Every finding on record at Trenton Health and Rehabilitation Center, LLC

Based on policy review, observation, and interview, the facility failed to ensure food was properly stored and labeled, and failed to ensure the kitchen equipment was clean. The facility had a census of 49 with 48 of those residents receiving a food tray from the Kitchen. The findings include: 1. Review of the facility policy titled, Food Storage, dated [DATE], revealed Food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded. During a power failure, frozen and refrigerated foods are properly handled .All products should be dated upon receipt and when they are prepared. Use 'use-by-dates on all food stored in refrigerators .Remember to cover, label, and date! Any expired or outdated food products should be discarded .Label and date all storage containers or bins . Review of the facility policy titled, Sanitation Criteria/Forms, dated [DATE], revealed .Check every piece of equipment for cleanliness inside, outside, top, bottom, and sides . Review of the facility policy titled, Cleaning Schedules, dated [DATE], revealed .The Dietary staff shall maintain the sanitation of the Dietary Department through compliance with written, comprehensive cleaning schedules . 2. Observation in the Kitchen on [DATE] at 8:05 AM, revealed the following: a. a thick black buildup of an unknown substance on the inside of the standing oven. b. a brown buildup of an unknown substance on the inside of the doors of the standing oven. c. a black, shiny buildup of an unknown substance on 3 of the cooking stoves. 3. Observation in the Kitchen refrigerator, and in the dry food storage area on [DATE] at 9:33 AM, revealed: a. a container of cottage cheese with an unreadable open date and a use by date of [DATE]. b. a container of potato salad with a use by date of [DATE]. c. a plastic bag of opened bologna with no expiration date. d. a plastic bag of cheese slices with no opened date, no expiration date or use by date. e. an unlabeled, undated plastic container which contained a white substance described by Dietary Manager (DM) as sugar. f. a plastic container of thickener with no use by date. During an interview on [DATE] 09:33 AM, the DM confirmed food items should be labeled to identify what it is, with an open date, and with a use by date. The DM confirmed food items passed the use by date should be discarded and not on the shelf for use. 4. Observation in the Kitchen on [DATE] at 8:41 AM, revealed the following: a. a thick black buildup of an unknown substance on the inside of the standing oven. b. a brown buildup of an unknown substance on the inside of the doors of the standing oven. c. a black, shiny buildup of an unknown substance on 3 of the cooking stoves. During an interview on [DATE] at 8:41 AM, the DM confirmed inside the standing oven there was a thick buildup of a black unknown substance, and it should not be there. The DM confirmed the standing oven doors had a buildup of a brown unknown substance, and it should not be there. The DM confirmed 3 of the cooking stove's eyes had a black, shiny buildup on them and it should not be there.

Based on policy review, medical record review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 2 staff (Licensed Practical Nurse (LPN A) failed to perform proper hand hygiene during medication administration, and when 1 of 1 staff (LPN B) failed to perform proper hand hygiene during wound care. The findings include: 1. Review of the facility policy titled, Handwashing/Hand Hygiene, dated 8/2019, revealed .This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub .or alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations .After removing gloves .Hand hygiene is the final step after removing and disposing of personal protective equipment .Washing Hands .Rinse hands with water and dry thoroughly with a disposable towel .Use towel to turn off faucet . 2. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes, Dysphagia, and Gastrostomy Status. Review of the Physician's Order dated 12/9/2024, revealed Gabapentin, used to treat neuropathy pain, 300mg 1 capsule via (by way of) PEG-Tube (Percutaneous Endoscopic Gastrostomy Tube inserted in the stomach to provide nutrients, hydration, and medication) two times a day related to Trigeminal neuralgia . Observation during medication administration on 12/10/2024 at 9:17 AM, revealed LPN A administered Gabapentin 300mg via Peg tube to Resident #16. LPN A removed gown and gloves, entered the resident's bathroom, and washed hands with soap and water. LPN A turned the faucet off with the left bare hand and dried her hand with a paper towel. LPN A failed to use a towel to turn off the water faucet. 3. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Heart Failure, and Unstageable Pressure Ulcer. Review of the admission Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview for Mental Status score of 9, which indicated moderate cognitive impairment. Review of the Physician's Order dated 11/15/2024, revealed APPLY SURE PREP TO ALL TOES ON BOTH FEET AND RIGHT HEEL Q SHIFT FOR PROTECTION. KEEP SOCK ON RIGHT FOOT WHILE IN BED AS RESIDENT WILL ALLOW. Review of the Physician's Order dated 12/4/2024, revealed CLEANSE TOP OF LEFT DORSAL FOOT WITH HIBICLENS [antimicrobial soap used to cleanse wounds] AND NORMAL SALINE. PAT DRY. PAINT ESCHAR AND PERIWOUND TO TOP OF LEFT FOOT WITH BETADINE [a topical used to reduce bacteria] DAILY, APPLY NONADHERENT DRESSING AND WRAP DAILY UNTIL RESOLVED. Review of the Physician's Order dated 12/6/2024, revealed CLEANSE LEFT HEEL WITH WOUND CLEANSER, PAT DRY, APPLY COLLAGEN THEN ALGINATE WITH SILVER, ABD PAD AND WRAP WITH KERLIX. CHANGE DAILY AND AS NEEDED UNTIL RESOLVED. Observation on 12/10/2024 at 4:08 PM, revealed LPN B in the hallway, preparing to do wound care for Resident #7. LPN B donned gloves, stuck her hand in the pocket of her scrub top and obtained the key to the cart, unlocked the cart, opened a drawer on the cart, obtained gauze pads from a multi pack container, and placed the gauze in a cup and placed the cup on a barrier on top of the treatment cart. LPN B then removed more gauze from the package and placed it in a second cup and placed it on the barrier on top of the cart. LPN B wet the gauze in the first cup with Hibiclens and wet the gauze in the second cup with Betadine, finished setting up treatment supplies, and removed her gloves. LPN B gathered the treatment supplies and placed them in plastic bags, knocked on the door and entered Resident #7's room. LPN B placed the treatment supplies on the over the bed table, entered the bathroom, washed her hands with soap and water, then turned the faucet off with her bare left bare hand, and dried her hands with a paper towel. LPN B donned a gown, and gloves positioned Resident #7, removed the dressing from the resident's Left foot, cleaned the wound to the top of the left foot with saline and Hibiclens gauze, painted the wound with the betadine-soaked gauze and completed wound care to the left foot as ordered. LPN B removed gloves, donned new gloves and applied sure prep to the toes on both feet, removed her gown and gloves, entered the bathroom and washed her hands with soap and water, turned off the faucet with her bare left hand, then dried her hands. LPN B donned gloves and removed trash from the room. LPN B failed to use a towel to turn off the water faucet and failed to use proper hand hygiene. 4. During an interview on 12/11/2024 at 8:11 AM, the Director of Nursing confirmed that faucet should not been turned off with bare hands and staff should perform hand hygiene in between changing gloves.

Based on policy review, medical record review, observation, and interview, the facility failed to follow physician orders for oxygen and provide necessary respiratory care consistent with professional standards of practice for 2 of 3 (Resident #35 and #39) sampled residents reviewed for oxygen therapy. The findings include: 1. Review of the undated facility policy titled, Oxygen Administration, revealed .Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration .The following equipment and supplies will be necessary when performing this procedure .Portable oxygen cylinder (strapped to the stand) .Humidifier bottle .Regulator . Review of the facility policy titled, Infection Prevention and Control Program, dated October 2018, revealed .An infection prevention .is established and maintained to provide safe, sanitary and comfortable environment . 2. Review of medical record revealed Resident #35 was admitted on [DATE], and readmitted on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, and Dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #35 was mildly cognitively impaired and was assessed for oxygen therapy. Review of the Physician's orders dated 10/4/2024, revealed .O2 @ 2L BNC every day and night shift related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . Review of the October, November, and December 2024 Medication Administration Record revealed oxygen at 2 liters BNC was documented as administered. Observation in the Resident's room on 12/10/2024 at 2:10 PM, 3:58 PM, and 4:00 PM, revealed Resident was sitting up in bed, oxygen at 3.5 liters/BNC. During an interview on 12/10/2024 at 4:18 PM, the Director of Nursing (DON) confirmed that oxygen should be set at the correct rate and that physician orders should be followed. 3. Review of the medical record revealed Resident #39 was admitted on [DATE], with diagnoses including Chronic Respiratory Failure, Cerebral Infarction, and Hemiplegia. Review of the Physicians Order dated 6/13/2024 revealed . O2 @ 2L/MIN BNC CONT. [continuous] SOB [short of breath]/SUPPLEMENTAL every day and night shift related to Chronic respiratory failure . Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #39 was cognitively intact. Observations in Resident #39's room on 12/9/2024 at 8:56 AM, 1:33 PM, and 3:49 PM, revealed 02 at 2l/min with the water humidifier bottle sitting. During an interview on 12/11/24 at 8:35 AM, the DON was asked should the oxygen humidified water bottle be on the floor. The DON stated, No, It should be held on the concentrator machine. [NAME], [NAME] (50408)

Based on policy review, medical record review, and interview, the facility failed to ensure residents were free from fall accident hazards for 1 of 3 (Resident #42) sampled residents reviewed for falls. The staff failed to the ensure the foot pedals where on the wheelchair and the resident's feet could rest on the foot pedals during wheelchair mobility. The finding include: 1. Review of the facility policy titled, Accident and Incident prevention of Residents, dated July 2017, revealed .Our facility strives to make the facility as free from accidents and incidents as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . 2. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Depression, Abnormal Posture, Neurocognitive Disorder with Lewy Bodies, and Adult Failure to Thrive. Review of the Incident Note dated 8/20/2024, revealed .Resdt [resident] unable to self propel. Feet went under wc [wheelchair] and resdt [resident] fell out of chair . Review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed Resident #42 had a Brief Interview for Mental Status score of 0, which indicated the resident was severely cognitively impaired and was dependent upon staff for wheelchair mobility. During an interview on 12/10/2024 at 2:49 PM, the Director of Nursing (DON) confirmed Resident #42 had a fall on 8/20/2024. The DON confirmed staff should have placed the resident's feet on the wheelchair's foot pedals before wheelchair mobility, which the staff failed to do. Resident #42 had a fall as a result of the staff's failure to ensure the resident's feet were placed on the wheelchair's foot pedals during wheelchair mobility.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a medication administration rate of less than 5 percent (%) when 1 of 3 nurses (Licensed Practical Nurse (LPN) #2) failed to properly administer medications for 1 of 5 sampled residents (Resident #20) observed during medication administration. This resulted in a medication administration error rate of 51.52 %. The findings include: Review of the facility's policy titled, Administering Medications through an Enteral Tube, dated 2018, revealed .Administrator each medication separately and flush between medications .Use a clean syringe with an .connector to administer medications through an enteral tube . Review of the facility's policy titled, Medication Administration, dated 3/16/2015, revealed .If applicable and/or prescribed, take vital signs or tests prior to administration of the dose .pulse with digitalis [medication used to treat abnormal heart rhythms] blood pressure with anti-hypertensive .Administer medications within 60 minutes of the scheduled times---For example, if the medication is ordered for 8:00 a.m., it must be give between 7:00 a.m. and 9:00 a.m. In order to be considered timely . Review of medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses of Rheumatoid Arthritis, Diabetes, Atrial Fibrillation, Angina Pectoris, Urinary Retention, Dysphagia, Congestive Heart Failure, and Chronic Kidney Disease. Review of the Physician Orders dated November 2023, revealed the following medications were to be administered at 8:00 AM: a. PREDNISONE (treats inflammation) 10 MG TABLET -oral 8 am Every Day. b. FERROUS SULFATE (treats low iron) 325 MG (65 MG IRON) TABLET, DELAYED RELEASE- oral 8 AM Every Day. c. ASPIRIN (blood thinner) 81 MG CHEWABLE TABLET-oral 8 AM Every Day d. AMIODARON (treats heart rhythms) 200 MG TABLET- oral 8 AM Every Day Take and record pulse. e. DUTASTERIDE (treats enlarged prostate) 0.5 MG CAPSULE 1 BY MOUTH (8 am) f. MULTIVITAMIN (supplement) TABLET -oral 8 AM Every Day. g. SULFASALAZINE (treats inflammation) 500 MG TABLET -oral 8 am 8pm Every Day h. FUROSEMIDE (treats fluid retention) 40 MG TABLET - ORAL twice a day AT 8am & (and) 8 pm Every Day. i. ACODPHILUS (treats digestive disorders) CAPSULE -oral TWICE A DAY AT 8AM & 8PM Every Day. j. ARGINAID (SUPPLEMENT) 4.5 GRAM -156 MG/9.2 GRAM ORAL POWDER PACKET -oral TWICE A DAY AT 8 AM & 8 PM Every Day. k. POTASSIUM CHLORIDE (TREATS LOW LEVELS OF POTASSIUM) 40 milliequivalents(meq)/15 milliliters (mls) ORAL LIQUID-Administer 15 milliliter(s) oral 8 am 8pm Every Day. l. BRILINTA (BLOOD THINNER) 90 MG TABLET -oral 8am 8pm Every Day m. METOPROLOL TARTRATE (treats high blood pressure) 25 mg tablet -ORAL 8AM 8PM Every Day. Take and record pulse. Record blood pressure. HOLD MEDICATION IF diastolic blood pressure LESS THAN 50 or systolic blood pressure less than 110. n. SPIRONOLACTONE (treats heart failure and high blood pressure) 50 MG TABLET-oral 8am 8pm Every Day. RECORD BLOOD PRESSURE. HOLD MEDICATION IF LESS THAN 110/50 AND NOTIFY MD . o. ASCORBIC ACID (VITAMIN C) 500 MG TABLET -oral 8am 8pm Every Day. p. ISOSORBIDE MONONITRATE (prevents chest pain] EXTENDED RELEASE 30 MG TABLET .oral 8am 8pm Every Day. q. RANOLAZINE ER 500 MG TABLET, EXTENDED RELEASE, 12 hour -oral 8am 8pm Every Day. Observations on 11/1/2023 starting at 8:44 AM through 9:20 AM, revealed LPN #2 administered the above listed medications approximately 20 minutes past the timeframe for 8:00 AM medications to be administered by. During an interview on 11/2/2023 at 7:02 AM, the Director of Nursing (DON) was asked if medications are ordered at 8:00 AM should they be administered at 9:20 AM. The DON stated, No ma'am. The DON was asked if the Physician Order specifies to record the pulse or blood pressure, should the vitals be obtained before administering the medications. The DON stated, Yes.

Based on policy review, observation, and interview, the facility failed to ensure proper infection control practices when 5 of 9 (Certified Nursing Assistants (CNA) #4, #5, #6, #7), and Licensed Practical Nurse (LPN #1) staff members failed to perform hand hygiene during meal pass, failed to clean reusable equipment after administering medications, and failed to place a clean barrier between medications and the surface under it. The findings include: 1. Review of the facility policy titled, Handwashing/Hand Hygiene, dated August 2019, revealed .this facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: .When hands are visibly soiled .After contact with a resident with infectious diarrhea including, but not limited to infections caused by .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: .before and after direct contact with residents .after contact with objects in the immediate vicinity of the resident . Review of the facility policy titled, Administering Medications through an Enteral Tube, dated November 2018, revealed .Use a clean enteral syringe .to administer medications . 2. Observation on 10/30/2023 at 11:39 AM, in the resident's room, revealed CNA #7 delivered Resident #141's meal tray, began setting up tray, and touched the milk spout of the milk carton with her bare hands. 3. Observation on 10/30/2023 at 11:40 AM, in the resident's room, revealed CNA #7 delivered a meal tray, placed it on Resident #35's overbed table, repositioned the resident in bed, removed the covers, donned gloves, repositioned the incontinence pad under the resident, then removed her gloves. CNA #7 failed to perform hand hygiene before continuing set up of Resident #35's meal tray. 4. Observation on 10/30/2023 at 11:40 AM, in the resident's room, revealed CNA #5 delivered a meal tray and placed it on the overbed table, repositioned Resident #11 in bed, raised the head of the bed, the CNA failed to perform hand hygiene before she continued to set up the meal tray. 5. Observation on 10/30/2023 at 11:43 AM, In the resident's room, revealed CNA #7 delivered a meal tray and placed it on Resident #19's overbed table, used the remote to adjust the bed, the CNA failed to perform hand hygiene before she continued preparing Resident #19's meal tray. 6. Observation on 10/30/2023 at 11:48 AM, in the resident's room, revealed CNA #5 repositioned Resident #15 in bed by pulling the incontinence pad under the resident without gloves. CNA #5 failed to perform hand hygiene before she continued to open and set up the resident's meal tray. 7. Observation on 10/30/2023 at 11:49 AM, in the resident's room, revealed CNA #7 delivered Resident #21's meal tray, removed the pillow between resident's legs, the CNA failed to perform hand hygiene before completing set up of the meal tray and touched the milk spout of the milk carton with bare hands. 8. Observation in the resident's room on 10/31/2023 at 8:50 AM, revealed RN #1 entered Resident #15's room with ordered medications, sat the nasal spray and cup containing medications on the over bed table, and administered insulin as ordered. After throwing the trash away, RN #1 placed the nasal spray and insulin pen on the top of the medication cart. RN #1 failed to place a barrier under the nasal spray and the insulin pen, didn't clean them, and placed them back into their respective sealed bags. 9. Observation in the resident's room on 10/31/2023 at 4:02 PM, revealed LPN #2 entered Resident #26's room with ordered medications. LPN #2 wiped down the over the bed table and placed the barrier on top of it. She set the cup of medications down on top of the barrier and went into the bathroom to wash her hands. LPN #2 failed to always keep ordered medications in her line of sight when she went into the bathroom. LPN #2 administered the medications through Resident #26's PEG tube with the provided syringe and failed to wash the syringe out before placing it back into its protective bag. 10. Observation in the resident's room on 11/2/2023 6:10 at 6:10 AM, revealed LPN #3 entered with Resident #142's ordered medications. LPN #3 administered the medications through Resident #142's PEG tube with the provided syringe and failed to wash the syringe out before placing it back into its protective bag. 11. Observation on 11/2/2023 at 7:20 AM, in the resident's room, revealed LPN #1 delivered Resident #93's meal tray, used the remote to elevate the head of the bed, the LPN failed to perform hand hygiene before setting up the meal tray and touched the milk spout of the milk carton with bare hands. 12. Observation on 11/2/2023 at 7:24 AM, in the resident's room, revealed CNA #6 delivered a meal tray and placed it on the overbed table, removed CPAP (Continuous Positive Airway Pressure) mask from Resident #30's face, placed the mask in the respective bag, placed oxygen tubing on Resident #30's face, repositioned resident in bed, the CNA failed to perform hand hygiene before continuing set up of the resident's meal tray. 13. Observation on 11/02/2023 at 7:30 AM, in the resident's room, revealed CNA #4 delivered Resident #29's meal tray and placed it on the overbed table, used remote to raise the head of the bed, the CAN failed to perform hand hygiene before she continued setting up the meal tray. 14. Observation on 11/02/2023 at 7:32 AM, in the resident's room, revealed CNA #4 entered Resident #35's room, placed the tray on the over the bed table, began opening items on the tray, the CNA failed to perform hand hygiene before setting up the meal tray after delivering previous meal tray to another resident. 15. Observation on 11/2/2023 at 7:33 AM, in the resident's room, revealed LPN#1 repositioned Resident #37 up in the bed, raised the head of the bed, moved the over bed table to the other side of the bed, the LPN failed to perform hand hygiene before she attempted to open the milk carton by using her fingers to pull on the milk spout of the carton. LPN #1 continued to open meal tray without hand hygiene. 16. Observation on 11/2/2023 at 7:35 AM, revealed CNA #4 delivered a meal tray and placed it on the overbed table, opened all items on the tray, donned gloves, repositioned Resident #143 in bed, used the remote to elevate the head of the bed, The CNA failed to doff gloves or perform hand hygiene before she began assisting the resident with her meal. 17. Observation on 11/2/2023 at 7:37 AM in resident's room, revealed LPN #1 delivered Resident #14's meal tray, switched on the light, used the remote to elevate the head of the bed, the LPN failed to perform hand hygiene before she continued setting up the meal tray. 18. Observation on 11/2/2023 at 7:39 AM, in resident's room, revealed LPN #1 delivered Resident #141's tray, assisted resident to the side of bed, washed resident's hands, the LPN failed to perform hand hygiene and touched the spout of the orange juice carton. 19. During an interview with the Director of Nursing (DON) on 11/2/2023 at 10:50, the DON confirmed hand hygiene should be performed prior to meal tray setup, after touching objects in the resident's room, and after readjusting the resident in in the bed. The DON was asked if staff should open the milk carton without performing hand hygiene, then using their bare fingers to open the inside spout of the milk carton. The DON stated, No, that shouldn't have happened .

Based on the medical record review, and interview, the facility failed to resubmit a Preadmission Screening and Resident Review (PASRR) after the resident had a new mental health diagnosis and new antipsychotic medication for 1 of 6 sampled residents (Resident #15) reviewed for PASRR. The findings include: Review of the medical record review revealed Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Dementia, Schizoaffective Disorder, Anxiety, and Delusional Disorder. Resident #15 had a PASRR completed in 2018 with diagnosis of anxiety disorder. On 12/13/2021, Resident #15 had a new mental health diagnosis of Schizoaffective disorder and the antipsychotic medication Seroquel was added. Review of the Physician's Order dated 3/27/2023 revealed, .Schizoaffective disorder .Seroquel 50 mg [milligram] tablet: Administer 1.5 tablet .TWICE A DAY . During an interview on 11/2/2023 at 6:20 AM, the Regional Director of Clinical Reburstment stated, .we did have a wavier but it's not going to help us .wavier started 12/22/2020 .if they have a diagnoses of terminal illness gave us 180 day to complete the PASRR should have had one 6 months after that .in October .because of the Schizoaffective disorder .Seroquel .waver ended May 23rd, of 2023 . The Regional Director of Clinical Reburstment confirmed a new PASRR should have been done for the new diagnosis and for the antipsychotic medication.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly and securely stored when a medication was left in a resident's room for 2 of 6 (Resident #31 and #26) sampled residents. The findings include: Review of the facility's policy titled, Medication Administration dated 3/16/2015, revealed .Observe that the resident swallow oral drugs. Do not leave medications with the resident . Review of the facility's policy titled, Storage of Medications dated 4/2019, revealed .The facility stores all drugs and biologicals in a safe, secure, and orderly manner .Drugs and biologicals used in the facility are stored in locked compartments .the nursing staff is responsible for maintaining medication storage . Observations in the resident room on 10/30/2023 at 9:40 AM, revealed Resident #31's door was open. Resident was in bed with her eyes closed. On top of the bedside table revealed 9 opened, unsecured medications in a medication cup left unattended beside the resident's bed. During an interview on 10/30/2023 9:43 AM, LPN #1 stated, .I left the meds .she does take them by herself .I sat them down on the table .I shouldn't have left them .I asked the resident to take them at 8:20 AM but she refused . LPN #1 was asked if Resident #31 was capable of administering her medications independently. LPN #1 stated, No. LPN #1 was asked if wandering residents were present on the hallway. LPN #1 stated, Yes, but I must not have shut the door good . Observations in the resident room on 10/31/2023 at 4:02 PM, revealed LPN #2 sat the cup containing Resident #26's medications on the overbed table and left the medications unattended and out of sight when LPN #2 went to the bathroom to wash her hands. During an interview on 11/2/2023 at 10:39 AM, the Director of Nursing (DON) was asked should medications be left in a resident's room unsecured and unattended. The DON stated No.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure the practices to prevent the potential spread of infection were followed when nursing staff did not keep an indwelling urinary catheter drainage bag off of the floor and failed to perform hand hygiene during catheter care for 2 of 3 (Resident #19 and #36) sampled residents reviewed with indwelling urinary catheters. The finding include: 1. The facility's Catheter Care, Urinary policy dated 2001 and revised (MONTH) 2014, documented .Be sure the catheter tubing and drainage bag are kept off the floor . The facility's Handwashing/Hand Hygiene policy dated 2001 and revised (MONTH) (YEAR), documented .Use an alcohol-based hand rub .or, alternatively, soap .and water for the following situations .After contact with objects ( .medical equipment ) in the immediate vicinity of the resident .After removing gloves .Perform hand hygiene before applying non-sterile gloves . 2. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].CATHETER TO BSDB (Bed Side Drainage Bag) R/T (Related To) UNSTAGEABLE SACRACALC[NAME]CYGEAL AREA . Observations in Resident #19's room on 7/8/19 at 8:39 AM, revealed the catheter bag was lying on the floor between the bed and the wall. Observations in Resident #19's room on 7/8/19 at 3:31 PM, 7/9/19 at 7:51 AM, and 9:49 AM, and 7/10/19 at 8:14 AM, revealed the catheter bag secured to the bed frame with the bottom of the bag resting on the floor. Observations in Resident #19's room on 7/10/19 at 10:28 AM, revealed Certified Nursing Assistant (CNA) #1 and #2 were preparing to do catheter care. CNA #1 and #2 washed their hands, donned gloves, and set up supplies on the bedside table. CNA #1 removed her gloves and donned new gloves, without performing hand hygiene, then CNA #1 and #2 performed catheter care on Resident #19. Interview with Licensed Practical Nurse (LPN) #1 on 7/9/19 at 9:49 AM, in Resident #19's room, LPN #1 was asked to observe the catheter bag. LPN #1 was asked if the catheter bag should be touching the floor. LPN #1 stated, No, Ma'am. 3. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED].FOLEY CATH (Catheter) .TO BEDSIDE DRAINAGE BAG R/T [MEDICAL CONDITION] BLADDER AND STAGE 4 PRESSURE ULCER . Observations in Resident #36's room on 7/10/19 at 7:27 AM, revealed Resident #36's indwelling urinary catheter bag was lying in the floor. Interview with the Director of Nursing (DON) on 7/10/19 at 1:30 PM, in the Conference Room, the DON was asked if catheter bags should be touching the floor. The DON stated, No. The DON was asked what would she expect staff to do when changing gloves. The DON stated, Wash their hands.

Based on policy review, observation and interview the facility failed to ensure food was prepared and served under sanitary conditions as evidenced when 1 of 4 (Dietary Manager) dietary staff members failed to perform hand hygiene, and 1 of 11 (Certified Nursing Assistant (CNA) #1) failed to perform hand hygiene during dining. The facility had a census of 45, with 43 of those residents receiving a tray from the kitchen. The findings include: 1. The facility's Hand-Hygiene Technique policy documented, .The purpose of this procedure is to provide guidelines to employees for proper and appropriate hand washing and hand hygiene techniques that will aid in the prevention of the transmission of infections .If hands are not visibly soiled, use an alcohol-based hand rub for all the following .After contact with inanimate objects .medical equipment . 2. Observations in the kitchen on 8/14/18 at 11:37 AM, revealed the Dietary Manager dropped a glove on the floor, picked the glove up, and threw it in the garbage can, then donned a pair of gloves and performed the tray line temperatures without performing hand hygiene. Interview with the Dietary Manager on 8/14/18 at 3:40 PM in the kitchen, the Dietary Manager was asked if staff should wash their hands before gloves are donned after a glove was dropped on the floor, picked up and placed in the garbage can. The Dietary Manager stated, .Yes . 3. Observations in the dining room on 8/13/18 beginning at 11:45 AM, revealed Certified Nursing Assistant (CNA) #1 touched the brake on Resident #41's wheelchair, cut up the vegetables on the resident's tray, placed the tray lid back on the serving cart with the meal trays that had not been served, took a tray off the serving cart, walked to the back of the dining room and placed the tray back on the serving cart with other meal trays. CNA #1 served Resident #39's tray and completed tray set up, served Resident #38's tray and completed tray set up, and then placed Resident #39's tray lid back on the serving cart with other meal trays. CNA #1 served Resident #9's tray, completed tray set up, placed butter on the resident's roll, cut up the resident's vegetable, moved the round table and then fed Resident #16 without performing hand hygiene. Interview with the Director of Nursing (DON) on 8/14/18 at 3:29 PM, in the DON office, the DON was asked if it was acceptable to touch a brake on a wheel chair and serve trays without performing hand hygiene. The DON stated, No, not without using hand sanitizer. The DON was asked if it was acceptable to put a resident's food tray back in the serving cart after a wheelchair brake had been touched while trays were being served. The DON stated, No.

Based on medical record review, observation and interview the facility failed to promote and maintain dignity for 1 of 2 (Resident #293) sampled residents reviewed with a urinary catheter when staff failed to provide a dignity bag for the urinary drainage bag. The findings include: Medical record review revealed Resident #293 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician orders [REDACTED]. Observations in Resident #293's room on 8/13/18 at 8:54 AM, 9:41 AM, 12:15 PM, and 5:15 PM and on 8/14/28 at 8:26 AM and 10:23 AM revealed a urinary drainage bag hanging from the bed with no dignity bag or cover over the drainage bag. Interview with the Director of Nursing (DON) on 8/14/18 at 10:20 AM, in the DON office, the DON confirmed there should be a dignity cover on the urinary drainage bag.

Based on observation and interview the facility failed to ensure the environment was free of accident hazards when aerosol spray and oxygen were observed in 2 of 30 (room [ROOM NUMBER] and #204) resident rooms. The findings include: 1. Observations in room [ROOM NUMBER] on 8/13/18 at 8:28 AM, 10:04 AM, 12:10 PM, 1:58 PM, and 5:02 PM, and 8/14/18 at 8:14 AM, revealed a can of aerosol hair spray on the bedside table and oxygen concentrator at the head of the bed. Observations in room [ROOM NUMBER] on 8/13/18 at 8:43 AM, revealed a can of aerosol hair spray on the bedside table and oxygen in use. Interview with the Director of Nursing (DON) on 8/14/18 at 8:40 AM, in the hall outside the Administrative offices, the DON was asked if aerosol hairspray should be stored in a resident's room where oxygen is stored. The DON stated, .No .

Based on policy review, medical record review, and interview the facility failed to refund 1 of 1 (Resident #6) sampled resident's trust account balances within 30 days of death. The findings included: 1. The facility's .Patient Trust fund policy and procedure documented, .refunds for expired residents must be complete and refunded within thirty days of date of death . 2. Medical record review of a Nursing note revealed XXX[DATE] .resident .expired . Interview with the Business Office Manager on [DATE] at 11:05 AM, in the Business Office Manager's office, the Business Office Manager was asked about Resident #6's trust account refund, the Business Office Manager stated, .it (balance of the resident's account) was refunded on the 10th (of July) . The facility did not convey Resident #6's funds within 30 days following her death.

Based on policy review, medical record review, observation and interview the facility failed to accurately assess the resident's dental status and [DIAGNOSES REDACTED].#29 and 30) residents reviewed of the 24 residents included in the Stage 2 review. The findings included: 1. The facility's .Dental Services . policy documented, .Purpose .To insure that proper oral health is maintained in the residents . 2. Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the dental section did not document cavity or broken natural teeth for Resident #29, but did check- none of the above, indicating no dental problems. Review of Resident #29's (named) DENTAL form dated 11/17/14 documented .Teeth are mostly broken . Observation in Resident #29's room on 7/31/17 at 9:52 AM, revealed Resident #29 had numerous missing and broken teeth. Interview with Certified Nursing Assistant (CNA) #1 on 8/1/17 at 3:48 PM, in the Cinema Room, CNA #1 was asked to describe Resident #29's teeth. CNA #1 stated, They are broken off down to the gums. They are rotten. They are black and have jagged edges. Interview with the MDS Coordinator on 8/2/17 at 10:04 AM, outside Resident #29's room, the MDS Coordinator was asked if the annual MDS was accurate. The MDS Coordinator stated, I should have marked the broken (teeth) .I didn't .They are worn down to the gum . 3. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].depressive episodes .[MEDICATION NAME] .(an antidepressant medication) 40 MG (milligrams) TABLET GIVE ONE TABLET BY MOUTH DAILY IN AM (morning) . Review of a 5 day comprehensive MDS dated [DATE] and a quarterly MDS dated [DATE] revealed that a [DIAGNOSES REDACTED]. Interview with the MDS Coordinator on 8/2/17 at 11:12 AM, in the MDS office, the MDS Coordinator was asked if the 11/1/16 and 3/4/17 MDS assessments for Resident #30 should have been coded for a [DIAGNOSES REDACTED].

Based on medical record review and interview, the facility failed to ensure the comprehensive assessments were accurate related to height, diagnosis, range of motion, and medications for 11 of 20 residents (Resident #12, 19, 26, 28, 40, 61, 62, 70, 38, 50 and 60) sampled residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] did not document a height for Resident #12. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] did not document a height for Resident #19. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] did not document a height for Resident #26. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] did not document a height for Resident #28. Medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] did not document a height for Resident #40. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] did not document a height for Resident #61. Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] did not document a height for Resident #62. Medical record review revealed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] did not document a height for Resident #70. Interview with the MDS Coordinator on 5/10/16 at 2:00 PM, in the MDS office, the MDS Coordinator was asked where the resident's height is coded. The MDS coordinator stated, It should be coded on the admission assessment and every assessment after that. I know that we don't have them like we are supposed to .the information just hasn't been in place .I knew it was going to be a problem . Interview with the MDS Nurse on 5/10/16 at 2:30 PM, in the MDS office, the MDS Nurse was asked if there were heights coded on the admission MDS assessments for Resident #61, 40, 26, 19, 12, 28, 62, and 70. The MDS nurse confirmed that there were no heights recorded for those residents' admission MDS assessments. 2. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented, .Functional Limitation in Range of Motion .Impairment on both sides .Upper extremity .Impairment on both sides .Lower extremity . The admission MDS dated [DATE] documented, .Functional Limitation in Range of Motion .No impairment .Upper extremity .Impairment on both sides .Lower extremity . Interview with the MDS nurse on 5/11/16 at 10:10 AM, in the MDS office, the MDS nurse was asked if the MDS dated [DATE] should have documented impairment in range of motion on both sides. The MDS nurse stated, I would say no. 3. Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] did not document a diuretic medication for Resident #50. The physician's orders [REDACTED].[MEDICATION NAME] 20 MG (milligrams) .Give 1 tablet 1 time daily . The annual MDS dated [DATE] did not document an antipsychotic medication for Resident #50. The physician's orders [REDACTED].[MEDICATION NAME] 5 MG .Give 1 tablet by mouth 1 time daily at bedtime . Interview with the Director of Nursing (DON) on 5/11/16 at 4:01 PM, in the conference room, the DON was asked should the quarterly MDS dated [DATE] have documented a diuretic medication for (Resident #50). The DON stated, Yes . The DON was asked should the quarterly MDS dated [DATE] have documented antipsychotic medication for Resident #50. The DON stated, Yes . 4. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED].[MEDICATION NAME] 0.5 MG (milligrams) TABLET GIVE ONE TABLET BY MOUTH FOUR TIMES DAILY AS NEEDED . The MAR indicated [REDACTED] a. 2/19/16 at 9:15 PM b. 2/20/16 at 7:44 PM c. 2/21/6 at 8:45 PM d. 2/24/16 at 11:13 PM The quarterly MDS dated [DATE] did not document a [DIAGNOSES REDACTED].#60. Interview with the MDS nurse on 5/11/16 at 7:35 PM, in the MDS office, the MDS nurse was asked if the quarterly MDS dated [DATE] documented a [DIAGNOSES REDACTED].#60. The MDS nurse stated, No.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner as evidenced by 4 of 8 staff members (Dietary Manager (DM), Cook, Dietary Aide (DA), and Certified Nursing Assistant (CNA) #2 and a delivery man had hair uncovered, and the Cook failed to perform proper hand hygiene on the tray line. The facility had a census of 36, with 33 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's Dietary Department Guidelines policy documented, .employees will wear .hair restraints . 2. Observations in the kitchen on 5/9/16 at 8:30 AM, revealed the DM with hair not completely covered by a hair restraint. Observations in the kitchen on 5/10/16 at 5:40 PM, revealed the DM, Cook, and DA with hair not completely covered by hair restraint. Observations on 5/11/16 at 9:35 AM, revealed CNA #2 entered the kitchen without a hair restraint. Observations on 5/11/16 at 10:41 AM, 10:45 AM, and 10:48 AM, revealed a delivery man entered the kitchen without a hair restraint. Interview with the DM on 5/11/16 at 3:30 PM, in the hall outside the conference room, the DM was asked if anyone entering the kitchen should wear a hair restraint. The DM stated, Yes . The DM was asked if hair should be completely covered by a hair restraint. The DM stated, I would agree . 3. Observations in the kitchen on 5/10/16 at 5:40 PM, revealed the Cook had on gloves and picked up a metal pan, touched the quiche with both hands, and picked up a roll, then opened the drawer on a metal stand with gloved hands and continued to serve the quiche touching it with both hands and picked up a roll without changing gloves and performing hand hygiene. Interview with the DM on 5/11/16 at 3:30 PM, in the hall outside the conference room, the DM was asked if you would expect staff to touch objects, then touch the food, with the same gloves without performing proper hand hygiene. The DM stated, No ma'am .

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and treatment as ordered to promote healing for 2 of 3 (Residents #26 and 60) residents reviewed with pressure ulcers. The findings included: 1. The facility's .Wound Care Management policy documented, When a pressure ulcer is identified, the licensed nurse will document the wound in the Wound Assessment Module .Residents with .known pressure ulcers will be assessed .weekly . 2. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Wound Assessment Report dated 3/23/16 documented, .Wound Type Pressure Ulcer .Wound Location Left Heel .Stage Unstageable due to suspected deep tissue injury .Date wound identified 3/23/2016 . Review of the Wound Assessment Reports revealed no wound assessments were documented from 4/20/16 to 5/4/16. Interview with the Director of Nursing (DON) on 5/11/16 at 1:25 PM, in the conference room, the DON confirmed there was a pressure ulcer on Resident #26's left heel. The DON was asked if she knew why the wound assessment had not been done from 4/20/16 to 5/4/16. The DON stated, No . 3. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Wound Assessment Report dated 1/18/16 documented, .Wound Type .Pressure Ulcer .Wound Location .Left Heel .Stage .Unstageable due to suspected deep tissue injury .Date wound identified .1/18/16 . Review of the Wound Assessment Reports revealed no wound assessments were documented from 4/18/16 to 5/4/16. Interview with the DON on 5/11/16 at 2:35 PM, in the conference room, the DON was asked about the wound assessments for Resident #60 for the time period between 4/18/16 and 5/4/16. The DON stated, .I can't find them .

Based on medical record review and interview, the facility failed to develop a care plan related to pressure ulcers, contractures and range of motion, weight loss, dehydration, and medications for 7 of 20 (Resident #26, 38, 60, 66, 30, 31, and 50) sampled residents of the 32 residents included in the stage 2 review. The findings included: 1. Medical Record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Wound Assessment Report dated 5/4/16 documented, .Wound Type .Pressure Ulcer .Wound Location .Left Heel .Stage .Unstageable due to suspected deep tissure injury . The care plan dated 4/5/16 did not document a care plan for a pressure ulcer. Interview with the Minimum Data Set (MDS) nurse on 5/11/16 at 2:10 PM, in the MDS office, the MDS Nurse was asked if Resident #26 had a care plan related to pressure ulcers. The MDS Nurse stated, No. The MDS Nurse was asked if there should be a care plan for pressure ulcers for Resident #26. The MDS Nurse stated, Yes ma'am, there should be . 2. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] documented, .Functional Limitation in Range of Motion .No impairment .Upper extremity .Impairment on both sides .Lower extremity . The care plan dated 4/21/16 did not document a care plan for contractures or range of motion (ROM) for Resident #38. Interview with the MDS Nurse on 5/11/16 at 10:10 AM, in the MDS office, the MDS Nurse was asked if she could see documentation on the care plan related to ROM or contractures for Resident #38. The MDS Nurse stated, I do not. The MDS Nurse was asked if there should be a care plan related to contractures or ROM for Resident #38. The MDS Nurse stated, I would assume so. 3. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Weight Report documented, .3/2/16 .197 (pounds) .3/9/16 .190 (pounds) .3/29/16 .177 (pounds) . A dietary note dated 4/14/16 documented, .IDT (interdisciplinary team) weight loss meeting today for drastic drop in weights . The care plan dated 2/26/16 did not document a care plan for weight loss for Resident #60. Interview with the DON on 5/11/16 at 5:10 PM, in the Administrative Office copy room, the DON was asked if there was a care plan for weight loss for Resident #60. The DON stated, I don't see one. 4. Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] documented, .Problem conditions: dehydrated . The care plan dated 1/6/16 did not document a care plan for dehydration for Resident #66. Interview with the DON on 5/11/16 at 3:05 PM, in the conference room, the DON was asked if she expected to see a care plan for dehydration for Resident #66. The DON confirmed that dehydration had not been addressed. 5. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] documented an antidepressant, antipsychotic, and antianxiety medication for Resident #30. The quarterly MDS dated [DATE] documented an antidepressant, antipsychotic, and antianxiety medication for Resident #30. The physician's orders [REDACTED].[MEDICATION NAME] 15 MG (milligram) TABLET GIVE BY MOUTH .[MEDICATION NAME] 50 MG TABLET GIVE BY MOUTH EVERY MORNING .[MEDICATION NAME] XR (extended release) 200 MG TABLET GIVE BY MOUTH AT BED TIME .[MEDICATION NAME] 0.5 MG TABLET GIVE BY MOUTH 3 TIMES A DAY . The care plan dated 4/19/16 did not document a care plan for the antidepressant, antipsychotic, and antianxiety medication for Resident #30. Interview with the DON on 5/11/16 at 4:19 PM, in the conference room, the DON was asked if there should be a care plan for antidepressant, antipsychotic and antianxiety medication for Resident #30. The DON stated, Yes, ma'am. The DON confirmed that it did not address the use of antidepressant, antipsychotic and antianxiety medication. 6. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] 15 mg capsule give one capsule as needed by mouth at bedtime for [MEDICAL CONDITION] . The physician's orders [REDACTED].[MEDICATION NAME] 2 mg tabet give one tablet by mouth every day at bedtime . The care plan dated 5/4/16 did not document a care plan for the antidepressant, hypnotic and antipsychotic medication for Resident #31. Interview with the DON on 5/11/16 at 4:04 PM, in the conference room, the DON was asked if the care should address antidepressant, hypnotic and antipsychotic medication for Resident #31. The DON stated, .yes, it should be on there . 7. Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] 5 MG .Give 1 tablet by mouth 1 time daily at bedtime . The care plan dated 5/6/16 did not document a care plan for the antipsychotic medication for Resident #50. Interview with the DON on 5/11/16 at 4:01 PM, in the conference room, the DON was asked if there should be a care plan for the antipsychotic medication for Resident #50. The DON stated, Yes.

Based on policy review, observation, and interview the facility failed to ensure the correct tube feeding was administered to Resident #74, on 1 of 3 (5/9/16) days observed during the survey. The findings included: The facility's SPECIFIC MEDICATION ADMINISTRATION PROCEDURES policy documented, .I. Check the Medication Administration Record [REDACTED]. Note: Medication administration via tube requires flushing with water at several steps in the procedure. The total volume of water used for flushing should be included in the total amount allowed per day for fluid-restricted residents . The medical record review revealed, Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #74's room, on 5/9/16 at 10:00 AM and 4:17 PM, revealed tube feeding of [MEDICATION NAME] 1.2 cal infusing per pump at 75 ml (milliliters)/ hr (hour) to Percutaneous Endoscopic Gastrostomy (PEG) tube. Observations in Resident # 74's room, on 5/9/16 at 4:24 PM, revealed Licensed Practical Nurse (LPN) #1 hung [MEDICATION NAME] 1.2 Cal (calorie) tube feeding at 75 ml/hr per pump. Interview with LPN #1 on 5/9/16 at 4:31 PM, in Resident #74's room, LPN #1 was asked does Resident #74 go back and forth from [MEDICATION NAME] to [MEDICATION NAME]. LPN #1 stated, No, it should have been [MEDICATION NAME] not [MEDICATION NAME].

Based on policy review, observation and interview, the facility failed to ensure 1 of 10 staff members (Certified Nursing Assistant (CNA) #1) performed hand hygiene to prevent the potential spread of infection during dining observation, 1 of 2 (Licensed Practical Nurse (LPN) #1) nurses failed to perform proper hand hygiene during medication administration, and 1 of 1 nurses (LPN #1) failed to maintain infection control practices during wound care (Resident #59) for pressure wound. The findings included: 1. Observations in Resident #38's room, on 5/9/16 at 12:24 pm, CNA #1 positioned the bedside table, removed the top bun of the sandwich, placed the bun back on the sandwich, laid her hand on the sandwich and cut it in half. CNA #1 picked up half of the sandwich handed it to the resident, and then touched the spout of cup. CNA #1 failed to perform hand hygiene before assisting resident. Interview with Director of Nursing (DON) on 5/11/16 at 7:27 PM, in the business office, the DON was asked is it okay for staff to touch food when assisting resident. The DON stated .No . 2. The facility's Hand-hygiene technique policy documented, .Use towel to turn off the faucet . Observations in Resident #8's room on 5/10/16 at 11:07 AM, revealed LPN #2 administered insulin injection and then went in the bathroom to wash her hands. LPN #2 washed her hands, then dried hands with paper towel, threw paper towel into trash and turned the faucet off with her bare hands. Interview with the DON on 5/11/16 at 4:02 PM, in the conference room, was asked about hand washing technique and would you expect them to turn off the faucet with their bare hand. The DON stated, No, ma'am with a paper towel. 3.Medical record revealed Resident # 59 was admitted to the facility on [DATE] readmission on 4/29/16 with [DIAGNOSES REDACTED]. Review of physician's order [REDACTED].cleanse sacrum wound with wound cleanser, pat dry, apply thin layer of santyl, then alginate to fit, cover with Levin, change every other day and prn . During wound care observation in Resident #59's room, on 05/11/16 at 10:31 AM, LPN #1 cleansed wound with wound cleanser, resident ' s brief touched wound, Santyl applied to wound, wound touched brief again, applied alginate, covered the wound to right buttock with Levin dressing. Interview with LPN #1 Nurse 05/11/2016 10:45 AM performing dressing change should wound be allowed to touch brief after cleaning the wound. LPN #1 stated . I may not have seen it touch . Interview with the DON on 5/11/16 4:01 PM, in the conference room, would you expect a pressure wound to be cleaned if it touches bed linens or brief? DON stated .should clean wound again .

Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure a resident's environment remain free of accident hazards when the staff failed to consistently implement the intervention to keep the wardrobe away from the resident's bed for 1 of 4 (Resident #47) sampled residents with accidents of the 30 sampled residents included in the stage 2 review. The failure to ensure the wardrobe was placed away from the resident's bed after being determined the probable cause of the resident's first fractured left wrist resulted in actual harm when Resident #47 sustained a second fracture to the left wrist. The findings included: Review of Accidents, Incidents, and Adverse Events policy documented: "All accidents, incidents or adverse events occurring on... premises should be reported, reviewed, and, if indicated, investigated without fear of reprisal... An adverse event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof... Purpose To provide a safe and healthful environment for patients... To define causative / contributing factors and institute preventive measures to avoid further occurrences... Adverse events require the completion of a thorough root cause analysis... Initiate actions to prevent further incidents..." Medical record review for Resident #47 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses notes documented the following: a. 10/11/13 - "...combative with adls (activities of daily living)..." b. 10/24/13 - "...combative with adls..." c. 11/22/13 - "...behaviors observed when waking... no further combativeness observed..." d. 11/24/13 - "(Named physician) contacted concerning swelling & (and) disalignment of left wrist, Hematoma observed, golf ball size... sons c(with) resident... and states I bet she hit is (it) on the cabinet beside her bed, it's on that side..." The care plan updated on 11/24/13 documented, "pain @ (at) L (left) wrist... keep wardrobe away from bed." The minimum data set (MDS) kardex care plan used by Certified Nursing Assistants (CNA's) updated on 11/24/13 documented, "...wardrobe cabinet pushed in corner not against bed." A physician's progress note dated 11/27/13 documented, "...Left distal radius fracture..." Nurse note date 12/30/13 documented, "LOA (leave of absence) to MD appt (appointment)... brace removed from Lt. (left) wrist." A change of condition documentation form dated 1/3/14 documented, "...found L wrist swollen recent splint removed from fx. (fracture) of that wrist.." Nurses note documented the following: a. 1/4/14 at 0515 - "...arm L where brace taken off recently swollen 2t (plus)..." b. 1/5/14 - "resident observed hitting bedside cabinet c (with) L arm this shift by multiple CNA's." c. 1/6/14 - "...son stated that he feels his Mother probably hit her arm on wardrobe when in bed, Furniture rearranged to distance wardrobe from bed vicinity." A radiology report of left wrist dated 1/3/14 documented, "...Fracture of distal ulnar shaft... Fracture of the radial styloid process..." Observations on 1/13/14 3:30 PM, revealed Resident #47 seated in wheelchair self propelling in hallway. Resident #19 had a cast on her left wrist and forearm. Observations in Resident #47's room on 1/15/14 at 7:30 AM, revealed Resident #47 in a wheelchair with a cast on left arm. The wardrobe was against the wall away from the bed. During an interview in the conference room on 1/14/14 at 4:30 PM, Nurse #3 stated, "(Named Resident #47) does have behaviors, gets resistant with adl care, her son suggested she might have hit her arm on the wardrobe that was beside the bed and injured her arm... we did rearrange her furniture..." During an interview in the conference room on 1/14/14 at 5:20 PM, the DON stated, "...she (Resident #47) has had 2 fractures, same wrist different areas..." During an interview in the conference room on 1/14/14 at 5:30 PM, the Administrator stated, "After first fracture (11/24/13) we moved her wardrobe away from the bed to prevent her from hitting it. We neglected to inservice housekeeping and when they cleaned her room they moved it (wardrobe) back (not sure when). We took care of that and inserviced them after the second fracture (1/3/14) happened. " During an interview in the conference room on 1/15/14 at 9:20 AM, the DON stated, "...We did move the wardrobe right after the first fracture... it got moved back against the bed we think housekeeping did it during cleaning that is the normal area for those to be placed, we think it was moved back shortly after... we put the intervention on the CNA care plan card, we just did not think of housekeeping." During an interview in the conference room on 1/15/14 at 9:50 AM, the DON was asked if staff should have recognized and addressed that the wardrobe had been moved back next to the bed. The DON stated, "Yes, I would expect staff to monitor and address it." The failure to consistently follow the care plan intervention to keep the wardrobe away from the resident's bed resulted in actual harm when Resident #47 sustained a second fracture to the left wrist.

Based on policy review, medical record review, observation and interview, it was determined the facility failed to follow the comprehensive care plan for providing pressure relief for a wound for 1 of 6 (Resident #19) sampled residents reviewed with a pressure ulcer and failed to consistently implement the intervention to keep the wardrobe away from the resident's bed for 1 of 4 (Resident #47) sampled residents with accidents of the 30 sampled residents included in the stage 2 review. The failure of the facility to provide pressure relief to the left elbow resulted in actual harm when Resident #19's wound worsened. The failure to consistently follow the intervention to keep the wardrobe away from the resident's bed resulted in actual harm when Resident #47 sustained a second fracture to the left wrist. The findings included: 1. Review of the facility's care plan policy documented, "A comprehensive, individualized care plan will be developed by the interdisciplinary team for each patient. The care plan will include measurable objectives to meet patient needs and goals as identified by the assessment process... Reviewed and revised... to reflect response to care and changing needs and goals... The care plan must be customized to each individual patient's needs..." 2. Medical record review for Resident #19 documented an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the skin integrity reports documented the following: a. 8/14/13 - initial assessment of a new pressure wound on the left elbow as follows: "...pressure ulcer stage- UN (stageable), appearance-pink/red and slough, length- 2.0 centimeters (cm), width-2.0 cm, depth- ? (unable to determine), Tunneling-no, Drainage-Min (minimal) P (purulent), and IHA (in house acquired). b. 8/28/13 - wound has worsened and measures "length- 2.2 cm, width 1.5 cm, depth 0.1 cm"... with a note "^ (changed) classification to ST (skin tear) per DON (Director of Nursing)..." c. 10/23/13 - wound is now "length-1.3 cm, width-1.2 cm, Depth 0.1cm with mod (moderate) drainage." d. 12/10/13 - wound was reclassified as a pressure sore, inhouse acquired, and documented deteriorization as follows: "...Stage III, Pain-yes, appearance-tan > (greater than) 75% (percent), pink < (less than) 25%, length-1.0 cm, Width-1.0 cm, depth-0.4 cm, tunneling-1.2 cm @ (at) 12:00, drainage-min (minimal) S (serous). e. 1/15/14 - continued deteriorization - stage III, appearance- pink, length-0.7 cm, width-0.4 cm, depth- 0.3 cm, tunneling- 1.5 cm @ 12:00, drainage- min S, Surrounding Tissue- IF (Inflamed/Indurated). The care plan dated 8/14/13 and revised on 12/11/13 documented "Alteration in Skin Integrity r/t (related to): wound to left elbow, as of 8/28/13 area classified as a skin tear Reclassified 12/10/13... Goals. Wound will decrease in size by next review. Wound will show no s/s (signs or symptoms) of infection... Interventions... offload pressure to left elbow via large stuffed bear, staff to encourage placement of stuffed bear in lap under left elbow, check to ensure placement as resident will remove... monitor daily for s/s of infection. report abnormalities to MD (Medical Doctor)..." Observations of Resident #19 on 1/13/14 3:38 PM, revealed the resident sitting, in a wheelchair, at the nurses' desk, oxygen in place, yells at persons passing by and states "I'm scared", appears very anxious. There was no stuffed bear observed offloading pressure under her left elbow as care planned. Observations in Resident #19's room on 1/14/14 at 8:37 AM, revealed Resident #19 sitting in a wheelchair. There was no stuffed bear observed under her left elbow as care planned. Observations in Resident #19's room on 1/15/14 at 3:50 PM, revealed Resident #19 in bed, with no large stuffed bear present offloading the pressure to the left elbow as care planned. During an interview in the conference room on 1/16/14 at 12:01 PM, the Director of Nursing (DON) was asked about the pressure wound of the elbow. The DON stated, "...it was found on August 14, 2013. I assessed it and labeled it an unstageable pressure sore, later the DON at that time reclassified it as a skin tear. On assessment by the Assistant Director of Nursing (ADON) on 12/10/13 we changed it back to a pressure ulcer. We now have tunneling that was not there prior. We don't know what happened in between." The facility failed to ensure interventions to promote healing by relieving pressure was provided as care planned resulted in actual harm when Resident #19's wound worsened. 3. Review of Accidents, Incidents, and Adverse Events policy documented: "All accidents, incidents or adverse events occurring on... premises should be reported, reviewed, and, if indicated, investigated without fear of reprisal... An adverse event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof... Purpose To provide a safe and healthful environment for patients... To define causative / contributing factors and institute preventive measures to avoid further occurrences... Adverse events require the completion of a thorough root cause analysis... Initiate actions to prevent further incidents..." Medical record review for Resident #47 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses notes documented the following: a. 10/11/13 - "...combative with adls (activities of daily living)..." b. 10/24/13 - "...combative with adls..." c. 11/22/13 - "...behaviors observed when waking... no further combativeness observed..." d. 11/24/13 - "(Named physician) contacted concerning swelling & (and) disalignment of left wrist, Hematoma observed, golf ball size... sons c(with) resident... and states I bet she hit is (it) on the cabinet beside her bed, it's on that side..." The care plan updated on 11/24/13 documented, "pain @ L (left) wrist... keep wardrobe away from bed." The minimum data set (MDS) kardex care plan used by Certified Nursing Assistants (CNA's) updated on 11/24/13 documented, "...wardrobe cabinet pushed in corner not against bed." A physician's progress note dated 11/27/13 documented, "...Left distal radius fracture..." Nurse note date 12/30/13 documented, "LOA (leave of absence) to MD appt (appointment)... brace removed from Lt. (left) wrist." A change of condition documentation form dated 1/3/14 documented, "...found L wrist swollen recent splint removed from fx. (fracture) of that wrist.." Nurses note documented the following: a. 1/4/14 at 0515 - "...arm L where brace taken off recently swollen 2t (plus)..." b. 1/5/14 - "resident observed hitting bedside cabinet c (with) L arm this shift by multiple CNA's." c. 1/6/14 - "...son stated that he feels his Mother probably hit her arm on wardrobe when in bed, Furniture rearranged to distance wardrobe from bed vicinity." A radiology report of left wrist dated 1/3/14 documented, "...Fracture of distal ulnar shaft... [MEDICAL CONDITION] styloid process..." Observations on 1/13/14 3:30 PM, revealed Resident #47 seated in wheelchair self propelling in hallway. Resident #19 had a cast on her left wrist and forearm. Observations in Resident #47's room on 1/15/14 at 7:30 AM, revealed Resident #47 in a wheelchair with a cast on left arm. The wardrobe was against the wall away from the bed. During an interview in the conference room on 1/14/14 at 4:30 PM, Nurse #3 stated, "(Named Resident #47) does have behaviors, gets resistant with adl care, her son suggested she might have hit her arm on the wardrobe that was beside the bed and injured her arm... we did rearrange her furniture..." During an interview in the conference room on 1/14/14 at 5:20 PM, the DON stated, "...she (Resident #47) has had 2 fractures, same wrist different areas..." During an interview in the conference room on 1/14/14 at 5:30 PM, the Administrator stated, "After first fracture (11/24/13) we moved her wardrobe away from the bed to prevent her from hitting it. We neglected to inservice housekeeping and when they cleaned her room they moved it (wardrobe) back (not sure when). We took care of that and inserviced them after the second fracture (1/3/14) happened. " During an interview in the conference room on 1/15/14 at 9:20 AM, the DON stated, "...We did move the wardrobe right after the first fracture... it got moved back against the bed we think housekeeping did it during cleaning that is the normal area for those to be placed, we think it was moved back shortly after... we put the intervention on the CNA care plan card, we just did not think of housekeeping." During an interview in the conference room on 1/15/14 at 9:50 AM, the DON was asked if staff should have recognized and addressed that the wardrobe had been moved back next to the bed. The DON stated, "Yes, I would expect staff to monitor and address it." The failure to consistently follow the care plan intervention to keep the wardrobe away from the resident's bed resulted in actual harm when Resident #47 sustained a second fracture to the left wrist.

Based on review of the "National Pressure Advisory Panel (NPUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE", policy review, medical record review, observation and interview, it was determined the facility failed to provide the necessary care to prevent the development of pressure sores, failed to provide timely treatment to promote the healing of pressure sores and/or failed to identify a pressure before it developed into a state III for 2 of 6 (Residents #19 and 63) sampled residents reviewed with a pressure sore. The failure of the facility to follow a care plan intervention for pressure relief resulted in actual harm when Resident #19 developed an avoidable in house acquired pressure sore that worsened to a stage III with tunneling. The failure of the facility timely identify avoidable in house acquired pressure sores (stage III left heel and stage II penis) and failure to provide timely treatments resulted in actual harm to Resident #63. The findings included: 1. Review of the "National Pressure Ulcer Advisory Panel Pressure Ulcer Prevention QUICK REFERENCE GUIDE" documented, "(page) 8 ...Category/Stage III: Fullthickness skin loss involving damageor necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia... deep crater with or without undermining of adjancent tissue... Stage II... Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation... (page) 12... 3. Inspect skin regularly for signs of redness... Ongoing assessment of the skin is necessary to detect early signs of pressure damage. 4. Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration (hardness), especially in individuals with darkly pigmented skin... (page) 13... 6. Observe the skin for pressure damage caused by medical devices... Many different types of medical devices have been reported as having caused pressure damage... 7. Document all skin assessments, noting details of any pain possibly related to pressure damage..." 2. Review of the facility's wound care evaluation policy for pressure ulcers documented "...Check for pressure related to positioning, shoes, contractures, deformities, or medical devices... (such as catheters)..." Review of the facility's pressure ulcer prevention guideline policy documented, "Basic Prevention Interventions for all patients at risk...Avoid/limit skin to skin contact, friction, or shearing forces. May use pillows, heel, or elbow protectors to keep bony prominence's from rubbing...Position body with pillows and foam support devices...Utilize pressure redistributing surface. include cushion for chair/seating..." 3. Medical record review for Resident #19 documented an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the skin integrity reports documented the following: a. 8/14/13 - initial assessment of a new pressure wound on the left elbow as follows: "...pressure ulcer stage- UN (stageable), appearance-pink/red and slough, length- 2.0 centimeters (cm), width-2.0 cm, depth- ? (unable to determine), Tunneling-no, Drainage-Min (minimal) P (purulent), and IHA (in house acquired). b. 8/28/13 - wound has worsened and measures "length- 2.2 cm, width 1.5 cm, depth 0.1 cm"... with a note "^ (changed) classification to ST (skin tear) per DON (Director of Nursing)..." c. 10/23/13 - wound is now "length-1.3 cm, width-1.2 cm, Depth 0.1cm with mod (moderate) drainage." d. 12/10/13 - wound was reclassified as a pressure sore, inhouse acquired, and documented deteriorization as follows: "...Stage III, Pain-yes, appearance-tan > (greater than) 75% (percent), pink < (less than) 25%, length-1.0 cm, Width-1.0 cm, depth-0.4 cm, tunneling-1.2 cm @ (at) 12:00, drainage-min (minimal) S (serous). e. 1/15/14 - continued deteriorization - stage III, appearance- pink, length-0.7 cm, width-0.4 cm, depth- 0.3 cm, tunneling- 1.5 cm @ 12:00, drainage- min S, Surrounding Tissue- IF (Inflamed/Indurated). The care plan dated 8/14/13 and revised on 12/11/13 documented "Alteration in Skin Integrity r/t (related to): wound to left elbow, as of 8/28/13 area classified as a skin tear Reclassified 12/10/13... Goals. Wound will decrease in size by next review. Wound will show no s/s (signs or symptoms) of infection... Interventions... offload pressure to left elbow via large stuffed bear, staff to encourage placement of stuffed bear in lap under left elbow, check to ensure placement as resident will remove... monitor daily for s/s of infection. report abnormalities to MD (Medical Doctor)..." Observations of Resident #19 on 1/13/14 3:38 PM, revealed the resident sitting, in a wheelchair, at the nurses' desk, oxygen in place, yells at persons passing by and states "I'm scared", appears very anxious. There was no stuffed bear observed offloading pressure under her left elbow as care planned. Observations in Resident #19's room on 1/14/14 at 8:37 AM, revealed Resident #19 sitting in a wheelchair. There was no stuffed bear observed under her left elbow as care planned. Observations in Resident #19's room on 1/15/14 at 3:50 PM, revealed Resident #19 in bed, with no large stuffed bear present offloading the pressure to the left elbow as care planned. During an interview in the conference room on 1/16/14 at 12:01 PM, the Director of Nursing (DON) was asked about the pressure wound of the elbow. The DON stated, "...it was found on August 14, 2013. I assessed it and labeled it an unstageable pressure sore, later the DON at that time reclassified it as a skin tear. On assessment by the Assistant Director of Nursing (ADON) on 12/10/13 we changed it back to a pressure ulcer. We now have tunneling that was not there prior. We don't know what happened in between." The failure of the facility to follow a care plan intervention for pressure relief resulted in actual harm when Resident #19 developed an avoidable in house acquired pressure sore that worsened to a stage III with tunneling. 4. Medical record review for Resident #63 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "BRADEN SCALE- For Predicting Pressure Sore Risk" revealed Resident #63 had a score of 17, which indicated the resident was a high risk for developing pressure sores. Admission physician order [REDACTED]." Review of the skin integrity reports documented the following: a. 10/2/13 - initial report admitted with "stage 2 on entire buttocks." b. 10/18/13 - a new area on left heel staged as Deep Tissue Injury (DTI) that was intact and deep purple that measured (L) (length) 4.6 cm x (by) (W) (width) 4.5 cm. There was no documentation of treatment to this new wound until 10/23/13. Review of rehabilitation service therapy note dated 11/14/13 documented, "...continues to utilize catheter. He has wound on left heel and bottom. Penis has dressing..." Review of the "Change of Condition Documentation" dated 11/5/13 documented a new pressure ulcer, "...ulcerated area approx. 10cm to side of penis with yellowish/greenish drainage... CNA (Certified Nursing Assistant) reported ulcer to penis hidden under folds of skin c (with) yellowish/greenish drainage... Foley cath (catheter)..." There was no documentation of treatment to this new wound until 11/8/13. This was a three day delay of treatment. The resident was discharged from the facility on 11/15/13. During an interview in the DON's office on 1/15/14 at 1:49 PM, the DON was asked about the delay in treatments. The DON stated, "Can't tell you, it says treatment started on 11/8(2013), they probably were cleaning it with catheter care." The failure of the facility timely identify avoidable in house acquired pressure sores (stage III left heel and stage II penis) and failure to provide timely treatments resulted in actual harm to Resident #63.

Based on policy review, medical record review, observation and interview, it was determined the facility failed to follow the comprehensive care plan for providing pressure relief for a wound for 1 of 6 (Resident #19) sampled residents reviewed with a pressure ulcer and failed to consistently implement the intervention to keep the wardrobe away from the resident's bed for 1 of 4 (Resident #47) sampled residents with accidents of the 30 sampled residents included in the stage 2 review. The failure of the facility to provide pressure relief to the left elbow resulted in actual harm when Resident #19's wound worsened. The failure to consistently follow the intervention to keep the wardrobe away from the resident's bed resulted in actual harm when Resident #47 sustained a second fracture to the left wrist. The findings included: 1. Review of the facility's care plan policy documented, "A comprehensive, individualized care plan will be developed by the interdisciplinary team for each patient. The care plan will include measurable objectives to meet patient needs and goals as identified by the assessment process... Reviewed and revised... to reflect response to care and changing needs and goals... The care plan must be customized to each individual patient's needs..." 2. Medical record review for Resident #19 documented an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the skin integrity reports documented the following: a. 8/14/13 - initial assessment of a new pressure wound on the left elbow as follows: "...pressure ulcer stage- UN (stageable), appearance-pink/red and slough, length- 2.0 centimeters (cm), width-2.0 cm, depth- ? (unable to determine), Tunneling-no, Drainage-Min (minimal) P (purulent), and IHA (in house acquired). b. 8/28/13 - wound has worsened and measures "length- 2.2 cm, width 1.5 cm, depth 0.1 cm"... with a note "^ (changed) classification to ST (skin tear) per DON (Director of Nursing)..." c. 10/23/13 - wound is now "length-1.3 cm, width-1.2 cm, Depth 0.1cm with mod (moderate) drainage." d. 12/10/13 - wound was reclassified as a pressure sore, inhouse acquired, and documented deteriorization as follows: "...Stage III, Pain-yes, appearance-tan > (greater than) 75% (percent), pink < (less than) 25%, length-1.0 cm, Width-1.0 cm, depth-0.4 cm, tunneling-1.2 cm @ (at) 12:00, drainage-min (minimal) S (serous). e. 1/15/14 - continued deteriorization - stage III, appearance- pink, length-0.7 cm, width-0.4 cm, depth- 0.3 cm, tunneling- 1.5 cm @ 12:00, drainage- min S, Surrounding Tissue- IF (Inflamed/Indurated). The care plan dated 8/14/13 and revised on 12/11/13 documented "Alteration in Skin Integrity r/t (related to): wound to left elbow, as of 8/28/13 area classified as a skin tear Reclassified 12/10/13... Goals. Wound will decrease in size by next review. Wound will show no s/s (signs or symptoms) of infection... Interventions... offload pressure to left elbow via large stuffed bear, staff to encourage placement of stuffed bear in lap under left elbow, check to ensure placement as resident will remove... monitor daily for s/s of infection. report abnormalities to MD (Medical Doctor)..." Observations of Resident #19 on 1/13/14 3:38 PM, revealed the resident sitting, in a wheelchair, at the nurses' desk, oxygen in place, yells at persons passing by and states "I'm scared", appears very anxious. There was no stuffed bear observed offloading pressure under her left elbow as care planned. Observations in Resident #19's room on 1/14/14 at 8:37 AM, revealed Resident #19 sitting in a wheelchair. There was no stuffed bear observed under her left elbow as care planned. Observations in Resident #19's room on 1/15/14 at 3:50 PM, revealed Resident #19 in bed, with no large stuffed bear present offloading the pressure to the left elbow as care planned. During an interview in the conference room on 1/16/14 at 12:01 PM, the Director of Nursing (DON) was asked about the pressure wound of the elbow. The DON stated, "...it was found on August 14, 2013. I assessed it and labeled it an unstageable pressure sore, later the DON at that time reclassified it as a skin tear. On assessment by the Assistant Director of Nursing (ADON) on 12/10/13 we changed it back to a pressure ulcer. We now have tunneling that was not there prior. We don't know what happened in between." The facility failed to ensure interventions to promote healing by relieving pressure was provided as care planned resulted in actual harm when Resident #19's wound worsened. 3. Review of Accidents, Incidents, and Adverse Events policy documented: "All accidents, incidents or adverse events occurring on... premises should be reported, reviewed, and, if indicated, investigated without fear of reprisal... An adverse event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof... Purpose To provide a safe and healthful environment for patients... To define causative / contributing factors and institute preventive measures to avoid further occurrences... Adverse events require the completion of a thorough root cause analysis... Initiate actions to prevent further incidents..." Medical record review for Resident #47 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses notes documented the following: a. 10/11/13 - "...combative with adls (activities of daily living)..." b. 10/24/13 - "...combative with adls..." c. 11/22/13 - "...behaviors observed when waking... no further combativeness observed..." d. 11/24/13 - "(Named physician) contacted concerning swelling & (and) disalignment of left wrist, Hematoma observed, golf ball size... sons c(with) resident... and states I bet she hit is (it) on the cabinet beside her bed, it's on that side..." The care plan updated on 11/24/13 documented, "pain @ L (left) wrist... keep wardrobe away from bed." The minimum data set (MDS) kardex care plan used by Certified Nursing Assistants (CNA's) updated on 11/24/13 documented, "...wardrobe cabinet pushed in corner not against bed." A physician's progress note dated 11/27/13 documented, "...Left distal radius fracture..." Nurse note date 12/30/13 documented, "LOA (leave of absence) to MD appt (appointment)... brace removed from Lt. (left) wrist." A change of condition documentation form dated 1/3/14 documented, "...found L wrist swollen recent splint removed from fx. (fracture) of that wrist.." Nurses note documented the following: a. 1/4/14 at 0515 - "...arm L where brace taken off recently swollen 2t (plus)..." b. 1/5/14 - "resident observed hitting bedside cabinet c (with) L arm this shift by multiple CNA's." c. 1/6/14 - "...son stated that he feels his Mother probably hit her arm on wardrobe when in bed, Furniture rearranged to distance wardrobe from bed vicinity." A radiology report of left wrist dated 1/3/14 documented, "...Fracture of distal ulnar shaft... [MEDICAL CONDITION] styloid process..." Observations on 1/13/14 3:30 PM, revealed Resident #47 seated in wheelchair self propelling in hallway. Resident #19 had a cast on her left wrist and forearm. Observations in Resident #47's room on 1/15/14 at 7:30 AM, revealed Resident #47 in a wheelchair with a cast on left arm. The wardrobe was against the wall away from the bed. During an interview in the conference room on 1/14/14 at 4:30 PM, Nurse #3 stated, "(Named Resident #47) does have behaviors, gets resistant with adl care, her son suggested she might have hit her arm on the wardrobe that was beside the bed and injured her arm... we did rearrange her furniture..." During an interview in the conference room on 1/14/14 at 5:20 PM, the DON stated, "...she (Resident #47) has had 2 fractures, same wrist different areas..." During an interview in the conference room on 1/14/14 at 5:30 PM, the Administrator stated, "After first fracture (11/24/13) we moved her wardrobe away from the bed to prevent her from hitting it. We neglected to inservice housekeeping and when they cleaned her room they moved it (wardrobe) back (not sure when). We took care of that and inserviced them after the second fracture (1/3/14) happened. " During an interview in the conference room on 1/15/14 at 9:20 AM, the DON stated, "...We did move the wardrobe right after the first fracture... it got moved back against the bed we think housekeeping did it during cleaning that is the normal area for those to be placed, we think it was moved back shortly after... we put the intervention on the CNA care plan card, we just did not think of housekeeping." During an interview in the conference room on 1/15/14 at 9:50 AM, the DON was asked if staff should have recognized and addressed that the wardrobe had been moved back next to the bed. The DON stated, "Yes, I would expect staff to monitor and address it." The failure to consistently follow the care plan intervention to keep the wardrobe away from the resident's bed resulted in actual harm when Resident #47 sustained a second fracture to the left wrist.

Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure a resident's environment remain free of accident hazards when the staff failed to consistently implement the intervention to keep the wardrobe away from the resident's bed for 1 of 4 (Resident #47) sampled residents with accidents of the 30 sampled residents included in the stage 2 review. The failure to ensure the wardrobe was placed away from the resident's bed after being determined the probable cause of the resident's first fractured left wrist resulted in actual harm when Resident #47 sustained a second fracture to the left wrist. The findings included: Review of Accidents, Incidents, and Adverse Events policy documented: "All accidents, incidents or adverse events occurring on... premises should be reported, reviewed, and, if indicated, investigated without fear of reprisal... An adverse event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof... Purpose To provide a safe and healthful environment for patients... To define causative / contributing factors and institute preventive measures to avoid further occurrences... Adverse events require the completion of a thorough root cause analysis... Initiate actions to prevent further incidents..." Medical record review for Resident #47 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses notes documented the following: a. 10/11/13 - "...combative with adls (activities of daily living)..." b. 10/24/13 - "...combative with adls..." c. 11/22/13 - "...behaviors observed when waking... no further combativeness observed..." d. 11/24/13 - "(Named physician) contacted concerning swelling & (and) disalignment of left wrist, Hematoma observed, golf ball size... sons c(with) resident... and states I bet she hit is (it) on the cabinet beside her bed, it's on that side..." The care plan updated on 11/24/13 documented, "pain @ (at) L (left) wrist... keep wardrobe away from bed." The minimum data set (MDS) kardex care plan used by Certified Nursing Assistants (CNA's) updated on 11/24/13 documented, "...wardrobe cabinet pushed in corner not against bed." A physician's progress note dated 11/27/13 documented, "...Left distal radius fracture..." Nurse note date 12/30/13 documented, "LOA (leave of absence) to MD appt (appointment)... brace removed from Lt. (left) wrist." A change of condition documentation form dated 1/3/14 documented, "...found L wrist swollen recent splint removed from fx. (fracture) of that wrist.." Nurses note documented the following: a. 1/4/14 at 0515 - "...arm L where brace taken off recently swollen 2t (plus)..." b. 1/5/14 - "resident observed hitting bedside cabinet c (with) L arm this shift by multiple CNA's." c. 1/6/14 - "...son stated that he feels his Mother probably hit her arm on wardrobe when in bed, Furniture rearranged to distance wardrobe from bed vicinity." A radiology report of left wrist dated 1/3/14 documented, "...Fracture of distal ulnar shaft... Fracture of the radial styloid process..." Observations on 1/13/14 3:30 PM, revealed Resident #47 seated in wheelchair self propelling in hallway. Resident #19 had a cast on her left wrist and forearm. Observations in Resident #47's room on 1/15/14 at 7:30 AM, revealed Resident #47 in a wheelchair with a cast on left arm. The wardrobe was against the wall away from the bed. During an interview in the conference room on 1/14/14 at 4:30 PM, Nurse #3 stated, "(Named Resident #47) does have behaviors, gets resistant with adl care, her son suggested she might have hit her arm on the wardrobe that was beside the bed and injured her arm... we did rearrange her furniture..." During an interview in the conference room on 1/14/14 at 5:20 PM, the DON stated, "...she (Resident #47) has had 2 fractures, same wrist different areas..." During an interview in the conference room on 1/14/14 at 5:30 PM, the Administrator stated, "After first fracture (11/24/13) we moved her wardrobe away from the bed to prevent her from hitting it. We neglected to inservice housekeeping and when they cleaned her room they moved it (wardrobe) back (not sure when). We took care of that and inserviced them after the second fracture (1/3/14) happened. " During an interview in the conference room on 1/15/14 at 9:20 AM, the DON stated, "...We did move the wardrobe right after the first fracture... it got moved back against the bed we think housekeeping did it during cleaning that is the normal area for those to be placed, we think it was moved back shortly after... we put the intervention on the CNA care plan card, we just did not think of housekeeping." During an interview in the conference room on 1/15/14 at 9:50 AM, the DON was asked if staff should have recognized and addressed that the wardrobe had been moved back next to the bed. The DON stated, "Yes, I would expect staff to monitor and address it." The failure to consistently follow the care plan intervention to keep the wardrobe away from the resident's bed resulted in actual harm when Resident #47 sustained a second fracture to the left wrist.