Every finding on record at The Springs of Texarkana

Based on observation, record review, interview, and facility policy review, it was determined the ice machine was not maintained in a clean and sanitary condition to prevent potential contamination of residents' food and beverages, and to minimize the potential for waterborne illness for 84 of 91 residents who received ice from the kitchen. Seven residents did not receive ice from the kitchen, six residents received thickened liquids and one resident was NPO (Nothing by Mouth). The findings include: During an observation and concurrent interview on 03/30/2026 at 10:09 AM, this surveyor asked the Dietary Manager (DM) to wipe out the ice machine with a paper towel. The DM wiped around the door opening at the top of the storage bin, the paper towel had a yellowish-brown substance on it. The DM indicated the substance on the paper towel looked like rust. The DM indicated the Maintenance Supervisor (MS) was responsible for and cleaned the ice machine once a month, but that the DM had only worked at the facility for one week and was unsure when the last time was that the MS had cleaned the ice machine. During an interview on 03/30/2026 at 3:40 PM, the Administrator stated the ice machine had been cleaned and asked this surveyor to observe the ice machine and advise if the facility needed to take the ice machine out of service. This surveyor indicated that the surveyor could not tell the facility if they needed to take the ice machine out of service. This surveyor asked the Administrator to wipe the inside of the ice machine up by the top of the door of the storage bin with a paper towel and observed the paper towel had a substance that looked brown and yellow in color. The Administrator was asked to describe the substance. The Administrator stated, it looked dirty, like rust. During an interview on 04/02/2026 at 10:56 AM, the MS was asked who was responsible for cleaning the ice machine. The MS indicated that he deep cleaned the ice machine every two months. When asked the MS stated he was unsure what the dietary staff did to clean the ice machine on a daily or weekly basis. During an interview on 04/02/2026 at 2:34 PM, the Administrator indicated the MS was responsible for cleaning the ice machine weekly, as well as deep cleaning the ice machine but did not indicate how often. Review of an Ice Machine Deep Cleaning Log, provided by the MS, indicated weekly cleaning with the following dates listed for when the MS completed cleaning on the ice machine: 10/16/2024, 12/12/2024, 02/18/2025, 04/23/2025, 06/12/2025, 08/20/2025, 10/15/2025, 12/11/2025, 02/05/2026. Review of a facility policy titled Sanitization, with a revised date of October 2008, revealed Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. Review of the ice machine's User Manual dated November 2012, revealed It is the User's responsibility to keep the ice machine and ice storage bin in a sanitary condition. Without human intervention, sanitation will not be maintained.

Based on observations, interviews, record review, and facility policy review, the facility failed to develop and implement a Comprehensive Person-Centered Care Plan for one (Resident # 12) of three residents reviewed. Specifically, the facility failed to ensure Resident #12's smoking safety was addressed in the Care Plan to prevent accidents or injuries. The findings include:Review of Resident #12's Medical Diagnosis revealed Resident # 12 had diagnoses which included hemiplegia (paralysis) affecting left non-dominant side, transient ischemic attack (TIA) or stroke. Review of Resident #12's admission Minimum Data Set (MDS) with an Assessment Reference Date of 02/12/2026 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #12 was cognitively intact. The MDS also revealed Resident #12 required use of wheelchair for mobility and identified Resident #12 as a current tobacco user. Review of Resident #12's admission Smoking Safety Screen dated 02/05/2026 indicated Resident #12 was safe to use tobacco with supervision and indicated Resident #12 smoked 5-10 cigarettes a day.Review of Resident #12's Care Plan dated 02/05/2026 does not address smoking, that Resident #12 smoked, or smoking safety. On 03/31/2026 at 3:30 PM, this surveyor observed Resident # 12 smoking with supervision during smoke break.During an interview on 04/02/2026 at 10:19 AM, Certified Nursing Assistant (CNA) #1 stated the Care Plan would reveal how to take care of a resident. During an interview on 04/02/2026 at 10:20 AM, Licensed Vocational Nurse (LVN) #2 stated the Assessment or Care Plan would reveal how much care a resident needed and how to take care of the resident. During an interview on 04/02/2026 at 1:17 PM, MDS Coordinator #3 stated information obtained from the MDS, and the Smoking Safety Screen would indicate if the resident smoked and how much care was needed to be placed on the residents' Care Plan. MDS Coordinator #3 stated Resident # 12's Care Plan dated 02/06/2026 did not identify Resident #12 as a smoker and was not accurate. MDS Coordinator # 3 stated it was important to ensure the Care Plan data was accurate, so all staff knew what care a resident needed. During an interview on 04/02/2026 at 1:31 PM, the Director of Nursing (DON) stated MDS Coordinator #3 was responsible for the review of Care Plans for accuracy. The DON stated it was important to ensure accuracy of Care Plans to know how to take care of the residents. The DON stated she was not aware of [any] inaccuracies related to Care Plans.Review of a facility policy titled Care Plans, Comprehensive Person-Centered revised March 2022 revealed A Comprehensive, person-centered Care Plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy also revealed The care plan describes the services to be furnished.

Based on interviews, record review, and facility policy review, it was determined the facility failed to notify a resident's family member/responsible party of the resident's fall and change in condition for 1 (Resident #2) of 5 residents reviewed for falls. The findings are: 1. Resident #2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 2/24/2025 documented a Brief Interview for Mental Status (BIMS) score 1 (0-7 indicates severe impairment) with medical diagnoses of diabetes mellitus (DM), Alzheimer's disease, and cerebrovascular accident (CVA) a. Review of a progress note dated 2/24/2025 at 10:33 pm indicated Resident # 2 had an unwitnessed fall and sustained a small laceration to the right eye. The progress note did not indicate the family/responsible party was notified of the fall. b. Review of Resident/Family Grievance/Concern Form dated 2/27/2025 revealed Resident #2's son was upset that he was not notified of a fall that occurred with Resident # 2. The resolution was that all nurses were in-serviced to ensure they were calling the family for fall notifications and the nurse (unidentified) was written up for failure to notify family. Additional comments stated that Resident #2's son was still frustrated with not being contacted but was satisfied with the actions taken to resolve the issue. c. On 3/10/2025 at 2:45 pm, during an interview Registered Nurse (RN) #1 was asked about Resident #2's fall on 2/24/2025. RN #1 stated she rounded on Resident #2 at around 9:00 pm. RN #1 stated Certified Nursing Assistant (CNA) #2 notified RN #1 of the resident in the floor around 10:00 pm. RN #1 stated she went to Resident #2's room and noted a laceration above the right eye with bleeding noted. RN #1 stated she stopped the bleeding and started neuro checks. The Medical Doctor (MD) and Director of Nursing (DON) were notified of Resident #2's fall. RN #1 stated Resident #2's son/resident family was not notified. d. On 3/10/2025 at 2:55 pm, during an interview Certified Nursing Assistant (CNA) #2 was asked about Resident #2's fall on 2/24/2025. CNA #2 stated she made rounds on Resident #2 around 9:00 pm. CNA #2 stated Resident #2 was in bed lying on left side, with the bed in low position. At around 9:40 pm on 2/24/2025, CNA #2 noted Resident #2 was in the floor. CNA #2 stated Resident #2 hit the resident's head on the trash can. CNA # 2 stated she notified RN #1 of Resident #2's fall. e. On 3/11/2025 at 9:02 am, this surveyor reviewed the Incident and Accident (I&A) note for Resident #2 for 2/24/2025. The I&A report stated: Agencies and People notified: Physician: 2/24/2025 at 10:26 pm; DON: 2/24/2025 at 10:26 pm; and Family Member: 2/27/2025 at 10:09 am. f. On 3/11/2025 at 9:15 am, this surveyor requested the facilities fall policy from the Administrator. g. On 3/11/2025 at 9:30 am, this surveyor interviewed the Director of Nursing (DON) regarding the incident on 2/24/25 with Resident #2. The DON stated she was notified immediately at 10:26 pm of Resident #2's fall with injury, the medical doctor (MD) was also notified immediately. The DON was asked if a family member was notified of Resident #2's fall. The DON stated RN #1 received counseling for not notifying a family member. h. On 3/11/2025 at 9:45 am, this surveyor received a policy from the Administrator titled, Assessing Falls and Their Causes (undated), the policy indicated the resident's family should be notified in an appropriate time frame after a fall. i. On 3/11/2025 at 1:05 pm, this surveyor received a form titled, Employee Memorandum from the Administrator that indicated RN #1 received a verbal warning on 2/27/2025 for failure to notify a family member when a resident had a fall. Corrective action: Ongoing monitoring. j. On 03/11/2025 at 1:40 pm, during an interview with Licensed Practical Nurse (LPN) #3 this surveyor asked who was to be notified when a resident had a fall. LPN #3 stated the family, the DON, the Nurse Practitioner, and the Administrator. This surveyor asked when they should be notified, and LPN # 3 stated immediately. k. On 3/11/2025 at 1:45 pm, during an interview this surveyor asked the Administrator about the facilities fall protocol. The Administrator stated staff should complete a resident assessment, an I&A report, if the resident hit their head neuro checks, and perform wound care if necessary. After assuring the resident was stable, contact the medical doctor, the DON, the Administrator and the family immediately. l. On 03/11/2025 at 1:55 PM, during an interview with Licensed Practical Nurse (LPN) # 4, this surveyor asked who was to be notified when a resident had a fall. LPN #4 stated the MD [doctor], the family, the DON and now the new Administrator. This surveyor asked when they should be notified. LPN #4 stated as soon as the fall happens. This surveyor asked if LPN #4 had been in-serviced on what to do when a resident falls. LPN #4 stated yes, just recently in the last week or two. m. On 3/11/2025 at 3:15 pm, this surveyor received an in-service from the Administrator dated 2/28/2025 titled, Abuse and Neglect and miscellaneous topics. Number 29 on the in-service stated: Nurses, please ensure that the incident report is filled out completely, accurately and all parties are notified including DON, administrator, Doctor and family and if on hospice, please notify a hospice provider.

Based on interview, record review, and the operational manual review for a borrowed lift van, the facility failed to ensure 1 (Resident #3) of 3 sampled residents received adequate supervision and assistance devices to prevent an accident; and, failed to ensure the Transport Driver (CNA #2) was properly trained in the use of a borrowed van with lift prior to Certified Nursing Aide (CNA) #2 transporting Resident #3 to an appointment, putting the resident at risk for serious harm, serious injury, serious impairment, or death. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25(d) (Accidents and Hazards) at a scope and severity of J. The IJ began on 11/06/2024, when Resident #3 was transported to an appointment using a borrowed van without appropriately training the staff transporting Resident #3 on the use of the lift of the borrowed van. The Administrator was notified of the past noncompliance (PNC) IJ on 02/26/2025 at 1:50 PM. The facility implemented corrective actions which were completed prior to the State Agency's completion of its survey; thus it was determined to be a Past Noncompliance citation. The findings are: Resident #3's Minimum Data Set (MDS)with an Assessment Reference Date of 2/10/2025 identified Resident #3 to have a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #3 was cognitively intact. Resident #3 was identified to be totally dependent on staff for chair to bed and chair to chair transfers and sit to stand. Resident #3 was identified to require a wheelchair and limb prosthesis for mobility. Resident #3 has diagnosis of type 2 diabetes mellitus, chronic kidney disease, bi-lateral lower extremities amputee, obesity, muscle weakness. Resident #3's Plan of Care, dated 11/21/2024, identified Resident #3 to have sustained a witnessed fall with injury from the van lift. On 2/24/25 at 3:00 PM, the Surveyor interviewed Resident #3, who reported Resident #3 had rolled off the van lift when the wheelchair rolled backwards while the lift was raised. Resident #3 said, I thinks the wheel must have caught between the tailgate like thing on the back of the lift and the side of the lift. Resident #3 said the wheelchair rolled backwards and was tilted after it caught in the lift. Resident #3 said the wheelchair wheels were not locked. Resident #3 said after falling from the lift onto the ground CNA #2 came around the van to assist Resident #3. Resident #3 said CNA #2 said, I should have double checked everything. Resident #3 said CNA #2 was very upset. Resident #3 said the wheelchair was not locked and I do not remember a belt being bucked behind the wheelchair. Resident #3 said, I had some bruises and scratches, and my right shoulder area was sore, but I was okay. Resident #3 said, I felt like I had been in a car wreck, just sore, but was okay after a few days. Resident #3 was very pleasant and able to answer the surveyor's questions. On 2/24/2025 at 4:30 PM, CNA #1 reported having been a van driver since 11/2023. CNA #1 said, I had been trained on the Springs of Texarkana facility van following an incident in November of 2024 where a resident fell from the borrowed van lift. CNA #1 said the Texarkana van was not the one the resident had fallen off. CNA #1 said the resident fell from the lift of a borrowed van, or bus. CNA #1 said the facility had borrowed the van from a sister facility nursing home and it was like a bus. CNA #1 said, I was not going to drive that bus. I was not trained or in-serviced on the borrowed van. CNA #1 provided a written statement stating she was not trained/in-serviced on any van other than the van provided by the Springs of Texarkana. On 2/24/2025 at 5:15 PM, CNA #3 stated she had been a van driver in the past but had transferred to the cottages. CNA #3 said she will continue to help with transport when needed. CNA #3 said she had not been trained on the van since May of 2024. CNA #3 provided a written statement stating she had transported a resident to dialysis about 3 weeks ago on a Saturday. CNA #3 said she was not aware of any van lift training over the last 4 months. On 2/24/2025 at 5:35 PM, CNA #2, the transport driver, stated he had taken the resident to an appointment at Hanger Clinic Prosthetics and Orthotics, and he loaded Resident #3, in a wheelchair, onto the wheelchair lift of the borrowed van and then activated the lift to raise the resident up. CNA #2 said I then went around the van and got in so I could assist the resident from the lift into the van. CNA #2 said he saw Resident #3 begin to roll backwards and fall off the lift in the wheelchair. CNA #2 said the van he had used that day was not the facility van but one that had been borrowed from another facility. CNA #2 said he had not been trained on the borrowed van, or its lift. CNA #2 said that the borrowed van's lift was on the side of the van and the Texarkana facility lift was on the back of the van. CNA #2 said the lifts loaded differently. CNA #2 said the lift on the borrowed van had a lean to it, the parking lot leaned downward, the resident was top heavy, and the wheelchair had a high back on it. CNA #2 said it was like the perfect storm, so to speak, Resident #3 fell off the lift in the wheelchair. CNA #2 said the van was parked on an incline. On 2/24/2025 at 6:08 PM, the Administrator said the facility's van lift had gone down around November the 4th or 5th and on November 6, 2024, we borrowed a lift van from a sister facility, (Named facility) in Nashville. The Administrator said the lift and its mechanics were the same as the lift on our lift van. The Administrator said he and the Maintenance Supervisor went to Nashville to get the van and when they got back, he told the Maintenance Supervisor to get the group together so we can in-service them on the van. The Administrator said the maintenance supervisor said, let's do the ones that are insured. The Administrator said they trained 3 staff, CNA #1, CNA #2, and CNA #4 on the use of the borrowed van and its lift. The Administrator said the staff were trained by verbal instructions, not demonstration. The Administrator said, we all got on the van and talked about how to use the lift. So, we in-serviced CNA #2 and CNA #1 on driving the borrowed van, the operating of the van, the use of the doors and the basic operations of the van. The Administrator said, we cannot find the documentation of this training. The Administrator said training is normally done by their van mobility company representatives. The Administrator said we showed them the lift, seat belts in the van and where the wheelchairs sat side by side in the borrowed van, where theirs sat one behind the other. We did not do actual demonstrations on the borrowed van or the lift. We explained that it is the same as our old one, but nothing really changes. The Administrator said when our van came back, we did actual demonstrations with me sitting in a wheelchair and being lifted onto the van using the lift. The Administrator said there were no issues with the borrowed van's lift. The surveyor asked the Administrator if the facility provided paperwork to the staff when they trained. The Administrator said, when it is a new employee, we do. The Administrator said the mobility representative provides annual training for our staff and the representative comes twice a year and inspects the van and does our training. The Administrator said normally he (the mobility representative) would have provided it, but we did not contact him regarding this training. The Administrator said that the borrowed van's lift goes out to the side, where ours goes out the back, but it's the same principle. This surveyor asked the Administrator if he in-serviced all the van drivers on the use of the lift following the incident. The Administrator said they in-serviced all the staff listed on the list provided in the Facility Reported Incident and most were completed on 11/14/2024 but a couple was on 11/18/24. The Administrator said he sat in the wheelchair, and we trained the staff, and the staff completed a return demonstration on the facility van, following the incident. This surveyor asked the Administrator if the borrowed van lift had a seatbelt. The Administrator said confirmed it did. The Administrator said ours did not have that yellow strap that goes behind the wheelchair, but we ordered one of the belts and we demonstrated the use of that belt during the training on 11/14/24. The Administrator said if the lifts are not level, they will not move, the kick plates must be up for it to operate properly. On 2/25/25 at 9:15 AM, the Administrator provided the survey team with the training the administrator and the Maintenance Supervisor had conducted on 11/6/2024. The Administrator told the surveyor the sections highlighted in green were covered during the verbal training. The Administrator said they did not provide a demonstration of the lift during that training. The Administrator attached a yellow sticky note to the training sheet where he had written: Training for borrowed van - verbal direction since lifts/safety mechanisms are similar in operations. The Administrator provided the survey team with a copy of the Operational Manual for the borrowed van. On 2/25/025 at 9:15 AM, the Administrator provided the survey team with an invoice dated 11/12/2024 for a Yellow Safety Belt. On 2/25/25 at 4:01 PM, an email was received from the ambulance service staff. On page 2 of the email the note states: the patient fell roughly 4-5 feet backwards from a wheelchair lift that broke midair and threw the patient back and off. The Narrative, on page 4, stated upon patient contact, the patient was lying on the ground holding patient head but appeared to be in no acute distress. The patient fell about 4-5 feet backwards. The patient had no loss of consciousness and took no blood thinners, the patient stated the patient was hurting all over, but the right shoulder and head hurt the worst. On 2/25/25 at 5:15 PM, a follow up phone interview was conducted by this surveyor with CNA #2. CNA #2 was asked if the lift itself had malfunctioned or broken. CNA #2 said the lift did not get down to the 45-degree angle. CNA #2 said the lift was that way when we got it from the other facility. It was not level, but it did lock into place, but it sagged away from van in the direction Resident #3 fell off the lift. This surveyor asked if the van was used to transport any other residents, following this incident. CNA #2 stated, yes, that very day. The Administrator told me to go pick up a wheelchair resident from dialysis on the way back to the facility. CNA #2 said he had told the Administrator about the lift leaning but was instructed to pick up the resident from dialysis first. The other resident was a wheelchair resident. CNA #2 said he used the lift, but did not have any issues with it when he picked the resident up. CAN #2 said the lift on the borrowed van goes up about 3 feet off the ground. The surveyor asked CNA #2 if Resident #3 had complained about Resident #3 head hurting. CNA #2 stated Resident #3 had not complained about that, but Resident #3 did not hit the ground headfirst, Resident #3 was shaken up, but the handles of the wheelchair hit the ground first and they bent. (Note: The Administrator had stated in his interview there were no problems with the lift). On 2/25/25 at 9:43 PM, the surveyor reviewed the Operational Manual for the van used to transport Resident #3 when the fall occurred. On page 10 of the manual, under lift operations safety is a list of warnings: Warning: Read manual and supplements before operating lift, become familiar with all safety precautions, operation notes and details, operating instructions and manual operating instructions before operating the lift . Warning: Load and unload on level surface only. Warning: Inspect the lift before operation, do not operate the lift if you suspect lift damage, wear, or any abnormal condition. On page 13 of the manual, it lists a Warning failure to follow these safety precautions may result in serious bodily injury and/or property damage.

Based on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure lift pads were in appropriate working order, free of fraying and loose strings to prevent potential accidents or injury for 1 sampled (Resident #10) resident; aerosol disinfectant was not stored at the bedside to prevent accidents or injury for 1 sampled (Resident #84); and failed to ensure the resident's environment remained free of accidents as possible and each resident received adequate supervision to prevent accidents for 1 sampled (Resident #69). Findings include: 1. A review of Medical Diagnoses revealed Resident #10 had diagnoses of stroke, heart failure, and diabetes type II. a. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/21/2024 suggested a Brief Interview for Mental Status (BIMS) score of 05 (0-7 indicates severe cognitive impairment). Section GG0139 indicated Resident #10 was totally dependent in all areas. b. A review of a policy titled, Lifting Machine, using a Mechanical, revised July 2017, revealed staff were to ensure all necessary equipment was in good working condition before use. c. A review of an in-service training dated 06/26/2024, revealed staff were trained on the safe transfer of residents, and the mechanical lift policy. d. Review of Resident #10's Care Plan revised 06/15/2023, revealed Resident #10 required assistance of 2 staff members with a mechanical lift transfers. e. On 10/07/24 at 10:00 AM, Certified Nursing Assistant (CNA) #9 was observed pushing the lift away from Resident #10's adjustable chair at Resident #10's bedside. The Surveyor observed the lift pad placed under Resident #10 had fraying and loose strings around the lift pad edges. f. On 10/07/24 at 10:05 AM, CNA #9 was asked to look at Resident #10's lift pad and CNA #9 pointed out frayed areas, and loose strings. CNA #9 stated it is tearing, and the thread is coming out. When asked if staff would want to use lift pads that are frayed and tearing, CNA #9 stated the resident could be dropped, and there was a possibility of the lift pad ripping while being used with a resident and the resident could be dropped in the air. g. During an interview the Director of Nursing (DON) on 10/09/2024 at 04:12 PM, the DON stated that the CNA supervisor is responsible for inspecting lift pads and confirmed that any lift pad with fraying or loose strings should be thrown away and reported to the DON for replacement. Please summarize/paraphrase your interview. The DON stated that using lift pads that are damaged could rip when being used with a resident and cause them to fall. 2. A review of Medical Diagnoses revealed Resident #84 had diagnoses of brain injury, anxiety, and depression. The a. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/20/2024 suggested a Brief Mental Status (BIMS) of 09 (8-12 indicates moderate cognitive impairment). b. On 10/07/24 at 10:24 AM, a can of disinfectant spray was observed at Resident #84's bedside. c. On 10/09/24 at 03:44 PM, Resident #84 was observed sitting in a wheelchair to the left of a bedside table with a can of disinfectant spray resting nearby. Resident #84 stated a relative brings the disinfectant spray for the bathroom. Certified Nursing Assistant (CNA) #10 stated that staff are not allowed to have a disinfectant spray but did not see a problem with family bringing it in for their use. d. During an interview with the Director of Nursing (DON) on 10/09/2024 at 04:12 PM, the DON confirmed residents were not allowed to have disinfectant spray at the bedside, and stated a confused person could spray it in their face. The DON stated there were no in-services or a policy or procedure addressing aerosol disinfectants at the bedside. 3. On 10/07/24 at 12:26 PM, during an interview, Resident #69 informed the surveyor that the resident took pain medications and was waiting on the nurse to bring the medications just anytime. LPN #1 knocked on Resident #69's door and partially opened it. Resident #69 greeted LPN #1 by her name. The surveyor was standing behind the partially opened door. The surveyor observed someone reach into the room and hand a clear medicine cup, with a white pill in it, to Resident #69. LPN #1 immediately shut the door without watching Resident #69 take the pill. Resident #69 reached for a cup of water, from her over the bed table, as she held the medicine cup with the white pill inside in her right hand. The surveyor asked Resident #69 if she could look at the pill. The surveyor noted it was a white round tablet with a 3 on the side facing up. The surveyor asked Resident #69 who had handed Resident #69 the medicine cup with the white pill. Resident #69 said [LPN #1] handed me my Acetaminophen-Codeine #3, my pain pill. Resident #69 then took the pill. Resident #69 then told the surveyor LPN #1 brought them Albuterol (a vial of medication) for their breathing machine and told Resident #69 to put it in their purse until they got ready to use it, and that LPN#1 told them not to tell anyone. So, I put it beside me in my chair until I was ready to use it. Resident #69 reported doing their own breathing treatments every day. Resident #69 said when they were administering their breathing treatment when the Infection Nurse saw them and informed the resident they wasn't supposed to be doing that by themselves. Resident #69 then asked why not. Resident #69 then said the Infection Nurse stood there and watched them until they finished the breathing treatment. a. On 10/07/24 at 12:43 PM, the Surveyor interviewed LPN#1. LPN#1 explained the process for administering medication, stating LPN#1 follows the 5-Rs (rights) of medication administration: right patient, right medicine, right time, right route, and right date. The surveyor asked LPN #1 if residents here administer their own breathing treatments or give their own medications. LPN #1 told the surveyor some residents hold their own tubing after we put the medication in the machine, and then we watch them to make sure they take all the medication correctly. No resident gives themselves their medication because we need to know they take it, and the right amount is taken at the right time. The surveyor asked LPN #1 if they had left Albuterol with a resident today and left the room before administering it. LPN #1 said, Yes, with [Resident #69], because [Resident #69] asked us to leave it. The surveyor asked if she saw Resident #69 administer the Albuterol. LPN #1 said No. The surveyor asked what the risk was of leaving the Albuterol with the resident. LPN #1 said, The resident could overuse it or not use all of it. The surveyor asked if she knew if Resident #69 still had the Albuterol in Resident #69's room. LPN #1 said, No, I don't know. The surveyor asked if she had handed a medicine cup with an Acetaminophen-Codeine to Resident #69 and shut the door without seeing Resident #69 take the Acetaminophen-Codeine. LPN #1 said, Yes, I was interrupting Resident #69, so I left it, but that is not a reason to leave a resident with their medication because a resident might not take it. The surveyor asked if she knew if Resident #69 took the medication. LPN #1 said, Yes because she always takes her pain medicine. The surveyor asked if she had seen Resident #69 take the medication. LPN #1 said No. b. On 10/07/24 at 1:00 PM, the surveyor informed the Director of Nursing (DON) and the Administrator of Acetaminophen-Codeine being left with Resident #69 to self-administer. c. On 10/07/24 at 1:15 PM, the Surveyor interviewed the Infection Preventionist (IP) Registered Nurse (RN) #5. The IP said she had not actually witnessed LPN #1 leave the Albuterol with the resident but that she had witnessed the resident administering the treatment without supervision, so she stayed and supervised the resident while the resident received the medication. d. A review of Resident #69's Order Summary Report, revealed Resident #69 takes 1 tablet of Acetaminophen-Codeine by mouth every six hours for pain; and Albuterol Sulfate Inhalation Nebulization Solution three milliliters via nebulizer two times a day due to chronic obstructive pulmonary disease (COPD). e. A review of Resident #69's care plan revealed Resident #69 takes Acetaminophen-Codeine with instructions to ensure accuracy when prescribing, dispensing, and administering acetaminophen/codeine oral solution or suspension. Dosing errors due to confusion between mg and mL and other codeine-containing oral products of different concentrations can result in accidental overdose and death. f. On 10/10/24 at 9:14 AM, Care Consultant #7 provided a policy titled, Administering Oral Medications. Item 21 instructs staff to remain with the resident until all medications have been taken. g. On 10/10/24 at 9:45 AM, the Director of Nursing informed the surveyor that a Self-Administration Assessment was completed for Resident #69 to self-administer Albuterol on 10/7/24 at 2:30 PM. h. On 10/10/24 at 11:45 AM, an interview was conducted with the Director of Nursing (DON). The DON said new Licensed Practical Nurses (LPNs) are provided three days of orientation unless they request more, then more is provided. The DON said she, and other nurses, provide on-going training for Medication Administration, and the Pharmacy Consultant along with other nurses, conduct medication pass observations with the nurses. A previous staff conducted the medication pass observation with LPN #1. The DON said LPN #1 should not have left the narcotic or the Albuterol with Resident #69 because Resident #69 had not been assessed to self-administrator medication. The DON provided the surveyor with in-service training dated 8/16/24 and 9/12/24 on Medication Administration in which LPN #1 was in attendance. The in-services dated 8/16/24 and 9/12/24 instructed the nurse to remain with the residents until medications are swallowed. In-service dated 9/12/24 gives a second instruction stating Please note the nurse must remain in the resident's room while medication is administered for nebulizer (Albuterol updrafts) setting up the medication and leaving the room will be considered a medication error unless the resident has an order to self-administer their medication. 49596

Based on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure medication carts were locked when left unattended to prevent accidents, or the misappropriation of medications on the 600 Hall; doctor ' s orders were followed; and a feeding tube was flushed before and after giving medications through a feeding tube for 1 sampled (Resident #306) resident of 3 sampled (Resident #76, #101, #306) residents reviewed for tube feeding. Findings include: 1. A review of a policy titled Storage of Medications, revised November2020, revealed compartments containing drugs or biologicals, including carts, are expected to be locked when they are not in use. a. A review of an in-service titled, Medication Pass Tip Sheet, dated 04/30/2024, revealed the medication cart should be locked when unattended, unless the cart is pulled up to the resident's door with the drawers opening into the room. b. On 10/07/24 at 10:44 AM, Licensed Practical Nurse (LPN) #1 was observed leaving the medication cart unlocked on 600 Hall when entering room [ROOM NUMBER]A and closing the door. c. On 10/07/24 at 10:56 AM, the Administrator walked down the hall and was observed locking the medication cart. d. On 10/07/24 at 11:12 AM, LPN #1 was asked the process for leaving the medication cart when going into a resident room. LPN #1 told the Surveyor that the medication cart should have been locked so nobody would have access to medications in the cart. e. During an interview with the Director of Nursing (DON) on 10/09/2024 at 04:20 PM, the DON stated the medication cart should be locked when left unattended to prevent residents from having access and taking medications from the cart. 2. A review of Medical Diagnosis, revealed Resident #306 had diagnoses of a brain bleed, respiratory failure, and type II diabetes. a. Review of the discharge assessment-return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/14/2024, and a Staff Assessment for Mental Status (SAMS) indicated Resident #306 had severe cognitive impairment. b. Review of a policy titled, Administering Medications through an Enteral Tube, revised November 2018, revealed staff should verify there is a physician's order, administer the medication between flushes, stop feeding and flush with at least 15 milliliters of warm purified water, and administer medication to gravity. c. A review of the Physician Orders, dated 07/17/2024, revealed medications can be crushed and mixed together with a flush of 60 milliliters of water before and after. d. A review of the Physician Orders, dated 09/27/2024, revealed an order for an anti-nausea medication every 8 hours as needed for nausea and vomiting via feeding tube. e. On 10/07/24 at 10:44 AM, Licensed Practical Nurse (LPN) #1 was observed crushing an anti-nausea medication and mixing it in 6 to 8 ounces of water. f. On 10/07/24 at 12:29 PM, LPN #1 was observed unhooking the feeding tube from Resident #306 and then she placed a syringe into the feeding tube and without checking placement or flushing, the anti-nausea medication in the water mixture was poured into the syringe. LPN #1 used the syringe plunger to get the mixture to go into the tube. LPN #1 did not flush behind the anti-nausea medication. g. On 10/07/2024 at 11:14 AM, during an interview the Surveyor asked LPN #1 the process for flushing and giving medications with a feeding tube. LPN #1 stated it was not necessary to flush before and after giving medication and confirmed there are orders to flush the feeding tube twice a day, but I just add a little more water to the crushed pills when I am giving them. h. On 10/10/24 at 09:40 AM, the Director of Nursing confirmed a nurse should flush the feeding tube before and after giving medications to make sure any medication is cleared from the tube.

Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff washed their hands before handling clean equipment when contaminated; the ice machine was maintained in clean and sanitary condition, and cold food items were maintained at 41 degrees Fahrenheit or below. The findings are: 1. On 10/9/24 at 1:19 PM, Dietary Aide (DA) #2 picked up tray cards and placed them on the trays located on the food carts. Without washing her hands, he picked up plates from the clean rack and placed them on the plate warmer with her hands inside of them. DA #2 stated he should have washed his hands. 2. On 10/9/24 at 1:24 PM, the top panel of the ice machine in the nourishment room on the 400 Hall had a wet reddish pink slimy residue on it. It was pointed out to the Dietary Manager, and the Dietary Manager was asked if the residue build up could be wiped off. She used a tissue and wiped it off. The pinkish residue easily transferred to the tissue. At 1:25 PM, during an interview the Dietary Manager stated that the residue was slimy, wet, and reddish pink, and the ice was being used by the Certified Nursing Assistants (CNAs) to fill the water pitchers in the residents' rooms and they cleaned it every month. 3. On 10/9/24 at 4:35 PM, the temperatures of the cold food items on pans of ice on the counter by the steam table were checked by Dietary [NAME] (DC) #4 were: a. Pimento cheese sandwich - 50.4 degrees Fahrenheit. b. Pureed pimentos cheese - 44.1 degrees Fahrenheit. c. Three bean salad - 53.2 degrees Fahrenheit. d. On 10/10/24 at 11:33 AM, during an interview DC #4 was asked about the process of keeping cold food items cold before being served. DC #4 stated she should have kept it on ice when she first put it in the refrigerator. 4. On 10/10/24 at 9:40 AM, DA #3 turned on the two compartment sink faucet and obtained water in a pitcher and then turned off the faucet. Without washing his hands, he picked up glasses by the rims and placed them on the trays to be used in portioning food items to be served to the residents for the lunch meal. 5. A review of a facility policy titled, QRT [Quick Reference Tool] Hand Washing, initiated on 9/1/2021 indicated, wash your hands as often as possible. Before starting to work with food utensils or equipment, and as often as needed during food preparation and when changing tasks.

Based on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure a resident's personal and medical information was protected from potential unauthorized persons for 1 (Resident #306) sampled resident. Findings include: 1. A review of Medical Diagnosis, revealed Resident #306 had diagnoses of a brain bleed, respiratory failure, and type II diabetes a. Review of the discharge assessment-return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/14/2024, and a Staff Assessment for Mental Status (SAMS) indicated Resident #306 had severe cognitive impairment. b. A review of a policy titled Confidentiality of Information and Personal Privacy, revised October 2017, revealed the facility will safeguard residents personal and medical records, and medical records will be limited to authorized staff. Computer stored information is protected according to resident rights, and privacy policies. c. On 10/07/24 at 10:44 AM, Licensed Practical Nurse (LPN) #1 went to Resident #306's room and left the computer screen open revealing Resident #306's name, room number, weight, vitals, allergies, and medications visible to anyone passing down the hall. d. On 10/07/2024 at 11:14 AM, LPN #1 told the Surveyor that the process for leaving the cart in the hall is to lock the medication cart and computer screen, so nobody has access to the resident information. It is the Health Insurance Portability and Accountability Act (HIPAA). e. A review of the Resident Rights, revealed that the information in a Resident's clinical record is confidential and requires a Resident's written consent to be disclosed. f. During an interview with the Director of Nursing (DON) on 10/09/24 at 04:19 PM, the DON stated there is a button on the computer screen the nurses are expected to push to lock the screen when they walk away from the computer. The DON confirmed that if the screen displays a resident's face, demographics, and medications then it is considered an invasion of privacy and a HIPAA violation. The Surveyor asked for any in-services, policy or procedures addressing privacy.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity to promote a dignified existence affecting 1 resident (Resident #7) of 3 sampled residents (Resident #7, Resident #13, Resident #46) residing on the 600 Hall, with the potential to affect 11 residents that live on the 600 Hall. The findings are: 1. Resident #7 had diagnoses of Hemiplegia, Unspecified affecting left nondominant side; Major Depressive Disorder, single episode, mild; and Type 2 Diabetes Mellitus without complications. The Quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 09/30/2023 documented a Brief Interview of Mental Status (BIMS) score of 15, (a score of 13-15 indicates cognitive intactness). Resident #7 requires extensive two-person assistance for bed mobility, transfers, extensive one person assistance with dressing and personal hygiene and supervised set up assistance with meals. a. On 11/06/2023 at 11:59 AM, the Surveyor observed Resident #7's lunch tray resting on the overbed table, with a clear brown fluid covering the entire tray surrounding Resident #7's plate, a soaked napkin, and cups of coffee, pudding, and fruit. There was an empty cup with brown residue covered in plastic wrap. The Surveyor asked Resident #7 if he had called for assistance and Resident #7 said, No, they get mad if you ask for anything. They say stuff like what do you want. Resident #7 demonstrated that the tone was abrupt. b. On 11/06/23 at 12:03 PM, Certified Nursing Assistant [CNA] #1 was observed entering Resident #7's room with a cup of brown fluid and napkins. CNA #1 said to Resident #7, what do you need. Resident #7 told CNA #1 that Surveyors had asked him if he was going to call for assistance. CNA said to the Surveyors, What do you want, did you need something, did you push his call light button? The Surveyor told CNA #1 that Resident #7 used his call light to ask for help cleaning up a spilled drink. CNA #1 said, Well, he and I had already discussed this when I left his room. c. On 11/06/23 at 03:57 PM, Resident #7 told the Surveyor that the tone CNA #1 used when speaking to Resident #7 and the Surveyor is how some of the staff have talked to the residents. d. On 11/07/2023 at 02:21 PM, the Administrator provided the Concern/Grievance Log showing the following: 1. On 08/15/2023 A resident stated a CNA talked to her in a rude tone. 2. On 08/22/2023 A resident said a nurse talked to her in a rude tone. 3. On 09/05/2023 Resident Council reported Residents felt like CNAs were disrespectful. Comment: Staff in-service regarding tone and speech when addressing residents. e. On 11/07/2023 at 02:21 PM, the Administrator provided the Resident Council Meeting (September 05, 2023) Minutes that documented, .Nursing: residents stated that CNAs are being disrespectful at times . f. On 11/08/2023 at 12:20 PM, the Surveyor asked CNA #1 if she was familiar with resident rights, and what in-services staff had received regarding resident rights. CNA #1 told the Surveyor she received in-service when she was hired, and a few months ago there was an in-service. CNA #1 said, The Residents have rights to refuse medications, and care. CNA #1 told the Surveyor that Residents have basic human rights to retain their dignity. g. On 11/08/2023 at 02:45 PM, the Surveyor asked the Director of Nursing (DON) how staff was expected to talk to the residents. The DON told the Surveyor that residents should be spoken to in a polite, kind manner just like they are a family member. The Surveyor asked if staff had in-services that address patient rights or behaviors. The DON told the Surveyor that CNAs had an in-service on 09/08/2023 that addressed rude behavior not being tolerated. h. On 11/08/2023 at 03:10 PM, the DON provided the policy titled Resident Rights (February 2021 Revision) that documented, .Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence. b. be treated with respect, kindness, and dignity . i. The DON also provided the policy titled CNA Inservice (September 8, 2023) that documented, .Being disrespectful to residents will not be tolerated . The residents can experience fear, anger, shame, confusion, uncertainty, isolation, self-doubt, and depression.

Based on observation, interview, and record review, the facility failed to ensure that the resident had functioning running hot water. This failed practice affected 1 (Resident #34) of 1 sampled resident and had the potential to affect 11 residents who resided on the 500 Hall. The findings are: 1. On 11/07/23 at 08:54 AM, Resident #34 told the Surveyor that she has had no hot water since she moved into this room two weeks ago. 2. On 11/07/23 at 02:15 PM, the Surveyor asked the Maintenance Supervisor to check Resident #34's hot water. The Surveyor observed the Maintenance Supervisor turn on the hot water faucet, and no water came out. The Surveyor asked if the resident might need hot water. The Maintenance Supervisor said, She should have hot water. She has to have hot water to wash the hands. 3. On 11/08/23 at 10:07 AM, the Surveyor asked the Director of Nursing (DON) if it was important to have functioning, hot water in the resident rooms. The DON said, Yes, of course you have to have hot water to properly clean hands. The Surveyor asked if not having hot running water contributed to a home like environment? The DON said, No, it does not. 4. On 11/8/23 at 09:12 AM, the Business Office Manager (BOM) provided the policy titled Preventative Maintenance Policy (February 2023 Revision) that documented, .Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public .Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that buildings, grounds, and equipment are maintained in a safe and operable manner .

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected on section A1500 the Preadmission Screening and Resident Review (PASRR) a serious mental illness and/or intellectual disability affecting 2 (Residents #13 and #37) of 3 sampled residents (Residents #13, #25 and #37) with a level II PASRR. This failed practice had the potential to affect 14 residents with a level II PASRR. The findings are: 1. Resident #13 had diagnoses of Bipolar II disorder, Anxiety Disorder, Unspecified and Vascular Dementia, Unspecified Severity, with other Behavioral Disturbance. The Annual MDS with an Assessment Reference review Date (ARD) of 07/18/2023 documented, No in Section A1500 if the resident was currently considered by the Level II PASARR process to have serious mental illness. 48390 2. Resident #37 had diagnoses of Unspecified Convulsions, Other Recurrent Depressive Disorders, Post Traumatic Stress Disorder, Chronic. The Annual MDS with an ARD of 08/21/2023 documented No in Section A1500 if the resident was currently considered by the Level II PASARR process to have serious mental illness. 3. On 11/08/2023 at 09:55 AM, the Surveyor asked the MDS Coordinator to look at section A1500 on the MDS of Resident #13, and Resident #37. The MDS Coordinator told the Surveyor that section A1500 shows Resident #13, and Resident #37 does not have a mental illness or intellectual disability. The MDS Coordinator checked her level II binder and said, Both residents have a level II PASRR. The Surveyor asked why it would be important to accurately code the MDS, and if she uses anything for a guide of reference. The MDS Coordinator told the Surveyor that she uses an online Resident Assessment Instrument [RAI] manual, and the MDS needs to be accurate so they can treat the resident properly. The MDS Coordinator said, I am the one responsible for the MDS. 4. On 11/08/2023 at 10:00 AM, the Surveyor asked the Director of Nursing (DON) why it was important to accurately code the MDS. The DON told the Surveyor that it was important for the MDS Coordinator to report correctly to the MDS, so the diagnoses are triggered on the care plan. 5. On 11/08/2023 at 12:15 PM, the policy titled, Comprehensive Assessment (revised March 2022) was provided by the Consultant and documented, Policy Statement: Comprehensive assessments are conducted to assist in developing person-centered care plans. Policy Interpretation and Implementation 1. Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual .

Based on observation, interview, and record review, the facility failed to ensure residents had sufficient water at the bedside to maintain hydration and health. This failed practice affected 1 (Resident #61) of 3 sampled residents (Residents #6, #61 and #62) who resided on the 400 Hall and had the potential to affect 7 residents who resided on the 400 Hall without fluid restrictions. The findings are: 1. Resident #61 had diagnoses of Alzheimer's Disease, Unspecified; Acute Kidney Failure, Unspecified, and Adult Failure to Thrive. The Quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 10/27/2023 documented a Brief Interview of Mental Status (BIMS) score of 00, (a score of 0-7 indicates severe cognitive impairment). Resident #61 required supervision or touching assistance with meals. a. On 11/06/23 at 12:46 PM, Resident #61's family member said Resident #61 normally has a pitcher of ice water on the bedside table, but she does not see one today. The Surveyor observed Resident #61 did not have fluids at the bedside. b. On 11/06/23 at 03:50 PM, the Surveyor observed there was not a water pitcher, or fluids in Resident #61's room. c. On 11/07/23 at 01:38 PM, the Surveyor observed Resident #61 resting quietly, eyes closed. There was an unopened super donut, and a small plastic cup and straw with an inch of clear fluid, out of reach, on the bedside table. d. On 11/08/2023 at 07:58 AM, the Surveyor observed an unopen package of super donuts, and a small plastic cup and straw with an inch of clear fluid resting on the bedside table. The cup of clear fluid was out of reach of the resident. e. On 11/08/2023 at 02:13 PM, the Surveyor observed Certified Nursing Assistant (CNA) #2 coming out of Resident #61's room. The Surveyor observed an unopened super donut, and a small plastic cup and straw with an inch of clear fluid resting on the bedside table. CNA #2 returned to Resident #61's room and the Surveyor asked CNA #2 about the procedure for passing out water. CNA #2 said they check and fill water pitchers at the beginning of the shift. The Surveyor asked what the procedure is when a resident does not have a water pitcher or is there any reason why a resident might not get water. CNA #2 told the Surveyor that they replace missing water pitchers, but residents like Resident #61 may not have water because they throw their water pitcher away because they have Dementia. f. On 11/08/2023 at 02:45 PM, the Surveyor asked the Director of Nursing (DON) about the procedure for providing water at the bedside. The DON said that everyone should have a water pitcher. Staff pass out ice and fluids. Restorative care goes around with the hydration cart at 10:00 AM, and 02:00 PM. If a resident does not have a water pitcher it should be replaced. g. On 11/08/2023 at 03:10 PM, the DON provided the policy titled Serving Drinking Water (October 2010 Revision) .Purpose The purposes of this procedure are to provide the resident with a fresh supply of drinking water and to provide adequate fluids for the resident . Steps in the Procedure 3. Go to the resident's bedside stand and pick up the water pitcher. 4. Take the water pitcher into the bathroom. Empty the contents into the commode. Flush the commode. 5. Rinse the water pitcher with tap water. Pour the water down the sink. 6. Fill the water pitcher one-half full with tap water. 7. Unless the resident is in isolation, take the water pitcher to the ice cart outside the room. Fill the pitcher with ice. Do not let the ice scoop touch the water pitcher. 8. Return the water pitcher to the resident's bedside stand.10. Offer the resident a fresh cup of water. 11. Place the water pitcher and cup within easy reach of the resident. Place flexible straws next to the water pitcher .

Based on observation, interview, and record review, the facility failed to ensure staff distributed and served food in a safe and sanitary manner. This failed practice affected 1 (Resident #3) of 3 sampled residents (Residents #3, #61 and #74) and with the potential to affect 13 residents that eat in the Dining Room. The findings are: 1. On 11/08/23 at 07:25 AM, the Surveyor observed Licensed Practical Nurse (LPN) #1 touching his scrub top and scratching the right side of his face without performing hand hygiene, while passing trays to staff in the Dining Room. The Surveyor asked LPN #1 what his process was for handing out trays. LPN #1 said, Well, you wash your hands and then hand the trays out to be passed to residents. The Surveyor asked LPN #1 if there is any change to the process if staff touches their clothing or scratches their face. LPN #1 said staff would need to sanitize their hands because germs would be a concern. 2. On 11/08/23 at 07:28 AM, the Surveyor observed Certified Nursing Assistant (CNA) #3 provide breakfast set up for Resident #3. Resident #3 had a clear, and orange colored drink arrived uncovered, and CNA #3 was observed placing both drinks on the table with her fingertips on the rim, and palm above fluids. The Surveyor asked CNA #3 what process was used for serving drinks. CNA #3 said, Do you mean by holding drinks by the bottom of the cup? Holding the cup at the rim can give germs to the residents. 3. On 11/08/2023 at 02:45 PM, the Surveyor asked the Director of Nursing (DON) what procedure they use to ensure proper hand hygiene while passing plates and cups out to staff in the dining room. The DON said if you are a nurse or CNA and you touch your clothing or scratch yourself then hands should be washed or sanitized with hand gel by the window in the dining room.

Based on observation and interview, the facility failed to ensure dietary staff washed their hands and changed gloves between dirty and clean tasks and before handling clean equipment or food items; failed to ensure leftover food items were not used in preparation for any future meals; food items stored in the refrigerator, freezer or dry storage area were sealed, covered, and dated; expired food items were promptly removed /discarded on or before the expiration or use by dates; an ice machine was maintained in clean and sanitary condition, to minimize the potential for food borne illnesses in 1 of 1 kitchen; failed to ensure one of two ice machines was maintained in clean condition; to ensure cold food was maintained at or below 41 degrees Fahrenheit and hot foods were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 82 residents who received meals from the kitchen (total census:84), as documented on a list provided by the Dietary Supervisor on [DATE]. The findings are: 1. On [DATE] at 12:25 PM, the following observations were made in the refrigerator: a. A ziplock bag was one-quarter full of sausage and slices of ham were on a shelf in the 2-door refrigerator. The Surveyor asked Dietary Employee #2, What is in this bag? She stated, Sausage from this morning's breakfast. We save and use them for pureed. b. Two opened containers of tuna salad were stored on a shelf in the 2 door refrigerator. There was no date when they were opened. 2. On [DATE] at 1:03 PM, the following observations were made in the storage room: a. There were 3 cases of bottled water stored on the floor in the storage room, each case contained 80 bottles of water. There was no date when they were received. b. A container of baking powder was stored on a shelf in the storage room with an expiration date of [DATE]. 3. On [DATE] at 1:17 PM, the following observations were made in the nourishment room on the 400 Hall: a. The interior surfaces of the ice machine in the nourishment room on the 400 Hall had a black wet residue on the interior surfaces. The top panel of the ice machine had an accumulation of brown and black residue across it. The Dietary Supervisor was asked to wipe the black wet residue on the interior surfaces of the ice machine and the black and brown residue on the top panel of the ice machine. She did so, and the black/brown wet substance easily transferred to the paper towel. The Surveyor asked, How often do you clean the ice machine and who uses the ice from the machine? She stated, The maintenance man cleans once every month. That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms. We use it to fill beverages served to the residents with meals. b. There was a bag of cheese, a bag of pepperoni and a bag of crackers in a container on a shelf in the refrigerator. The pepperoni had sage/black and green color mixed in. The cheese was dried and had cream color all over. There was no date when the food items were received and there was no name to indicate whom the food items belong to. The Dietary Supervisor was asked to describe the appearance of the food items. She stated, Pepperoni looked slimy, and they were spoiled. 4. On [DATE] at 1:25 PM, the following observations were made in the refrigerator in the Unit (800 Hall): a. An opened cup of orange juice with a straw was stored on a shelf in the refrigerator. There was no date when it was stored or a name to indicate whom it belonged to. b. An opened box of bacon was stored on a shelf in the refrigerator. There was no date or name on the box. c. A box of stir fry rice and chicken was stored on a shelf in the freezer with no date or name on it. d. A bottle of hazelnut was stored on inside the door shelf with no date or name on it. e. A styrofoam plate that contained cooked rice was on a shelf in the refrigerator. There was no date or name on it. f. A slice of pizza wrapped in foil was stored on shelf in the in the refrigerator with no date or name on it. 5. On [DATE] at 3:04 PM, Dietary Employee #1 was wearing gloves on her hands. She turned off the 3 compartment sink faucets, contaminating the glove. Without changing gloves and washing her hands, she picked up clean bowls and placed them on the trays with her fingers inside the bowls to be used in portioning dessert to be served to the residents for supper meal. 6. On [DATE] at 3:18 PM, Dietary Employee #1 washed her hands, after washing her hands, she untied a bag that contained Styrofoam bowls. Without changing gloves. She removed bowls from the bag and placed them on the counter with her gloved finger inside the bowls to be used in portioning dessert to be served to the residents for supper meal. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I guess wash my hands. 7. On [DATE] at 4:46 PM, the temperature of the ground hamburger patties when tested and read on the steam table by Dietary Employee #2 was 130 degrees Fahrenheit, instead of 135 degrees or above. 8. On [DATE] at 4:50 PM, the temperature of the sliced turkey meat plated to be served to the resident when tested and read by Dietary Employee #1 was 50.5 degrees Fahrenheit. 9. The facility policy titled, Hand Washing, provided by the Dietary Supervisor on [DATE] at 11:53 AM documented, It is essential for each Food service worker to wash his/her hands at times stated, 4. After handling soiled dishes at any point in department or dish room . 6. Any other time the hands become soiled or contaminated. Hands harbor dirt, grime, and germs, Hands cannot be over cleaned . Turn off water with towel so as not to contaminate the hands . 10. The facility policy titled, Hand Sanitization Procedure for One Person Dishwashing Operation, provided by the Dietary Supervisor on [DATE] at 11:53 AM documented, . Hands will be sanitized between clean and dirty operations to prevent cross contamination .

Based on observation, record review and interview, the facility failed to ensure toenail care was regularly provided to promote good foot care for 1 (Resident #36) of 21 (Residents #1, #9, #12, #13, #23, #26, #31, #35, #36, #37, #42, #44, #46, #49, #52, #56, #64, #65, #68, #72 and #233) sampled residents who were dependent for nail care according to the list provided by the Assistant Director of Nursing (ADON) on 08/11/2022. The findings are: 1. Resident #36 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5 Day Medicare Minimum Data Set with an Assessment Reference Date of 06/20/2022 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status and required extensive physical assistance of one person with personal hygiene and was totally dependent of one person for bathing. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Care Plan with a revision date of 10/18/21 documented, . I have an ADL [activities of daily living] Self Care Performance Deficit I require assist with my ADL'S bathing . Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . c. On 08/09/22 at 10:16 AM, Resident #36 had just came back from a whirlpool bath. She was wrapped in a sheet and propelled into room by Certified Nursing Assistant (CNA) #1 and CNA #2 and transferred into bed via lift. She was then towel dried and her clothes were put on. The resident's toenails on the left foot were approximately ½ inch long with sharp edges and the great toe on her right foot extended approximately 2 inches over the end of the toes and was brown in color. d. On 08/10/22 at 11:30 am, the Surveyor asked CNA #3, When should you cut a resident's toenails? CNA #3 stated, Whenever needed, especially on bath days. Cut if needed, keep clean. e. On 08/10/22 at 11:45 am, the Surveyor asked CNA #4, When should you cut a resident's toenails? CNA #4 stated, Check them every day. If need cleaning, clean them. Cut when needed. f. On 08/11/2022 at 11:08 am, the Surveyor asked CNA #5 When should you cut and clean a resident's toenails? She stated, You should let the treatment nurse know that there is a problem with the resident's toenails, that they are long and clean them when needed, especially on bath days. g. The facility policy titled, Care of Fingernails/Toenails, provided by the ADON on 08/11/22 at 11:50 AM documented, .Purposes: The Purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . General Guidelines 1. Nail care includes daily cleaning and regular trimming.

Based on observation of the 9:00 a.m. medication passes on 08/10/22, record review and interview, the facility failed to ensure a medication error rate of less than 5% was maintained to prevent potential complications for 2 (Residents #21 and #50) of 2 sampled residents who were observed during the medication passes resulting in medication errors by 2 Licensed Practical Nurse (LPN) #1 and LPN #3. The failed practice had the potential to affect all 84 Residents who reside in the facility as documented on the Resident Census and Conditions of Residents provided on 08/8/22 by the Administrator on 08/8/22. The medication error rate was 5.13% based on observation of 39 medications administered and a total of 2 errors detected. The findings are: 1. Resident #21 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] a. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. On 8/10/22 at 8:37 am, during medication administration, LPN #1 administered medication to Resident #21. She administered a Chewable Aspirin 81mg [milligrams]. c. On 8/11/22 at 11:10 am, the Surveyor asked LPN #1, Should you make sure you give delayed release aspirin versus chewable, when delayed release is ordered? She stated, Yes, we would want the aspirin to work over a longer period. I guess I didn't realize the difference. 2. Resident #50 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] a. The Physicians Order dated 06/28/22 documented, .[MEDICATION(S)] Complete Solution 0.6 % ([MEDICATION(S)] [MEDICATION(S)]) Instill 2 drop in both eyes two times a day for DRY EYES . b. On 8/10/22 at 8:06 am, during the morning medication administration LPN #3 only gave one [MEDICATION(S)] Eye Drop in each eye. c. On 08/11/2022 at 10:02 am, the Surveyor asked LPN #3 How many drops did you give [Resident #50] in each eye on yesterday? He stated, One drop in each eye, see (he pointed to the label on the plastic bag that the eye drops came in which documented, [MEDICATION(S)] Sol [solution] instill one dop in both eyes 2 times a day. He then went to the current orders which documented, .06/28/22 [MEDICATION(S)] Complete Solution 0.6 % ([MEDICATION(S)] [MEDICATION(S)]) Instill 2 drop in both eyes two times a day for DRY EYES . LPN #3 stated, It is on the bag, instill one drop but it says here on the orders to instill two drops two times a day.

Based on observation, record review and interview, the facility failed to ensure privacy was provided during incontinent care for 1 (Resident #49) of 23 (#1, #4, #11, #26, #31, #35, #36, #42, #47, #49, #52, #56, #65, #67, #68, #69, #72, #73, #81, #82, #233, #234 and #237) sampled residents who were dependent for incontinent care according to the list provided by the Assistant Director of Nursing (ADON) on 08/11/2022. The findings are: 1. Resident #49 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 06/26/2022 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status and required extensive physical assistance of two plus persons with bed mobility and was always incontinent of bowel and bladder. a. The Care Plan with a revision date of 11/15/21 documented, I am incont [incontinent] of bowel and bladder I require assist [assistant] with toileting . BRIEF USE: I use disposable briefs. Change every 2 hours and prn [as needed] .Check me every 2 hours and prn as required for incontinence AND OFFER TOLIETING . b. On 08/09/22 at 10:12 AM, Certified Nursing Assistance [CNA] #1 was providing incontinent care to Resident #49. The privacy curtains were not pulled and when the surveyor entered the room the resident's body was exposed from the waist down and could be seen when the surveyor entered the room. c. On 08/10/2022 at 11:30 am, the Surveyor asked CNA #3, When giving incontinent care to a resident should the privacy curtains be pulled? CNA #3 stated, Of course you always pull privacy curtains and close the door and blinds when giving care. d. On 08/10/2022 at 11:45 am, the Surveyor asked CNA #4, When giving incontinent care to a resident should the privacy curtains be pulled? CNA #4 stated, Yes, always. e. On 08/11/22 at 11:08 am, the Surveyor asked CNA #5, When giving incontinent care to a resident should the privacy curtains be pulled? CNA #5 stated, Always, because you don't know who might walk in. Another resident could walk in and the resident be exposed.

Based on record review and interview, the facility failed to promptly notify the state mental health authority or state intellectual disability authority to have a Preadmission Screening and Resident Review (PASARR) evaluation completed to determine the care and services needed for 1 (Resident #82) of 1 sampled resident who required a PASARR evaluation after a significant change. The findings are: 1. Resident #82 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/17/22 documented the resident scored 12 (7-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. a. The Care Plan with a revision date of 7/21/21 documented, . I have a mood problem, my moods fluctuate Dx: [diagnosis] Mood Disorder Dx: Anxiety Dx: Bi-Polar 2 . b. As of 08/10/22 at 10:00 AM, there was not a documented PASARR screening in Resident #82's medical record. c. On 8/10/22 at 1:30 PM, the Surveyor asked the Business Development Employee, Were you able to locate a PASARR screening for [Resident #82]? She said, No. [Resident #82] does not require a PASARR because he has a Dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #82] have received a PASRR screening when the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ? The Business Development Employee stated, I'm not real sure, but I will try to find out. d. On 8/10/22 at 3:54 PM, during a phone interview with a representative from a state screening agency regarding the PASRR, this Surveyor asked, If a resident in a Long-Term Care Facility has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ? The Agent stated, The facility should submit the proper paperwork for a Level 1 to ensure the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interview, the facility failed to ensure the residents and/or their families were notified by 5 PM the next calendar day following the occurrence of confirmed positive COVID-19 for 1 (Resident #7) of 1 resident who tested positive for COVID-19 in the past month. This failed practice had the potential to affect all 94 residents who resided in the facility, according to the Resident Census and Conditions of Residents form dated 2/8/22 The findings are: Resident (R) #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/21 documented the resident scored 12 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. The [Facility] [CONDITION(S)]-CoV-2 [severe acute respiratory syndrome, coronavirus-2] rapid point-of-care (POC) testing form dated 2/2/22 documented the resident tested positive for COVID-19. b. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] c. On 2/8/22 at 9:00 am, the Administrator was asked if he had any COVID-19 positive residents in the facility. He stated, Yes, we have 2 at the present time and they are on the 300-Hall in the COVID unit. The Administrator was asked to provide copies of the notifications to the families or direct the surveyors where to locate the information. The Administrator stated, Our Activity Director does that; she calls the families and lets them know. She has the record of that, and I will get it. d. On 2/8/22 at 9:30 am, the medical records for Residents #1, #3, #4, and #7 were reviewed for notification to the residents' families of COVID-19 positive residents in the facility. R #7's progress notes dated 2/2/22 documented the resident's family was notified that the resident had tested positive for COVID-19. There was no documentation in the Progress Notes on 2/2/22 or 2/3/22 of notification to the other residents' family members regarding positive cases of COVID-19 residents in the facility. e. On 2/8/22 at 11:00 am, the Administrator was asked for the latest family contacts made regarding COVID-19 positive residents in the facility. The Administrator replied, Our Activities Director has that in her office; let me get you a copy of it. f. On 2/8/22 at 12:25 pm, a copy of the Covid Family Call Update was provided by the Administrator. It documented, 2/1/22 .just letting you know that we currently only have 2 positive Covid residents in the building . The list documented the resident's name, the family member's name, and the comment that the family made when they made the contact. g. On 2/8/22 at 12:30 pm, the Activity Director was asked, Is this [contact dated 2/1/22] the last family contact you have? The Activity Director replied, That is the last one I have; of course, I will start calling today because we have a positive staff member that was tested today and is positive. She was asked, Where is the notification for the last positive resident you have, [Resident #7], who tested positive 2/2/22? The Activity Director replied, Oh, well that [2/1/22] is the last call update I have. h. On 2/9/22 at 8:40 am, the Activity Director (AD) was asked, How many positive residents did you have on 2/1/22? The Activity Director replied, We had 2 and they were [Residents #13 and #14]. The AD was asked, [Resident #7] was positive for COVID-19 on 2/2/22; where is the COVID Family Call Update for [Resident #7]? The Activity Director replied, Oh, that one you have [2/1/22] is the last COVID Family Call Update I have. She was asked, when was the next positive resident after 2/7/22? The Activity Director replied, On 2/2/22 we had [Resident #7] test positive for COVID-19 and then on 2/5/22 we admitted [Resident #15] and he was positive with COVID-19 when he was admitted . i. On 2/9/22 at 10:38 am, the Infection Preventionist (IP) nurse was asked, When is the facility to notify about COVID-19 positive residents in the facility? The IP replied, Well, first we notify the family of the resident that is positive for COVID-19, and then we notify the Doctor and then we have till 5:00 pm the next following day to notify all the residents' families. She was asked, Who is responsible for those notifications at this time? The IP replied, I think the Activity Director is making the calls and I think the Social Worker may be helping with it sometimes. j. On 2/9/22 at 11:00 am, the Administrator was asked, Who is responsible for the family notifications when you have a resident become positive in the facility? The Administrator replied, Our Activity Director. He was asked, How does she notify family of COVID-19 positive in the facility? The Administrator replied, We are presently calling all of them and we have to have it done by 5:00 pm the following day of the positive resident. He was asked if your last positive resident tested positive on 2/2/22, where is the call update notifying the families by 5:00 pm on 2/3/22 of that resident becoming COVID-19 positive? The Administrator replied, I am unsure, but she [Activity Director] was probably overlapping with the 2/1/22 call update, but I can't be sure. k. On 2/10/22 at 8:40 am, the Administrator was asked to provide the policy/procedures for notification of families regarding COVID-19 positive residents or staff in the facility. l. The policy titled, COVID-19 Emergency Plan, provided by the Administrator on 2/11/22 at 9:16 am, documented, .Families will be notified of any new positive resident or staff member before 5 pm of the following day .

Based on observation and interview, the facility failed to store food products after opening based on the manufacture's recommendation, discard food products before the expiration date and to air dry dishes to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 82 residents who received meals from the kitchen (total census: 86), as documented on a list provided by the Dietary Manager on 5/27/2021. The findings are: 1. On 5/24/2021, the following observations were made in the kitchen 05/24/2021: a. On a shelf in the dry storage room there was an opened gallon jug of barbecue sauce with a received date of 3/29/21 with three fourths of its contents used. On the back of the jug, the manufacture's label documented, .Refrigerate After Opening . The Dietary Manager was asked if the sauce should be refrigerated and she replied, We usually don't, but we can. b. On another shelf in the dry storage room there were 2 opened gallon jugs of Head Country Barbecue sauce with a received date of 5/17/21. One jug had half of its contents used and the other had three fourths of its contents used. On the back of the jugs the manufacturer's label documented, .Refrigerate After Opening . Next to the Head Country Barbecue sauce, there was an opened five-pound jug of Teriyaki sauce with a received date of 12/18 and an open date of 2/9/21. The label documented, .Refrigerate After Opening . c. In the two door refrigerator in front of the steam table, there were 3 tubs of low fat cottage cheese with a received date of 2/22/21 and a use by date of 5/9/21 and a five pound tub of sour cream with a received date of 2/22/21 and a best by date of 3/26/21. 2. On 5/26/2021, the following observations were made in the kitchen: a. At 9:57 A.M., there were five stacks of plastic beverage glasses stacked wet on the clean side of the dish room worktable. The Dietary Manager was asked if the glasses should be stacked wet. She replied, No. I'm going to take care of these right now. Thank you. b. At 1:56 P.M., there were seven stacks of plastic beverage glasses stacked wet at the end of the serving line worktable. The dish washer, Dietary Employee #1 was asked how clean glasses should be stored and he replied, Stacked in a rack so they can air dry.

Based on observation, record review and interview, the facility failed to ensure planned fall prevention interventions were consistently implemented to prevent a fall with resultant injury for 1 (Resident #20) of 1 case mix resident who was care planned to have a wedge cushion in place when sitting in a wheelchair. This failed practice resulted in actual harm to Resident #20, a bilateral below-knee amputee, who experienced a fall while in the wheelchair and sustained a mandible fracture, lip laceration and fractured teeth. The failed practice had the potential to affect only this resident (the only resident in the facility care planned for a wedge cushion) according to documentation provided by the Director of Nursing on 8/3/17. The facility corrected this failed practice on 7/31/17, prior to the survey; however, there were additional failed practices at F323 which will require correction. The facility also failed to ensure mobility equipment was maintained in safe operating condition to prevent potential injury for 1 (Resident #15) of 1 case mix resident who used a rolling walker. The failed practice had the potential to affect only this resident, the only resident in the facility who used a rolling walker, as documented on a list provided by the Director of Nursing on 8/3/17. The findings are: 1. Resident #20 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference (ARD) date of 6/26/17 documented the resident had severely impaired cognitive skills for daily decision making, required extensive assistance of one person for transfers, had functional limitation in range of motion to the lower extremities on both sides and had a history of [REDACTED]. a. A Care Plan dated 5/9/17 documented, I have potential for falls r/t (related to) impaired mobility and blindness .Wedge cushion . b. A Fall Risk Evaluation dated 6/8/17 documented, .Total Score: 26. The form documented a score of a 10 or higher indicated a risk for falls. c. An Incident/Accident Report dated 7/25/17 at 7:11 a.m. documented, .LPN (Licensed Practical Nurse) called to rm (room number) res. (resident) noted in floor on l-side bleeding profusely from mouth with misalignment of bottom teeth . d. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities documented, .Date and Time of Incident 7/25/2017 . On 7/25/17 at 7:11 a.m., the Charge Nurse was called to room and noted resident on the floor on her left side with bleeding noted from the resident month. Gauze applied to mouth. Staff stayed with the resident until the ambulance arrived to take her to the hospital for evaluation. Resident had been sitting up in her wheelchair .A Nursing Intervention listed on the resident care plan for 5/9/17 was to drop wheelchair seat and place a wedge cushion in the seat. At the time of the fall the wheelchair (seat) was dropped, but there was not a wedge cushion in the seat. The CNA who got the resident up was spoken to by the CNA supervisor and stated that there was not a cushion in the seat when she got resident up. The Resident CNA Care plan was reviewed and it was noted that there was no notation for the resident to have a wedge cushion in her wheelchair . e. An physician note dated 7/26/17 documented, .7/26/17 Simple extraction of tooth #23, #24, #25, and #26 . f. A Hospital Summary of hospitalization dated 7/26/17 at 12:00 p.m. documented, .Tooth extraction . Diagnoses: [REDACTED]. functional status: difficulty swallowing liquids and food . Chief Complaint: Fall; mandible fracture . History of present illness: .female transferred with known facial trauma after fall from a wheelchair. Minor lip laceration repaired . Oral cavity: Fractured and loose teeth with fragment of bone to alveolar ridge. Palate elevates normal and symmetrically. Tongue protrudes in the midline . Plan: Removal of fractured teeth and bone segment under MAC (Monitored Anesthesia Care) anesthesia . g. A Nurses Note dated 7/26/17 at 11:00 p.m. documented Resident returned via (Ambulance Service) .(at) 2255 (10:55 p.m.) .7/27/17 at 7:00 p.m. documented, Res. (Resident) had 4 teeth extracted with sutures in the bottom lip resident tolerated a soft diet well. On 8/2/17 at 3:04 p.m., the resident was in bed resting quietly with eyes closed . On 8/3/17 at 8:24 a.m., the resident was in a high back wheelchair in the hallway by the Nurses Stat h. At 8/3/17 at 12:10 p.m., the Director of Nursing was asked, Should the resident have had the wedge cushion in her wheelchair in order to prevent falls and injury? She stated, Yes. i. The facility provided the following evidence to indicate the failed practice was corrected prior to the survey: The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities dated 7/25/17 documented, .When it was noted that the wedge cushion was not written on the Aide Care Plan a member of Nurse Management immediately reviewed all Aide Care Plans to ensure that interventions that have been put in place to help prevent resident falls have been written on the Aide Care Plan. Members of Nursing Management also rounded on all residents with intervention in place to prevent falls to ensure the interventions were in place. All Licensed Nursing staff were inserviced that intervention such as wedge cushion, anti-tippers on wheel chairs, pommel cushions, alarms, tray tables, Broda Chairs, self-releasing seat belts must be written on the CNA Care Plan in addition to the Nursing Care Plan so that the CNAs are aware as failure to put these interventions in place could be considered neglect. The CNAs were inserviced that they must read the CNA Care Plan before providing care to any resident to ensure any interventions such as wedge cushion, pommel cushion anti tippers, self-releasing seat belt, alarms, tray table put in place to help prevent falls are being carried out. Staff was instructed that if they do not have the equipment listed that they must notify the Charge Nurse or a member of Nurse Management. That failure to have the equipment listed in place could be neglect. All Nursing staff were inserviced that when washing wheelchairs to make sure if you take anything off the wheelchair that it is put back on and to make sure the resident gets their own wheelchair back after they have been cleaned. A monitor has been put in place for restorative staff to round twice daily to ensure the interventions put in place to prevent falls are in place, they will report to the Director of Nurse or a member of Nurse Management if an intervention is not in place for immediate follow up. The In-service Training Rosters were provided by the Director of Nursing on 8/3/17 at 5:20 p.m. and indicated the above in-services were conducted on 7/25/17 and 7/31/17. 2. Resident #15 had a [DIAGNOSES REDACTED]. a. A Care Plan dated 6/7/2017 documented, .Transfer : I use walker as assistive device to transfer . Anticipate and meet needs . b. A Fall Risk Evaluation dated 6/8/17 documented, .Total Score 21. The form documented a score of 10 or higher indicated the resident was at risk for falls. c. On 7/31/17 at 5:35 p.m., the resident was ambulating in the hallway using his red rolling walker. The brake lines on the left side of the rolling walker were hanging loosely from the frame and dragging on the floor. CNA #1 was standing in the hallway asking the resident where he was going, but did not intervene to correct the brake line that was dragging on the floor. The resident continued to ambulate up and down the hallway with the brake line dragging the floor. After approximately 10 minutes, CNA #1 assisted the resident to the dining room table. While assisting the resident, the CNA's feet became tangled in the brake line. The CNA did not intervene or get assistance to repair the brake line that was dragging on the floor. At 5:40 p.m., the resident removed himself from the dining table using the rolling walker. When he reached the hallway, Licensed Practical Nurse #1 (LPN) asked the resident, You going to your room? The resident continued to wander the hallway with the rolling walker, with the brake line dragging the floor. d. On 8/3/17 at 9:10 a.m., Registered Nurse #1 (RN) was asked, Should the brake lines on a resident's rolling walker drag on the floor? The RN stated, No.

Complaint # (AR 298) was substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility failed to ensure supervision was consistently provided to prevent repeated elopements from the facility for 1 (Resident #2) of 3 (Residents #2, #3 and #4) case mix residents who were at risk for elopement. The failed practice resulted in past immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #2, who left the facility unsupervised on 5/28/16, went to his former home and returned to the facility on the same date without staff knowledge. The facility was informed of the past immediate jeopardy situation on 6/25/16 at 2:54 p.m. The failed practice had the potential to affect 32 residents who were at risk for elopement, according to a list provided by the Assistant Director of Nursing (ADON) on 6/26/16 at 7:24 a.m. The findings are: Resident #2 had a [DIAGNOSES REDACTED]. a. A Letter of Guardianship of the Person and Estate dated 4/18/16 documented, Be it known: that (resident's wife) . having been duly appointed guardian of the person and estate of (Resident #2), an incompetent person and having qualified as such guardian, is hereby authorized to have the care and custody of and to exercise control over the person and to take possession of and administer the property of said (Resident #2) as authorized by law . b. A Nurse's Note dated 5/1/16 at 9:45 a.m. documented, Patient has his items packed and insists on leaving. Unable to talk resident in agreeing to stay. 1:1 (one-on-one supervision) on pt (patient) to attempt to keep him from leaving. Spouse number called, recording came on stating number not working. Contact #1 . number was called - no answer - message was left to call facility as soon as possible regarding her father. (Son) Contact #2 was called, was informed that his dad is trying to leave the facility and someone needs to come as soon as possible to talk him into staying . c. A Nurse's Note dated 5/1/16 at 10:10 a.m. documented, Resident's daughter here, pt was asked to go on pass with his daughter but he refused. 4:00 p.m. Daughter here for a long time. Resident finally agreed to remain here after his daughter spoke with her brother and told him his son will pick him up in the a.m. (morning), carry him to speak with the people he desires to speak with. d. The Plan of Care dated 5/16/16 documented, .I have impaired cognitive function / dementia or impaired thought processes related to dx (diagnosis) of Alz (Alzheimer's) Dementia with behavioral disturbances. A Plan of Care dated 5/23/16 documented .I am risk for elopement . Interventions . Monitor resident Q (every) 15 mins (minutes) and PRN (as needed); family to take on outings PRN; place on 1:1 as needed; med (medication) review . e. A Nurse's Note dated 5/23/16 at 2:30 p.m. and written by the ADON documented, Staff reports resident down at bottom of steps at bottom of hill walking at edge of property line. Resident stated he was trying to go to his house, that he had been OK'd to go to his house . Staff talked him into getting into car and drove around block a few times. (Wife) notified, told her we were going to place resident on the arbor (secure unit) due to elopement risk. f. A Nurse's Note dated 5/23/16 at 7:30 p.m. documented, Pt expressing (verbal) discontent with being placed in lock unit . Pt was able to leave lock unit by way of visitor. Visitor normally sees pt outside of unit and states he didn't know pt was supposed to be in there. Pt refuses to go back into lock unit (Arbor) despite nurses explaining importance of being in unit. ADON notified of Pt being out of lock unit. States if pt will not go into lock unit then place pt on every 15 (minute) checks. Assure pt will not elope or shows s/sx (signs/symptoms) that he will attempt to elope then pt can go back to his room. Pt promised he would not elope . g. An In-service Training form dated 5/25/16 documented staff received an in-service on elopement. h. A Nurse's Note dated 5/28/16 at 1:10 p.m. documented, Police called facility and asked if (resident) was here. Nurse went out front doors of (facility) and resident was outside under gazebo. Nurse reported to officer that resident was outside. Will continue to monitor. 1:25 p.m. - Nurse went back outside to talk with resident. Resident informed nurse that he had left the facility and went to his home, but would not tell nurse how he got to home and back to facility. Resident stated, 'I will take that info to my grave.' Will continue to monitor. ADON and DON (Director of Nursing) aware . i. A Management Note dated 5/31/16 and written by the ADON documented, Staff received a call from resident's wife who said resident was at his house. Staff went to check for resident and he was sitting on gazebo. Resident's wife had called police who called us and we reported to them resident was here. Resident was placed on 1:1 supervision due to wife's accusations . Monday 30th resident was questioned about incident by myself and DON. He said he had not been anywhere. Then he said a big bird took him . keeping him 1:1 to monitor . j. An In-service Training form dated 6/6/16 documented staff had an in-service that included, No staff is allowed to give any resident a ride for any reason in their personal car. If a resident needs to go somewhere, make sure we take them in the facility van and management is aware. Make sure all visitors sign out family members. k. An In-service Training form dated 6/7/16 documented staff had an elopement drill. l. A Social Service Progress Note dated 6/15/16 documented, (Resident) attempted to leave facility. Has had one on one monitoring. Resident made his way to front yard. Staff members attempted to redirect resident. Continued to cross street with staff in attendance. Resident rambled on and on about going home, that he paid for the home . Police were called . Worker's attempts to obtain family assistance were futile . Resident has been assessed by (behavioral unit) personnel. Does not qualify for placement at time of assessment. 2:05 p.m. - A local facility has been contacted regarding transfer of resident. Resident will be evaluated later today . m. On 6/21/16 at 8:15 a.m., Resident #2 was asked if he had ever left the facility unsupervised by staff. He stated he did and that a bird took him. He stated no one was going to tell him what he could or couldn't do or that he couldn't go check on his home place. n. On 6/21/16 at 9:14 a.m., the ADON stated, I called the two taxi companies in town to see if they made a run out here, I talked to all the regular visitors to see if any of them took him anywhere, all the staff . Nobody took him anywhere. We have the Wanderguard system and we asked about putting one on him and he said, 'you can try.' He sits on the front porch. That's all he does. He is on 15 minute checks right now. The ADON was asked if she thought he could leave sometime in the middle of that 15 minutes. She stated, I don't think he will. He always tells us when he's getting ready to try to leave. o. On 6/21/16 at 9:54 a.m., the resident's wife was asked during a telephone interview if the resident had been to her house recently. She stated, Yes he has. A couple of times. I called the police. He came walking up the steps, and I saw him and screamed. He left before the police got here. The police called the nursing home and he was already back there. He's dangerous. I don't want him here. He's not thinking right. He has dementia. I'm 75 and he got physical, so I had to call the police to pick him up and I got guardianship of him. He wants to come out here and claim his territory. She was asked if anyone else could verify he was there at the house. She stated, I don't know . the employees can. They know he left. I know my husband. He was standing on my front porch! I have a no contact order. They even put him back in the back on the locked unit and he got out. A visitor let him out. She was asked how far she lived from the facility. She stated, About 4 miles. p. On 6/21/16 at 10:45 a.m., Licensed Practical Nurse (LPN) #1 was asked about the resident's alleged elopement on 5/28/16 and stated, I was working the 28th. It was around lunch and (Former Employee #1) got a call that said he was there on the property and he knocked on the door. (Former Employee #1) got up and he was sitting under the gazebo. She was asked if it was possible the resident went home without staff knowing he was gone. She stated, I wouldn't put anything past him. If he says he left, he left. One day, I was coming in to work, and he was walking down the hill by the church. They were behind him in a car. He has to be talked down and talked into going back. She was asked if it was dangerous for the resident to be leaving the facility on his own. She stated, Yes, and it's getting hot outside. We have been told to just really keep an eye on him. She was asked if the resident had a Wanderguard bracelet. She stated, There was talk about one at some point, but he wasn't going for that. She was asked if the resident could come and go as he pleased through the front door. She stated, Yes, and he will ask 'so you're the one who is following me today?' q. On 6/21/16 at 3:26 p.m., the Administrator was asked about the allegation of the resident leaving on 5/28/16. She stated, I came here when I heard about it to lay eyes on him and I asked him if he went and he told me no. I don't think he was ever gone. How could he go home and come back without someone here knowing it. And, I wouldn't put it past him to make that up, because she says she's scared of him and that he's mean to her. r. A Nurse's Note dated 6/22/16 and written by the ADON documented, Resident has been 1:1 today, says he is going home. We have been with him all day. CNA walking with him outside and resident ran. CNA followed, resident never left her sight. Van left out behind them. Resident ran 3 blocks, never left our sight. Cop was in area, stopped and talked with them. Stayed in street for 30-45 min (minutes). Four staff members and police. Police said there was nothing they could do to help. Floor nurse met them in her car. She talked him into getting into her car as he refused to get into the van. She had to tell him she was taking him home, but drove around to the back and got him into back arbor door, but he yanked the front arbor doors open (busted out). Unable to keep in. Resident saying he was lied to and don't have to stay here. Administrator tried to call wife multiple times and did not answer. Resident just wants to go home. We cannot allow him to go home with his wife as his guardian and she will not answer. She left messages with (daughter). (Son) called and he did not have a voicemail set up . APS (Adult Protective Services) was called as we are unable to reach resident's guardian for his safety and she will not act on his behalf . Resident remains 1:1 . 8:00 p.m. - (representative with behavioral hospital) called . Resident has been accepted for treatment. (Spouse) and (daughter) present at facility at this time. Aware of acceptance. Will arrange transport. s. On 6/25/16 at 11:18 a.m., during a telephone interview, (Former Employee #1) was asked if she had any information about Resident #2 leaving the facility property on 5/28/16. She stated, The police called and said (Resident #2) was at his home. I went outside, and he was sitting in the gazebo. She was asked if any employee saw the resident leave or come back. She stated, Not that I know of, but there was a visitor under the gazebo with him. An out of town visitor. I think it was (Resident #7's) daughter. She said she saw him get out of a Jeep. When I first looked out around the corner, I was looking to see if he was there, but when I started walking out there to talk to him, he started saying, 'I know why you're coming out here. Yes, I did leave and go home, but I'm not telling you how I went. I did it because y'all told me I couldn't. Nobody's gonna tell me I can't go home.' The visitor was standing there beside him when he said this, and that's when she told me she saw him get out of a Jeep, because she didn't want me thinking she was the one who gave him a ride. I don't know why she was sitting there. The LPN was asked if the visitor knew Resident #2 was a resident. She stated, She said she wasn't sure he was a resident, but wondered about it. She was asked if she felt the resident did actually go home. She stated, Oh, he went. I know he went. He told me the exact story that his wife told me. He told me he knocked on the door, she opened it and she screamed. That's exactly what she told me. She was asked if the resident was on every 15 minute checks on that day. She stated, I don't think so, but I placed him 1:1 after that. She was asked if the resident had been out and off the premises any other time without staff knowledge. She stated, He was at the church about a week before. He made it there before anyone knew it. He will say he's exercising, but if you don't watch him, he will leave. He knows exactly what's going on. t. On 6/25/16 at 12:31 p.m., Resident #7's daughter was interviewed by telephone. She was asked if she remembered an incident on 5/28/16 regarding a male resident possibly leaving the nursing home. She stated, Oh yes. I remember that. It's been a while, and I can't remember all of the detail, but he got out of a Jeep, I believe. He had kind of long gray hair, older white man. The driver of the vehicle was an older white male. I was sitting in the gazebo smoking and he got out of the vehicle and came over and sat down. He started telling me he was a veteran and he didn't want to lose his land and home and he was fighting to keep it. I wasn't even sure if he was a resident. She was asked if a nurse came out to talk to the man. She stated, Yes. I don't remember what all the conversation was, but she asked him if he had been somewhere, and I was concerned she would think I was the one who gave him a ride, so I told her what I saw. She was asked if she could remember the color of the Jeep. She stated she could not. She stated, After he got out, the vehicle left. u. On 6/25/16 at 2:31 p.m., CNA #1 was asked if she knew of the resident ever leaving without staff knowledge or supervision. She stated, I was coming to work one day and I saw him by the church. Another CNA stopped in front of me and we tried to convince him to go back to the nursing home. The other CNA called the facility and told them and they brought a car and he got in and they drove him a block and back. v. On 6/25/16 at 2:43 p.m., CNA #2 was asked if she knew of the resident ever leaving without staff knowledge or supervision. She stated, I saw him walking by the church one day when I was coming in to work. She was asked if anyone was with him. She stated, No one was with him. I rolled down my window and asked him what he was doing. I called the nursing home, and they sent someone to get him. The church was measured as being approximately 2 tenths of a mile from the facility. w. The facility removed the immediate jeopardy and corrected the deficient practice prior to the survey date. Monitoring forms provided by the ADON on 6/25/16 at 3:30 p.m. documented the resident was on every-15-minute checks from 4/12/16 through 4/18/16 and from 4/30/16 through 5/1/16; was on 1:1 supervision from 5/2/16 through 5/14/16 and 5/28/16 through 6/3/16; was reduced to every-15-minute checks again from 6/3/16 through 6/21/16; then was placed back on 1:1 supervision on 6/22/16 and was sent to a behavioral unit on 6/23/16. There was no documentation or other evidence during the investigation to indicate the resident had succeeded in eloping from the facility without staff knowledge again after 5/28/16. During the survey, observations of Resident #2 were made by the surveyor on the following dates and times, and the resident was never observed to be out of staff's line of sight: 6/20/16 at 11:39 a.m., 1:24 p.m. and 3:19 p.m.; and 6/21/16 at 8:15 a.m.

Complaint # and # , substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure bowel assessments and ongoing monitoring of bowel status were conducted and documented and that an enema ordered by an emergency room physician to address severe constipation was administered for 1 of 1 (Resident #1) case mix resident who had constipation. The failed practice likely resulted in actual harm to Resident #1, who required a second trip to a hospital emergency room to remove a large fecal impaction, and had the potential to cause more than minimal harm to 3 residents who were transferred to the hospital from 1/10/11 to 1/13/11, as documented on the 24 Hour Nursing Reports dated 1/10/11 through 1/13/11. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 10/14/10 documented the resident was severely impaired in cognitive skills for daily decision-making according to a staff assessment for mental status, rarely able to understand others and rarely able to make self understood, totally dependent on 1 staff person for toilet use and was always incontinent of bladder and bowel. a. The Care Plan dated 1/30/10 and updated on 10/14/10 documented, "Problem - Incontinent of Bowel and Bladder - Approaches... Assess for signs of constipation or fecal impaction." b. Nurses Notes dated 1/11/11 at 4:30 p.m. documented, "Staff paged... resident had (increased) respirations... pulse (increased), BP (blood pressure) (increased). Resident unable to follow simple instructions, resident had uncontrollable shakes family made aware of situation and stated to send resident to (Hospital #1)..." 1.) Nurses Notes dated 1/11/11 at 9:15 p.m. documented, "(Name) from (Hospital #1) called and stated resident was ready to be picked up she stated resident was constipated..." 2.) Hospital Physician order [REDACTED].#1's emergency room (ER) with a physician order [REDACTED]. Tonight." The word, "tonight" was underlined twice. 3.) Nurse's Notes dated 1/11/11 at 10:00 p.m. documented, "Res (resident) return to facility with new orders, 1. Resume all previous orders. 2. Fleet enema prn (as needed) constipation. 3. [MEDICATION NAME] 2 capfuls BID (twice daily)." The Nurse's Note did not accurately reflect what the ER physician ordered for the resident and there was no documentation an enema was administered to the resident on the night shift of 1/11/11. There was also no documentation of checks for fecal impaction or assessments of the resident's abdomen and bowel sounds from 1/11/11 through 1/13/11. 4.) On 1/28/10 at 9:05 a.m., Licensed Practical Nurse (LPN) #2, who worked the 10:00 p.m. to 6:00 a.m. shift, was asked what she thought the physician meant when she reviewed the physician order [REDACTED]. She stated she thought the enema order was, "as needed." When asked if she gave the resident an enema, the LPN stated, "The resident was grunting when I saw him at 5:00 a.m., so I checked his rectum, felt some stool and gave him an enema. The BM (bowel movement) was firm and about 3/4 cup of stool came out." The LPN was asked, "Did anyone help you give the resident an enema?" She stated, "No." She was then asked, "Did you chart that you gave an enema in the Nurses Notes, on the MAR (Medication Administration Record) or 24 Hour Report?" She stated, "No." When asked if she reported the resident's condition to the oncoming 6:00 a.m. to 2:00 p.m. shift, the LPN stated, "I don't recall." 5.) On 1/27/11 at 3:15 p.m., LPN #3, who worked the day shift on 1/12/11, was asked, "Did you give an enema to the resident?" The LPN stated, "No." When asked if he did assessments to monitor the resident's constipation during his shift, he stated, "No." 6.) On 1/28/11 at 8:45 a.m., Certified Nursing Assistant (CNA) #2, who worked the 10:00 p.m. to 6:00 a.m. shift, was asked, "Did the resident have a BM on 1/11/11 after returning from the hospital?" The CNA stated, "No, he did not." c. An Advanced Practice Nurse (APN) Note dated 1/12/11 documented, "...Abd (abdomen): slight distention, some rigidity to abdomen... 1. S/P (status [REDACTED]. Constipation..." On 1/27/11 at 8:25 a.m., the APN was asked if, during her visit with the resident on 1/12/11, she did a rectal exam. She stated, "No." d. Nurses Notes dated 1/13/11 at 11:30 a.m. documented the resident was transferred to Hospital #2 for garbled speech and weak grips on the right side. 1.) The ER Patient Care form dated 1/13/11 documented, "Per (LPN #3) at (nursing home), pt (patient) has not been given fleets enema for constipation at NH (nursing home)..." The form documented that ER Physician #1 disimpacted the resident, who was then returned to the facility at 5:30 p.m. with a physician order [REDACTED]. 2.) On 1/25/11 at 2:30 p.m., ER Physician #1 (from Hospital #2) stated the resident did have a fecal impaction upon presenting to theER on [DATE] and that the impaction was removed with digital extraction. The physician estimated that 3 to 4 pounds of stool was removed at that time. 3.) On 1/26/11 at 3:08 p.m., the ER Physician from Hospital #1 was interviewed and stated, "Had the orders been followed for enemas (on 1/11/11), it would have prevented the fecal impaction 2 days later. " e. Nurses Notes dated 1/13/11 through 1/23/11 documented 2 occasions when the resident's abdomen and/or bowel sounds were checked. There was no other documentation of nursing assessments to monitor for further gastrointestinal problems. f. As of 1/27/11, the Plan of Care dated 10/15/10 had not been updated to include the resident's problems with constipation and fecal impactions. g. The January 2011 CNA-ADL (Certified Nursing Assistant Activities of Daily Living) Tracking Forms documented no bowel movements from 1/18/11 through 1/21/11. There was no documentation on the January 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].

Complaint # was substantiated (all or in part) based on these findings: Based on record review and interview, the facility failed to ensure fluid intake was monitored and documented to ensure adequate daily fluid intake and specific interventions were developed, communicated to staff and implemented to prevent the potential for the recurrence of dehydration for 1 (Resident #6) of 8 (Residents #1, #3, #4, #6, #8, #10, #11, and #12) case mix residents who were at risk for dehydration. The failed practice resulted in a pattern of actual harm to Resident #6, who experienced 2 episodes of dehydration that resulted in 2 emergency room hospitalization s for dehydration resulting in intravenous fluid administration and had the potential to cause more than minimal harm to 22 residents who were at risk for dehydration as documented by the Director of Nursing on 10/8/10. The findings are: 1. Resident #6 had [DIAGNOSES REDACTED]. The Medicare 30 Day Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent on staff for eating, and had functional limitation in range of motion of one side with full loss of voluntary movement of the arm and hand. a. Nurses notes dated 8/4/10 at 5:45 a.m. documented, "Per CNA (certified nursing assistant) resident felt warm. CNA taken temp 101. Tylenol 325mg (milligrams) (tabs 2) PO (by mouth) given." Nurses Notes dated 8/4/10 at 7:00 a.m. documented, "100.8 will continue to monitor." Nurses Note at 7:05 a.m. documented, "(physician assistant) paged for temp. (temperature) awaiting return call." No response to call made to physician assistant documented on this day in the Nurses Notes. b. Nurses Note dated 8/5/10 at 10:00 a.m. documented, "CNA reported that pad was brown from urine. Upon examining res (resident) urine noted to have dark brown urine (with) foul odor (and) res currently running fever. MD (Medical Doctor) notified received order for UA (urinalysis) (with) C & S (culture and sensitivity) if indicated. UA collected using sterile technique using I & O (in and out) cath. (catheter). Procedure tolerated well ..." c. Nurses Notes dated 8/6/10 at 7:30 a.m. documented, "Temp 102.4. ...strong smelling urine noted...." Nurses Note at 7:35 a.m. documented, "Rec'd N/O (new order) to send to ER (emergency room ) for eval (evaluation) of temp 102.4 ..." No outcome documented in the Nurses Notes. d. A Nurses Note dated 8/6/10 at 7:30 a.m. documented, " Temp 102.4, Tylenol 325 mg (milligram) (two given (by mouth) ...(Physician Assistant) paged (at) this time. ... " 7:35 Nurses Noted documented, " Rec ' d (Received) N/O (new order) to send to ER (emergency room ) for eval (evaluation) of temp 102.4. " e. A hospital emergency room Patient Care note dated 8/6/10 documented, "...Onset of symptoms: several days...color pale...0840 I & O cath-urine dark amber...Interventions IV (intravenous) liter NS (normal saline) 2nd liter NS 3rd NS @ 280 ml (millileters)/hr. [MEDICATION NAME] (increased) (at) wide open rate ...Clinical Impression...Dehydration...Electrolyte disturbance..." 1) A hospital History and Physical dated 8/6/10 documented, "...HEENT (head ear eye nose throat): Right eye sunken....mucosa was dry. ...Cardiovascular: Patient was in sinus tachyrhythm. ...Laboratory Data: Sodium 155, ...BUN (blood urea nitrogen) 51...Impression and Plan: ...5. Dehydration-normal saline at 167 ml. ...7. [MEDICAL CONDITION]-this is due to concentration and dehydration, push fluids. ...Cumulative Lab Summary Report ...8/6/10 ...BUN (5-26) 51 H (high) ..." 2) Hospital patient notes dated 8/6/10 documented, "...Lethargic unless moved...weak. ...NS (normal saline) [MEDICATION NAME] was hung..." 3) A hospital Discharge summary dated 8/12/10 documented, "...Admission Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 7. Dehydration. ...Discharge Diagnoses: [REDACTED]..6. [MEDICAL CONDITION]. 7. Dehydration..." f. The Resident Plan of Care dated 8/17/10 documented, "...Monitor for signs of dehydration, poor skin turgor, sunken eyes, dry cracked lips, decreased urine output, dry mucosa, weakness, rapid pulse. ...At risk for fluid volume deficit (dehydration) R/T (related to) DX (diagnosis) of UTI (urinary tract infection),[MEDICAL CONDITION], and pneumonia during hospital stay (resident) will be adequately hydrated and will exhibit no S/S (signs or symptoms) of dehydration for next 90 days. Approaches Encourage fluids with med pass, meals, incont. (incontinent) care, Q (every) 2 hrs. and PRN (as needed). ...Monitor for signs of dehydration-poor skin turgor, sunken eyes, dry, cracked lips, decreased urine output, dry mucosa, weakness, rapid pulse. Keep water pitcher filled with fresh water and readily available to (resident) Inform her where the pitcher is on bedside table D/T (due to) her poor vision. ...Ensure adequate hydration with med pass, meals, incont. care Q (every) 2 hrs (hours) and PRN (as necessary)..." On 10/8/10 at 2:07 p.m., the Minimum Data Set Assessment and Care Plan Coordinator was asked how it was determined (Resident #6) was at risk for fluid volume deficit or dehydration and the Coordinator stated, "First of all the resident is a feeder. The resident is totally dependent on nursing staff for all of her PO (by mouth) intake of nutrition and fluids. The resident on 8/12/10 had returned to facility from the hospital with [DIAGNOSES REDACTED]." The Coordinator was asked how information is communicated to the nursing staff and the Coordinator stated, "This care plan is in the resident's chart, the CNA's (Certified Nursing Assistant) have a care plan that reflect's the resident is dependent on staff for nutrition and hydration. Every resident's meal consumption and fluid intake on the residents monitored on the meal consumption sheet. On care plans and the nurses reinforce it to the CNA's." The Coordinator was asked how the hydration of a resident at risk is monitored and the Coordinator stated, "Meal consumption sheets, hydration book, labs are used, the nurses would monitor for signs and symptoms of dehydration, UTI, [MEDICAL CONDITION], fever, decreased output of urine, dry mouth, cracked lips, skin turgor, color, and decreased level of consciousness, discolored, foul smelling urine." g. The August and September 2010 A.D.L. (activities of daily living) Flow sheet had no documentation for the amounts of fluid intake. h. The August 2010 Meal Intake Documentation form documented for the fluid intake on 8/4/10 "R", 8/5/10 R, 8/14/10 thru 8/28/10 R and on 8/30/10 R. The legend on the form documented, "Fluids A= Accepted R=Refused." The September 2010 Meal Intake Documentation documented for the fluid intake on 9/1/10 thru 9/22/10 "R." The legend on the form documented, "Fluids A=Accepted R=Refused." i. Nurses notes dated 9/25/10 at 8:30 a.m. documented, "Res (resident) (up) in gerichair. Noted to have poor po (by mouth) intake for breakfast. Skin w/d (warm and dry) to touch..." Nurses notes at 10:00 a.m. documented, "Unable to get res to take 9 a.m. meds. Res not drinking (water) @ this time." Nurses notes at 12:00 p.m. documented, "Res continues to not respond verbally to staff. Attempts to give po fluids (at) this time (without) success." Nurses notes at 12:20 p.m. documented, "(physician's assistant) paged regarding condition." Nurses notes at 2:00 p.m. documented, "(physician's assistant) notified of condition, no verbal responses, poor po intake. Pulse 94. Order received transfer to ER (emergency room ) for eval." j. The hospital ER Patient Care form dated 9/25/10 documented, "...Pt (patient) has upper and lower bilateral contractures. Pt was sent from nursing home for decreased LOC (level of consciousness)...Clinical Impression: [MEDICAL CONDITION] Dehydration..." The hospital history and physical dated 9/25/10 documented, "Laboratory Data: ...hemoglobin 30.8, hematocrit 43.8, Sodium 170 ...BUN (blood urea nitrogen) 65,... Free water deficit 6.4 liters. ...Assessment/plan...2. [MEDICAL CONDITION]. Start the patient on 1/2 normal saline at 125 cc/hr (cubic centimeters per hour). 3. Altered mental status, secondary to urinary tract infection, dehydration and [MEDICAL CONDITION]" k. On 10/7/10 at 6:25 p.m., the Director of Nursing (DON) was asked if intake and output was done on residents. The DON stated, "Not on every resident, no." The DON was asked who had received I & O. The DON stated, "Residents that have foley catheters, some residents that have fluid restriction, some residents that may have fluid retention that the doctor may order and we can at our nursing discretion." The DON was then asked if there had been concern from residents regarding hydration. The DON stated, "The Resident Council meeting that I've just got minutes, a resident felt her room-mate wasn't getting water or being helped enough with fluids not that I feel there is a problem and at our morning meeting our charge CNA (Certified Nursing Assistant) talks with us about who has a problem so we do try to stay on top of this." The DON was asked how residents were monitored for fluid intake. The DON stated, "If you thought they are not taking enough fluids with their diet or if when the hydration cart goes around." The DON was asked if a resident with a recent history of hospital admission for dehydration would be an indication to monitor for I & O and the DON stated, "Yes." The DON was then asked if (Resident #6) was on an I & O monitoring and the DON stated, "No." The DON was asked if (Resident #6) should have been on an I & O monitoring and the DON stated, "Based on what I've said that would have been an indication. I didn't know she had dehydration. I knew she [MEDICAL CONDITION] and UTI (urinary tract infection). I was aware she had been in the hospital with UTI [MEDICAL CONDITION]." The DON was asked if fluids were documented on the Activities of Daily Living (ADL) flow sheet and the DON stated, "Fluids are not documented on this. I think they have something." l. On 10/8/10 at 1:20 p.m., Licensed Practical Nurse (LPN) #9 was asked where the amount of fluids given is documented and the LPN stated, "If we have a specific order to increase fluids to a specific amount then it's put on the MAR (Medication Administration Record)." The LPN was asked if (Resident #6's) fluid intake should have been monitored and the LPN stated, "Yes." The LPN was asked if the resident's fluid intake was monitored when she returned from the hospital and the LPN stated, "She was fed in the back dining room and they gave fluids then. The only other times when it's monitored is when it's on the MAR, it's an actual order. The I (and) O's we do routinely just for residents with catheters unless we have an order stating otherwise." The LPN was asked if the resident could see and pick up a glass of water and the LPN stated, "No. I always put the water glass in her hand." The LPN was asked if the resident's fluid intake should have monitored and the LPN stated, "Yes. It was not monitored as closely as it should have been." The LPN was asked if staff was to refer to the care plan for resident needs and LPN #9 stated, "Yes." The LPN was asked how it is ensured that staff provided residents with hydration and the LPN stated, "If I'm working the floor they do a hydration and I ask them if someone doesn't take it then to let me know." The LPN was asked if she had been informed that (Resident #6) had not taken fluids and the LPN stated, "They never did tell me."

Complaint #'s was substantiated (all or in part) with these findings: Based on record review and interview the Nursing Administration failed to ensure fluid intake was monitored and documented to ensure adequate daily fluid intake and interventions were developed, communicated, and implemented to prevent the potential for the recurrence of dehydration for 1 (Resident #6) of 8 (Residents #1, #3, #4, #6, #8, #10, #11, and #12) case mix residents who were at risk for dehydration. The failed practice resulted in a pattern of actual harm to Resident #6, who experienced 2 episodes of dehydration that resulted in 2 emergency room hospitalization s requiring intravenous fluid administration, and had the potential to cause more than minimal harm to 22 residents who were at risk for dehydration as documented by the Director of Nursing on 10/8/10. The Nursing Administration also failed to ensure dressing changes were completed as ordered by the physician and documented in the resident's clinical record for 4 (Residents #2, 5, 10 and 11) of 6 (Resident #2, #5, #8, #9, #10 and #11) case mix residents with physician orders [REDACTED].# 2, who had multiple dressing changes omitted and was hospitalized with [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) wound infection, and had the potential to affect 12 residents in the facility with physician orders [REDACTED]. The findings are: 1. The Job Summary of the Director of Nursing (DON), received on 10/8/10 at 2:00 p.m. from the Administrator, documented, "The Director of Nursing manages the Nursing Department with high professional and personal standards. He/she plans, organizes, coordinates and directs all the nursing functions for professional and nonprofessional nursing personnel to ensure the highest quality of care is provided...The DON exercises administrative authority, responsibility and accountability for nursing service objectives, policies and procedures, nursing functions and activities, nursing care and the nursing staff and training...qualifications...must demonstrate ability to evaluate nursing staff needs and implement systems to assure staff education is provided to provide quality care..." 2. The Job Summary of Licensed Staff , Registered Nurse/ Practical or Vocational Nurse received from Licensed Practical Nurse #10 on 10/7/10 at 11:45 a.m. documented, "He/she is responsible for the care of the residents in a designated area of the facility...communicates with off going and arriving shifts of personnel to assure the continuum of quality care...Prepares and administers medications and treatments according to procedures...reviews resident's Care Plans and assures these plans are followed ...Documents on records as per policy and procedures of the facility...Provides special procedures as ordered. Completes the treatments as ordered. Assesses and documents new and old areas of treatment describing in detail the results of staff action and the results of the treatment. Prepares a weekly skin report for the DON...Continually assesses and reassesses residents for risk of complications as result of being in the facility." 3. Resident #6 had [DIAGNOSES REDACTED]. The Medicare 30 Day Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent on staff for eating, and had functional limitation in range of motion of one side with full loss of voluntary movement of the arm and hand. a. Nurses notes dated 8/4/10 at 5:45 a.m. documented, "Per CNA (certified nursing assistant) resident felt warm. CNA taken temp 101. Tylenol 325mg (milligrams) (tabs 2) PO (by mouth) given." Nurses Notes dated 8/4/10 at 7:00 a.m. documented, "100.8 will continue to monitor." Nurses Note at 7:05 a.m. documented, "(physician assistant) paged for temp. (temperature) awaiting return call." No response to call made to physician assistant documented on this day in the Nurses Notes. b. Nurses Note dated 8/5/10 at 10:00 a.m. documented, "CNA reported that pad was brown from urine. Upon examining res (resident) urine noted to have dark brown urine (with) foul odor (and) res currently running fever. MD (Medical Doctor) notified received order for UA (urinalysis) (with) C & S (culture and sensitivity) if indicated. UA collected using sterile technique using I & O (in and out) cath. (catheter). Procedure tolerated well ..." c. Nurses Notes dated 8/6/10 at 7:30 a.m. documented, "Temp 102.4. ...strong smelling urine noted...." Nurses Note at 7:35 a.m. documented, "Rec'd N/O (new order) to send to ER (emergency room ) for eval (evaluation) of temp 102.4 ... " No outcome documented in the Nurses Notes. d. A Nurses Note dated 8/6/10 at 7:30 a.m. documented, " Temp 102.4, Tylenol 325 mg (milligram) (two given (by mouth) ...(Physician Assistant) paged (at) this time. ... " 7:35 Nurses Noted documented, " Rec ' d (Received) N/O (new order) to send to ER (emergency room ) for eval (evaluation) of temp 102.4. " e. A hospital emergency room Patient Care note dated 8/6/10 documented, "...Onset of symptoms: several days...color pale...0840 I & O cath-urine dark amber...Interventions IV (intravenous) liter NS (normal saline) 2nd liter NS 3rd NS @ 280 ml (millileters)/hr. [MEDICATION NAME] (increased) (at) wide open rate ...Clinical Impression...Dehydration...Electrolyte disturbance..." 1) A hospital History and Physical dated 8/6/10 documented, "...HEENT (head ear eye nose throat): Right eye sunken....mucosa was dry. ...Cardiovascular: Patient was in sinus tachyrhythm. ...Laboratory Data: Sodium 155, ...BUN (blood urea nitrogen) 51...Impression and Plan: ...5. Dehydration-normal saline at 167 ml. ...7. [MEDICAL CONDITION]-this is due to concentration and dehydration, push fluids. ...Cumulative Lab Summary Report ...8/6/10 ...BUN (5-26) 51 H (high) ..." 2) Hospital patient notes dated 8/6/10 documented, "...Lethargic unless moved...weak. ...NS (normal saline) [MEDICATION NAME] was hung..." 3) A hospital Discharge summary dated 8/12/10 documented, "...Admission Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 7. Dehydration. ...Discharge Diagnoses: [REDACTED]..6. [MEDICAL CONDITION]. 7. Dehydration..." f. The Resident Plan of Care dated 8/17/10 documented, "...Monitor for signs of dehydration, poor skin turgor, sunken eyes, dry cracked lips, decreased urine output, dry mucosa, weakness, rapid pulse. ...At risk for fluid volume deficit (dehydration) R/T (related to) DX (diagnosis) of UTI (urinary tract infection),[MEDICAL CONDITION], and pneumonia during hospital stay (resident) will be adequately hydrated and will exhibit no S/S (signs or symptoms) of dehydration for next 90 days. Approaches Encourage fluids with med pass, meals, incont. (incontinent) care, Q (every) 2 hrs. and PRN (as needed). ...Monitor for signs of dehydration-poor skin turgor, sunken eyes, dry, cracked lips, decreased urine output, dry mucosa, weakness, rapid pulse. Keep water pitcher filled with fresh water and readily available to (resident) Inform her where the pitcher is on bedside table D/T (due to) her poor vision. ...Ensure adequate hydration with med pass, meals, incont. care Q (every) 2 hrs (hours) and PRN (as necessary)..." On 10/8/10 at 2:07 p.m., the Minimum Data Set Assessment and Care Plan Coordinator was asked how it was determined (Resident #6) was at risk for fluid volume deficit or dehydration and the Coordinator stated, "First of all the resident is a feeder. The resident is totally dependent on nursing staff for all of her PO (by mouth) intake of nutrition and fluids. The resident on 8/12/10 had returned to facility from the hospital with [DIAGNOSES REDACTED]." The Coordinator was asked how information is communicated to the nursing staff and the Coordinator stated, "This care plan is in the resident's chart, the CNA's (Certified Nursing Assistant) have a care plan that reflect's the resident is dependent on staff for nutrition and hydration. Every resident's meal consumption and fluid intake on the residents monitored on the meal consumption sheet. On care plans and the nurses reinforce it to the CNA's." The Coordinator was asked how the hydration of a resident at risk is monitored and the Coordinator stated, "Meal consumption sheets, hydration book, labs are used, the nurses would monitor for signs and symptoms of dehydration, UTI, [MEDICAL CONDITION], fever, decreased output of urine, dry mouth, cracked lips, skin turgor, color, and decreased level of consciousness, discolored, foul smelling urine." g. The August and September 2010 A.D.L. (activities of daily living) Flow sheet had no documentation for the amounts of fluid intake. h. The August 2010 Meal Intake Documentation form documented for the fluid intake on 8/4/10 "R", 8/5/10 R, 8/14/10 thru 8/28/10 R and on 8/30/10 R. The legend on the form documented, "Fluids A= Accepted R=Refused." The September 2010 Meal Intake Documentation documented for the fluid intake on 9/1/10 thru 9/22/10 "R." The legend on the form documented, "Fluids A=Accepted R=Refused." i. Nurses notes dated 9/25/10 at 8:30 a.m. documented, "Res (resident) (up) in gerichair. Noted to have poor po (by mouth) intake for breakfast. Skin w/d (warm and dry) to touch..." Nurses notes at 10:00 a.m. documented, "Unable to get res to take 9 a.m. meds. Res not drinking (water) @ this time." Nurses notes at 12:00 p.m. documented, "Res continues to not respond verbally to staff. Attempts to give po fluids (at) this time (without) success." Nurses notes at 12:20 p.m. documented, "(physician's assistant) paged regarding condition." Nurses notes at 2:00 p.m. documented, "(physician's assistant) notified of condition, no verbal responses, poor po intake. Pulse 94. Order received transfer to ER (emergency room ) for eval." j. The hospital ER Patient Care form dated 9/25/10 documented, "...Pt (patient) has upper and lower bilateral contractures. Pt was sent from nursing home for decreased LOC (level of consciousness)...Clinical Impression: [MEDICAL CONDITION] Dehydration..." The hospital history and physical dated 9/25/10 documented, "Laboratory Data: ...hemoglobin 30.8, hematocrit 43.8, Sodium 170 ...BUN (blood urea nitrogen) 65,... Free water deficit 6.4 liters. ...Assessment/plan...2. [MEDICAL CONDITION]. Start the patient on 1/2 normal saline at 125 cc/hr (cubic centimeters per hour). 3. Altered mental status, secondary to urinary tract infection, dehydration and [MEDICAL CONDITION]" k. On 10/7/10 at 6:25 p.m., the Director of Nursing (DON) was asked if intake and output was done on residents. The DON stated, "Not on every resident, no." The DON was asked who had received I & O. The DON stated, "Residents that have foley catheters, some residents that have fluid restriction, some residents that may have fluid retention that the doctor may order and we can at our nursing discretion." The DON was then asked if there had been concern from residents regarding hydration. The DON stated, "The Resident Council meeting that I've just got minutes, a resident felt her room-mate wasn't getting water or being helped enough with fluids not that I feel there is a problem and at our morning meeting our charge CNA (Certified Nursing Assistant) talks with us about who has a problem so we do try to stay on top of this." The DON was asked how residents were monitored for fluid intake. The DON stated, "If you thought they are not taking enough fluids with their diet or if when the hydration cart goes around." The DON was asked if a resident with a recent history of hospital admission for dehydration would be an indication to monitor for I & O and the DON stated, "Yes." The DON was then asked if (Resident #6) was on an I & O monitoring and the DON stated, "No." The DON was asked if (Resident #6) should have been on an I & O monitoring and the DON stated, "Based on what I've said that would have been an indication. I didn't know she had dehydration. I knew she [MEDICAL CONDITION] and UTI (urinary tract infection). I was aware she had been in the hospital with UTI [MEDICAL CONDITION]." The DON was asked if fluids were documented on the Activities of Daily Living (ADL) flow sheet and the DON stated, "Fluids are not documented on this. I think they have something." l. On 10/8/10 at 1:20 p.m., Licensed Practical Nurse (LPN) #9 was asked where the amount of fluids given is documented and the LPN stated, "If we have a specific order to increase fluids to a specific amount then it's put on the MAR (Medication Administration Record)." The LPN was asked if (Resident #6's) fluid intake should have been monitored and the LPN stated, "Yes." The LPN was asked if the resident's fluid intake was monitored when she returned from the hospital and the LPN stated, "She was fed in the back dining room and they gave fluids then. The only other times when it's monitored is when it's on the MAR, it's an actual order. The I & O's we do routinely just for residents with catheters unless we have an order stating otherwise." The LPN was asked if the resident could see and pick up a glass of water and the LPN stated, "No. I always put the water glass in her hand." The LPN was asked if the resident's fluid intake should have monitored and the LPN stated, "Yes. It was not monitored as closely as it should have been." The LPN was asked if staff was to refer to the care plan for resident needs and LPN #9 stated, "Yes." The LPN was asked how it is ensured that staff provided residents with hydration and the LPN stated, "If I'm working the floor they do a hydration and I ask them if someone doesn't take it then to let me know." The LPN was asked if she had been informed that (Resident #6) had not taken fluids and the LPN stated, "They never did tell me." 4. Resident #2 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an assessment reference date of 9/3/10 documented the resident had modified independence in cognitive skills for daily decision making, required limited assistance with transfers, dressing, toilet use and personal hygiene and had an ulcer that was resolved or cured in the last 90 days. a. The Care Plan last reviewed dated 6/10/10 documented, " Problem ...Risk of Infection of wound area in abdominal fold ...Approaches: Monitor site for signs of infection, redness, swelling ...report findings promptly to physician. ... " b. Resident Council Meeting minutes dated 7/6/10 documented, " .... (Resident #2) stated that their treatments are not being done on the weekends. ... " c. The September 2010 Treatment Administration Record (TAR) documented an order dated 8/20/10 Clean wound to Abd (abdominal) fold with [MEDICATION NAME] tid ( 3 times a day). " There was no documentation to indicate the dressing had been done on the 7-3 shift for 9/4/10, 9/5/10 and 9/16/10; 3-11 shift for 9/1/10-9/24/10; or the 11-7 shift for 9/2/10, 9/5/10-9/24/10. 1) On 10/7/10 at 6:15 p.m., LPN #1 was asked about the omitted documentation on the TAR. The LPN stated, "I believe I did the dressing for 9/4/10 and 9/5/10 but it is not documented." 2) On 10/7/10 at 5:45 p.m., LPN #2 was asked about the omitted documentation on the TAR stated, "I did the dressing on 9/16/10 but didn't document. " The LPN stated that she usually works days. 3) A written statement dated 10/8/10 and signed by LPN #3 regarding the omitted treatments on the TAR for Resident #2 documented, "9/5/10, 9/6/10, 9/9/10, 9/10/10, 9/11/10 and 9/12/10 treatments were done. I forgot to sign the Treatment Book. (On) 9/21/10 and 9/22/10 I forgot to do the treatments." 4) A written statement dated 10/8/10 and signed by LPN #4 regarding the omitted treatments on the TAR for Resident #2 documented, "9/7/10, 9/8/10 and 9/17/10 treatment to resident was done to lower abdominal and dressings changed as ordered, however not signed for, an oversight by nurse in treatment book. " 5) A written statement dated 10/8/10 and signed by LPN #5 regarding the omitted treatments on the TAR for Resident #2 documented, "I was not aware of treatment order that were Q (every) shift. I will be more aware for resident orders and check my MAR (Medication Administration Record) and TAR at the end of each shift..." 6) On 10/7/10 at 7:15 p.m., Licensed Practical Nurse (LPN) #8 was asked if she had changed and documented the dressing changes for Resident #2 for the evening shift and the LPN stated, "I didn't know they were to be done, (Resident) asked me to do her dressing changes and I pulled them off and I did it. I got the treatment book and saw what was to be done. My understanding everywhere when there's a treatment nurse they do the treatment. I just did it as a favor to (Resident)." The LPN was asked if there is a treatment nurse scheduled daily and the LPN stated, "No there is not. Usually the weekend supervisor does them." The LPN was asked if there was a supervisor that was to have done the dressing changes and the LPN stated, "Other places I've worked there always is." The LPN was asked if there was someone else designated to do the dressing changes in the facility that she is currently working in and the LPN stated, "I was never told I had to do treatments until about a week ago." The LPN was asked where were the dressing changes documented and the LPN stated, "I didn't. This was just a favor." d. A Concern/ Grievance report dated 9/24/10 documented, "Resident states dressing was not changed 9/22/10 and 9/23/10...Action Taken: Treatment Nurse counseled. All staff in-serviced regarding performing and documenting treatments. Treatment Nurse instructed not to hand wound care onto the next shift to ensure wound care is done. (Resident #2) asked to let me (Director of Nurses-DON) know immediately if wound care not performed as ordered. On 9/27/10 the Treatment Nurse received a written warning due to failure to perform wound care on one resident." On 10/6/10 at 4:45 p.m., the Director of Nurses (DON)provided the following documentation that stated, "...On September 24th I (DON)was informed by my Assistant Director of Nurses that (Resident #2) had wanted to talk to me about her wound care and that she stated it had not been done for the past 2 days. At the time I was notified the treatment nurse had already left and the 7-3 charge nurses had been instructed that they were to do wound care for their shift. When (Resident # 2) wound care was performed she was noted to have bloody drainage. The MD was notified and an order was received to send to ER for evaluation. I spoke with (Resident #2) prior to leaving for the hospital and asked her to let me know as soon as possible if staff are not doing her treatments as ordered...At this time I discovered that (Resident #2 ' s) dressing was no longer daily but tid (3 times a day)...review of (Resident ' s) September TAR showed that wound care had not been done on 9/22/10 or 9/23/10 and that there were multiple skips on 3-11 and 11-7 shift. I reviewed a random selection of September TAR's and noted some skips, as in July they occurred more on the weekend. ..." The document was signed by the DON. e. The Nurse's Notes dated 9/24/10 at 1420 (2:40 p.m.) documented, "...paged (named physician assistant) concerning wound to abdominal area was draining bloody drainage..." On 10/7/10 at 6:15 p.m., LPN #1 was asked if she had done the dressing change on 9/24/10 and stated, "Yes, it was about 2:00 p.m., she (Resident #2) had bloody drainage under the abdomen skin fold with the abdominal dressing saturated with bloody drainage...the date on the abdominal dressing was 9/21/10. There were 6 missed dressing changes from 9/21/10 according to the physician order..." f. The Nurse's Notes dated 9/24/10 at 16:15 (4:15 p.m.) documented, "...( physician assistant) called back informed him of the bloody drainage to abdomen area gave orders to send to hospital ER (emergency room )." 1) The hospital History and Physical dated 9/25/10 documented, "Chief complaint: Chronic abscess...presents with chronic [MEDICAL CONDITION] of her pannus inferior to the umbicus. There is a wound draining serosanguineous fluid. ... Past Medical History: Diabetes Mellitus, ...Past surgical History: [MEDICAL CONDITION] Stapling...Assessment/Plan: [MEDICAL CONDITION] get wound care consult. Start the patient on [MEDICATION NAME] and [MEDICATION NAME]" 2) A Hospital wound culture report of the abdominal wound dated Final 9/28/10 documented [MEDICATION NAME] ([MEDICAL CONDITION]) Resistant Staph Aureus, Burkolderia cepacia and [MEDICATION NAME] faecalis. Previous Laboratory Abdominal wound culture reports dated 6/13/10, 7/10/10 and 8/20/10 documented a growth of "Providencia stuarti." g. On 10/5/10 at 9:05 a.m., the resident was asked had she been to the hospital lately? The resident stated, "Yes, I was hospitalized from Friday (9/24/10) until last Thursday (9/30/10) because my wound went bad. It had been doing real well and then it went backwards. My wound was almost closed from about 12 cm (centimeters). For almost 2 years I have had this wound, but there was a little spot that didn't heal. They (hospital) put me on IV antibiotics. I am not a candidate for surgery." 1) On 10/5/10 at 9:15 a.m., the resident was asked if she was aware of any days that her abdominal wound treatment was omitted? The resident stated, "Yes, from 9/21/10 to 9/24/10 (Licensed Practical Nurse (LPN) #1 did my dressing on 9/24/10 and saw that my wound had really gotten bad, she had to call the doctor and told him that it had gotten worse...when she cleaned the wound and blood and pus ran out everywhere, all over me and the bed. Then the doctor sent me to the hospital. I told the Director of Nurses (DON) before I went to the hospital that the treatment nurse had not changed my dressing since the 21st of September." 2) On 10/10/10 at 9:10 a.m., the resident was asked what were the nurses supposed to do about her wound. The resident stated, "They were supposed to put some cream and dress it three times a day." The resident was asked if she had any concerns about the way the nurses took care of her wound?" The resident stated, "Yes, they (facility) changed the treatment nurse about two months ago and this treatment nurse (the nurse that is doing the treatments now) isn't as careful as the previous wound care nurse. This one gets by with as little as possible. The wound was to be changed and treated three times a day and this treatment nurse didn't keep on top of it." h. The October 2010 TAR documented: "(9/30/10) [MEDICATION NAME] Ag. cut to fit and cover with 4x4 and secure with tape. Change Q (every) 3 days. " There was no documentation on the October 2010 TAR to indicate the dressing was changed on 10/4/10. 5. Resident # 5 had [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] documented the resident had severely impaired cognitive skills for daily decision making, required extensive to total assistance with activities, was incontinent of urine and stool, had one Stage II pressure sore, one Stage III pressure sore and one Stage IV pressure sore. a. The September 2010 TAR documented a physician's orders [REDACTED]. Apply Santyl and cover with S (Saline) fluffed gauge q d (every day). The TAR also documented a physician order [REDACTED]. The treatments were scheduled to be complete on the 8:00 a.m. -5:00 p.m. shift and the 11 p.m. - 7:00 p.m. shift. The TAR had no documentation to indicate the dressing had been done on the 8-5 shift for 9/9/10 - 9/10/10. Crossed through on the TAR was a wound care order that documented to cleanse stage III to (left buttock 1) On 10/7/10 at 2:55 p.m., LPN #6 was asked if she was responsible for wound treatments on September 9th and10th for (Resident #5)? LPN #6 stated, "Yes." LPN #6 was unable to show documentation on the TAR that the dressing on the right leg and buttocks had been done for 9/9/10 and 9/10/10. LPN #6 stated, "It is not documented that the treatment to the right leg and Stage 3 (decubitus) on the buttocks were done, but I did them. 2) A written statement dated 10/8/10 and signed by LPN #5 documented, "Not aware of any treatment order that were Q (every) shift. I will be more aware for resident orders and check my MAR/TAR at the end of each shift..." 3) A written statement dated 10/8/10 and signed by LPN #7 documented, "The treatments on (Resident #5) were not done because I was not aware that he had an 11-7 treatment due. This was an oversight and I will check the TARS in the future..." b. A Physician's telephone order dated 10/4/10 documented, "Discharge to home with meds with personal effects. (Home Health Agency) to evaluation..." c. The (Home Health Agency) documented on 10/7/10, "...Pt's (patient's) wound measurements obtained this visit. Prior to rehab stay right heel measured 2 cm (centimeter) x 2 cm x 1 cm, granulating, beefy red in color and draining serous colored drainage. Pt's wound this date with large amount of black eschar to heel measuring 5 cm x 5 cm...Pt's wound to buttocks before rehab stay measured 4 cm x 2 cm, beefy red and granulating. Pt's wound now after rehab stay continues to be Stage 2 decub to upper buttocks measuring 3 cm x 2 cm x 0.1 cm..." 6. Resident #10 had [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented the resident had modified independence in cognitive skills for daily decision making, required total assistance with activities of daily living, was incontinent of urine and stool and had no wound or skin problems. a. The Care Plan with a review date of 7/28/10 documented, " Problem: Risk for skin breakdown related to incontinence and decreased mobility. ...Approaches: ...Tx (treatment) ...as ordered per M.D. (Medical Doctor). " b. A physician order [REDACTED]. Apply TAO (Triple Antibiotic Ointment) and cover with 4 x 4's and wrap with Kerlix Q day till healed." The September 2010 TAR showed no documentation to indicate the dressing had been done on 9/25/10 and 9/26/10. c. On 10/7/10 at 6:15 p.m., LPN # 1 was asked about the omitted documentation on the TAR. The LPN stated, "I did the dressing on the skin tear both days, but did not document it." 7. Resident #11 had [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented the resident had severely impaired cognitive skills for daily decision making, required total assistance from staff for activities of daily living, was incontinent of urine or stool and had 2 Stage II decubitus ulcers a. The September 2010 TAR documented the following physican wound care orders: 1) " (5/28/10) Allenderm to Stage 2 on coccyx Q day. " There was no documentation on the TAR that a dressing change was done on 9/4/10, 9/5/10 and 9/16/10. 2) " (5/28/10) [MEDICATION NAME] to right hip wound pack with 4 x 4, cover with ABD and secure with tape Q day". There was no documentation on the TAR that the dressing was done on 9/4/10, 9/5/10 and 9/16/10. 3) "(6/10/10) [MEDICATION NAME] Cream to groin rash Bid (2 times a day)." There was no documentation that the treatment was done on 9/4/10, 9/5/10 and 9/6/10. 4) "(7/8/10) [MEDICATION NAME] to coccyx/buttocks Q day." There was no documentation that the treatment was done on 9/4/10, 9/5/10 and 9/16/10. 5) "(8/25/10) [MEDICATION NAME] to Stage 2 on right foot, great toe Q day." There was no documentation that the treatment was done for 9/4/10, 9/5/10, 9/16/10, 9/25/10 and 9/26/10. b. On 10/7/10 at 6:15 p.m., LPN #1and LPN #2 were asked regarding the wound care for (Resident #11). LPN #1 stated, "The dressings were not done on 9/4/10 and 9/5/10." LPN # 2 stated, "I did the dressing on 9/16/10 but did not document." 8. On 10/8/10 at 1:45 p.m., the Director of Nurses (DON) was asked who was responsible for ensuring that the staff followed the physician orders [REDACTED]. The DON was asked, "Do you have any documentation that the issues of dressing changes that were omitted and /or not documented were discussed? The DON stated, "No, I don't believe we have any documentation stating that we (facility) had problems with residents with dressings not being done or documented." 9. On 10/8/10 at 4:45 p.m. the Director of Nurses provided a written statement that documented, "On 10/7/10 and 10/8/10 I spoke to and obtained statements from 6 staff members regarding why they had not completed and documented treatments that were scheduled to be performed on their shift. On the whole the staff voiced that the treatment nurse was responsible for the treatments. They did not appear to recognize that they were also responsible for treatments and that the treatment nurse cannot be the only person responsible as she does not work 24 hours a day or 7 days a week. The staff also did not appear to recognize the importance of documenting the treatments that they did provide or that as charge nurses that they should be knowledgeable of the orders which include treatment on all the residents that they are assigned to care for. "

Complaint # was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure that dressing changes were completed as ordered by the physician and documented in the resident's clinical record for 4 (Resident #s 2, 5, 10 and 11) of 7 (Resident #s 1, 2, 5, 8, 9, 10 and 11) case mix residents with physician orders [REDACTED].#2, who had multiple dressing changes omitted and was hospitalized with [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) wound infection, and had the potential to affect 12 residents in the facility with physician orders [REDACTED]. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an assessment reference date of 9/3/10 documented the resident had modified independence in cognitive skills for daily decision making, required limited assistance with transfers, dressing, toilet use and personal hygiene and had an ulcer that was resolved or cured in the last 90 days. a. The Care Plan last reviewed dated 6/10/10 documented, " Problem ...Risk of Infection of wound area in abdominal fold ...Approaches: Monitor site for signs of infection, redness, swelling ...report findings promptly to physician. ... " b. Resident Council Meeting minutes dated 7/6/10 documented, " .... (Resident #2) stated that their treatments are not being done on the weekends. ... " c. The September 2010 Treatment Administration Record (TAR) documented an order dated 8/20/10 Clean wound to Abd (abdominal) fold with [MEDICATION NAME] tid ( 3 times a day). " There was no documentation to indicate the dressing had been done on the 7-3 shift for 9/4/10, 9/5/10 and 9/16/10; 3-11 shift for 9/1/10-9/24/10; or the 11-7 shift for 9/2/10, 9/5/10-9/24/10. 1) On 10/7/10 at 6:15 p.m., LPN #1 was asked about the omitted documentation on the TAR. The LPN stated, "I believe I did the dressing for 9/4/10 and 9/5/10 but it is not documented." 2) On 10/7/10 at 5:45 p.m., LPN #2 was asked about the omitted documentation on the TAR stated, "I did the dressing on 9/16/10 but didn't document. " The LPN stated that she usually works days. 3) A written statement dated 10/8/10 and signed by LPN #3 regarding the omitted treatments on the TAR for Resident #2 documented, "9/5/10, 9/6/10, 9/9/10, 9/10/10, 9/11/10 and 9/12/10 treatments were done. I forgot to sign the Treatment Book. (On) 9/21/10 and 9/22/10 I forgot to do the treatments." 4) A written statement dated 10/8/10 and signed by LPN #4 regarding the omitted treatments on the TAR for Resident #2 documented, "9/7/10, 9/8/10 and 9/17/10 treatment to resident was done to lower abdominal and dressings changed as ordered, however not signed for, an oversight by nurse in treatment book. " 5) A written statement dated 10/8/10 and signed by LPN #5 regarding the omitted treatments on the TAR for Resident #2 documented, "I was not aware of treatment order that were Q (every) shift. I will be more aware for resident orders and check my MAR (Medication Administration Record) and TAR at the end of each shift..." 6) On 10/7/10 at 7:15 p.m., Licensed Practical Nurse (LPN) #8 was asked if she had changed and documented the dressing changes for Resident #2 for the evening shift and the LPN stated, "I didn't know they were to be done, (Resident) asked me to do her dressing changes and I pulled them off and I did it. I got the treatment book and saw what was to be done. My understanding everywhere when there's a treatment nurse they do the treatment. I just did it as a favor to (Resident)." The LPN was asked if there is a treatment nurse scheduled daily and the LPN stated, "No there is not. Usually the weekend supervisor does them." The LPN was asked if there was a supervisor that was to have done the dressing changes and the LPN stated, "Other places I've worked there always is." The LPN was asked if there was someone else designated to do the dressing changes in the facility that she is currently working in and the LPN stated, "I was never told I had to do treatments until about a week ago." The LPN was asked where were the dressing changes documented and the LPN stated, "I didn't. This was just a favor." d. A Concern/ Grievance report dated 9/24/10 documented, "Resident states dressing was not changed 9/22/10 and 9/23/10...Action Taken: Treatment Nurse counseled. All staff in-serviced regarding performing and documenting treatments. Treatment Nurse instructed not to hand wound care onto the next shift to ensure wound care is done. (Resident #2) asked to let me (Director of Nurses-DON) know immediately if wound care not performed as ordered. On 9/27/10 the Treatment Nurse received a written warning due to failure to perform wound care on one resident." On 10/6/10 at 4:45 p.m., the Director of Nurses (DON)provided the following documentation that stated, "...On September 24th I (DON)was informed by my Assistant Director of Nurses that (Resident #2) had wanted to talk to me about her wound care and that she stated it had not been done for the past 2 days. At the time I was notified the treatment nurse had already left and the 7-3 charge nurses had been instructed that they were to do wound care for their shift. When (Resident # 2) wound care was performed she was noted to have bloody drainage. The MD was notified and an order was received to send to ER for evaluation. I spoke with (Resident #2) prior to leaving for the hospital and asked her to let me know as soon as possible if staff are not doing her treatments as ordered...At this time I discovered that (Resident #2 ' s) dressing was no longer daily but tid (3 times a day)...review of (Resident ' s) September TAR showed that wound care had not been done on 9/22/10 or 9/23/10 and that there were multiple skips on 3-11 and 11-7 shift. I reviewed a random selection of September TAR's and noted some skips, as in July they occurred more on the weekend. ..." The document was signed by the DON. e. The Nurse's Notes dated 9/24/10 at 1420 (2:40 p.m.) documented, "...paged (named physician assistant) concerning wound to abdominal area was draining bloody drainage..." On 10/7/10 at 6:15 p.m., LPN #1 was asked if she had done the dressing change on 9/24/10 and stated, "Yes, it was about 2:00 p.m., she (Resident #2) had bloody drainage under the abdomen skin fold with the abdominal dressing saturated with bloody drainage...the date on the abdominal dressing was 9/21/10. There were 6 missed dressing changes from 9/21/10 according to the physician order..." f. The Nurse's Notes dated 9/24/10 at 16:15 (4:15 p.m.) documented, "...( physician assistant) called back informed him of the bloody drainage to abdomen area gave orders to send to hospital ER (emergency room )." 1) The hospital History and Physical dated 9/25/10 documented, "Chief complaint: Chronic abscess...presents with chronic [MEDICAL CONDITION] of her pannus inferior to the umbicus. There is a wound draining serosanguineous fluid. ... Past Medical History: Diabetes Mellitus, ...Past surgical History: [MEDICAL CONDITION] Stapling...Assessment/Plan: [MEDICAL CONDITION] get wound care consult. Start the patient on [MEDICATION NAME] and [MEDICATION NAME]" 2) A Hospital wound culture report of the abdominal wound dated Final 9/28/10 documented [MEDICATION NAME] ([MEDICAL CONDITION]) Resistant Staph Aureus, Burkolderia cepacia and [MEDICATION NAME] faecalis. Previous Laboratory Abdominal wound culture reports dated 6/13/10, 7/10/10 and 8/20/10 documented a growth of "Providencia stuarti." g. On 10/5/10 at 9:05 a.m., the resident was asked had she been to the hospital lately? The resident stated, "Yes, I was hospitalized from Friday (9/24/10) until last Thursday (9/30/10) because my wound went bad. It had been doing real well and then it went backwards. My wound was almost closed from about 12 cm (centimeters). For almost 2 years I have had this wound, but there was a little spot that didn't heal. They (hospital) put me on IV antibiotics. I am not a candidate for surgery." 1) On 10/5/10 at 9:15 a.m., the resident was asked if she was aware of any days that her abdominal wound treatment was omitted? The resident stated, "Yes, from 9/21/10 to 9/24/10 (Licensed Practical Nurse (LPN) #1 did my dressing on 9/24/10 and saw that my wound had really gotten bad, she had to call the doctor and told him that it had gotten worse...when she cleaned the wound and blood and pus ran out everywhere, all over me and the bed. Then the doctor sent me to the hospital. I told the Director of Nurses (DON) before I went to the hospital that the treatment nurse had not changed my dressing since the 21st of September." 2) On 10/10/10 at 9:10 a.m., the resident was asked what were the nurses supposed to do about her wound. The resident stated, "They were supposed to put some cream and dress it three times a day." The resident was asked if she had any concerns about the way the nurses took care of her wound?" The resident stated, "Yes, they (facility) changed the treatment nurse about two months ago and this treatment nurse (the nurse that is doing the treatments now) isn't as careful as the previous wound care nurse. This one gets by with as little as possible. The wound was to be changed and treated three times a day and this treatment nurse didn't keep on top of it." h. The October 2010 TAR documented: "(9/30/10) [MEDICATION NAME] Ag. cut to fit and cover with 4x4 and secure with tape. Change Q (every) 3 days. " There was no documentation on the October 2010 TAR to indicate the dressing was changed on 10/4/10. 2. Resident #5 had [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] documented the resident had severely impaired cognitive skills for daily decision making, required extensive to total assistance with activities, was incontinent of urine and stool, had one Stage II pressure sore, one Stage III pressure sore and one Stage IV pressure sore. a. The September 2010 TAR documented a physician's orders [REDACTED]. Apply Santyl and cover with S (Saline) fluffed gauge q d (every day). The TAR also documented a physician order [REDACTED]. The treatments were scheduled to be complete on the 8:00 a.m. -5:00 p.m. shift and the 11 p.m. - 7:00 p.m. shift. The TAR had no documentation to indicate the dressing had been done on the 8-5 shift for 9/9/10 - 9/10/10. Crossed through on the TAR was a wound care order that documented to cleanse stage III to (left buttock 1) On 10/7/10 at 2:55 p.m., LPN #6 was asked if she was responsible for wound treatments on September 9th and10th for (Resident #5)? LPN #6 stated, "Yes." LPN #6 was unable to show documentation on the TAR that the dressing on the right leg and buttocks had been done for 9/9/10 and 9/10/10. LPN #6 stated, "It is not documented that the treatment to the right leg and Stage 3 (decubitus) on the buttocks were done, but I did them. 2) A written statement dated 10/8/10 and signed by LPN #5 documented, "Not aware of any treatment order that were Q (every) shift. I will be more aware for resident orders and check my MAR/TAR at the end of each shift..." 3) A written statement dated 10/8/10 and signed by LPN #7 documented, "The treatments on (Resident #5) were not done because I was not aware that he had an 11-7 treatment due. This was an oversight and I will check the TARS in the future..." b. A Physician's telephone order dated 10/4/10 documented, "Discharge to home with meds with personal effects. (Home Health Agency) to evaluation..." c. The (Home Health Agency) documented on 10/7/10, "...Pt's (patient's) wound measurements obtained this visit. Prior to rehab stay right heel measured 2 cm (centimeter) x 2 cm x 1 cm, granulating, beefy red in color and draining serous colored drainage. Pt's wound this date with large amount of black eschar to heel measuring 5 cm x 5 cm...Pt's wound to buttocks before rehab stay measured 4 cm x 2 cm, beefy red and granulating. Pt's wound now after rehab stay continues to be Stage 2 decub to upper buttocks measuring 3 cm x 2 cm x 0.1 cm..." 3. Resident #10 had [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented the resident had modified independence in cognitive skills for daily decision making, required total assistance with activities of daily living, was incontinent of urine and stool and had no wound or skin problems. a. The Care Plan with a review date of 7/28/10 documented, " Problem: Risk for skin breakdown related to incontinence and decreased mobility. ...Approaches: ...Tx (treatment) ...as ordered per M.D. (Medical Doctor). " b. A physician order [REDACTED]. Apply TAO (Triple Antibiotic Ointment) and cover with 4 x 4's and wrap with Kerlix Q day till healed." The September 2010 TAR showed no documentation to indicate the dressing had been done on 9/25/10 and 9/26/10. c. On 10/7/10 at 6:15 p.m., LPN # 1 was asked about the omitted documentation on the TAR. The LPN stated, "I did the dressing on the skin tear both days, but did not document it." 4. Resident #11 had [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented the resident had severely impaired cognitive skills for daily decision making, required total assistance from staff for activities of daily living, was incontinent of urine or stool and had 2 Stage II decubitus ulcers a. The September 2010 TAR documented the following physican wound care orders: 1) " (5/28/10) Allenderm to Stage 2 on coccyx Q day. " There was no documentation on the TAR that a dressing change was done on 9/4/10, 9/5/10 and 9/16/10. 2) " (5/28/10) [MEDICATION NAME] to right hip wound pack with 4 x 4, cover with ABD and secure with tape Q day". There was no documentation on the TAR that the dressing was done on 9/4/10, 9/5/10 and 9/16/10. 3) "(6/10/10) [MEDICATION NAME] Cream to groin rash Bid (2 times a day)." There was no documentation that the treatment was done on 9/4/10, 9/5/10 and 9/6/10. 4) "(7/8/10) [MEDICATION NAME] to coccyx/buttocks Q day." There was no documentation that the treatment was done on 9/4/10, 9/5/10 and 9/16/10. 5) "(8/25/10) [MEDICATION NAME] to Stage 2 on right foot, great toe Q day." There was no documentation that the treatment was done for 9/4/10, 9/5/10, 9/16/10, 9/25/10 and 9/26/10. b. On 10/7/10 at 6:15 p.m., LPN #1and LPN #2 were asked regarding the wound care for (Resident #11). LPN #1 stated, "The dressings were not done on 9/4/10 and 9/5/10." LPN # 2 stated, "I did the dressing on 9/16/10 but did not document." 5. On 10/8/10 at 1:45 p.m., the Director of Nurses (DON) was asked who was responsible for ensuring that the staff followed the physician orders [REDACTED]. The DON was asked, "Do you have any documentation that the issues of dressing changes that were omitted and /or not documented were discussed? The DON stated, "No, I don't believe we have any documentation stating that we (facility) had problems with residents with dressings not being done or documented." 6. On 10/8/10 at 4:45 p.m. the Director of Nurses provided a written statement that documented, "On 10/7/10 and 10/8/10 I spoke to and obtained statements from 6 staff members regarding why they had not completed and documented treatments that were scheduled to be performed on their shift. On the whole the staff voiced that the treatment nurse was responsible for the treatments. They did not appear to recognize that they were also responsible for treatments and that the treatment nurse cannot be the only person responsible as she does not work 24 hours a day or 7 days a week. The staff also did not appear to recognize the importance of documenting the treatments that they did provide or that as charge nurses that they should be knowledgeable of the orders which include treatment on all the residents that they are assigned to care for. "