" and she stated, "(Resident #5)." Then she was asked, "Have you ever seen any resident with a roll belt in the bed with their feet and legs hanging off the bed?" and CNA #5 stated, "(Resident #5), she moves a lot." 5. On 10/4/11 at 5:45 p.m., the Immediate Jeopardy was removed and the scope/severity reduced to "E" when the facility implemented the following plan of removal: a. Resident #2, #6, and #5 have had their roll belts d/c'd (discontinued) as of 10/4/2011 (at) 4:45 p.m.. b. All residents with restraint orders were assessed on 10/4/11 by the DON (Director of Nursing). Three residents with roll belt orders were d/c'd on 10/4/11. c. The DON and ADON (Assistant DON) will begin inservice on 10/4/11 on the 3/11 shift with direct care staff on the non-use of roll belts. The inservice will continue shift by shift until all direct staff has been inserviced. All staff will be inserviced prior to starting their shifts. d. Personal alarm devices have been placed on Residents #2, #6, and #5 to notify the staff when they attempt to leave their beds. All roll belts have been removed from the direct care area and are not available to the staff. e. The charge RN (Registered nurse) / LPNs (Licensed Practical Nurses) on each shift will monitor residents daily to ensure roll belts are not being placed on the residents. f. One charge nurse on each shift will be assigned to monitor all residents to ensure roll belts are not in use. The assigned charge nurse will complete the daily checklist to ensure no roll belts are in use. B. Based on observation, record review, and interview, the facility failed to ensure that the lower body was supported during transfers to minimize the potential for injury to the arms and shoulders for 1 (Resident #2) of 3 (Residents #2, #5, and #6) case-mix residents who required non-weight bearing transfers. This failed practice was likely to affect 13 residents in the facility who required non weight bearing transfers according to the list provided by the Administrator on 10/6/11. The facility failed to ensure soft belt restraints were tied in a manner to allow quick release in the event of an emergency for 1 (Resident #6) of 3 (Residents #2, #5, and #6) case-mix residents who were restrained in a chair with soft belt restraints. This failed practice was likely to affect 4 residents who were restrained in a chair with soft belt restraints according to the list provided by the Director of Nursing on 10/4/11. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/2/11 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status and was dependent on two or more staff for transfers. a. The Plan of Care dated 8/5/11 documented, "Problem: At risk for falls and other injuries. Approaches: ...Assist as needed with all ADLs (Activities of Daily Living)." There was no documentation in the plan of care the manner in which the resident was to be transferred and how much assistance was needed to transfer the resident. b. On 10/4/11 at 3:20 p.m., CNA #1 and CNA #2 sat the resident on the side of the bed. The resident's legs were straight out from the bed with the back of each heel on the floor. With an aide lifting under each arm and without using a gait belt, the resident was lifted up off the bed. The resident's heels were dragged across the floor. The resident was lifted up over a pommel cushion into the wheelchair with the resident's weight borne by the upper arms and shoulders. CNA #2 was asked, "Did he put any weight on his feet?" CNA #2 stated, "No." 2. Resident # 6 had [DIAGNOSES REDACTED]. The Admission MDS 3.0 with an ARD of 7/24/11documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status; was totally dependent with one to two person assist for transfers and one person assist for locomotion on and off the unit, activity did not occur for walk in room or corridor, surface to surface transfer was not steady, only able to stabilize with human assistance, impairment on both sides in the upper and lower extremities; was always incontinent of bladder and bowel; had no falls since admission; and restraints were not used. a. On 10/4/11 at 5:35 p.m., the resident was sitting up in the wheelchair with the soft belt in place. It was tied in a knot on the anti-tipper bars. b. The Manufacturer Guidelines for Application and Care of Medline Wheelchair Belts documented: "...Application instructions: ...3. Crisscross the straps behind the wheelchair and secure each strap to the corresponding kickspur using a quick release tie..." c. On 10/4/11 at 5:00 p.m. when the Administrator was informed of the restraints being tied in a knot he stated: "They are tied like that because the husband wanted it so she couldn't keep untying them and fall. I have a form he signed releasing the facility from responsibility due to not being tied right."

Based on observation, record review and interview, the facility failed to ensure nutritional assessments were conducted and interventions were developed and implemented to meet the resident's nutritional needs and prevent further weight loss for 1 (Resident #1) of 1 case mix resident who was fed via feeding tube and experienced significant weight loss. The failed practices resulted in a pattern of actual harm to Resident #1, who experienced a severe weight loss, and was likely to affect 3 residents with feeding tubes, according to the Administrator on 10/5/11. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/22/11 documented the resident was comatose, received more than 51% of calories and more than 501 cubic centimeters (cc) of fluid through a feeding tube and had a significant weight loss. a. The physician's orders [REDACTED]. Check Residual Q (every) 4 hours. Hold if residual is more than 120 ml (milliliters). Glucerna 1.5 per pump @ (at) 40 ml / HR (hour). Flush [DEVICE] with 300 cc water QS (every shift)." b. A Telephone Order dated 2/10/11 documented, "[MEDICATION NAME] Susp (suspension) 250 mg (milligrams), give 10 ml per tube TID (three times a day) X (times) 7 days for resp. inf. (respiratory infection). Decrease tube feeding to 20 ml / hr (milliliters per hour)." Glucerna 1.5 has 1.5 calories per ml. 1.5 calories multiplied by 20 ml / hr = 30 calories per hour. This reduced the resident's caloric intake from 1,440 calories per day to 720 calories per day. c. The Nutritional Progress Notes dated 2/14/11 documented, "Wt. (weight) - 175.1 # (pounds). (Down) 3.5 # or 1.96% in 1 month: 3.5 % or 6.4 # (down) in 3 months. 3.5# or 1.96% (down) in 6 months. IBWR (Ideal Body Weight Range) 154 - 166 #. 2/10/11 - decreased TF (tube feeding) to 20 ml/hr... Was 40 ml per hour via pump... Recommend: gradual (increase) of T.F. (tube feeding) back to 40 ml / hour to original flushes." d. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"0" was documented on every entry. e. The Nutritional Progress Note dated 3/31/11 documented, "Wt. 167.8 #: (down) 4.17% 1 month; (down) 7.55% in 3 month: 5.25% (down) in 6 months... ER (emergency room ) for [DEVICE] Replacement. Feeding was reduced 20 ml/hr for short time period. No chg (change). Cont (continue) same." There were no recommendations at this time to address the weight loss. f. The MAR for March 2011 documented the resident received Glucerna 1.5 at 20 milliliters per hour for the entire month of March. The MAR indicated [REDACTED]. All other entries were documented as "0". g. The Nutritional Progress Notes dated 4/28/11 documented, "Todays wt. 157#: 8.6 # (loss) < (less than) 1 month: April 1st weight - 165.5#. (Down) 1.3% 1 month; (Down) 7.28% in 3 months: (Down) 6.97% in 6 months... admitted to hospice. Has Stage IV decub (decubitus) on coccyx. Issues (with) major fluid overload if T.F. (tube feeding) is increased. Recommend: Prostat 64 - 15 cc BID (twice a day) (with) FeSO4 ([MEDICATION NAME]) 325 Q (every) day, Liquid Vit (vitamin) 1 dose (15 cc) q (every) day. Continue to monitor." 1.) The February 2011 physician's orders [REDACTED]. 2.) There were no new interventions to address the resident's weight loss recommended by the dietician. h. The Nutritional Progress Notes dated 5/31/11 documented, "158.2#: 7.4# (down) in one month: 16.9 # (down) in 3 months: 23.3 # (down) in 6 months. IBWR 142 - 154 #... Stage IV to coccyx... Same meds... On Hospice. 5/28/22 had [DEVICE] replaced. Cont to monitor." There were no interventions recommended at this time to address the continued weight loss. i. The Nutritional Progress Notes dated 6/8/11 documented, "Wt. - 154.2#: (down) 2.53% 1 month; (down) 8.1% in 3 month: 13.6 % (down) in 6 months. Major issues (with) fluid overload if T.F. (tube feeding) is increased. On hospice. Continue to monitor." There were no interventions recommended at this time to address the significant weight loss documented by the dietician. j. The Nutritional Progress Notes dated 7/28/11 documented, "Wt. 147.3 #. 3.76% (down) in 1 month: 10.39 % (down) in 3 month: 16.19% (down) in 6 month. Major issues (with) volume overload... Stage IV wound to coccyx... On Hospice... Cont to monitor." There were no interventions to address the significant weight loss documented by the dietician. k. The Nutritional Progress Notes dated 8/25/11 documented, "Wt. 144.8 # : (down) 2.43% 1 month; 8.47% (down) in 3 months; (down) 13.71 % in 6 months: admitted to hospice... Cont T.F. Tolerate OK." There were no interventions to address the significant weight loss documented by the dietician. l. The Nutritional Progress Notes dated 9/26/11 documented, "Wt. 143.2#: (down) 1.6% in 1 month: 11% wt loss in 3 months: 22.4% wt. loss in 6 months. IBW (Ideal Body Weight) 148#... T.F. Formula Glucerna 1.5 @ 20 ml continuous pump via peg (percutaneous endoscopic gastrostomy); Med adjustment including insulin. Contractures of upper and lower extremities noted. admitted to Hospice Care. Wound treatment for [REDACTED]. Continue to monitor." There were no interventions to address the significant weight loss documented by the dietician. The resident had lost 31.9 pounds since February 2011, an 18.2 % weight loss, with no new interventions recommended or implemented during the 7-month period. m. The physician's orders [REDACTED]. Flush [DEVICE] with 100 cc water AC & PC Meds. Check Residual Q 4 Hours. Hold if Residual is more than 120 ml. Glucerna 1.5 cans per pump @ 20 ml / hr." n. On 10/4/11 at 3:13 p.m. and 5:08 p.m. and 10/5/11 at 8:30 a.m., the resident was receiving Glucerna 1.5 at 20 milliliters per hour via a feeding pump. o. On 10/5/11 at 9:45 a.m., the Administrator was asked, "Is there a reason the resident is getting only 720 calories a day through the tube feeding?" The Administrator stated, "Hospice makes the recommendations for the feedings." p. On 10/5/11 at 10:50 a.m., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Hospice Nurse #1 and Hospice Nurse #2 were in the conference room. Hospice Nurse #1 was asked, "Why is the resident only getting 20 cc per hour of feeding?" Hospice Nurse #1 stated, "When we admitted him on April 12, 2010, he had aspiration pneumonia. We discovered at the time it was the type of feeding he was on. We have maintained him with 20 cc per hour. He has a history of aspiration pneumonia, so he couldn't tolerate that volume of feeding at 40 cc per hour. He has gastroparesis. We tried medications, but they didn't work.". The Surveyor asked, "Has a more concentrated type of feeding been tried to decrease the fluid but maintain the calories?" The ADON stated, "I've contacted our supplier. There's no formula like that for diabetics." Hospice Nurse #1 was asked, "Is there a Registered Dietician in Hospice that assesses the residents?" Hospice Nurse #1 stated, "We have one on contract." Hospice Nurse #1 was asked, "Has the (Hospice) dietician ever evaluated the resident?" Hospice Nurse #1 stated, "No. The Primary Care Physician handles the tube feeding orders. Not Hospice. We don't do feeding recommendations from Hospice. He was continued on whatever he was on." q. On 10/5/11 at 11:20 a.m., the orders for fluids and feedings were reviewed for Resident #1 in the presence of the Administrator, DON, ADON, Hospice Nurse #1 and Hospice Nurse #2. The DON stated the resident received medications (per the current MAR) at 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. The resident received 100 cc of water before and after each medication time, so received 200 cc of water at each medication pass. The resident received 150 cc flushes twice a shift at the following times: 10:00 a.m., 2:00 p.m., 6:00 p.m., 8:00 p.m., 12:00 a.m. and 4:00 a.m. The group was asked by the Surveyor, "If the resident can tolerate 200 cc of water at 8:00 a.m., 150 cc of water at 10:00 a.m., 200 cc of water at 12:00 noon, 150 cc of water at 2:00 p.m., 200 cc of water at 4:00 p.m., 150 cc of water at 6:00 p.m., 200 cc of water plus 100 cc of water at 8:00 p.m., then 150 cc of water at 12:00 a.m., and 150 cc of water at 4:00 a.m., is there any reason he couldn't tolerate an increase in the Glucerna?" Hospice Nurse #1 stated, "No." r. On 10/5/11 at 12:10 p.m., a telephone interview was conducted with Registered Dietician (RD) #1. RD #1 was asked, "There is a concern that the resident's calorie intake is less than his needs" RD#1 stated, "He can't tolerate a higher flow rate. We tried to up it and he couldn't tolerate it." RD #1 was asked, "When was it increased?" RD #1 stated, "I don't know." RD #1 was asked, "Had you looked at the amount of water he was getting?" RD #1 stated, "No." RD #1 was asked, "When was the last time you calculated the resident's needs?" RD #1 stated, "We usually do it on admission. I'll get with (Dietary Manager's Name) and re-calculate." s. On 10/5/11 at 12:15 p.m., the ADON was asked, "If you have any documentation that there were attempts to give more than 20 cc per hour of Glucerna 1.5 since February (2011), I would like to see it." There were no documents provided to the Surveyor. t. The Nurses Notes for August, September and October 2011 to date were reviewed and contained no documented incident of the resident throwing up or aspirating. u. On 10/5/11 at 2:45 p.m., Licensed Practical Nurse (LPN) #1 was asked, "Can you remember giving the resident's PEG feeding at a different rate than 20 cc per hour?" LPN #1 stated, "Yes." LPN #1 was asked, "When?" LPN #1 stated, "A long time ago. I don't remember." LPN #1 was asked, "Has the resident ever thrown up while you were on duty?" LPN #1 stated, "No." v. On 10/5/11 at 3:00 p.m., the Administrator was asked, "Has the DON or ADON found any documentation that the Glucerna has been given at a higher rate than 20 cc per hour since February?" The Administrator stated, "We couldn't find documentation of any increase. The Dietician should have recommended that in March if it hadn't been done."

Complaint # was substantiated. Based on observation, record review and interview, the facility failed to provide adequate supervision to reduce the risk of accidents for Residents #1 and #3, who were at risk for elopement. The facility failed to develop and implement interventions to ensure staff knew how to respond to elopement incidents, failed to ensure all exit alarms were working properly, exits without alarms were monitored, and that interventions were revised when residents continued to get outside without staff awareness for 2 (Resident #1 and #3) of 4 case mix residents (Resident #1, #2, #3 and #6) who had a history of [REDACTED]. This failed practice resulted in immediate jeopardy which caused or could have caused serious harm, injury or death to Resident #3, who eloped from the facility on 9/3/11 and walked approximately 0.4 miles off facility grounds to a hotel located on a busy street in town, and was likely to affect 6 residents in the facility who were assessed as being at risk for elopement, according to the Director of Nursing (DON) on 9/8/11 at 8:35 a.m. The facility was informed of the immediate jeopardy on 9/7/11 at 6:40 p.m. The findings are: 1. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/31/11 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, had short and long term memory problems, was independent with ambulation, and required extensive assistance with toileting and personal hygiene. a. The July 2010 physician's orders [REDACTED]. b. The following nurse's notes were documented from 6/12/10 through 9/3/11 regarding Resident #3's elopement history: 1) On 6/12/10 at 6:00 a.m., "This nurse was in another resident's room when CNA (certified nursing assistant) was on over head speaker stating '(Resident #3) is outside.' Alarm was sounding when staff made it to parking lot...attempted to stop resident, resident started hollering '(expletive) don't touch me' and attempted to swing at employee twice. Employee backed off, CNA attempted to stop resident with personal vehicle. Resident started hollering, 'Back the (expletive) up' and was extremely agitated. ..This nurse was staying with resident to ensure safety. Several attempts was made to stop resident. Each time resident became increasingly agitated. ..We made to 167 North when (Police Department) arrived. ..Resident seemed calm but when (Sergeant) touched his arm resident became agitated again, stating 'I'm a good man why y'all keep (expletive) with me' Resident charged at (Sergeant) at this time. (Sergeant) pepper sprayed resident and placed him in cuffs. ..It took two police officers to place resident in care. (Sergeant) informed us he was going to be taken to the police department to be cleaned from pepper spray, ...police would bring resident back to the facility. ..At 7:10 a.m., Resident assisted back in facility by officer, calm and cooperative at this time." 2) On 7/27/10 at 11:30 p.m., "Heard door alarm going off, it was the front entry alarm, shut alarm off checked outside the building but didn't see anyone. When rounds was made resident was in his bed. After entering back into the building checked res. (resident) room again and he wasn't there, checked the bathrooms and the building and didn't find res. At 11:35 p.m., I called 911 to report res. missing from the building, (staff) and myself was outside the building we saw res. on East Short Hillsboro, we called to him but he started a fast pace walking from us. At about 11:40 p.m. the police officers arrived, I gave them a report about the res. About 11:50 p.m. I called his brother and told him of his brother missing from the N.H. (nursing home) and about 12 (midnight) I called (Administrator) and told him of what happened. At 12:40 a.m. officer returned ...and said that they were unable to find res. at this time. Officer took information for a missing person's reports. Will continue to keep watchful eye out for resident. On 7/28/10 at 2 a.m., Res. still missing from N.H. ...will continue to watch... at 7:05 a.m., RTF (return to facility) with police x3 (times 3) and brother." 3) On 8/18/10 at 9:40 p.m., "Res. down in driveway past (assisted living facility), talked back into building given 1 PRN (as necessary) Ativan for agitation." 4) On 8/27/10 at 8:55 p.m., "Resident outside walking toward (assisted living facility) able to coax back in building given PRN Ativan ..." 5) On 8/31/10 at 8:00 p.m., "Res. seen walking by (assisted living center)... This nurse sees him across street in front of (grocery store). Another nurse tries to get resident to get in vehicle to come back to nursing home, resident continues to walk. This nurse along with 2 CNAs ...go back and pick up resident... Resident before getting into truck curses hollering and jumping up and down, 'Y'all better get the (expletive) away from me' Res told by staff 'You can get in the truck or we can call the police.' Resident in the truck without any problems. On return to building resident given Ativan 1 po (by mouth)..." 6) On 9/22/10 at 7:10 p.m., "Elopement attempt made. Left out front door. Wanderguard bracelets in place and functional. Res. was followed around building by several staff members x3. Res. states 'I'm trying to get the (expletive) outta here.' Eventually came in building..." 7) On 10/22/10 at 8:30 p.m., "Res. went outside of facility. Standing in doorway. Able to coax resident back into building..." 8) On 11/30/10 at 8:12 p.m., "Res. left out of lobby door. Wanderguard in place and functional. Attempted to (talk) resident back in building. Offered cigarettes, drink to come back in. Walking out to end of drive with fast pace. Hands in fists. (Police) notified of elopement - description given. .. at 8:24 p.m., RTF on his own accord..." 9) On 1/16/11 at 6:40 p.m., "Res. eloped from facility. Attempted to get res. back in building by numerous staff. Con't (continue) to walk swiftly down parking lot heading toward road - then turned off. (Police department) notified. Description of resident along with description of clothing was given... At 7:04 p.m., brought back to facility by (police) clothes wet, escorted to room. Clothing changed... Haldol 10mg given at this time ..." 10) On 2/17/11 at 7:00 p.m., "Haldol 10mg 1 po given for Awol (absent without leave) attempt alarm working properly. Res. exited building walked down driveway ignoring commands to stop and turn around. (Dietary Manager) from kitchen parked vehicle beside him and resident cont. to walk. Res. walking on Hillsboro toward the middle school. This nurse had 911 on the phone. (Dietary Manager) from kitchen gave nurse a ride to where resident was at. Res. re-directed back toward facility. This nurse was then helped by other staff when resident was back in the facility." 11) On 2/19/11 at 7:00 p.m., "Res. eloped. Unable to coerce resident back in building. Staff found res. 2 miles up the road. Got in car and brought back to facility without agitation or hostility, Haldol 10mg given PO." 12) On 3/28/11 at 2:00 p.m., "Res. eloped from facility but was brought back in, in a short period of time. Will continue to monitor. At 6:15 p.m., Res. down by end of driveway walking in a fast pace. Assisted back into building given Haldol 1 10mg po..." 13) On 3/29/11 at 7:00 p.m., "Restless this p.m., went out dining room door and turned toward laundry. Went behind laundry thru 2 gates before I could re-direct him. Once in facility attempted to go out thru (assisted living facility) - was able to detain him. agitated - apprehensive - Haldol 10mg po given. Prepared him for bed ...by staff, placed in bed by staff." 14) On 4/6/11 at 3:30 p.m., "Resident redirected back into building by 3 staff given Haldol 10mg 1 po for agitation. At 6:30 p.m., Res. attempted to AWOL again became agitated and balled up fist at staff, able to redirect into room by 2 staff and assist to bed giving pericare." 15) On 4/8/11 at 7:45 p.m., "Res. had AWOL attempt. Refused to turn around, when asked to, refused to stop. Finally CNAs able to catch up with resident..." 16) On 5/4/11 at 6:45 p.m., "Res. went out side door of dining room, assist back in. Res. cursing stating, 'I'm not going back in, get the (expletive) away from me. I'm not going to my house.' Res. assisted to room, given pericare by staff and assisted to bed..." 17) On 9/3/11 at 7:00 p.m., "Resident seen outside by aide at end of property walking towards the road. Residents alarm failed to activate because resident went through kitchen, back entrance and there is no alarm on that door. Staff encourage resident to come back. Res. did not respond or turn around. I notified police department. They located resident and brought him back at 7:20 p.m. At 7:30 p.m., resident was given PRN Haldol for agitation..." On 9/7/11 at 4:15 pm., LPN #5 stated, "(9/3/11) I was told by CNA #4 (Resident #3) had went out the door. At the same time, I saw him out the window walking up the driveway. I tried to encourage him to come back. He disregarded what I said, he ignored me." She was asked, "You documented (Resident #3) went out the kitchen door, how do you know that? " LPN #5 stated, "I'm assuming he went through that door. I'm not sure which door in the dining room he got out. (LPN #7), who lives next to the nursing home, followed him and (LPN #6) went in her car and followed him." On 9/7/11 at 5:20 p.m., LPN #6 was asked about Resident #3's elopement on 9/3/11. LPN #6 stated, "He got out and got a long way. I went looking for him." LPN #6 stated, "(LPN #5) called over to the other nurse's station and asked if me or the other nurse could come over and help her get (Resident #3) back into the facility. She said that (Resident #3) got to the road and would not come back..." LPN #6 stated LPN #5 told her no one was following Resident #3. LPN #6 stated, "I asked her (LPN #5) why didn't she send other people to follow him and she said, 'Well, I thought I'd call the police'... " LPN #6 stated she decided to go look for him. She stated she looked for him everywhere and never found him. She stated she got a call from the nursing home saying they found him. On 9/9/11 at 9:15 a.m., LPN #7 was asked if she thought the alarm system at the facility was appropriate for Resident #3. LPN #7 stated, "No, I think he should be somewhere the doors will lock." c. The care plan updated 8/4/11 documented, "...wear alarm device and check every shift to ensure it is working properly. If alarm sounds, check all exits to prevent elopement. Ensure door alarms are working properly to alert staff of elopement attempts." d. On 9/7/11 at 11:55 a.m., during an observation of all the exit doors located on A-wing and C-wing, when the exit doors were approached with the alarm bracelet, the exit doors did not lock. The Wanderguard alarm system did not sound when the bracelet was near the door, the alarm would only sound when the doors were pushed opened. Therefore the alarm system would not alert staff that a resident was near the door until the resident opened the door to walk out. e. On 9/7/11 at 6:30 p.m., the DON provided a copy of the facility's policy and procedure for "Wandering Residents" revised date 5/11/05. The Policy and Procedure documented, "...Interventions into elopement episodes will be entered onto the resident's care plan and medical record. ...Should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented on the nurse's notes..." On 9/9/11 at 8:25 a.m., the Director of Nursing (DON) was asked since Resident #3 had repeatedly eloped and had repeated attempts to elope, had the facility discussed anything about his behaviors in their Quality Assurance meetings. The DON stated, "Not that I can recall." The DON did not respond with any comments when the surveyor informed her that Resident #3's care plan did not indicate what the staff should do when he eloped from the facility, such as a staff member should follow the resident on foot or by vehicle to ensure his safety and location. 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/6/11 documented the resident scored a 6 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), was independently ambulatory and had a behavior of wandering daily. a. The Plan of Care dated 8/10/11 documented in the Problem section, "At risk for complications due to wandering all over facility and not knowing where she is." The Approach section documented, "Wear alarm device bracelet to make staff aware that she is going outside... Observe closely to ensure resident's safety. If (resident) is seen off unit, redirect her to safer environment... Listen for alarms and be aware that (resident) is going outside when alarm sounds. Ensure all exit alarms are working properly." b. Nurses Notes from 11/13/10 to 9/5/11 documented the following attempts to elope: 1) A Nurse's Note dated 11/13/10 at 5:20 p.m. and signed by LPN #7 documented, "...Wears secure and Wanderguard bracelet. Resident tries to go in/out of door all day. 1 on 1 with resident. No change, still tries to get out. Mood usually good but will get upset at times when one tries to get her to stay inside..." 2) A Nurse's Note dated 11/21/10 at 4:00 a.m. documented, "...Has to be reminded not to go outdoors, states OK, but she does go out the doors..." 3) A Nurse's Note dated 12/13/10 at 1:46 p.m. and signed by LPN #8 documented, "Resident ambulating in hallways. Medicare doors lock, A-wing locks and C-wing allows resident to leave facility. Staff has been turning resident around. Reported to department heads..." 4) A Nurse's Note dated 12/28/10 at 10:29 a.m. documented, "...Wanders outside if she can find a door open..." 5) A Nurse's Note dated 12/28/10 at 5:00 p.m. and signed by RN #2 documented, "...Goes outside and across parking lot to other entrance often. Must be redirected by staff and will reluctantly comply..." 6) A Nurse's Note dated 1/10/11 at 1:58 p.m. and signed by LPN #8 documented, "...Resident pushes frequently on exterior doors to see if they will open. When redirected, resident states she is so lost and where is her room. When directed to her room she will go in and walk a circle and then comes right back out..." 7) A Nurse's Note dated 2/14/11 at 1:06 p.m. and signed by LPN #8 documented, "Resident exited Medicare wing door to outside. Quickly assisted back into facility. Resident stated I wondered why I was out here. Resident's Wanderguard and secure guard working. Resident pushed on door long enough for it to open..." 8) A Nurse's Note dated 6/6/11 at 4:00 p.m. and signed by LPN #7 documented, "...Got out of laundry door this p.m. (afternoon), was brought back by staff..." 9) A Nurse's Note dated 6/18/11 at 8:52 a.m. and signed by LPN #8 documented, "...Resident holds exterior doors long enough they will come open, alarm sounds and resident continues to exit even with staff attempting to help her turn around. When staff takes her out she comes back in building. Resident is an elopement risk. All precautions have been taken with resident continuing to be persistent on exiting facility." 10) A Nurse's Note dated 6/28/11 at 5:00 p.m. documented, "...Goes out doors repeatedly throughout the day. Wears Wanderguard and secure guard to prevent elopement..." 11) A Nurse's Note dated 7/28/11 at 4:25 p.m. and signed by LPN #7 documented, "...Wears secure and Wanderguard bracelet. Resident will still manage to get out of doors. 1 on 1 with resident about not going outside due to it being hot and her safety but resident continues to go out of doors. Does this throughout shift..." 12) A Nurse's Note dated 8/6/11 at 4:25 p.m. and signed by LPN #7 documented, "Resident tries often almost all shift trying to get out of doors. Does at times find ways to get out of facility. Redirected back in facility when she gets out of doors. One on one with resident about staying inside due to it being very hot outside. Resident continues to go outside." On 9/7/11 at 11:00 a. m., LPN #7 was asked about Resident #1. She stated, "She's sweet. She tries to get out the doors often. Several times a day." LPN #7 was asked if the resident ever gets out of the facility. She stated, "Sometimes she gets out of the building. She'll walk across the parking lot and yard and she'll go over to the (Assisted Living) building." She was asked what door the resident uses to exit the building. She stated, "She'll get out of the front door. It will sound, but it doesn't lock. She'll go out the doors by the administrative offices." LPN #7 was asked if she knew of any occasions when the alarms on the doors did not function. She stated, "There's no alarm at all on the administrative door." She was asked how often the resident used that door to exit. She stated, "Probably every day." LPN #7 was asked about her Nurse's Note dated 8/6/11 when she documented she was one on one with the resident. She stated, "That means I visited with her about being outside. It was too hot. I've seen her in the parking lot when I come in to work at 3:00 p.m." She was asked if she had been instructed by administration on any other interventions to prevent the resident from going outside unsupervised. She stated, "No." She was asked if administration was aware the resident was going outside unsupervised. She stated, "Yes." 13) A Nurse's Note dated 8/20/11 at 11:25 a.m. documented, "...In and out building throughout day. At times will turn alarm off after entering building..." 14) A Nurse's Note dated 8/28/11 at 9:30 a.m. and signed by LPN #7 documented, "...Resident wanders hallways and outside continuously, redirected to stay in because of the heat but just finds a way to go back out..." 15) A Nurse's Note dated 9/5/11 at 5:00 p.m. and signed by RN #2 documented, "...Goes outside, walks across parking lot without supervision..." On 9/7/11 at 3:35 p.m., Registered Nurse (RN) #2 was asked about Resident #1. She stated, "I think she knows what she's doing. She'll look both ways, and then get out the door." RN #2 was asked what the resident does when she gets out. She stated, "She just walks. She's not aware of her surroundings. She likes to go out A-wing dining room and Medicare dining room, then go towards (Assisted Living)." RN #2 was asked about her Nurse's Note dated 9/5/11 and the resident being in the parking lot. She stated, "I mean, we know she's out there, but she's so fast she's across the parking lot before we get to her." She was asked if it was possible that the resident could exit the building and then another resident turn off the alarm. She stated, "Absolutely." c. On 9/6/11 at 4:00 p.m., the resident was observed in the dining room with a walker. A secure bracelet was observed on the resident's right ankle and on the walker. 1) On 9/7/11 at 10:28 a.m., LPN #9 was asked about Resident #1. She stated, "She loves going outside. She'll go out and the alarms go off and whoever hears it, they go out and get her. They'll try to walk her back this way to get her closer to our end and satisfy her. She goes out all the time. Recently she was real flushed and hot. She was walking across the parking lot by herself. If she knows you're watching, she walks real slow, but when she hits the door she picks up speed. One day I was with her and the flower guy was driving too fast in the parking lot. The facility van was parked and he couldn't see around the van and he would've hit her if she'd been by herself." 2) On 9/7/11 at 12:40 p.m., CNA #5 was asked about Resident #1. She stated, "She normally uses A-wing dining room door to get out. Sometimes she gets to the parking lot or in the yard before we get to her." She was asked how the resident gets that far. She stated, "I don't know." CNA #5 was asked if she knew of any occasions when the doors did not function. She stated, "Sometimes the C-hall door won't alarm." 3) On 9/7/11 at 1:00 p.m., CNA #6 was asked if she knew of any occasions when Resident #1 was outside without staff knowledge. She stated, "I heard she was outside in the back behind (Assisted Living)." She was asked how that would happen if the doors alarm. She stated, "Sometimes the alarm goes off and lets us know, sometimes they don't. Sometimes the A-wing door doesn't alarm and sometimes she don't use her walker. Sometimes the C-wing door alarms, sometimes not." The CNA was asked if the resident was behind the building by the dumpster without staff knowledge. She stated, "She was back there and nobody knew it. She's really fast and you have to make sure she actually turns around when you tell her because she will be gone. She will be outside and get real hot. We'll bring her in and give her water." CNA #6 was asked how the resident could've gotten out back without staff knowledge. She stated, "If we are providing care in a room and we hear an alarm, we can't quit what we're doing." The CNA was asked if she had been recently inserviced on elopement. She stated, "It's been a while." 4) On 9/7/11 at 1:45 p.m., CNA #7 was asked if he had observed Resident #1 outside without supervision. He stated, "One day the alarm by the shower was going off. She was outside walking around so I brought her back in. She'll pick her walker up and try to run from you to get outside." The CNA was asked if he was aware of any of the doors not working. He stated, "Some aides say the dining room door on C-wing don't always work, but I've never seen that." 5) On 9/7/11 at 2:00 p.m., LPN #10 was asked if she had ever observed Resident #1 outside the facility without supervision. She stated, "Yes. I get here at 6:30 a.m. and I have seen her in the parking lot. I'll just bring her back in." LPN #10 was asked how the resident gets all the way to the parking lot and someone not be outside with her. She stated, "I guess they're just busy." 6) On 9/7/11 at 2:20 p.m., CNA #8 was asked if she had ever observed Resident #1 outside the facility without supervision. She stated, "Yes, she goes out by herself all the time. The alarm goes off, but when we are down the hall, it's a while before we can get to her." The CNA was asked if she had ever known the resident to get around behind the building by the dumpster. She stated, "I've had to go around and get her by the dumpster." She was asked how the resident would get all the way around there without staff being with her. She stated, "If we are way down the hall, we have to go find which door it is, and she will pick up that walker and run. She can get a ways. And I'm afraid she's fixing to get blindsided in the parking lot. People speed in the parking lot." CNA #8 was asked if she remembered any occasions when the alarms on the doors didn't work. She stated, "Sometimes C-wing alarm will not sound. (Resident #1) can turn the alarm off and so can a few other residents. She has that one bracelet on her ankle and one on her walker, you know, for the different doors? Monday she had somebody else ' s walker and went outside. The door did not alarm because she didn't have her walker." d. On 9/7/11 at 11:50 a.m., rounds were made through the facility with the Maintenance Director to check all exit doors. The south half of the building, which included the private and medicare wing, had a system that would lock the door when a secure bracelet approached it. The north half of the building had a system that would not lock when a Wanderguard approached it, but it would alarm when someone with a bracelet exited the door. Several pieces of scrap metal and trash were found behind the facility where the resident had been previously found. e. On 9/8/11 at 8:25 a.m., LPN #8 was asked if she had observed Resident #1 outside without supervision. She stated, "All the time, but (Director of Nursing) told me that the care plan says she's got the alarms and that she's not prohibited from going outside." LPN #8 was asked if she thought it was safe for Resident #1 to go outside without supervision. She stated, "No it's not safe. She's gonna get hurt. Recently it's been so hot. I know I've dealt with her a couple of times because of the heat and she'll get red faced and sick at her stomach. I really worry about her getting hit in the parking lot." LPN #8 was asked if the resident goes outside without staff knowledge. She stated, "She goes out all the time without people knowing it. She even goes out through (Assisted Living)." On 9/8/11 at 9:45 a.m., CNA #1 was asked if she knew of an occasion when Resident #1 had been found out behind the facility without supervision. She stated, "That wouldn't be a surprise. She's found all over the place - behind the building, by the dumpster ... " CNA #1 was asked if she thought it was safe for the resident to go outside unsupervised. She stated, "No it's not. She's got Alzheimer's. Thank God her mind has never led her out in the street. She needs to be supervised. That's why she's in here." The CNA was asked how the resident would get behind the building without staff being with her. She stated, "People are so used to the alarm they don't pay much attention to it because they know it's her." CNA #1 was asked if she knew of any occasion when the door did not function. She stated, "Sometimes the alarms don't work. One time she went out the A-wing door and it didn't alarm, but I told (Maintenance Director) and he fixed it." On 9/8/11 at 3:10 p.m., CNA #3 was asked if Resident #1 had been found out behind the building without supervision. She stated, "I've heard that. I have driven up to the facility and found her outside when nobody knows she's outside." The CNA was asked if she thought it was safe for the resident to be outside without supervision. She stated, "No. Any person that's elderly and has Dementia, I don't think they should be out alone. One day I was leaving and another car was coming through the parking lot at the same time, and there was (Resident #1). The other driver was like - man I almost hit her." f. On 9/9/11 at 8:30 a.m., the Director of Nursing was asked if Resident #1 was supposed to be outside the facility without supervision. She stated, "She's not to roam out there by herself. When the alarm goes off, they are to go get her and maybe sit with her, then bring her back in." 3. The immediate jeopardy was removed and the scope and severity reduced to an "E" on 9/8/11 at 9:42 a.m. when the facility initiated the following plan of removal: a. Beginning 09/07/11 at 6:55 p.m., Resident #1 and Resident #3 will be assigned a staff member to be with them 24 hours a day until other placement options are found. b. The DON and ADON will assess all residents in the facility for elopement risk by 10am on 09/08/11. If a resident is assessed as inappropriate for the facility, a staff member will be assigned 24 hours a day until other placement options are found. c. The DON and ADON will begin an in-service on 09/08/11 with the 7-3 shift by wing and department regarding the facility elopement policy and procedure. The in-service will be conducted on all shifts until all staff members have been in-serviced. Any staff members on leave or vacation will be in-serviced regarding elopement policy and procedures before allowed to return to work. d. The DON and ADON will monitor and interview the staff daily to ensure all staff are knowledgeable regarding the facility elopement policy and procedures, and are in compliance with the policy and procedures for three weeks.