Every finding on record at Tuscany Village Nursing Center

Based on observation, record review, and interview, the facility failed to:a. assess, monitor, and intervene for urine changes for 1 (#9) of 4 sampled residents; andb. failed to ensure a resident with a catheter had a physician order specifying the type of catheter for 1 (#8) of 4 sampled residents reviewed for catheter care. The corporate nurse identified 11 residents had catheters. Findings: A Care and Removal of an Indwelling Catheter policy, revised 01/12/20, read in part, Evaluate the need for catheter removal by validating the record and physician's order.Staff will provide care and removal of an indwelling catheter in accordance with standard practice guidelines.Observe urinary output and urine characteristics; evaluate for discharge, redness, bleeding, or presence of tissue trauma around the urethral meatus. 1.An admission assessment for Resident #8, dated 10/08/25, did not show the resident had a catheter upon admission. Physician orders for Resident #8, dated 10/08/25, showed the resident had physician orders to: a. change suprapubic catheter as needed, b. monitor the output on every shift, and c. suprapubic catheter care every shift. Resident #8's physician orders did not show an order specifying the type of catheter and supporting diagnosis. A treatment administration record for Resident #8, dated 10/08/25 through 10/31/25, showed the resident received care for a suprapubic catheter. A comprehensive care plan for Resident #8, initiated on 10/09/25, did not show a focus or interventions for catheter care. An annual assessment for Resident #8, dated 10/14/25, showed the resident's cognition was severely impaired with a BIMS score of 3. The assessment showed Resident #8 was admitted with a diagnoses of obstructive uropathy and non-Alzheimer dementia. The assessment showed Resident #8's urinary continence was not rated due to Resident #8 had a catheter at the time of the assessment. On 02/03/26 at 9:35 a.m., resident representative #1 stated Resident #8 had a catheter upon admission and throughout their stay at the facility. On 02/06/25 at 9:23 a.m., CNA #3 stated they did not have any documentation to direct them to provide catheter care. CNA #3 stated they checked and provided care to all catheters every two hours. On 02/06/26 at 9:36 a.m., LPN #6 stated when a resident was admitted to the facility with a catheter, they should look for the size and type from the admitting orders. They stated every resident with a catheter should have an order specifying the type of catheter. LPN #6 stated Resident #8 had a catheter upon admission. LPN #6 reviewed Resident #8's physician orders and stated there was not a physician order for a catheter. On 02/06/26 at 10:49 p.m., the DON stated Resident #8 had a catheter upon admission. The DON stated Resident #8 had orders for suprapubic catheter care and did not have a physician order for a catheter. The DON stated it was important to have physician orders for the correct type of catheter because staff would not be able to provide the care for the catheter. The DON stated the catheter was not on the baseline care plan or comprehensive care plan. 2. On 02/04/26 at 11:57 a.m., Resident # 9's indwelling catheter was observed to have a thick off-white substance filling almost the entire visible tubing. A physician order, dated 11/26/25, showed Resident #9 was to have the catheter changed as needed or clinically indicated. A comprehensive assessment for Resident #9, dated 11/29/25, showed the resident had a BIMS score of 00 indicating severe problems with memory and thinking. The assessment showed Resident #9 had a diagnoses of cerebral palsy and traumatic brain injury and was dependent on staff for all of their needs. On 02/04/26 at 11:58 a.m., LPN #1 stated the indwelling catheter should be changed if there were signs of an infection, and Resident #9 did not have a fever. LPN #1 stated if they noticed a difference with the catheter they would be keyed into potentially call the physician. LPN #1 stated the indwelling catheter had a thick off-white substance in it from Resident # 9's body all the way down into the bag. LPN #1 stated it was sometimes normal for the contents inside the tubing to look like that. On 02/04/26 at 12:31 p.m., the DON stated LPN #1 was about to change the catheter because the orders were to change the indwelling catheter as needed. The DON stated the catheter tubing was stained and very cloudy with sediment in the drainage tubing. The DON stated they were unsure if it was normal for Resident #9's catheter to look like that. The DON stated the catheter tubing was not secured to Resident #9's leg and it was advised to have the catheter secured to keep it from pulling against the bladder wall.

Based on record review and interview, the facility failed to ensure family and the physician was notified of a resident's refusal of care for 1 (#8) of 14 sampled residents reviewed for notification of refusal of care.The administrator identified 120 residents resided in the facility. Findings:A facility policy titled Refusal of Care and Treatment, dated 02/16/23, read in part, When a resident refuses treatment/procedure ordered by the physician, staff shall notify the physician.Staff will notify the resident's responsible party unless the resident chooses not to allow.Physician orders for Resident #8, dated 10/08/25, showed the resident had the following orders:a. weekly weights for 4 weeks,b. 60 milliliters of milk/soy protein supplement twice a day, andc. sodium bicarbonate (an antacid) 650 milligrams tablet twice a day.An admission assessment for Resident #8, dated 10/14/25, showed the resident's cognition was severely impaired with a BIMS score of 3. The assessment showed Resident #8 was admitted with a diagnoses of obstructive uropathy and non-Alzheimer dementia. The assessment showed Resident #8 did not reject care during the seven days look back period.Nurses' notes for Resident #8, dated 10/2025 through 11/2025, showed the resident refused care on the following dates:a. on 10/12/25, refused protein supplement health shake,b. on 10/18/25, refused protein supplement health shake,c. on 10/19/25, refused protein supplement health shake, d. on 10/25/25, refused to be weighed,e. on 10/26/25, refused protein supplement health shake, f. on 11/01/25, refused protein supplement health shake and sodium bicarbonate,g. on 11/02/25, refused protein supplement health shake and sodium bicarbonate, andh. on 11/08/25, refused protein supplement health shake and sodium bicarbonate.On 02/03/26 at 9:35 a.m., resident representative #1 stated they were not notified Resident #8 refused care. On 02/04/26 at 2:44 p.m., CNA #4 stated when a resident refused care, they should notify a nurse who charted the refusal and notified the family and physician.On 02/06/26 at 9:36 a.m., LPN #6 stated when a resident refused care, medications, and/or supplements, they made a nurses note documenting the refusal, notification of the family, and notification of the physician. On 02/06/26 at 10:49 a.m., the DON was shown Resident #8's nurses' notes. The DON stated the nurses should have notified the family and physician of any refusals of care and documented the notification in the nurses' notes. The DON stated there was a problem with no documentation to show the family and physician were notified of the refusals. The DON stated the notification of family, and the physician was important to ensure the residents received the care they required. The DON stated there was no documentation showing Resident #8's family and physician were notified of the refusals of care.

Based on record review and interview, the facility failed to obtain a physician's order for suctioning of a tracheostomy for 1 (#1) of 3 sampled residents reviewed for tracheostomy care.The DON stated three residents had a tracheostomies. Findings:A facility Tracheostomy Care policy, dated 03/02/23, showed staff would provide care for residents with a tracheostomy (an opening in the neck into the windpipe) in accordance with standard practice guidelines and provide suctioning per practice guidelines.A baseline care plan for Resident #1, dated 01/14/26, showed the resident required suctioning and had a tracheostomy.Physician orders for Resident #1, dated 01/14/26 through 01/27/26, showed no order for tracheostomy suctioning.An admission assessment for Resident #1, dated 01/21/26, showed the resident's cognition was severely impaired and had a BIMS score of 07. The assessment showed the resident required suctioning and tracheostomy care and had a diagnosis of chronic obstructive pulmonary disease.On 02/03/26 at 3:26 p.m., the DON stated Resident #1 should have had a physician order for tracheostomy suctioning. The DON stated the resident's physician orders showed no order for tracheostomy suctioning.On 02/03/26 at 9:37 p.m., LPN #2 stated on 01/26/26 Resident #1's family reported the resident needed to be suctioned. LPN #2 stated the resident was not in distress and was suctioned via the resident's tracheostomy after the resident finished eating and the family left the facility. LPN #2 stated the resident's tracheostomy was suctioned regularly.

Based on record review and interview, the facility failed to ensure a residents physician orders were accurate for 1 (#8) of 14 sampled residents reviewed for accurate physician orders.The administrator identified 120 residents resided in the facility. Findings:A facility policy titled Care and Removal of an Indwelling Catheter, dated 01/12/20, read in part, Evaluate the need for catheter removal by validating the record and physician's order.Physician orders for Resident #8, dated 10/08/25, showed the resident had physician orders to:a. change suprapubic catheter as needed,b. monitor the output on every shift, c. suprapubic catheter care every shift, andd. enteral tube feeding twice a day. A treatment administration record for Resident #8, dated 10/08/25 through 10/31/25, showed the resident received care for a suprapubic catheter.An annual assessment for Resident #8, dated 10/14/25, showed the resident's cognition was severely impaired with a BIMS score of 3. The assessment showed Resident #8 was admitted with a diagnoses of obstructive uropathy and non-Alzheimer dementia. The assessment showed Resident #8's urinary continence was not rated due to the resident had a catheter at the time of the assessment. The assessment showed Resident #8 did not have a tube feeding device and ate with supervision or touching assistance by staff.A discharge assessment for Resident #8, dated 11/13/25, showed the resident had a planned discharged for a short-term hospital stay.On 02/03/26 at 9:35 a.m., resident representative #1 stated Resident #8 had a catheter upon admission and throughout their stay at the facility and was not receiving enteral tube feeding.On 02/06/26 at 9:36 a.m., LPN #6 stated when a resident was admitted to the facility with a catheter, they should look for the size and type from the admitting orders. They stated every resident with a catheter should have an order specifying the type of catheter. LPN #6 stated Resident #8 had a catheter upon admission. LPN #6 reviewed Resident #8's physician orders and stated there was not a physician order for a catheter. LPN #6 stated the orders were not accurate due to Resident #8's orders showed they had an order for suprapubic catheter care when Resident #8 had a catheter. LPN #6 stated Resident #8 had a regular diet and was not an enteral tube feed. LPN #6 was asked to review the orders. They stated the orders were not accurate. On 02/06/26 at 10:49 p.m., the DON stated Resident #8 had a catheter upon admission. The DON stated Resident #8 had orders for suprapubic catheter care and did not have a physician order for a catheter. The DON stated it was important to have physician orders for the correct type of catheter because staff would not be able to provide the care for the catheter. The DON stated the catheter care orders were not correct due to the orders specifying the wrong type of catheter care. On 02/06/26 at 3:30 p.m., the DON stated Resident #8 was not nothing by mouth and received a regular diet. The DON stated the orders for enteral tube feeding dated 10/08/25 was an error.

Based on record review and interview, the facility failed to provide a physician ordered dressing change as ordered for 1 (#12) of 4 sampled residents reviewed for wound care.The DON identified 23 residents required wound care.Findings:A physician's order for Resident #12, dated 07/09/25, showed IV-Midline (access device inserted into upper arm veins) dressing change on the day shift weekly on Friday, or when it becomes damp, loose, soiled, or if the patient develops problems at the site that require further inspection.A medication administration record for Resident #12, dated 07/11/25, showed the IV-Midline dressing change was missed. The record showed no reason the dressing change was missed.An admission assessment for Resident #12, dated 07/12/25, showed the resident was admitted to the facility on [DATE] and their cognition was severely impaired. The assessment showed the resident's BIMS score was 07, required assistance for activities of daily living, and had IV access while a resident. The assessment showed the resident had diagnoses which included septicemia and renal failure.A grievance form for Resident #12, dated 07/16/25, showed Resident #12's family reported the resident's IV dressing had not been changed since being admitted to the facility. The grievance form showed the dressing would be changed that day.A nurse progress note for Resident #12, dated 07/18/25, showed the resident's IV dressing change was not performed due to it being changed on 07/16/25.A care plan for Resident #12, dated 07/28/25, showed the resident was on IV therapy for infection. The care plan showed medications and treatments were to be administered as ordered.On 02/04/26 at 9:49 a.m., family member #1 stated on 07/16/25 Resident #12's IV dressing was dated 07/03/25. Family Member #1 stated they asked the nurse why it had not been changed and were told the resident was at dialysis when the dressing change was scheduled. They stated they were told the dressing would be changed that day.On 02/06/26 at 11:13 a.m., the DON stated Resident #12 was out of the facility for an appointment and the dressing change should have been done upon return.On 02/06/26 at 1:30 p.m., the regional nurse consultant stated there was no documentation the IV dressing change was performed before 07/16/25.

Based on observation, record review, and interview, the facility failed to ensure residents were bathed for 2 (#1 and #2) of 14 sampled residents reviewed for bathing.The administrator identified 120 residents resided in the facility. Findings: 1.A facility policy titled Bathing (Not Partial or Complete Bed Bath), revised 02/12/20, read in part, Staff will provide bathing services for residents with standard practice guidelines.If the resident refuses to independently or allow staff to assist with bathing, document the refusal in the record. A CNA flow sheet, dated 01/14/26 through 01/27/26, showed Resident #1 received a shower on 01/18/26 and 01/25/26. Interdisciplinary progress notes for Resident #1, dated 01/14/26 through 01/27/26, showed no documented refusals of showers. An admission assessment for Resident #1, dated 01/21/26, showed the resident's cognition was severely impaired, and had a BIMS score of 07. The assessment showed the resident was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease and had not exhibited any rejection of care behaviors. A care plan for Resident #1, dated 01/23/26, showed the resident required the assistance of one staff member for activities of daily living. On 02/03/26 at 10:07 a.m., family member #2 stated Resident #1 was scheduled for showers on Tuesdays and Fridays. Family Member #2 stated the resident only received a shower on Sunday, 01/18/26 and Sunday, 01/25/26 after they complained to staff. On 02/03/26 at 1:53 p.m., CNA #5 stated there was not enough time and help to get all scheduled showers done daily. 2. On 02/06/26 at 1:36 p.m., Resident #2 was observed in bed. Resident #2's hair was not brushed. An annual assessment for Resident #2, dated 09/18/25, showed the resident's cognition was intact with a BIMS score of 14. The assessment showed Resident #2 was admitted with diagnoses which included polyneuropathy, anxiety disorder, and depression. The assessment showed Resident #2 had impairments on both sides of their upper and lower extremities. The assessment showed Resident #2 required substantial to maximum assistance with showers/baths and personal hygiene. The assessment showed Resident #2 was dependent for tub/shower transfers and did not ambulate. A care plan for Resident #2, initiated 04/10/25, showed a focus for activities of daily living. The care plan showed an intervention for ADL assistance/ADL assistance as needed. Physician orders for Resident #2, dated 08/15/25, showed the resident's bath days were weekly on Mondays and Thursdays on the first shift. A TAR for Resident #2, dated 12/01/25 through 12/31/25, showed the resident did not receive a bath on 12/29/25. A MAR for Resident #2, dated 12/01/25 through 12/31/25, showed the resident received a bath on 12/29/25. The MAR showed LPN #3 initialed the MAR on 12/29/25 that Resident #2 received a bath. Nurses' notes for Resident #2, dated 12/29/25, showed no documentation the resident refused a shower/ bath on 12/29/25. On 02/03/26 at 1:53 p.m., CNA #5 stated the showers were not getting done for all residents. CNA #5 stated Resident #2 reported to them they had not had a shower for two weeks. CNA #5 stated they tried to ensure residents were showered once a week. They stated when a resident did not get showers/baths, the residents and resident representatives got frustrated. CNA #5 stated they had reported the residents not getting showers to the DON. On 02/04/26 at 9:16 a.m., LPN #3 was shown the MAR and TAR for Resident #2 dated 12/01/25 through 12/31/25. LPN #3 stated they signed the MAR on 12/29/25 because Resident #2 was scheduled for a shower. They stated the MAR initial on 12/29/25 was not to indicate Resident #2 received a shower/bath, but only initialed because it was Resident #2's scheduled bath day. LPN #3 stated Resident #2's bath days were on Mondays and Thursdays. LPN #3 stated when a resident refused a shower/bath, the CNA should have reported to them, they should have contacted the family and physician and put a note in the EHR documenting the refusal and notification. LPN #3 stated they were never notified Resident #2 refused showers on 12/29/25 and there was no documentation Resident #2 received a shower on 12/29/25. LPN #3 stated bath sheets were given to the MDS coordinator to file after all baths. On 02/04/26 at 9:36 a.m., MDS coordinator #1 stated the DON reviewed all bath sheets and checked the EHR to ensure the family and physician were notified. They stated there were no bath sheets for Resident #2 from 12/26/25 through 12/31/25. On 02/04/26 at 10:08 a.m., resident representative #2 stated Resident #2 was not getting their baths and assistance with hygiene. On 02/04/26 at 2:44 p.m., CNA #4 stated when a resident refused a shower/bath, they notified the nurse who charted the refusal and notified the family and physician. They stated when a resident refused a shower/bath, the nurse would try and offer it. CNA #4 stated they charted yes or refused in the EHR. On 02/04/26 at 2:55 p.m., LPN #7 stated when a resident reused a shower/bath, the CNA would have notified the nurse who would go speak with the resident and try and offer the shower/bath. They stated if the resident continued to refuse, they would have notified the family and physician, and a note should have been entered into the EHR documenting the family and physician were notified. On 02/04/26 at 3:09 p.m., the ADON stated when a resident refused a shower, the aide should have notified the charge nurse. They stated the charge nurse should have notified the family and physician of the refusal and placed a note in the EHR the family and physician were notified. The ADON was asked to review Resident #2's TAR and progress notes dated 12/01/25/ through 12/31/25. The ADON stated there was no documentation the shower was refused or received. They stated there was no documentation family and physician were notified. They stated it did not look like the policy and procedure was followed. They stated Resident #2 did not usually refuse showers. On 02/05/26 at 10:54 a.m., the DON reviewed Resident #2's progress/nurses notes, MAR, and TAR dated 12/01/25 through 12/31/25. The DON stated the MAR initial on 12/29/25 should have been initialed to indicate Resident #2 received a bath. The DON stated they needed to educate the nurse who initialed the bath was given on 12/29/25. The DON stated there was no documentation Resident #2 received or refused a bath on 12/29/25. On 02/06/25 at 1:36 p.m., Resident #2 stated they did not receive a bath from 12/26/25 through 12/31/25. They stated the aides told them there was not enough staff to bathe all the residents.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for 1 (#8) of 14 sampled residents reviewed for comprehensive care plans.The administrator identified 120 residents resided in the facility. Findings:A facility policy titled Comprehensive care plans, dated 04/17/23, read in part, It is the policy of this facility to develop and implementation a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.The comprehensive care plan will be developed within seven (7) days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record.An admission assessment for Resident #8, dated 10/08/25, did not show the resident had a catheter upon admission.Physician orders for Resident #8, dated 10/08/25, showed the resident had physician orders to:a. change suprapubic catheter as needed,b. monitor the output on every shift, andc. suprapubic catheter care every shift.A treatment administration record for Resident #8, dated 10/08/25 through 10/31/25, showed the resident received care for a suprapubic catheter.A comprehensive care plan for Resident #8, initiated on 10/09/25, did not show a focus or interventions for catheter care. The care plan had a focus for activities dated 10/09/25. There were no other areas of focus on the care plan. An admission assessment for Resident #8, dated 10/14/25, showed the resident's cognition was severely impaired with a BIMS score of 3. The assessment showed Resident #8 was admitted with a diagnoses of obstructive uropathy and non-Alzheimer dementia. The assessment showed Resident #8's urinary continence was not rated due to Resident #8 had a catheter at the time of the assessment. The assessment showed Resident #8 required supervision to touching assistance for eating, substantial to maximum assistance for showers/baths and dressing and was dependent for bed transfers. On 02/03/26 at 9:35 a.m., resident representative #1 stated Resident #8 had a catheter upon admission and throughout their stay at the facility.On 02/06/25 at 9:23 a.m., CNA #3 stated they did not have any documentation to direct them to provide catheter care. CNA #3 stated they checked and provided care for all catheters every two hours. On 02/06/26 at 10:49 a.m., the DON reviewed Resident #8's comprehensive care plan dated 10/09/25. The DON stated the care plan only had a focus for activities and did not document the resident's catheter care and ADL's. The DON stated the comprehensive care plan was not created and it was the responsibility of the MDS coordinator. On 02/06/26 at 11:53 a.m., MDS coordinator #1 stated comprehensive care plans should be completed after admission by day twenty-one after admission. They stated Resident #8's care plan only had activities for a focus. They stated Resident #8's comprehensive care plan was not completed because it got missed.

Based on record review and interview, the facility failed to ensure activities of daily living documentation was completed for 1 (#2) of 3 sampled residents reviewed for ADL's.LPN #2 identified 120 residents resided at the facility.Findings:An undated face sheet for Resident #2, showed diagnoses which included hemiplegia and hemiparesis following cerebral infarction affection left non-dominant side, muscle weakness, cerebral infarction, and bipolar disorder. Resident #2's significant change assessment, dated 05/01/25, showed cognitively intact cognition with a BIMS of 15.A policy titled ADL Dysphagia and Dining, dated 01/23/23, read in part, 17. Document percentage consumed in EHR. Review of the ADL documentation for March and April 2025, did not show any documentation of intake and output or meal percentages for 04/01/25 through 04/07/25, the days leading up to the 04/07/25 hospital stay.On 06/18/25 at 3:49 p.m., the regional nurse consultant stated via an email response, they had provided all the ADL documentation they had for March and April 2025.On 06/20/25 at 9:33 a.m., the regional nurse consultant stated they did not have a generalized policy for ADLs, but had it broken down into subgroups that talk about documentation. The regional nurse consultant stated they did not find one for eating or intake or output.

Based on record review and interview, the facility failed to assess, monitor and intervene in a timely manner for 1 (#3) of 3 sampled residents reviewed for care and treatment.LPN #2 identified 120 residents resided in the facility.Findings: An Interdisciplinary Team Notes, dated 04/09/25 at 9:17 p.m., showed family member #1 called the facility requesting their family member be sent to the emergency room to be tested for C-Diff since their other family member that was a roommate was hospitalized and positive for it. A Medication Administration Record, dated 04/01/25 through 04/30/25, showed Zofran (medication for nausea and vomiting) ordered PRN, was administered on:a. 04/07/25 at 10:40 p.m. b. 04/08/25 at 12:05 p.m.c. 04/09/25 at 8:37 p.m.A facility policy Medication Administration, dated 01/2024, read in part, If two consecutive doses of a vital medication are withheld or refused, the physician is notified.An Interdisciplinary Progress Notes, dated 04/02/25 through 04/11/25 showed the following:On 04/08/25 at 10:45 a.m., CMA#1 documented all morning medications were refused, and the charge nurse was notified of the refusal.On 04/08/25 at 4:49 p.m., CMA #2 documented rabeprazole sodium (a medication for gastro esophageal reflux disease) was held due to refusal.On 04/08/25 at 10:44 p.m., CMA #2 documented docusate sodium (a medication for constipation) was held due to refusal:On 04/09/25 at 9:51 a.m., CMA #3 documented the following medications were held due to refusal:a. furosemide (medication for edema),b. Linzess (medication for irritable bowel syndrome),c. rabeprazole sodium (medication for gastro esophageal reflux disease),d. vitamin c (a supplement), e. calcium carbonate/vitamin d (a supplement), andf. potassium chloride (a supplement).On 04/09/25 at 9:51 a.m., CMA #3 documented the charge nurse was notified of medication refusal.On 04/09/25 at 7:52 p.m., CMA #2 documented the following medications were held due to refused:a. gabapentin (medication for pain),b. rabeprazole sodium, andc. docusate sodium.On 04/10/25 at 9:40 a.m., CMA #1 documented the following medications were held due to refusal and charge nurse was notified:a. rabeprazole sodium,b. furosemide,c. Linzess,d. morphine sulfate (medication for pain),e. vitamin c, andf. calcium carbonate/vitamin d.On 04/10/25 at 9:40 a.m., CMA#1 documented the charge nurse was notified of medication refusal.On 4/10/25 at 10:23 p.m., CMA #2 documented docusate sodium was held due to refusal.On 04/11/25 at 10:40 a.m., CMA#1 documented all morning medications were refused, and the charge nurse was notified of the refusal.An Interdisciplinary Team Notes, dated 04/11/25 at 3:03 p.m., read in part, Physician in the building and ordered C-diff lab test per resident family request. Order in place with lab. There was no documentation in the EHR to show the c-diff test was completed or other attempts were made to obtain it. An Interdisciplinary Team Notes, dated 04/11/25 at 06:07 p.m., showed Resident #3 had an altered mental status and was sent to the emergency room for evaluation.On 06/18/25 at 1:40 p.m., documentation of intake and output for Resident #3 was requested. The DON stated there were not any intake and output records past 02/02/25 due to change in the EMR systems. The DON was asked how they knew if a resident had consistent intake and output. The DON stated they monitored weights for weight loss.A review of Resident Weight Record for Resident #3, showed monthly weights from 10/03/24 through 03/04/25 as refused. There was no weight documentation after 03/04/25.On 06/20/25 at 9:20 a.m., NP #1 was asked about the documentation of a phone conversation from the facility nurse on 04/09/2. The NP stated they were on call the evening of 04/09/25. NP #1 was asked about a phone conversation with facility regarding Resident #3. The NP stated they did remember part of the conversation and the reason for the call, but they did not recall all of the conversation. NP #1 stated they did remember a facility nurse had called them regarding a family member requesting a C-diff test. The NP stated they reviewed the symptoms the resident was having with the facility nurse, specifically regarding diarrhea or abnormal vital signs. The NP stated his vitals were within normal limits and the resident did not have loose stools or diarrhea, other gastrointestinal symptoms or abnormal vital signs, so they did not order the C-diff test since they had lab facilities decline test samples if there were not any loose stool. NP #1 was asked if they were aware the resident had refused some of his routine medications that morning, as well as the previous two days, and had required PRN medications for nausea the two days prior. The NP stated they were not aware of that assessment. NP #1 stated they instructed the facility nurse to have physician #1 follow up and to call if there were any changes in condition. NP #1 was asked about nurses' documentation regarding the family requesting the resident to be sent to emergency room. The NP stated they did not remember that conversation and they were usually supportive of family requests and feels like they would have told them to send the resident to emergency room if they had been aware of the family request. On 04/20/25 at 1:15 p.m., the DON was asked about the process for medications held or refused. The DON stated the CMA notified the charge nurse, and if there were two consecutive holds, the nurse should call the physician and family. The DON was asked what the expectation of the nurse assessment for change of condition. The DON stated it would not be based on medications given or refused.On 04/20/25 at 3:30 p.m., LVN #3 was asked about the process for PRN medications. The LVN stated the nurses administered the PRN meds. LVN #3 stated they completed an assessment and gave medications based on the assessment. LVN #3 was asked about the procedure for calling the physician or family if PRN medications were administered. The LVN stated they did not call unless there were other issues or something significant going on. LVN #3 was asked if they felt taking a PRN does of Zofran 3 days in a row, when a resident had not taken it in several months, would be something that would be significant. The LVN stated No, people got nauseated. LVN #3 was asked about PRN doses that were administered on their shift. The LVN stated they did not remember giving Resident #3 anything for nausea. The MAR for the first part of April 2025 was reviewed with LVN #3 . The MAR showed two doses were documented on their shift. LVN #3 identified the initials documenting the administration as their initials. LVN #3 was asked if they called anyone regarding the PRN medications they administered. The LVN stated, No, I did not.

Based on record review and interview, the facility failed to accurately code a significant change MDS assessment for 1 (#2) of 3 sampled residents reviewed for accuracy of assessments.LPN #2 identified 120 residents resided at the facility.Findings:An undated face sheet for Resident #2's, showed diagnoses which included hemiplegia and hemiparesis following cerebral infarction affection left non-dominant side, muscle weakness, cerebral infarction, and bipolar disorder. Resident #2's significant change assessment, dated 05/01/25, showed cognitively intact cognition with a BIMS of 15. The assessment showed the Special treatments, procedures, and programs section, O0100 Z1 was coded as none of the above. Hospice care while a resident at K1 was not marked. A hospice certification document, dated 04/17/25, showed the certification date range of 04/17/25 to 07/15/25. The document was signed by an RN. A physician's order, dated 04/18/25, showed admit to hospice.On 06/19/25 at 12:56 p.m., MDS coordinator #1 stated the significant change assessment, dated 05/01/25, for Resident #2 was related to going on hospice. The MDS coordinator stated the resident went on hospice services on 04/17/25. MDS coordinator #1 reviewed the MDS and stated the MDS did not have hospice coded and was not accurately coded to reflect the resident's status at that time.

Based on record review and interview, the facility failed to ensure responsible parties were notified:a) for a change in condition, and b) an order for a new medication for 1 (#2) of 3 sampled residents who were reviewed for notification of change.LPN #2 identified 120 residents resided in the facility.Findings:A policy titled Change of Condition, dated 02/13/23, read in part, Patient families, guardians, or other appropriate people are to be contacted when there is a significant change in a patients condition or health status.An undated face sheet for Resident #2's showed diagnoses which included hemiplegia and hemiparesis following cerebral infarction affection left non-dominant side, muscle weakness and cerebral infarction, and bipolar disorder. The face sheet showed HealthCare Contact to be Resident #2's daughter. The resident's spouse/roommate was listed as the primary contact.Resident #2's significant change MDS, dated [DATE], showed cognitively intact cognition with BIMS of 15. An Interdisciplinary Progress Notes, dated 04/07/25 at 2:42 p.m., showed a new order from the physician to send the resident to the emergency room for vomiting and not being able to keep food, water and medication down, and with increased confusion and hallucinations. An SBAR Communication Form, showed the husband, the residents' roommate, was notified on 04/07/25 at 1:00 p.m. There was no documentation the HealthCare contact was notified. A physicians order, dated 04/23/25, showed alprazolam (a benzodiazepine) 0.5 mg tablet was to be administered by mouth twice a day for anxiety. An Interdisciplinary Progress Notes, dated 04/23/25, showed a new physicians order for alprazolam 0.5 mg twice a day. The note showed the resident, and the hospice company were notified. There was no documentation the HealthCare contact was notified. On 06/19/25 at 2:13 p.m., the IP, working as the charge nurse on the hall stated, to determine who was notified for a residents change in condition, they would look on the face sheet for the power of attorney or next of kin and notify them and the physician. The IP stated the representative for Resident #2, when they went to the hospital on [DATE], was the guarantor/emergency, [the resident's daughter]. The IP stated the husband was notified on 04/07/25 at 1:00 p.m. The IP stated the previous electronic record used had switched and had Resident #2's daughter as the HealthCare contact. On 06/19/25 at 2:30 p.m., the IP stated there were no notes for notification.On 06/19/25 at 2:42 p.m., the IP stated Resident #2's daughter probably should have been contacted.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate was less than 5 percent for 5 (#70, 71 77, 106, and #226) of 10 sampled residents reviewed for medication administration. The medication error rate was 23.68 percent. The DON identified 111 residents resided in the facility. Findings: 1. On 04/01/25 at 7:17 a.m., CMA #2 was observed to administer medications to Resident #71. Resident #71 had an order for hydrocodone/acetaminophen (an opiate medication) 7.5/325 mg every six hours that was not administered. 2. On 04/01/25 at 7:25 a.m., CMA #2 was observed to administer medications to Resident #226. Resident #226 was administered Vitamin B12 10 mcg without an order. Resident #226 had physician's orders to administer thiamine (a vitamin) 100 mg daily at 9:00 a.m. and ferrous sulfate (a iron supplement) 325 mg daily at 9:00 a.m. that were not observed to be administered. 3. On 04/01/25 at 7:46 a.m., CMA #2 was observed to administer medications to Resident #106. Resident #106 had an order for lisinopril (an ACE inhibitor)10 mg daily at 9:00 a.m. that was not observed to be administered. 4. On 04/01/25 at 8:05 a.m., CMA #1 was observed to administer medications to Resident #70. Resident #70 had orders for amlodipine (a calcium channel blocker) 5 mg daily at 9:00 a.m. and clindamycin (an antibiotic) 150 mg every six hours that were not observed to be administered. 5. On 04/02/25, at 8:17 a.m., LPN #2 was observed to prepare medication for Resident #77. Resident #77 had orders for two capsules of gabapentin (an anticonvulsant)100 mg twice daily and one tablet of potassium (electrolyte supplement)10 meq daily. LPN #2 was observed to administer one capsule of gabapentin and was not observed to administer potassium. A Medication Administration policy, dated 01/2024, read in part, Medications are administered in accordance with written orders of the prescriber. On 04/01/25 at 8:08 a.m., CMA #1 stated the clindamycin for Resident #70 was not in the facility. On 04/01/25 at 10:35 a.m., LPN #2 stated they only administered one capsule of gabapentin and should have administered two capsules for Resident #77. They stated they did not administer the potassium tablet. On 04/02/25 at 11:56 a.m., the corporate nurse was asked how they ensured medications were administered per physician orders. They stated they would get physician orders, order the medication from the pharmacy, make sure the medications were on the carts, and follow the MAR. The corporate nurse was made aware of the above observations for #70, 71, 77, 106, and #226.

Based on observation, record review, and interview, the facility failed to ensure staff did not use disinfectant wipes to clean residents' skin for 2 (#23 and #70) of 2 sampled residents observed during a finger stick for blood sugar and insulin observation. The corporate nurse identified 39 diabetic residents resided in the facility. Findings: On 04/01/25 at 7:41 a.m., LPN #2 was observed to gather supplies to obtain a blood sugar. They were observed to go to Resident #70 and clean the resident's finger with a disinfectant wipe prior to obtaining the blood sugar. On 04/01/25 at 7:49 a.m., the disinfectant wipe container was observed to show Not for use on skin. On 04/01/25 at 7:51 a.m., LPN #2 was observed to gather supplies to obtain another blood sugar. They were observed to go to Resident #23 and clean the resident's finger with a disinfectant wipe prior to obtaining the blood sugar. On 04/01/25 at 8:02 a.m., LPN #2 was observed to clean Resident #23's skin on their abdomen with a disinfectant wipe and administer insulin. A Safety Data Sheet for the disinfectant wipes, dated 06/29/22, showed to avoid contact with skin. A policy titled Bedside Blood Glucose Monitoring, dated 04/26/24, showed to cleanse the finger with alcohol. On 04/01/25 at 10:36 a.m., LPN #2 stated they were suppose to use alcohol swabs when obtaining blood glucose and administering insulin. They were asked if the disinfectant wipes were safe to use on skin. LPN #2 stated they did not think so.

Based on observation, record review, and interview, the facility failed to ensure infection control practices were maintained for handling soiled linen and hand hygiene during incontinent care for 1 (#52) of 23 sampled residents reviewed for infection control. The DON identified 111 residents resided in the facility. Findings: On 03/25/25 at 9:18 a.m., LPN #1 was observed exiting a resident's room while holding a soiled incontinent pad and took it into the soiled utility room. On 03/31/25 at 5:46 a.m., CNA #1 was observed to provide incontinent care to Resident #52 whose brief was soiled with urine and feces. CNA #1 did not change their gloves after cleaning the resident. CNA #1 used soiled gloves to put a clean brief on Resident #52 and placed a clean incontinent pad and a clean draw sheet under the resident. CNA #1 placed the soiled linen and soiled wipes onto the floor and not into a plastic bag. On 03/31/25 at 6:01 a.m., CNA #1 was observed to place soiled items from the floor into a plastic bag. CNA #1 used soiled gloves to place a clean sheet on top of Resident #52. CNA #1 was not observed to perform hand hygiene during the observation. A policy titled Hand Hygiene for Staff and Residents, revised 02/2025, read in part, Hand hygiene is done .Before .resident contact .After .contact with soiled or contaminated articles, that are contaminated with body fluids .toileting or assisting others with toileting. A policy titled Linen and Laundry Services, revised 03/2025, read in part, Contaminated laundry is bagged or contained at the point of collection (location where it was used) .Linen is not placed on the floor. On 03/25/25 at 9:19 a.m., LPN #1 stated they should have placed the soiled incontinent pad in a bag prior to transporting them to the soiled utility room. On 03/31/25 at 6:02 a.m., CNA #1 stated staff were to place soiled items in the trash, change their gloves, and wash their hands during incontinent care. On 03/31/25 at 6:14 a.m., the DON stated staff were to change their gloves between soiled and clean items when they were providing incontinent care to the residents. The DON stated soiled items went into bags and not on the floor.

Based on observation, record review, and interview, the facility failed to ensure medications were administered as ordered for 5 (#70, 71, 77, 106, and #226) of 10 sampled residents reviewed for medications. The DON identified 111 residents resided in the facility. Findings: 1. On 04/01/25 at 7:17 a.m., CMA #2 was observed to administer medications to Resident #71. Resident #71 had an order for hydrocodone/acetaminophen (an opiate medication) 7.5/325 mg every six hours that was not administered. 2. On 04/01/25 at 7:25 a.m., CMA #2 was observed to administer medications to Resident #226. Resident #226 was administered Vitamin B12 10 mcg without an order. Resident #226 had physician's orders to administer thiamine (a vitamin) 100 mg daily at 9:00 a.m. and ferrous sulfate (a iron supplement) 325 mg daily at 9:00 a.m. that were not observed to be administered. 3. On 04/01/25 at 7:46 a.m., CMA #2 was observed to administer medications to Resident #106. Resident #106 had an order for lisinopril (an ACE inhibitor)10 mg daily at 9:00 a.m. that was not observed to be administered. 4. On 04/01/25 at 8:05 a.m., CMA #1 was observed to administer medications to Resident #70. Resident #70 had orders for amlodipine (a calcium channel blocker) 5 mg daily at 9:00 a.m. and clindamycin (an antibiotic) 150 mg every six hours that were not observed to be administered. 5. On 04/02/25, at 8:17 a.m., LPN #2 was observed to prepare medication for Resident #77. Resident #77 had orders for two capsules of gabapentin (an anticonvulsant)100 mg twice daily and one tablet of potassium (electrolyte supplement)10 meq daily. LPN #2 was observed to administer one capsule of gabapentin and was not observed to administer potassium. A Medication Administration policy, dated 01/2024, read in part, Medications are administered in accordance with written orders of the prescriber. On 04/01/25 at 8:08 a.m., CMA #1 stated the clindamycin for Resident #70 was not in the facility. They stated it had been ordered yesterday and they did not know how quickly the pharmacy delivered new orders. On 04/01/25 at 10:35 a.m., LPN #2 stated they only administered one capsule of gabapentin and should have administered two capsules for Resident #77. They stated they did not administer the potassium tablet because the card of medication was empty. On 04/02/25 at 11:56 a.m., the corporate nurse was asked how they ensured medications were administered per physician orders. They stated they would get physician orders, order the medication from the pharmacy, make sure the medications were on the carts, and follow the MAR. They stated they purchased over the counter medications. The corporate nurse was asked what the policy was for ordering new medications. They stated their EMR interfaces with the pharmacy. The corporate nurse stated they would fax a new order if the EMR was not working. They stated staff would follow up with the pharmacy to ensure they received the orders. The corporate nurse was made aware of the above observations for #70, 71, 77, 106, and #226. Surveyor: Green, [NAME] 41318

Based on observation, record review, and interview, the facility failed to ensure staff were competent with the facility's EMR for 3 (CMA #1, LPN #2, and AD) of 3 staff observed for competent staff. The DON identified 111 residents resided in the facility. Findings: On 04/01/25 at 8:05 a.m., during a medication observation pass with CMA #1, a medication for a Resident #70 was observed not to be administered. In-service sheets for the new EMR, dated 03/05/25, 03/06/25, 03/10/25, and 03/12/25, did not show CMA #1, LPN #2, or the AD attended the in-services. On 04/01/25 at 8:08 a.m., CMA #1 stated the medication was not in the facility. They were asked how medications were ordered. CMA #1 stated as far as they knew, it was on the new EMR system. CMA #1 was asked if they could look at the new EMR and tell if the medication had been ordered. They stated they had not been trained on the new EMR and did not know how to tell if the medication had been ordered. CMA #1 stated they came into work one morning and the new EMR was in place. On 04/02/25 at 10:35 a.m., LPN #2 stated they did not know how to order medication on the new EMR system. On 04/02/25 at 11:56 a.m., the corporate nurse was asked how they ensured staff were competent with the new EMR. They stated corporate staff had conducted a two day training with key staff and nursing administration. The corporate nurse stated those staff members then trained the rest of the staff. On 04/02/25, at 12:01 p.m., during the interview with the corporate nurse, the AD entered and asked the corporate nurse how to get to care plans in the new system. The corporate nurse stated there should be in-service sheets. On 04/02/25 at 1:37 p.m., the corporate nurse stated they could not find any other in-service sheets. They stated without the inservice sheets, they could not say everyone had been in-serviced. 41318

Based on observation, record review, and interview, the facility failed to provide treatment and services to promote the healing of a pressure ulcer for one (#2) of three residents reviewed for pressure ulcers. The DON identified eight residents in the facility with pressure ulcers. Findings: A policy titled An Overview of Wound Care, dated July 2018, read in parts .The comprehensive assessment should provide the basis for defining approaches to address residents at risk of developing or already having a PU/PI .Effective prevention and treatment are based upon consistently providing routine and individualized interventions .Repositioning or relieving constant pressure is a common, effective intervention for an individual with a PU/PI or who is at risk of developing one . Resident #2 had diagnoses which included Parkinson's disease, cognitive communication deficit, and overactive bladder. A care plan, dated 08/09/23, documented at risk for/actual skin breakdown. The care plan documented staff where to assist the resident to turn and reposition frequently and inspect skin of the complete body head to toe every week and document. A nurse note, dated 03/12/24, documented the resident was seen by the wound physician and the wound to the buttock was resolved. A significant change assessment, dated 03/30/24, documented the resident was severely impaired cognitively and was dependent for most ADLs. The assessment documented the resident was always incontinent of bowel and bladder. A wound report, dated 04/15/24, documented the resident had a stage 3 pressure wound to the sacrum and measured 2cm X 2cm X 0.1cm. A wound report, dated 04/23/24, documented the resident had a stage 3 pressure wound to the sacrum and measured 4cm X 2cm X 0.2cm. A physician orders, dated 04/23/24 documented the resident was to have wound care every Monday and Thursday in the morning to the sacrum. The staff were to apply medical honey, cover with a mepilex dressing, and change when needed. The ETAR for April 2024, documented from 04/23/24 to 04/30/24 the resident received one wound care treatment. The ETAR documented missed treatments. The ETAR for May 2024, documented from 05/01/24 to 05/08/24 the resident received one wound care treatment. The ETAR documented missed treatments. A coordination note, dated 05/12/24, documented the hospice service was in the facility to provide wound care. The note documented the wound measured 4cm X 4.5cm X 0.5cm. On 05/13/24 at 1:20 p.m., an observation of wound care was conducted for the resident. On 05/13/24 at 3:48 p.m., the DON stated the does not document turning or repositioning, they just know to make every two hour rounds. The DON stated the facility staff does not perform measurements of the wound, the hospice service does weekly wound measurements.

The facility failed to ensure a resident experiencing pain received treatment for pain for two (#1 and #15) of four sampled residents reviewed for pain. CNA #1 failed to notify the nurse when Resident #15 experienced pain during incontinent care. Resident #15 continued to holler/cry out in pain throughout the incontinent care provided by CNA #1. The Administrator identified a census of 128. Findings: A Pain Management and Basic Comfort Measures policy, revised 08/19/20, read in part, .Staff will evaluate pain and provide basic comfort measures in accordance with standard practice guidelines .Utilize pain level scale to determine acceptable level of pain .Examine the site of patient's pain .Evaluate the resident's medical history for successful pain relief therapies .Provide pain medication as prescribed by an authorized prescriber . 1. Resident #15 had diagnoses which included Parkinson's disease without dyskinesia and cognitive communication deficit. A Pain Care Plan, last reviewed 02/12/24, documented interventions which included assess characteristics of pain including location, severity, type of pain, frequency, precipitating factors, and relief factors using the pain assessment form. A Quarterly Resident Assessment, dated 02/16/24, documented Resident #15 had severe cognitive impairment, they received scheduled pain medication, and had no pain present upon staff pain assessment interview. Resident #15's Incident Report, dated 03/17/24, documented the resident fell on [DATE] at 8:20 p.m. It documented the nurse was called to the resident's room by the nurse aide. It documented the resident was lying on the floor on their left side next to the recliner. Resident #15 was unable to describe what happened. It documented the resident admitted to hitting their head, a head to toe assessment was completed, and the resident was able to move all extremities. It documented the resident was assisted to bed with the help of the nurse aide with no signs of distress/discomfort noted at the time. Staffing schedules documented CNA #1 was working on Resident #15's hall on 03/17/24 on the 3:00 p.m. to 11:00 p.m. shift and 11:00 p.m. to 7:00 a.m. shift. Resident #15's x-ray result, dated 03/18/24 at 8:22 p.m., documented an acute mildly displaced, mildly impacted fracture at the left femoral head neck junction. Hospital records, dated 03/18/24, documented Resident #15 had experienced a ground level fall at the nursing facility. It documented the resident had been complaining of pain, was brought to the hospital, and x-ray showed a valgus impacted femoral neck fracture. It documented Resident #15 had underwent a hip and femur fracture repair. On 03/22/24 at 11:07 a.m., Family Member #1 stated Resident #15 had fallen around 8:03 p.m. on 03/17/24. They stated on 03/18/24 at 3:00 a.m., CNA #1 came in to change Resident #15 and the family member could hear the resident screaming out in pain. Family Member #1 stated CNA #1 was rough with Resident #15, and they identified later the resident had broken their hip. They reported the concern the next morning to the DON and showed them the video surveillance. They stated they told the DON CNA #1's treatment looked like they were rastling with a bear. The Family Member stated the DON did not watch all of the video because they were in a hurry and didn't want to see the rest. Family Member #1 stated they spoke with hospice and had agreed to wait to x-ray until Monday morning. On 03/22/24 at 11:31 a.m., Surveyor #1 observed the video surveillance of Resident #15 for 03/18/24 from 3:14 a.m. through 3:20 a.m. CNA #1 was observed providing incontinent care to Resident #15. CNA #1 lifted Resident #15's left leg, the resident screamed out and the CNA stated You're wet. CNA #1 removed clothing from the resident's lower body, the resident stated, Please quit. The CNA placed a new brief on and began putting the resident's pants back on. Resident #15 stated, Oh that hurts, Quit it, Stop, Get out of here. CNA #1 took Resident #15's left leg and bent it over their straight right leg creating a triangle shape. Resident #15 began screaming out and crying. CNA #1 continued to provide care to the resident. CNA #1 pushed Resident #15 to the right side and the resident screamed out help. The resident was observed hollering out in pain multiple times as care was being provided. CNA #1 failed to stop and go get the nurse, and instead continued to provide incontinent care to the resident and redress the resident. At the very end of care, CNA #1 asked Resident #15 Are you ok. The Resident stated, No, I'm not ok. CNA #1 asked what was not ok, did not receive a response, and covered the resident up. There was no documentation in Resident #15's clinical record that CNA #1 notified the nurse of the resident's pain experienced during care. On 03/22/24 at 2:23 p.m., the DON stated Resident #15's family member had shown them a video of the resident's fall on 03/17/24, and of care being provided during the next shift from CNA #1. They stated Resident #15 was yelling during care. They stated CNA #1 Kept changing [Resident #15]. The DON stated they did a one on one training with CNA #1 informing them if a resident yelled stop, they were to go get the nurse. They stated CNA #1 was aware the resident had fallen on 03/17/24 as they were working on the resident's hall when they fell . On 03/22/24 at 2:30 p.m., the DON stated the resident hollered often and it did not appear CNA #1 was rough. The DON stated it was determined later that day Resident #15 had broken their hip. On 03/25/24 at 10:10 a.m., an attempt to interview Resident #15 was made, the resident had their eyes open but did not respond to the surveyor. On 03/26/24 at 12:00 p.m., CNA #2 stated they would alert the nurse anytime a resident experienced pain/discomfort during care. On 03/26/24 at 12:05 p.m., CNA #3 stated they would let the nurse know if a resident experienced pain/discomfort during care. On 03/26/24 at 12:08 p.m., CNA # 5 stated they would ask a resident what was wrong if they experienced pain/discomfort, and notify the nurse. On 03/26/24 at 12:11 p.m., LPN #2 stated a CNA would need to stop anytime a resident experienced pain or discomfort during care and notify the nurse that moment. They stated they would follow up by completing an assessment of the resident, address the pain, see if there was an as needed pain medication ordered and assist with position changes to help if needed. They stated they would notify the physician if the resident did not have an order to treat pain. On 03/26/24 at 1:35 p.m., LPN #3 stated CNAs should stop and notify the nurse if a resident experienced pain or discomfort during care. LPN #3 stated they would gather as much information as possible, assess the resident, administer medications as ordered, and reposition the resident for comfort. 2. Resident #1 admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, rhabdomyolysis, and anxiety disorder. A Physician Order, dated 02/22/24, documented acetaminophen 325 mg take two tablets by mouth every four hours as needed for pain. A Physician Order, dated 02/22/24, documented oxycodone 5mg take one tablet by mouth every six hours as needed. A Physician Order, dated 02/29/24, documented oxycodone 5mg take one tablet by mouth two times a day. The Count Sheet for Resident #1's oxycodone 5mg tablet take one tablet by mouth twice daily documented the first dose was administered on 02/29/24. The February 2024 medication administration record documented: a. the first dose of oxycodone 5mg was administered to the resident at 9:00 a.m. on 02/29/24; b. acetaminophen 325 mg was administered once on 02/22/24 for a pain level of 2, once on the 25th for a pain level of three, and once on the 29th for a pain level of two; c. the oxycodone 5mg one tablet by mouth every six hours as needed for pain was not administered for the month; and d. Resident #1's pain scale for the day shift was rated at a five on the 22nd, 23rd, and 29th, rated at a four on the 25th, 26th, and 27th, and rated at a three on the 24th. On 03/21/24 at 11:35 a.m., Resident #1 stated it took the facility 1 1/2 weeks to get their pain pills at the facility. They stated they had pain medications at the facility they came from. Resident #1 stated the staff stated the doctor was called. They stated staff offered them Tylenol. Resident #1 stated their pain radiated from the right leg to the ankle, and they had pain in their back from a previous surgery which burned and at times was generalized. They stated when their pain medication was finally ordered, they received oxycontin 5mg twice a day routinely and never needed the as needed dose. On 03/22/24 at 9:02 a.m., LPN #2 stated they assessed residents for verbal and nonverbal signs of pain. On 03/22/24 at 9:03 a.m., LPN #2 stated they used a one to ten scale for pain. They stated a three to five was considered mild pain and needed a pain intervention. On 03/22/24 at 9:05 a.m., LPN #2 stated if a resident complained of pain, they would review their orders and administer medication as ordered. On 03/22/24 at 9:07 a.m., LPN #2 stated if a resident wanted an alternative pain medication or the medication was not effective, they would notify the physician for an intervention. On 03/22/24 at 9:47 a.m., the DON stated for a pain level of one to five staff would usually give Tylenol. They stated for a pain level higher than five they would give something stronger. They stated if the pain was consistent over a week, they would call the doctor. On 03/22/24 at 9:50 a.m., the DON stated Resident #1's initial pain scale on admission was a four. They stated from 02/22/24 through 02/29/24 the resident's pain level was a five three times, a four three times, a three one time, and a zero one time all on the day shift. They stated the evening and night shifts all had documented a zero for pain. On 03/22/24 at 9:53 a.m., the DON stated they would have expected the nurses' to give Tylenol for the above pain ratings. On 03/22/24 at 10:00 a.m., the DON stated Resident #1 received Tylenol on the 22nd, 25th, and 29th. They stated the resident only received Tylenol from 02/22/24 through 02/28/24. They stated the resident did not receive oxycodone. On 03/22/24 at 10:07 a.m., the DON stated Resident #1 had received oxycodone at the previous facility, but did not have a script at this facility for it. They stated the order was for oxycodone 5 mg every six hours as needed. They stated the doctor had to see the resident before writing a script for the pain medication. They stated the facility received the order for the oxycodone on 02/29/24 and it was received in the building that same day. On 03/22/24 at 10:16 a.m., the DON stated staff should offer the resident oxycodone if they requested it. On 03/22/24 at 11:07 a.m., LPN #2 stated there was no documentation in the nurse notes of what Resident #1's pain effectiveness was for 02/22/24 and 02/29/24 after the Tylenol administration.

Based on record review and interview, the facility failed to ensure resident records were accurate for one (#3) of three sampled residents reviewed for accurate records. The Administrator identified a census of 128. Findings: A Records Management policy, revised 06/01/17, read in part, .The Organization requires that its records be maintained in a consistent and logical manner and be managed so that the Organization .Meets legal standards for protection, storage, and retrieval .Protects the privacy of healthcare facility residents and patients . Resident #3 had diagnoses which included cerebral infarction and aphasia. Resident #14's hospital records, dated 08/05/23, were observed in Resident #3's clinical record. Resident #13's hospital records, dated 08/07/23, were observed in Resident #3's clinical record. Resident #11's hospital records, dated 09/08/23, were observed in Resident #3's clinical record. Resident #12's hospital records, dated 09/25/23, were observed in Resident #3's clinical record. On 03/21/24 at 2:42 p.m., Medical Records stated they received any resident information in a basket located by the scanner. They stated the ADON reviewed them to ensure the orders were put in correctly, then Medical Records would scan them in. They stated everything had a resident's name, dates of service, and who created the document. They stated they would email Corporate and have the above documents removed from Resident #3's record.

The facility failed to ensure a care plan meeting was held and a resident's representative was included for one (#4) of three sampled residents reviewed for representative included in plan of care. The Administrator identified a census of 128. Findings: Resident #4 had diagnoses which included chronic kidney disease and chronic pain. Resident #4 had a Care Plan Conference on 07/31/23. Resident #4's Annual Resident Assessment was completed on 10/10/23. A Nurse's Note, dated 10/17/24, documented an email was sent to Resident #4's representative regarding setting up a care plan meeting. The next documented Care Plan Conference for Resident #4 was on 02/09/24. On 03/27/24 at 9:18 a.m., LPN #1 stated they were responsible for care plan meetings. They stated the meetings were supposed to be every three months. They stated Resident #4 had a care plan meeting that was missed. They stated the meeting was scheduled, but LPN #1 wasn't working, and no one covered them. They stated it was the meeting that fell between the 07/23 and the 02/24 care plan meetings.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facilities failure to ensure Resident #1 received CPR for one (#10) of two sampled residents for CPR. Resident #1 was admitted to the facility on [DATE] and had diagnoses which included end stage renal disease, hypertension, diabetes mellitus II, iron deficiency and anemia. Resident #1 admitted late in the day and the facility documented TBD as the Resident's code status. No assessments were completed at the time of admission. Resident #1's documentation from the hospital dated [DATE] documented they were a full code status. On [DATE] the fire department arrived to facility at 2:01 p.m. The fire department run report documented upon their arrival at the facility the nurse stated that the patient had been unresponsive for 30 minutes prior to their arrival. Two employees stated to the fire department that the patient had been unresponsive for 30 minutes prior to our arrival. They stated the reason for the delay CPR or calling 911 was due to contacting the patient's physician for medical direction and having to clean the patient due to bowel incontinence. emergency room documentation, documents Due to prolonged downtime and no return of spontaneous circulation, the decision to terminate resuscitation efforts were made. Time of death was noted at 2:52 P.M. on [DATE]. LPN #1, the charge nurse on [DATE], stated CPR was not performed on Resident #1. They stated that they thought Resident #1 had DNR, they could not find it that night. The DON stated, If they don't have an advance directive or a DNR on file they are a full code and it would be expected for staff to perform CPR. On [DATE] at 4:52 p.m., The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On [DATE] at 5:05 p.m., the Administrator and the DON were notified of the IJ situation. On [DATE] at 9:52 p.m., the facility submitted an acceptable a plan of removal. The plan of removal documented the following: 1) The DON/designee will educate all licensed nurses on when to initiate CPR and what to do if the code status has TBD. Licensed nurses will be shown how to correct the code status order once they confirm whether the resident is a full code or DNR upon admission. They will also be educated by the Director of Nursing or designee by 11:59pm [DATE] that they must print the DNR/Advanced Directive Report from [facility EHR] at the beginning of their shift. Any licensed nurse not educated by end of day on [DATE] will not return to work until they have received the education. 2) DON/Designee will print the DNR/Advance Directive report from [facility EHR] on [DATE] to assure all code status orders are entered correctly. Staff will be educated on where to find the Code Status in [facility EHR] by 11:59pm [DATE]. 3) Mock Code Blue to be initiated for each shift with return demonstration from staff by end of day (11:59PM) 0n [DATE] then randomly weekly for 2 weeks, then q month for 90 days. a. Staff to remain in room and initiate CPR b. Code Blue announced c. C N A or staff will retrieve emergency crash cart and initiate 911 on each shift. The DON/designee will be conducting the code blue. There will be repeat training for any staff that do not achieve successful completion of code blue. On [DATE], staff were interviewed regarding recent training/updates in regards to the CPR policy and protocol. Staff stated they had received in-services/training from the DON/designee and verbalized understanding of the information provided in the in-service pertaining to the plan of removal. On [DATE] at 7:27 p.m., the Administrator RNC #1 and RNC #2 was informed the immediacy was lifted effective [DATE] at 5:30 p.m. The deficiency remained at an isolated level of actual harm. Based on record review and interview, the facility failed to ensure a newly admitted resident's code status was known upon admission. Resident #1's code status upon admission was TBD (to be determined) and the resident was found unresponsive and the charge nurse failed to initiate CPR due to the lack of knowledge of residents code status. The Resident Census and Conditions of Residents report, dated [DATE], documented 107 residents resided in the facility. Findings: AEmergency Standards of Practice policy, revised [DATE], read in parts, .The staff will call 911 .when the resident's condition is life threatening in accordance with his/her Advanced Directives .Qualified staff initiates the appropriate emergency procedure, i.e., oxygen, suction, CPR . A Cardiopulmonary Resuscitation (CPR): Basic Life Support (BLS)/Hands-Only CPR, policy and procedure, revised [DATE], read in parts, .Standard of Practice: CPR (BLS and/or Hands-Only) will be initiated for residents that experience a witnessed or unwitnessed cardiopulmonary arrest while in the community If an individual is found unresponsive by an employee of the community the employee will initiate CPR unless: .it is known that a Do Not Resuscitate order exists for the resident . Resident #1 was admitted to the facility on [DATE] and had diagnoses which included artherosclerotic heart disease of native coronary artery without angina pectoris, diabetes mellitus type 2, chronic kidney disease, stage 3, COPD, and obstructive sleep apnea. The EHR documented Resident #1's code status as TBD. There was no documentation in the EHR or admission record the resident had a DNR. Resident #1's documentation from the hospital dated [DATE] documented the Resident had a full code status. A nurse's note, dated [DATE], read in parts, This nurse was called to room due to staff reported unable to obtain O2 sat, unable to feel pulse skin was cool to touch. He was laying on mattress urine output was noted in cath collection system. Notified DON and assistance from another staff member. Notified [DATE] for ambulance for non-responsive resident, upon CPR given EMSA noted area on side of head, unknown to this nurse and not reported, appearance of dried blood noted to face as staff was cleaning resident due to incontinent of BM and .this nurse stated 30 minutes passed and was not clear on the exact time . This note was electronically signed by LPN #1 as a late entry on [DATE] at 9:45 a.m., 27 days after the resident was found unresponsive and CPR was not performed by the facility. A fire department run report, dated [DATE], read in parts, .arrived 14:01:20 [2:01 p.m. and 20 seconds] was this a full arrest yes .attempted defibrillation, attempted ventilation, initiated chest compressions .narrative .upon arrival, the nurse stated the pt had been unresponsive for 30 minutes prior to our arrival. The two employees from the facility who were are the room .stated the reason for delay CPR or calling 911, was due to contacting the physician for medical direction and having to clean the pt due to bowel incontinence .pt was lying supine on the floor unresponsive and pulseless . A hospital emergency room report, dated [DATE], read in parts, .due to prolonged downtime and no return of spontaneous circulation, the decision to terminate resuscitation efforts were made. Time of death was noted at 1452 [2:52 p.m.] . A discharge assessment, dated [DATE], documented Resident #1 had died in the facility. A signed memorandum from the fire department, dated [DATE], read in parts, .On [DATE] at 1357 our fire department responded to a cardiac arrest call at Tuscany Village .upon our arrival we discovered that the patient had been found unresponsive approximately thirty minutes prior to our call. Instead of imitating immediate CPR, the nursing staff focused on cleaning the patient .The delayed initiation of CPR significantly reduced the patient's chance of survival . On [DATE] at 3:45 p.m., LPN #1, the charge nurse on [DATE] stated CPR was not performed on Resident #1. They stated that they thought Resident #1 had DNR, they could not find. On [DATE] at 2:25 p.m. the DON stated, if a resident does have an advance directive or a DNR on file they are a full code and it would be expected for staff to perform CPR. The DON further stated Resident #1 code status was listed as TBD on admission because they were admitted late that evening. The DON further confirmed Resident #1 did not have a DNR or advanced directive and CPR should have been provided. On [DATE] at 2:39 p.m., the admission coordinator stated that Resident #1 came in late on a Friday evening. They stated that if the hospital paperwork says the resident was a full code then on admission the Resident would be a full code and CPR should be performed.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were treated with dignity for one (#8) of one sampled resident reviewed for dignity. This resulted in the resident feeling miserable, un-digitized and he wanted to die. The administrator identified 126 residents resided in the facility. Findings: Resident (Res) #8 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Res's care plan, dated 07/20/21, documented to respect the Res's privacy. The Res's quarterly assessment, dated 01/12/22, documented the Res's cognition was intact. Res #8's ADL report, dated 01/15/22, documented the Res was totally dependent on staff for bed mobility and toilet use. On 01/31/22 at 5:55 a.m., Res #8 was observed from the hall, laying in bed, in only an adult brief. His blanket was observed hanging off the side of the bed. The call light was observed, out of reach, attached to the blanket. He stated he needed to be changed and he has to wait for hours for staff assistance. On 02/01/22 at 7:46 a.m., Res #8 was observed from the hall, laying in bed, in only an adult brief. His blanket was observed hanging off the end of the bed. At 8:32 a.m., Res #8 was observed in the same uncovered position. A meal tray was observed on a bedside table positioned over the Res. The meal was still covered. At 9:00 a.m., Res #8 stated he hadn't eaten breakfast. He stated, I need to be fed, diaper changed, and covered up. I haven't been checked on for 3-4 hours. I'm cold. At 9:02 a.m., NCNA #1 was observed to come in to Res #8's room and retrieve his roommate's breakfast tray. At 9:20 a.m., another Res brought Res #8 a cup of coffee. NCNA #2 came in and moved the bedside table closer to the Res for the Res to drink coffee. NCNA #2 took the resident's breakfast tray and heated it up. At 9:25 a.m., Res #8 was asked how he felt. He stated, Like a piece of[OBSCENITY] Makes me feel like an un-respected piece of[OBSCENITY] No dignity, no pride. When you are stuck to this rubber mat, it's miserable. I have had to lower my standards to lay here in my underwear for everyone to see. Makes me want to give up on life. It doesn't make your day start out right. Then I will yell for help and they tell me to push my call light. Well, I can't reach my call light. At 1:32 p.m., NCNA #1 was asked how staff ensured residents were treated with dignity. She stated, Treat them how you would want to be treated. At 1:34 p.m., the DON was asked how staff ensured residents were treated with dignity. She stated to knock and announce before entering in the room, explain what care they are providing, and provide privacy when providing care. She was asked if a resident was able to be seen from the hallway, wearing only a adult brief, was that treating the resident in a dignified manner. She stated, No.

Based on record review and interviews, the facility failed to ensure pressure ulcers did not develop and weekly skin assessments were conducted for two (#1 and #2) of three sampled residents reviewed for pressure ulcers. This resulted in resident #2 developing an unstageable pressure ulcer. The DON identified 18 residents had wounds. Findings: 1. Resident #2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 12/22/21 at 11:12 p.m., read in part, .Resident admitted to facility .skin CDI [clean, dry, intact] without redness or open areas noted . An admission resident assessment, dated 12/26/21, documented the resident required extensive assistance for transfers and bed mobility and had no un-healed pressure ulcers. A care plan, dated 12/29/21, read in part, .Skin Breakdown: At risk for/actual .Measures will be taken to prevent skin breakdown .Assist resident to turn and reposition frequently .Inspect skin complete body head to toe every week and document results . There was no documentation of a skin assessment from 12/22/21 to 01/01/22. A nurse's note, dated 01/01/22 at 6:32 a.m., read in part, .Wound noted to sacrum - Unstageable - 3.5CM x 3.5CM x UT - adherent slough noted to peri bed - moderate serous sanquinous [sic] drainage noted - MD contacted - received new order . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .CLEANSE SACRUM WITH NS AND/OR WIPES; PAT DRY; APPLY [MEDICATION(S)] TO PERIBED; APPLY BORDER DRESSING Q MWF AND PRN Dx : Pressure ulcer of sacral region, unstageable . A wound report, dated 01/12/22, documented the wound was 2.5 CM x 1.4 CM x 0.2 CM. On 02/07/22 at 10:48 a.m., the wound care nurse was asked if resident #2 had pressure ulcers on admit. She stated, No. She was asked what type of assistance the resident required. She stated moderate to maximum assistance with turning and repositioning. She was asked if the resident developed a pressure ulcer. She stated, Yes. She was asked if there were any skin assessments from 12/22/21 to 01/01/22. She stated no. The WC nurse was asked if the pressure ulcer was unavoidable. She stated, Yes and no. 2. Resident (Res) #1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 05/05/21, read in part, .Wounds to buttocks, scrotum . Res's care plan, dated 05/07/21, read in part, .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . The Res's admission assessment, dated 05/09/21, documented the Res's cognition was moderately impaired, required extensive staff assistance with bed mobility, transfers, toilet use, and hygiene. A nurse's note, dated 05/11/21, read in part, .Resident scrotum noted w/open areas . A nurse's note, dated 05/15/21, read in part, .open wound to sacrum note . A nurse's note dated 05/16/21, read in part, .wound to sacrum . On 02/07/22 at 2:45 p.m., the DON was asked who was responsible for assessing the resident's wounds. She stated the wound care nurse would assess wounds weekly. She was asked what was assessed. She stated odor, characteristics, and measurements. She was shown the nurses' notes and was asked if wounds were assessed. She stated, Should be. At 4:20 p.m., the DON stated she was not able to locate the wound assessments.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from neglect for one (#8) of four sampled resident reviewed for dignity. This resulted in the resident feeling miserable, un-dignified and he wanted to die. The administrator identified 126 residents resided in the facility. Findings: A facility policy titled, Neglect, revised 06/23/17, read in part, .Each resident has the right to be free from neglect .The facility must prohibit and prevent .neglect .Neglect: Failure of the facility .to provide .services to a resident that are necessary to avoid .mental anguish, or emotional distress . Resident (Res) #8 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Res's care plan, dated 07/20/21, documented to respect the Res's privacy. The Res's quarterly assessment, dated 01/12/22, documented the Res's cognition was intact. The Res's ADL report, dated 01/15/22, documented the Res was totally dependent on staff for bed mobility and toilet use. On 01/31/22 at 5:55 a.m., Res #8 was observed from the hall, laying in bed, in only an adult brief. His blanket was observed hanging off the side of the bed. The call light was observed, out of reach, attached to the blanket. He stated he needed to be changed and he has to wait for hours for staff assistance. On 02/01/22 at 7:46 a.m., Res #8 was observed from the hall, laying in bed, in only an adult brief. His blanket was observed hanging off the end of the bed. At 8:32 a.m., Res #8 was observed in the same uncovered position. A meal tray was observed on a bedside table positioned over the Res. The meal was still covered. At 9:00 a.m., Res #8 stated he hadn't eaten breakfast. He stated, I need to be fed, diaper changed, and covered up. I haven't been checked on for 3-4 hours. I'm cold. At 9:02 a.m., NCNA #1 was observed to come in to Res #8's room and retrieve his roommate's breakfast tray. She did not attempt to assist resident #8. At 9:20 a.m., another Res brought Res #8 a cup of coffee. NCNA #2 came in and moved the bedside table closer for the resident to drink coffee. NCNA #2 took the resident's breakfast tray and heated it up. At 9:25 a.m., Res #8 was asked how he felt. He stated, Like a piece of[OBSCENITY] Makes me feel like an un-respected piece of[OBSCENITY] No dignity, no pride. When you are stuck to this rubber mat, it's miserable. I have had to lower my standards to lay here in my underwear for everyone to see. Makes me want to give up on life. It doesn't make your day start out right. Then I will yell for help and they tell me to push my call light. Well, I can't reach my call light. At 1:32 p.m., NCNA #1 was asked how staff ensured residents were treated with dignity. She stated, Treat them how you would want to be treated. At 1:34 p.m., the DON was asked how staff ensured residents were treated with dignity. She stated to knock and announce before entering in the room, explain what care they are providing, and provide privacy when providing care. She was asked if a resident was able to be seen from the hallway, wearing only a adult brief, was that treating the resident in a dignified manner. She stated, No.

On 06/30/21, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to supervise a resident to prevent elopement, failure to perform 30-minute visual checks, and failure to ensure consistent and uninterrupted one-on-one supervision after the residents' return to the facility. On 06/26/21 at approximately 4:00 p.m., resident #1 was observed attempting to exit the front door and again around 4:45 p.m. The resident was redirected both times back to the nurse's station. It was reported the resident was last seen at approximately 5:00 p.m. attempting to exit the facility from the 300 hall exit door, triggering the door alarm. The nurse on duty for the 300 hall reportedly came out of a resident's room when the alarm sounded but did not ensure the resident was safe and went back to what she was doing. At approximately 8:00 p.m., the facility received a call from Oklahoma City fire station #32, informing the facility the resident had been dropped off at the fire station by two men who had picked up the resident at a local 7-11. The fire station was reported to be 20 miles from the facility. Facility staff went to the fire station to pick up the resident and returned the resident to the facility at approximately 9:15 p.m. No one in the facility knew the resident had been missing. Upon return to the facility, the resident was placed on one-on-one observation but this intervention did not occur on 06/27/21, 06/29/21, or 06/30/21. On 06/30/21, the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 5:25 p.m., the facility administrator was notified of the IJ situation. At 7:56 p.m., an acceptable plan of removal was provided. The plan of removal documented: All residents will be re-evaluated for elopement risk by noon on 07/01/21 and their care plan updated as indicated. If elopement risk is identified the Elopement Risk book will be updated with their face sheet and picture. All department heads will be trained by regional corporate nurse (RCN), then they will train their staff on the elopement policy to include, how to identify who is at risk for elopement and effective supervision to prevent missing residents, including how to identify an acute change of condition with increased elopement risk behaviors on one shift, they will place the resident on 1:1 supervision to include a person with the patient at all times, notify physician and administration; this will be done by noon on 07/01/21. If staff is unable to be reached in person or by phone, they will be in-serviced prior to their next shift. An Elopement Drill will be conducted on 3-11 6-30-21, on 11-7 7-1-21 and 7-3 on 7/1/21 before noon on 7-1-21. The resident identified with an elopement on 6/26/21 is in process of discharge at this time, 6-30-21 is exiting at 6 p.m. to a new secured unit. One other resident identified on elopement precautions, care plan reviewed for elopement risk and precautions in place. On 07/05/21 and 07/06/21, interviews were conducted with the nursing staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. Staff reported an in-service was provided on 06/30/21 and 07/01/21 by 12:00 p.m. Staff members were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. On 07/01/21 at 12:00 noon, the IJ immediacy was removed when all components of the plan of removal had been completed. The deficiency remained at a level of isolated with the potential for more than minimal harm. Based on observation, interview and record review, it was determined the facility failed to ensure a resident received adequate supervision to prevent elopement for one (#1) of four residents reviewed for elopement risk. The resident exited the facility unattended and remained off the premises for approximately three hours without staff being aware. The facility reported a resident census of 112. The facility reported no other incidents of resident elopement. Findings: Resident #1 had diagnoses which included Alzheimer's disease, impulse disorder, and depression. A quarterly assessment, dated 04/07/21, documented the resident's cognition was severely impaired. The assessment documented the resident was independent with activities of daily living. A care plan, dated 05/07/21, documented an incident on 05/05/21 at 5:28 p.m., when the resident was found walking around outside. An intervention was for every 30 minute visual checks. The care plan documented elopement attempts on 05/17/21 3:30 p.m., 05/21/21 at 7:00 p.m., and 05/22/21 at 10:45, all with the intervention of redirecting the resident. The care plan documented an elopement on 06/26/21 when the resident left the property, with an intervention added of one-on-one (1:1) observation with staff until other placement. An incident report, dated 05/21/21, documented the resident went out the gate of the back patio area and was found in the parking lot. A nurse note, dated 05/28/21, documented late entry for 05/21/21 at 6:00 p.m., laundry staff returned with res from rear of facility, staff reported that res entered the back of the facility through the laundry and that res had exited the backyard area through the rear gate. An incident report, dated 06/26/21, documented the resident had eloped from the facility. A facility document, titled Med in eTAR, dated 06/01/21 ~ 06/30/21, documented frequent visual checks, every shift 1:1 began 8 p.m. 6/26 upon return to the facility following elopement. On 06/26/21, the record documented the resident had been checked every 30 minutes on the evening shift. A nurse note, dated 06/26/21, documented .Approximately 8:00 p.m. this nurse was notified by receptionist that resident had successfully eloped from the facility to Mustang, Mustang PD made the phone call to the facility verifying the pt's identity and residency .returned to the facility at 9:10 .new intervention for 1:1 is now in place. The document, Med in eTAR, dated 6/01/2021 ~ 06/30/21, documented 1:1 observation was not performed on 06/27/21. On 06/30/21, the facility produced two elopement books, one was at the front receptionist desk and one was provided by the assessment coordinator. Neither book contained information concerning elopement for this resident. On 06/30/21 at 10:30 a.m., the resident was observed sitting on her bed in her room. The resident was alone with no 1:1 staff monitoring the resident. At 11:00 a.m., certified nurse aide (CNA) #1 reported the resident did not have 1:1 observation in place when the aide started her shift at 7:00 a.m. The CNA reported she saw the resident leave her room at approximately 8:00 a.m. and thought she was going to the dining room. The aide reported no one told me she was supposed to be 1:1. The CNA was asked if she had been in-serviced on elopement since the resident eloped on 06/26/21. She stated, No, I haven't been in-serviced on elopement. At 11:15 a.m., CNA #2 reported she had not been in-serviced on elopement and was not aware the resident was supposed to have 1:1 observation. The aide reported there were only two aides working the hall with 25 residents, and stated she had recently worked the hall by herself. At 11:30 a.m., licensed practical nurse (LPN) #1 was asked if the resident had been on 1:1 observation. The nurse reported she had been on that hall all morning with the treatment cart and considered that to be 1:1 observation because she could see the resident if she left her room. At 1:00 p.m., a fireman from station #32 reported two men in a truck had dropped the resident off at the station. He stated the men reported they had picked her up at a 7-11 where she was getting some coffee. He reported he called the facility at 7:44 p.m. and the lady who answered the phone said, Oh my goodness she got out. He stated facility staff showed up at 8:30 p.m. to get the resident. At 3:00 p.m., the maintenance manager was asked if he had checked all the doors after this resident eloped. He said he did not check all the doors right away. He stated, She really got out, I didn't know she actually got out. He reported residents had told him on different occasions that some of the residents knew the code to exit the facility. He was asked about the incident on 05/21/21 in which the resident had exited the back yard through the back gate, and was asked if anything had been done at that time to change the lock. He stated, No, I didn't know about that. He reported he had noticed there was an additional rope lock on the back gate, which the administrator had placed on the gate. At 4:00 p.m., CNA #3 reported the resident had been on 1:1 observation on Monday when she returned to work but had not been for the past 2 days. At 4:03 p.m., CMA/Receptionist #2 reported the resident had tried to get out the front door around 4:00 p.m. on 06/26/21 and again at 4:45 p.m., stating she wanted to get out of here and her daughter had said it was okay to leave. She reported the fire department called at approximately 7:45 p.m. to report the resident was at the fire station. The receptionist stated no one knew the resident was missing or how she got out. She reported there had been a bird in the building and some of the staff who knew the door codes had been opening the doors to try and let the bird out. She stated the alarms wouldn't go off when the code was entered. She stated after the fire station called, she reported to the director of nurses (DON), LPN #2, and CNA/staffing coordinator #4, none of which knew the resident was missing. At 4:13 p.m., LPN #3 reported at approximately 5:00 p.m. on 06/26/21, the resident was on hall 300 and trying to get out the exit door. The LPN reported she was in a room and heard the alarm go off. She stated she came out of the room and saw the resident at the door. She stated the door didn't open for the resident and she turned around and headed back up the hall acting real frustrated. The nurse stated she didn't say anything to the resident and went back to finish what she was doing. The nurse stated she didn't tell anyone the resident was trying to exit the building. At 4:24 p.m., certified medication aide (CMA) #1 reported the resident did not have medications ordered on the 3p-11p shift. The aide stated she was not aware the resident was missing on 06/26/21. She stated she was told the resident would have 1:1 observation but she wasn't sure if that had occurred. She stated she had not been in-serviced on elopement after the incident. On 07/08/21 at 11:51 a.m., the DON reported 1:1 observation would involve staff being with the resident at all times. The DON stated this was not being done. The DON agreed staff could not have been visually checking the resident every 30 minutes, as they documented, when she was gone from the facility over three hours.

Based on record review and interviews, it was determined the facility failed to consistently monitor skin, provide treatment and ensured resident received care to prevent an avoidable pressure ulcer, for one (#4) of four sampled residents who were reviewed for pressure ulcers. Resident #4 developed an unstageable pressure ulcer to posterior penile shaft. The facility identified 17 residents with pressure ulcers. Findings: A facility policy, dated July 2018, titled Prevention of Pressure Ulcers/Injuries PU/PI, documented, Residents will receive care to maintain skin integrity and prevent pressure ulcers/injuries . Prevention and treatment strategies .A determination that a resident is at risk for developing a PU/PI has significant implications for prevention and treatment strategies .Effective prevention and treatment are based upon consistently providing routine and individualized interventions. .Monitoring Staff should remain alert to potential changes in the skin condition and should evaluate, report and document changes as soon as identified .After completing a thorough evaluation, the interdisciplinary team should develop .measurable goals for prevention and management of PU/PI with appropriate interventions . Many clinicians recommend evaluating skin condition at least weekly, or more often if indicated .Defined interventions should be implemented and monitored for effectiveness . Assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] It is important that .PU/PI be identified .present on admission or developed after admission .be recognized, assessed and addressed . Resident #4 was readmitted to the facility on [DATE]and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility's admission data Skin section, dated 03/04/21, documented, the resident admitted with wound to upper back and redness to buttocks. Treatment in place for the wound to upper back and house cream for buttocks. There was no admission documentation of impaired skin integrity on the resident's penis. A physician order, dated 03/04/21, documented, [MEDICATION(S)]/[MEDICATION(S)] 1 (one) paste topically every am pm shift apply to affected area. A facility's skin data, dated 03/04/21, documented, rash/redness to buttocks- coccyx .wound left shoulder .skin tear to left arm . No other skin concerns identified. A facility's skin data, dated 04/14/21, documented, rash/redness to buttocks, surgical left foot, skin tear to arm left and wound to upper back. No other skin issues identified. A facility's skin data, dated 4/21/2, documented, rash/redness to buttocks, surgical left foot, skin tear to arm left and wound to back. No other skin issues identified. A nurse's note, dated 04/25/21, documented, .staff notified nurse that resident condom cath came off and that there was a sore on the bottom of penis .open area to bottom penile shaft, swelling to bottom of distal penile shaft. Area cleansed with sterile water .pat dry, applied santyl, durafiber and small bordered gauze . [named physician] and DON (director of nurses) notified. There was no documented physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 04/28/21, documented, .Nurse went to assess. Excoriation redden center noted in 2 (two) places beneath shaft of posterior side of penis, peri-care performed. Thin foam cushion applied gently and condom cath applied .will continue to monitor. There was no documentation the physician was notified of the impaired skin integrity on the resident's penis. There was no documentation of treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, updated 05/07/21, documented, care area skin breakdown: at risk/ actual Goal: measures will be taken to prevent skin breakdown . Interventions: .Condition of each area of skin breakdown to be documented with every treatment and/or dressing change . Inspect skin complete body head to toe every week and document results . Position resident properly; use pressure-reducing / relieving devices . Notify physician of any worsening of skin breakdown . A facility's skin data, dated 05/26/21, documented, rash/redness to peri-area, buttock, other, wound to buttocks. No other skin concerns identified. A physician order, dated 05/19/21, documented, External catheter (condom style) every shift size 28mm (millimeter) for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Change condom cath as needed if dislodge. A nurse's note, dated 06/05/2, documented, patient has been without external for last 2 (two) days due to excessive redness . A nurse's note dated 06/07/2, documented, .excoriation to shaft .less redness last 3 days . A quarterly assessment, dated 06/21/21, documented the resident was cognitively intact and required extensive assist for activities of daily living (ADLs). There was no pressure ulcer/pressure injury identified in the assessment. A facility's skin data, dated 06/30/21, documented, no skin concerns on data sheet identified. A nurse's note, dated 07/03/21 at 5:51 a.m., documented, impaired skin integrity observed to penile shaft. Pt (patient) aware but insists on having condom in place. Size 28 currently unavailable. Pt has size 26 which is too small and increases skin breakdown. A nurse's note, dated 07/03/21 at 10:10 p.m., documented, upon assessment, unstageable pressure ulcer noted to posterior penis D/T (due to) condom cath. Condom cath dcd (discontinued) until wound resolved. New order obtained to cleanse with nss (normal saline), pat dry, apply triad every shift/prn (as needed). Redness noted to groin. New order obtained to cleanse with normal saline, pat dry, apply antifungal cream every shift/prn. Right thigh resolved at this time. MD notified . A physician order, dated 07/03/21 at 10:20 p.m., documented, Cleanse wound every shift penis with normal saline, pat dry, apply Triad Q (every) shift prn (as needed) Dx (diagnosis) pressure ulcer other site unstageable. On 07/07/21 at 5:06 p.m., the DON (director of nurses) was asked what the facility protocol was for monitoring of a resident's skin. She stated the resident skin is assessed on admission by charge nurse who admitted resident. She stated the wound nurse would assess the resident skin within 24 hours of admission. She continued by stating the resident skin is checked weekly after initial admission assessment. After reviewing the resident medical record, the DON acknowledge the resident skin had not been assessed weekly by charge nurse or wound nurse. At 5:14 p.m., the DON was asked to show the order for Santyl in reference to the nurse's note dated 04/25/21. She stated there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] At 5:17 p.m., the DON was asked if the physician was notified of skin changes identified on 04/28/21. She replied, No. At 5:21 p.m., the DON was asked if resident's skin was consistently assessed, monitored, treatment provided, and ensured resident received care to prevent an avoidable pressure ulcer. She replied, No.

Based on record review and interview, it was determined the facility failed to ensure an external urinary device was utilized according to standard of practice, monitored and intervened timely for catheter related complication, for one (#4) of one resident reviewed for use of external condom catheter. The facility identified 10 residents who had a Foley or suprapubic indwelling catheter. 1. Resident #4 was readmitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 03/10/21, documented, pt's (patient's) condom cath fell off, and new cath placed this shift. The resident's medical record documents no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 04/25/21, documented, .staff notified nurse that resident condom cath came off and that there was a sore on the bottom of penis .open area to bottom penile shaft, swelling to bottom of distal penile shaft. Area cleansed with sterile water .pat dry, applied santyl, durafiber and small bordered gauze. Swelling to bottom of penis did not allow full replacement of foreskin . [named physician] and DON (director of nurses) notified. A nurse's note, dated 04/28/21, documented, .Nurse went to assess. Excoriation redden center noted in 2 (two) places beneath shaft of posterior side of penis, peri-care performed. Thin foam cushion applied gently and condom cath applied .will continue to monitor. There was no documentation the physician was notified of the impaired skin integrity on the resident's penis. There was no documentation of treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 04/30/21, documented, Pt came to nurse to remove current cath size 28 to 36. Cleaned area and applied new condom cath pt. reports a better fit and less discomfort .less excoriation observed to posterior penile shaft . A nurse's note, dated 05/19/21, documented, .condom changed during bedtime from 28 to 36 d/t small circumference of size 28. Pt felt more comfortable with 36 . A physician order, dated 05/19/21, documented, External catheter (condom style) every shift size 28 mm (millimeter) for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Change condom cath as needed if dislodge. A nurse's note, dated 05/24/21, documented, condom cath replaced D/T tear and leak. A nurse's note, dated 05/27/21, documented, Pt insist on condom cath size 28 despite excoriation. A nurse's note, dated 06/05/2, documented, patient has been without external for last 2 (two) days due to excessive redness . A nurse's note dated 06/07/2, documented, .excoriation to shaft .less redness last 3 days . A quarterly assessment, dated 06/21/21, documented the resident was cognitively intact and required extensive assist for activities of daily living (ADLs). External catheter addressed on assessment. Resident incontinent of bladder. A nurse's note, dated 07/03/21 at 5:51 a.m., documented, impaired skin integrity observed to penile shaft. Pt (patient) aware but insists on having condom in place. Size 28 currently unavailable. Pt has size 26 which is too small and increases skin breakdown. A nurse's note, dated 07/03/21 at 10:10 p.m., documented, upon assessment, unstageable pressure ulcer noted to posterior penis D/T (due to) condom cath. Condom cath dcd (discontinued) until wound resolved. New order obtained to cleanse with nss (normal saline), pat dry, apply triad every shift/prn (as needed). Redness noted to groin. New order obtained to cleanse with normal saline, pat dry, apply antifungal cream every shift/prn. Right thigh resolved at this time. MD notified . A physician order, dated 07/03/21 at 10:20 p.m., documented, Cleanse wound every shift penis with normal saline, pat dry, apply Triad Q (every) shift prn (as needed) Dx (diagnosis) pressure ulcer other site unstageable. On 07/06/21 at 10:21 a.m., resident #4 was asked if the facility discussed other options to address his bladder incontinence. He stated no other options was discussed. He stated he utilized a condom catheter prior to admission to facility. He stated he utilized a size 28 and requested a larger size as the 28 was becoming uncomfortable and causing injury. He stated the facility offered a larger size twice and returned to utilizing the size 28. He stated the facility ran out of 28 and utilized a size 26 it hurt. He stated he was informed the facility did not have the correct size. On 07/07/21 at 5:17 p.m., the DON was asked if the physician was notified of skin changes identified on 04/28/21. She replied, No. At 5:18 p.m., the DON was asked if the physician was notified of continued concern with tight fit of condom catheter and injury being caused. She replied, The physician should have been notified. At 5:21 p.m., the DON was asked if resident's skin was consistently assessed, monitored, treatment provided, and ensured resident received care to prevent an avoidable pressure ulcer. She replied, No.

Based on record review and staff interviews, it was determined the facility failed to consistently monitor skin/wounds and provide wound treatments as ordered by the physician, for one (#2) of three sampled residents who were reviewed for pressure ulcers. Resident #2 acquired a stage II pressure ulcer which developed into a stage III pressure ulcer within five days. The facility identified ten residents with pressure ulcers. Findings: Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A baseline care plan, dated 01/07/19, documented the resident required one person assist for activities of daily living (ADLs) and was using a wheelchair for mobility. It documented the resident was alert but cognitively impaired and had current skin integrity issues. There was no admission documentation of impaired skin integrity on the resident's sacrum. A physician's orders [REDACTED]. A comprehensive resident assessment, dated 01/14/19, documented the resident's cognition was intact, she required extensive assistance of one person to perform ADLs, and was at risk for developing pressure ulcers. There were no weekly skin assessments documented from 01/07/19 through 01/17/19. A comprehensive care plan, dated 01/16/19, documented the resident had acquired a left buttock shear. A nursing progress note, dated 01/18/19, documented, Open area noted to sacrum, order received for Triad, family aware. A weekly pressure injury record, dated 01/18/19, documented site/location sacrum, stage two, size in centimeters (cm) 1.5cm x 1cm, exudate scant serous, no odor, wound bed granulated, skin color pink, surrounding tissue soft. The treatment was Triad two times daily. There was no documentation on the current careplan related to this wound. The (MONTH) 2019 treatment administration record (TARs) documented the resident was to be checked and repositioned if unable to reposition self, at least every two hours every shift. The TARs documented gaps on the following dates: The overnight shift on 01/13/19, the evening shift 01/15 through 01/17/19 and 01/21 through 01/24/19. The TARs also documented gaps in the Triad wound dressing on the evening shifts 01/21 and 01/22/19. A nursing progress note, dated 01/23/19, documented, Resident seen by wound care physician, treatment order changed to Santyl daily, family notified. An Initial wound evaluation and management summary, dated 01/23/19, documented, Focused Wound Exam (Site 1), unstageable (due to necrosis) sacrum. Etiology .pressure, MDS 3.0 Stage .unstageable necrosis, wound size, length x width x depth .5cm x 2.4cm x 0.2cm, surface area .12.00cm, exudate .light serous, thick adherent devitalized necrotic tissue .30%, granulation tissue .50%, other viable tissue .20%. Primary dressing Santyl apply once daily for 30 days, secondary dressing gauze island apply once daily for 30 days, recommendations, off load wound, reposition per facility protocol .Site 1: Surgical Excisional Debridement Procedure: Remove necrotic tissue and establish the margins of viable tissue. Procedure note: .a curette was used to surgically excise 3.60cm of devitalized tissue and necrotic subcutaneous fat surrounding connective tissues were removed at a depth of 0.3cm and healthy bleeding tissue was observed. Hemostatsis was achieved and a clean dressing was applied . A weekly pressure injury record, dated 01/23/19, documented site/location sacrum, stage unable to determine, size 5cm x 2.4cm, depth 0.2cm, exudate light serous, no odor, wound bed necrosis, skin color pink, surrounding tissue soft. Treatment, seen by wound doctor treatment changed to Santyl daily. The resident was discharged home with home health on 01/25/19. On 02/28/19 at 12:21 p.m., the wound care nurse was asked if the resident had been admitted with any skin breakdown. She stated she thought on her bottom. The wound care nurse was asked what the resident's wound looked like on 01/18/19 when the wound on the sacrum was noted. She stated she couldn't remember. The wound care nurse was asked what the wound looked like on 01/23/19 when the wound doctor saw the resident. She stated the doctor debrided the wound at that time. She was asked if the resident was sent home with wound care instructions and supplies. She stated she gave wound care instructions to family, including to keep the resident off of her wound and that nursing would have provided her medications. A discharge medication list documented the resident was given Santyl ointment upon discharge from the facility. On 02/28/19, assistant director of nursing (ADON) #1, was asked to explain what the blanks on the TARs for dressing changes and turning every two hours meant. She stated if it was blank it meant they didn't chart it. It did not necessarily mean they didn't do it, but they did not chart it. On 03/04/19 at 9:53 a.m., a physical therapist assistant (PTA) was asked if the resident had a pressure relieving cushion in her wheelchair. She stated, Yes, she had a cut-out cushion for pressure wounds. She was asked if the resident had the cushion before her pressure wound developed. She stated she thought so. The PTA was asked if there was any documentation that showed the cushion was in the resident's wheelchair. She stated nursing would do that and the medical records/supply nurse would know. At 10:00 a.m., the staff member in charge of supplies was asked if the resident had been given a pressure relieving cushion on admission. She stated it was issued on admit the first day along with the right sized wheelchair. She was asked if there was documentation showing the resident had the cushion in her chair, she stated that would be up to nursing to document. At 10:21 a.m., the director of nurses (DON), was asked for documentation the resident had a pressure relieving cushion in her wheelchair and that staff were monitoring that it was in place. No documentation was provided. Four nurses were asked how they ensured pressure ulcer treatments were administered per physician's orders [REDACTED]. One staff member stated she checked the orders and followed the TARs. She stated medication administration records and TARs were audited as well.

Based on record review and staff and resident interviews, it was determined the facility failed to have a urologist change a resident's indwelling urinary catheter as ordered. This caused the resident acute pain, bleeding and eventual hospitalization for one (#1) of three sampled residents reviewed for indwelling urinary catheters. The facility identified seven residents with indwelling urinary catheters. Findings: An After Visit Summary from a local hospital for resident #1, dated 07/19/17, documented, .Instructions: To be discharged with Foley catheter in place and return to my office one month for catheter change . The resident was admitted to the facility with [DIAGNOSES REDACTED]. The August 2017 Order Summary Report documented the urinary catheter was to be changed in the urologist's office in one month and on the night shift, on the 15th of every month, start date of 07/19/17. The report also documented the urinary drain bag was to be changed on the 1st and the 15th of every month. An admission resident assessment, dated 07/26/17, documented the resident was cognitively intact, had an indwelling urinary catheter and had no pain. A care plan, dated 08/01/17, documented, .Problem: Urinary Catheter . Goal: Resident will be free of complications of indwelling catheter over the next 90 days . Interventions: .Catheter to be changed by Urologist as ordered .Urology consult as ordered . The August 2017 treatment administration records (TARs) documented the resident's urinary drain bag was changed per orders on the 1st and the 15th. The TARs also documented the urinary catheter was changed on the 15th. A telephone order, dated 08/17/17 at 1:00 p.m., documented, Flush catheter c (with) NS (normal saline) = deflate Balloon on catheter and advance catheter. A facility nurse's note, dated 08/17/17 at 1:00 p.m., documented, notified DR (name deleted) once again to tell him resident's foley was not flushing only had small amount of blood in leg bag after flushing no return received instruction to deflate balloon on catheter and move it up into the bladder further I deflated balloon and moved catheter closer to hub moderate size clot moved to catheter bag and urine started draining into bag received 600 cc (cubic centimeters) dark amber urine immediately. A facility nurse's note, dated 08/17/17 at 2:15 p.m., documented, resident discharged back to (Name deleted) Assisted Living in stable condition called report to (Name deleted) I informed her of situation of foley catheter having clots and I received order to flush and move catheter up and it as (sic) now draining dark amber urine at this time . An assisted living resident note, dated 08/17/17 at 3:00 p.m., documented, Resident returned from Tuscany Village Rehab (rehabilitation) c Catheter .Cloudy yellow urine c blood tinge - leg bag . An assisted living resident note, dated 08/17/17 at 10:50 p.m., documented, Res (Resident) asked to see foley bag. Res present with blood in pants, on brief and in leg bag. Res states he is not in pain .Staff assisted res c changing clothes. Res actively bleeding from catheter .res notified he will be sent hospital if bleeding persists. An assisted living resident note, dated 08/18/17 with no time, documented, .area where blood was present. Active bleeding to penile area. resident didn't c/o (complain of) pain to penile area, where cath (catheter) is placed. Resident stated as I was assessing the penile area it hurt .Stated he wanted to go to hospital .Sent to hospital .transfer at 0100 (1:00 a.m.). ED (emergency department) notes from a local hospital, dated 08/18/17 at 1:36 a.m., documented, .Clinical Impression .1. Acute [MEDICATION NAME] without hematuria 2. Penile bleeding 3. [MEDICAL CONDITION] 4. Type II diabetes mellitus with complication, with long-term current use of insulin 5.[MEDICAL CONDITION], due to unspecified organism . A facility nurse's note, dated 08/21/17 at 11:52 a.m., documented, Late entry for 8/18/17 at approximately 1150am (11:50 a.m.) this DON (director of nursing) spoke with nephew (Name deleted) and (Name deleted) wife via telephone related to resident being sent to ER (emergency room ) from assisted living on 8/17/17. This DON informed by family of resident that resident was sent to ER from assisted living after discharge from Tuscany due to concern of blood in urine and blood coming from tip of penis. Mr. (Name deleted) express that he was informed by doctors after assessment and gathering information from resident in ER that resident catheter that was changed early morning of 8/17/17 (0400am) (4:00 a.m.) was placed incorrectly causing pain, trauma minor irritation and blood clots; that after it was re-adjusted by 7-3 (7:00 a.m. to 3:00 p.m. shift) nurse that he had some relief .Mr. (Name deleted) voiced concern abou (sic) the possibility of set-back for resident as resident was recently discharged from skilled . A discharge summary from a local hospital, dated 08/22/17 at 12:06 p.m., documented, .Discharge [DIAGNOSES REDACTED].~ Type 1 diabetes mellitus without complication ~ Acquired [MEDICAL CONDITION] ~ Essential hypertension ~ Mild cognitive impairment ~ Pacemaker ~ Orthostatic [MEDICAL CONDITION] ~ Urinary tract infection associated with indwelling urethral catheter .found to have a principle [DIAGNOSES REDACTED].The patient was noted to have so (sic) mild bleeding near his urethra on presentation and this resolved within a day in the hospital . On 09/06/17 at 10:30 a.m., the corporate nurse stated the nurse did not see the order for the physician to change the resident's catheter. She stated the resident was very hard to catheterize due to [MEDICAL CONDITION] and the prostrate being enlarged. At 11:35 a.m., the corporate nurse was asked about the August 2017 TARs which documented the resident's catheter was changed on 08/15. She stated the nurse took out supplies, but did not change it until the morning of the 17th. She was asked about the catheter size and bulb size being blank on the August TARs. The corporate nurse stated the catheter size would have been added later when the size was known. She stated she had spoken with the MDS (minimum data set) nurse about how the order was input into the computer. The MDS nurse had stated to the corporate nurse she thought it made sense at the time. There was no narrative nursing documentation for the date and time of 08/17/17 at 4:00 a.m. On 09/18/17 at 9:10 a.m., the resident was asked to explain what happened on the morning of 08/17/17. The resident stated two nurses, who he did not know, came into his room the morning of the 17th around 4:00 a.m. and stated they were going to change his catheter. He stated he told them it was not to be changed except by the doctor. The resident stated they just rammed it in and he screamed out in pain. He stated he had never screamed like that before. He stated there was blood in the urine and they had injured the urethral opening. The resident was asked if the pain continued after the catheter was changed. He stated the pain was not acute afterwards, but it was very uncomfortable and felt better after the other nurse had repositioned the catheter later in the day.

On 10/05/15, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure hazardous chemicals were securely stored out of the reach of residents in the central bathing room, the medication cart, and soiled work room located on Hall 300, the janitor's closet, soiled work room and restorative room located on Hall 400, and in the kitchenettes on Hall 300 and Hall 500. At 8:56 a.m., the existence of the IJ was verified with the Oklahoma State Department of Health (OSDH). At 10:00 a.m., the administrator (ADM) and corporate consultant #1 were notified of the existence of the IJ. A definite number of residents who wandered could not be determined as interviews with 5 staff members and a group of residents identified conflicting numbers and residents. At 12:35 p.m., an acceptable plan of removal was received. The facility's plan of removal documented: .10/5/2015 Verbal Plan of removal: 1. The facility will be searched to ensure there are no other chemicals left unsecured, and if found they will be secured immediately. 2. An in-service will be done with all current 7-3 staff in attendance, in all departments regarding securing of chemicals. 3. All other employees will be in-serviced by 12am on 10/6/2015, to include all departments, either in person or by phone. 4. Locked cabinets will be placed in the shower rooms and old cabinets with broken locks will be removed. Plan of Removal: 1. The facility will be searched to ensure there are no other chemicals left unsecured, and if found they will be secured immediately. 2 An in-service will be done with all current 7-3 staff in attendance, in all departments, regarding securing of chemicals. Any employees on leave or vacation will not return to work until in-serviced over storage of chemicals. 3. All other employees will be in-serviced by 12am on 10/6/2015, to include all departments, either in person or by phone. 4. Compliance rounds will be conducted each shift by charge nurse for the hall they are assigned to ensure there are no chemicals left unsecured for at least 90 days or longer if needed. 5. Daily compliance rounds will be conducted by nurse managers, maintenance supervisor, DON, Administrator, and other department heads as instructed by Administrator Monday-Friday. 6. The Weekend RN (registered nurse) Supervisor will conduct compliance rounds to ensure all chemicals are secured on Saturday and Sunday. 7. Housekeepers will ensure their carts are locked and no chemicals are removed. 8. Housekeeping Supervisor will check carts daily and make random checks to ensure they are locked and no chemicals have been removed. 9. All janitor/maintenance closets will be checked by Maintenance Supervisor daily to ensure they are locked. 10. Locked cabinets will be placed in the shower rooms and old cabinets with broken locks will be removed. 11. Quality Assurance Committee will review for any issues related to chemical storage monthly x3 then quarterly and make any needed revisions. On 10/06/15 at 8:50 a.m., 19 staff members were interviewed. All stated they had been inserviced and were able to verbalize the safe storage of chemicals and the need to keep the doors locked. At 9:50 a.m., the in-service documentation was reviewed. The staff were educated in the safe storage of chemicals. The IJ was removed effective 10/06/15 at 12:00 a.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern with no actual harm with the potential for more than minimal harm. Based on observations, record review and staff interviews, it was determined the facility failed to ensure hazardous chemicals were securely stored out of the reach of residents: ~ in one (Hall 400) of one restorative rooms, ~ in one (Hall 400) of three janitor closets, ~ in one (Hall 300) of nine medication carts, ~ in two (Hall 300 and Hall 400) of five soiled work rooms, ~ in one (Hall 300) of three central bathing rooms and ~ in two (Hall 300 and Hall 500) of four kitchenettes. Corporate consultant #2 identified two cognitively impaired residents who wandered the facility. The Resident Census and Conditions report, dated 10/06/15, documented 112 residents resided in the facility. Findings: A hazardous chemical/material policy, undated, documented, .Policy: All hazardous chemicals and/or materials will be maintained in a secure location that is not accessible to residents when not in use . Chemicals and/or cleaning products will never be left in a location accessible to residents or unattended .Locked cabinets will be available in the shower rooms and chemicals will be locked up between use when not attended . All maintenance and janitorial closets and carts will be locked at all times when not in use and attended .Adhere to common sense and basic safety practices during use of all chemicals and lock in secured area when not using . On 10/05/15 at 7:55 a.m., an environmental tour of the facility was conducted. One 32 oz (ounce) container of Fabuloso Power Degreaser was observed inside the unlocked central bathing room located on Hall 300. The warning label documented keep out of reach of children. A clear bottle with a liquid substance was located inside the same room. The bottle had the word Unitol written on it in black ink. There was no manufacturer label located on the bottle. One 32 oz bottle of Comet cleaner with bleach was observed inside the cabinet above the sink in the unlocked soiled room located on Hall 300. The warning label documented: warning causes eye irritation, keep out of reach of children. Two 32 oz bottles of Febreeze and one 32 oz bottle of Comet cleaner with bleach were located in the cabinet above the sink in the kitchenette on Hall 300. The warning label on both bottles documented: Keep out of reach of children. A bottle of Fabuloso Power Degreaser was located in a lower unlocked cabinet in the kitchenette on Hall 500. The label documented, Keep out of reach of children. A 160 count of Sanicloths was observed on a medication cart located on Hall 300. The warning label documented: keep out of reach of children. At 8:17 a.m., the following items were observed in an unlocked janitor closet located on Hall 400: ~ One 2.5 L (liter) container of Extraction carpet cleaner. The warning label documented: avoid contact with eyes, skin and clothing; ~ Two 2.5 L containers of Good Sense liquid air freshener; ~ One 2.5 L container of Virex One Step disinfectant cleaner. The warning label documented: danger keep out of reach of children; ~ One 2.5 L container of Crew- multi purpose restroom cleaner and ~ One 2.5 L container of Glance HC (hyperconcentrate) glass and multipurpose cleaner. A posted sign with break times was observed in the janitor closet which documented, Don't Lock IT!! Chains were observed on the door frames of two rooms on Hall 300, seven rooms on Hall 400, four rooms on Hall 500 and one room on Hall 600. At 8:30 a.m., certified nurses aide (CNA) #2 was asked what was the purpose of the chains on the residents' door frames. She stated the chains were used to keep the wanderers out of the residents' rooms. She stated one resident in a wheelchair liked to go in other residents' rooms. The soiled room located on Hall 400 was observed unlocked with the following items located inside the cabinet above the sink: ~ One 2.5 L container of Glance HC glass and multipurpose cleaner. The warning label documented: keep out of reach of children and ~ One 2.5 L container of Virex One Step disinfectant cleaner. The warning label documented: danger keep out of reach of children. One 2.5 L container of Crew multi purpose restroom cleaner was observed in the unlocked restorative room on Hall 400. The warning label documented: may cause serious skin irritation and eye damage. At 9:12 a.m., assistant director of nursing (ADON) #1 was asked if the janitor closet located on Hall 400 should be kept locked. She stated the door should always be locked. She was asked how many residents were wanderers. She stated there is a book at the front desk. The book she referred to was the 'elopement risk' book which contained seven residents. At 9:20 a.m., ADON #2 was asked if there were any wanderers who resided in the facility. She stated, Yes. She stated one resident wandered in and out of residents' rooms when the doors were left open. At 9:30 a.m., ADON #2 was shown all areas with unlocked chemicals identified on Hall 300 and 400. She stated all chemicals should be locked behind a cabinet or door. At 3:00 p.m., a confidential group meeting was held with 20 cognitive residents. They were asked if there were any residents who wandered the facility. They identified two residents who would enter other residents rooms and often take items which didn't belong to them. These residents were not the residents named by CNA #2, ADON #1 or ADON #2. These residents were not located in the 'elopement risk' book. On 10/07/15 at 10:15 a.m., the director of nursing (DON) was asked for a list of residents who wandered. At 10:30 a.m., corporate consultant #2 presented a list of two names of residents who wandered.

On 08/14/14, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to identify a soft belt waist restraint as a safety hazard and intervene after the resident had slid out of the wheelchair three times with the restraint still fastened and in place while the wheelchair remained in the upright position. At 4:20 p.m., the existence of the IJ was verified with the Oklahoma State Department of Health (OSDH). At 4:50 p.m., the administrator and the corporate nurse were notified of the existence of the IJ. At 5:00 p.m., an acceptable verbal plan of removal was received. The administrator stated: a. The soft belt waist restraint will be removed from the resident immediately, b. The resident will be placed on one-on-one supervision when out of bed and for the first 72 hours after determining the proper restraint to be used, c. The facility will evaluate a pelvic restraint for use with the resident and she will be placed in the restraint when determined it is the proper restraint, d. All direct care staff will be inserviced on the proper use and fastening of the new restraint by 5:00 p.m. on 08/15/14, and e. The physician and family will be notified of the need for a restraint change and an order and consent will be obtained immediately. On 08/15/14 at 9:10 a.m., an acceptable written plan of removal was received. The facility's Immediate Jeopardy Plan for Removal, dated 08/14/2014, documented, "...8/14/2014 Verbal Plan of removal: 1. Remove soft waist restraint for resident (#10) and provide one-one-one supervision until patient in bed out of restraint. 2. Notify physician of need for change in restraint, request order for pelvic restraint. New pelvic restraint order obtained from Dr. Martin at 5:20pm. 3. Notify family of need for change in restraint and obtain consent for pelvic restraint. Verbal consent obtained from daughter at 5:20pm. 4. In-service all nursing staff on application and observation of pelvic restraint on duty for 3-11 shift, staff on duty for 11-7 and in the morning 8-15-4 for 7-3 shift. All other staff will be in-serviced as they arrive for duty. All nursing staff/all shifts that work for Tuscany will be in-serviced by 5:00PM 08/15/2014. 8/15/2014 The soft non-releasing waist restraint for resident (#10) was removed. A new restraint evaluation was completed for a pelvic restraint for resident (#10). an order for [REDACTED]. Family notified of new restraint evaluation, verbal consent received at 5:20pm. The pelvic restraint was placed on the resident and all staff working 3-11 and 11-7 were in-serviced over proper application as they arrive on duty on 7-3 etc. All other residents were reviewed and no other restraints were noted in the facility. All nurse managers will be in-serviced on 8-15-14 regarding restraint evaluations to ensure all appropriate device are utilized appropriately and re-evaluated as needed. Care plan updated to reflect changes. Pelvic restraint will be apply (sic) only when up in wheelchair. Resident will be placed on Q shift focused charting X's 72 hours to document use/benefit of device, if appropriate any negative or adverse effects noted of the device, proper placement of device and to notify physician of any problems noted with device or device use. Resident will continue on one on one supervision when up in chair with restraint x 72 hours to evaluate effectiveness/compliance of device. Every shift restraint monitoring will continue indefinitely. Resident will be toileted according to toileting schedule: Upon rising in the AM, before meals, after meals, at bedtime and as needed. Restraint will be release at least every 2 hours, for meals, during care, and for positioning. A monthly restraint evaluation will be completed by the QA nurse to monitor/record the continuing risks/benefits for the device, alternatives to the restraint, the need for on-going use and continued justification for the device. A restraint reduction will be completed monthly to determine the continue justification of the device." On 08/18/14, the inservice documentation was reviewed. All direct care staff had been inserviced on the proper use and fastening of the pelvic restraint. Twelve direct care staff members were interviewed. All stated they had been inserviced and were able to verbalize and demonstrate the proper fastening of the pelvic restraint. The IJ was removed on 08/15/14 at 5:00 p.m., when all direct care staff had been inserviced. The deficient practice remained at a level of no actual harm with potential for more than minimal harm. Based on observation, record review and interview, it was determined the facility failed to ensure a soft belt waist restraint was identified as a safety hazard and intervene after a resident had slid out of the wheelchair three times with the restraint still fastened and in place while the wheelchair remained in an upright position for one (#10) of one sampled resident with a restraint. The Census and Conditions, dated 08/12/14, identified one resident with a restraint in the facility. Findings: An application instruction sheet, dated 2009, for Posey soft belts, documented, "...APPLICATION INSTRUCTIONS: CHAIR 1. Position the patient as far back in the seat as possible, with the buttocks against the back of the chair. 2. Lay the lap belt across the patient's thighs with the foam facing in. 3. Bring the ends of the connecting straps down at a 45-degree angle between the seat and the wheelchair sides (fig. 1). Criss-cross the straps behind the chair and draw them around the opposite side kick spurs. 4. Secure each connecting strap, out of the patient's reach, using a quick-release tie or buckle (figs. 2A and 2B). Check that the straps are secure and will not change position, loosen, or tighten if the patient pulls on them, or if the chair is adjusted. 5. The belt must be snug, but not interfere with breathing. To check for proper fit, slide an open hand (flat) between the belt and the patient... WARNING... There is a risk of chest compression or suffocation if the patient's body weight is suspended off the mattress or chair seat. Use extreme caution with chair cushions. If a cushion dislodges, straps may loosen and allow the patient to slide off the seat... Monitor per facility policy to ensure that the patient cannot slide down, or fall off the chair seat or mattress and become suspended or entrapped... STOP USE AT ONCE: if the patient has a tendency to slide forward or down in the device; or is able to self-release. NOTE: A restraint with a pelvic piece will reduce the risk of sliding, or of the patient pulling the device over his or her head..." Resident #10 was readmitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. She had a history of [REDACTED]. It was documented the resident had behaviors of hitting, kicking, biting and being combative. The resident was placed in a self-releasing soft belt buckle in December 2013. The device was a waist belt with velcro fasteners on the waist padding which allowed the resident to self release the belt. The resident assessment, dated 03/17/14, documented the resident had severely impaired cognitive skills. She required limited assistance of one person with her mobility. In the last 90 days, she had two or more falls with no injury and two or more falls with minor injuries. The assessment documented a trunk restraint was used daily. The assessment also documented the resident had physical behaviors toward others. An incident report, dated 03/18/14 at 3:00 a.m., documented, "...This LPN (licensed practical nurse) noted resident sliding out of w/c (wheelchair) with one knee on the floor while she was visiting another resident. Restraint was in place...Intervention: Ensure that restraint is properly fastened and straps are adequately taut..." The comprehensive care plan, dated 03/18/14, documented under a care plan for falls, "...Self release soft belt buckle while up in w/c release every 2 hours for ADLs (activities of daily living), Meals and other care...." A care plan for a self release soft belt buckle documented, "...Evaluate use monthly...Apply self release soft belt buckle while in w/c, due to leaning forward, falls with injury, dementia, poor safety awareness..." No documentation was located for a quick release soft belt buckle. An incident report, dated 03/21/14 at 11:53 p.m., documented, "...CNA (name deleted) notified this LPN that resident was on the floor. This LPN noted resident on floor on her right side in front of w/c in kitchenette. Restraint was in place but loose...3/24/14 Intervention: Staff inservice on correct application of self release soft buckle seat belt..." A nurse's note, dated 05/31/14 at 11:10 p.m., documented, "...This lpn (LPN) summoned to resident room in bathroom. Resident being assisted to toilet, cna (CNA) informed this lpn that resident had bruise around waist line where lap buddie is in place. This lpn assessed resident and noted purple discoloration bruising around waist line where lap buddie (sic) belt is in place. This lpn educated cna's (sic) to keep belt loose around waist line to prevent friction against skin..." An incident report, dated 05/09/14, documented the resident had self released the soft buckle and was found on the floor. A nurse's note, dated 05/24/14, documented the resident had, "self released," the soft buckle and attempted to stand. The note documented the resident did not fall at that time. The only documented incidents of the resident self releasing the soft buckle were on 05/09/14 and 05/24/14. A physician's orders [REDACTED]. (From the August 2014 physician's orders [REDACTED]. The resident was placed in a quick releasing soft belt buckle on 06/03/14. The device was a solid waist belt which tied in the back of the wheelchair. The resident was unable to release the device. The resident assessment, dated 06/17/14, was exactly the same as the assessment documented on 03/17/14. On 08/11/14 at 12 noon, resident #10 was observed in her wheelchair in the assisted dining room. The soft belt buckle was observed in the resident's lap with the ties unfastened. She was not observed to attempt to stand during the meal. On 08/12/14 at 10:00 a.m., the resident was observed in the lobby area with the soft belt buckle in place. The ties were fastened in the back of the chair. She was leaning forward attempting to reach the floor. She was observed with the quick release soft belt buckle in place when she was in the wheelchair from 08/11/14 through 08/14/14. The belt was unfastened when she was at the dining room table on those days. She was observed sleeping in the chair, leaning forward toward the floor and leaning to the side in the chair. She would sometimes scoot forward in the chair. On 08/14/14 at 2:30 p.m., the QA (Quality Assurance) nurse and corporate nurse #1 were interviewed. They were asked what other devices had been attempted to prevent the resident's falls. Corporate nurse #1 stated the facility had attempted numerous devices including a wedge cushion, a pommel cushion and a lapbuddy. She stated the resident had tipped the chair over when the lapbuddy was in use and a self releasing soft belt buckle was initiated in December. They were asked what had made them change from a self releasing belt to the quick releasing belt on 06/03/14. Corporate nurse #1 stated the resident had been self releasing the belt and falling. They were asked if they were aware it was only documented two times the resident had self released the belt and only one fall had occurred. Corporate nurse #1 stated, "No." The QA nurse stated, "I think she did more than that." They were asked if they were aware it was documented the resident had bruising around her waist and the nurse told the staff to keep the soft belt loose on the resident. They both stated they were unaware of any bruising or the nurse's comments until now. Corporate nurse #1 stated, "We will check into that." They were asked who was responsible for monitoring the incident reports, especially the falls. The QA nurse stated the director of nursing (DON) used to be responsible, but she had been monitoring them for the last couple of months. She was asked how the incident reports were reviewed. She stated they were reviewed in stand-up (an interdisciplinary team meeting) every day. They were asked if two falls in three days with the restraint in place should have thrown up a red flag. Corporate nurse #1 stated, "Probably." The QA nurse was asked if she should have questioned the falls. She stated, "Yes." They were asked if after the first fall with the restraint in place, did they possibly consider the soft belt buckle to be a safety hazard. Corporate nurse #1 stated, "Not Really." She stated that once the staff had been inserviced on the proper fastening of the belt, it didn't happen again. They were asked about the fall with the restraint in place on 07/14/14. Corporate nurse #1 stated the restraint was a different type of restraint. She stated since the staff were inserviced on the proper fastening of the belt, the resident hadn't fallen again. They were asked what was the difference in the belts except one the resident could self release and the other the resident could not. Corporate nurse #1 stated, "They are different restraints." She was asked if they tied the same. She shook her head, "Yes."

Based on observation, record review, and interview, it was determined the facility failed to monitor, assess and develop specific and appropriate interventions for a resident with 22 falls which resulted in injury and actual harm to one (#7) of 10 sampled residents with frequent falls. The facility Roster/Sample Matrix, dated 08/20/2012, documented 36 residents who resided in the facility had triggered for falls. Findings: The facility's, "Falling Leaves Prevention Program Form," documented: "Policy Statement: It is the policy of this facility to promote resident safety and decrease the risk of injury from falls. Procedure: 1. A Fall Risk Assessment will be performed: a. On admission/readmission b. Quarterly c. Annually d. Significant Change 2. If a resident's Fall Risk Assessment is determined to be high, they will be identified to the staff by placing multi-colored leaves at the resident's door and other significant areas as needed. 3. The Interdisciplinary Team will identify appropriate interventions to prevent falls when a resident is identified as "High Risk" and note those on the care plan. 4. The Safety Committee will meet monthly and review all incident reports and make monthly documentation of all falls for trending. If a resident's fall history is indicative of frequent falls and/or their plan of care needs to be re-evaluated for interventions, the following steps can be initiated, as indicated: i. A Frequent Fall Assessment to determine causative factors. ii. Notify physician of frequent fall history and request a review of any possible treatable medical conditions or problems. iii. Physical Therapy / Restorative Nursing Screening. iv. Consultant Pharmacists review of medications. v. Assessment of possible issues. vi. Vision screening. 5. From the Safety Committee's monthly fall documentation the QA Committee will identify all potential problems to be addressed. 6. The "Falling Leaves" designation will mean: a. Upon each pass down the hallway, staff will look into all "Falling Leaves" rooms to ensure that the resident is not attempting to get up without assistance, or has fallen. b. If a resident is attempting to get up without assistance, staff will assist resident with the task and will redirect resident to ask for assistance. c. Staff will be responsible for monitoring each resident with a "Falling Leaves" designation on their wheelchair more closely for any attempts at getting up without assistance. d. Staff will notify the Charge Nurse of resident's attempts or of resident falling per policy for incident reports. 7. Staff will be inserviced during orientation and as needed to the Falling Leaves Fall Prevention Program. 8. Quality Assurance will evaluate this policy as needed." The score on the facility's Fall Risk Assessment for resident #7, dated 09/07/11, was a 12. A score greater than ten indicated the resident was a high risk for falls and should be placed on the Falling Leaves program. The resident had [DIAGNOSES REDACTED]. The resident's quarterly assessment, dated 07/18/12, documented she was not on a restorative program and required staff to propel her wheelchair. She required extensive assistance with one staff member for transfers and dressing. She was continent of bowel and occasionally incontinent of bladder. She had functional range of motion impairment in all four extremities, her vision was highly impaired, and she wore no glasses during this testing. The care plan dated 12/08/11, documented: "Problem (Name deleted) has a hx (history) of falls d/t (due to) impaired mobility, poor eyesight r/t (related to) [MEDICAL CONDITION] with potential for self-injury. Goal (Name deleted) will be free of self-injury r/t falls QD (every day) Approach (1) Remind/encourage (Name deleted) to ask for or wait for assistance with transfer and/or ambulation (2) Keep call light in reach at all times when in room (3) Keep adaptive device: wheelchair in reach at all times and remind (name deleted) to use.... (5) Monitor (name deleted) frequently for fall risk (6) Assess for need of restorative nursing to increase independence in mobility (7) Keep room free of clutter to prevent tripping hazards. 8) (not dated and written in by hand) Soft buckle belt while up in chair related to leaning forward. Comment 07/18/12 Cont current plan of care Problem (18) Resident is on scheduled toileting program Goal (1) (Name deleted) will regain bowel and bladder control AEB maintenance of continence thru target date Approach (1) Assess for ability to participate in program ( E.G. some awareness of toileting needs...)... (8) Encourage (name deleted) to hold urine until next scheduled time but do assist to toilet if requested... (11) Encourage (name deleted) to perform Kagel exercises... Comment 07/18/12 Cont current plan of care Problem Limited abilities and potential for injury d/t highly impaired vision and [MEDICAL CONDITION] Approach (1) Provide adaptive devices: glasses clean and on QD (every day) when awake... Comment 07/18/12 Cont current plan of care" The resident's care plan dated 03/29/2012 documented: "Problem (The area named the Problem had a line drawn through it and the word resolved was written under it.) (Name deleted) has a Maxillary fracture and laceration of face r/t fall Goal (Name deleted) will be free from infection r/t facial injuries sustained from fall. Approach (1) Remind/encourage (Name deleted) to ask for or wait for assistance with transfer and/or ambulation (2) 03/29/2012 Keep call light in reach at all times when in room (3) 03/29/2012 Keep adaptive device: in reach at all times and remind (name deleted) to use... (6) 03/29/2012 Low bed with mat on floor beside bed with bolster pillows. Keep floor clean and free of debris and other items... (8) 03/29/2012 Apply bed alarm and remind (Name deleted) not to get up without assistance (9) 03/29/2012 Monitor (Name deleted) Q 2 hours for safety and comfort... Comment (this area was left blank)" Incident management reports (investigations) for falls had not been conducted for 12 of the 22 falls. The Care Plan Fall Log documented she had 22 falls between 09/05/11 and 08/15/12. All the falls occurred while the resident was alone in her room. "Fall: 09/05/11 Res. (Resident) was observed sitting on floor mat by her bedside @ (at) 0500 (5:00 a.m.). No injuries noted. Intervention(s): Instructed to call for assistance. 09/15/11 Res. was observed on the floor on her L (left) side over the floor mat. States she fell out of the bed and hit her nose. Intervention(s): Res. to be monitored Q (every) 2 hours for bed alarm placement; to be offered toileting PRN (as necessary) and Q 2 hrs. 09/20/11 Res. was found to be sitting on floor on bottom next to bed, upright. Res. still had alarm attached; no injuries noted Intervention(s): Frequent visual checks, Keep necessary items within reach. 09/25/11 Res. found sitting on floor on bottom next to bed. no injuries present. Intervention(s): Res. to be monitored Q 2hrs (hours) For Bed alarm placement. Scheduled toileting PRN and Q 2 hrs. 10/25/11-Res. was found on floor beside her w/c (wheelchair), states that she slid out of her w/c. Intervention(s): Res. evaluated for new w/c for (decreased) risk of falls, by P.T./O.T. (physical therapy and occupational therapy). 10/26/11-Res. found on floor in front of w/c. No c/o (complaints of) pain. Intervention(s): Res. received new w/c with pommel cushion device to reduce risk of sliding out of w/c. 10/26/11 11:40 pm Res. stated she toileted herself and as she tried to sit back down in her chair, she fell on to floor. Intervention(s): Toileting schedule in place, Res. to be toileted Q 2 hrs./PRN by staff. 10/28/11 Res. tried to get out of w/c while toileting and fell forward and hit right side of head. Intervention(s): Res. to wear shoes c (with) rubber sole. Toileting Q 2 hours/PRN Toileting schedule. 11/24/11 Resident climbed out of low bed and was sitting on mat. Intervention(s): Res. cont. (continue) to be re-oriented on use of call light. Res. monitored Q 2 hrs/PRN. 12/08/11 Res. found on her knees on floor mat by bed. Intervention(s): Res. placed on toileting schedule Q 2 hrs / PRN. 12/26/11 Resident found sitting on safety mat by bedside. Res. stated "I got out of bed, I wanted to be in drivers seat." Intervention(s): Res. encouraged to use call light. Bed alarms are checked and working properly. 01/01/12 Res. found on her bottom on bathroom floor. Res. stated she needed to void. Intervention(s): Initiated visual checks. 01/17/12 Resident found resting on floor in front of w/c with alarm personal alarming. Intervention(s): Res. to be monitored with visual checks Q 2 hours. 01/29/12 CNA (certified nurse aide) found resident on bottom beside her bed. Denies hitting head. Res. states she slid out of her chair. Intervention(s): (This space was blank). 03/17/12 Resident was found sitting on safety mat on floor beside bed. No injury. Intervention(s): Res. encouraged to use call light for all assistance. 03/28/12 Res. noticed sitting on bedside mattress by bedside stating that she slid out of bed while trying to get up. Intervention(s): Res. toilets Q 2hrs/PRN 03/28/12 1435 pm (2:35 p.m.) Res. alarm sounding off. CNA entered room and found resident lying face down on floor in res room. Intervention(s): Res. sent to Mercy Hosp. 04/22/12 CNA found resident sitting on safety mat by bed. Res. say I was trying to go home. No injuries noted. Intervention(s): Toileting schedule Q 2hrs to be done by staff. 06/17/12 found on floor. Abrasion noted on head. Intervention(s): Continue frequent visual checks. 07/06/12 Found sitting on floor beside bed. No injuries noted. Intervention(s): Encouraged to use call light for assistance. 07/30/12 Found sitting on floor on bottom beneath w/c. No injuries noted. Intervention(s): Continue frequent visual checks. Encourage resident to participate in activities outside of room. 08/15/12 Found on the floor in room c bleeding laceration to forehead. Tx (treatment) to ER (emegency room). Intervention(s): Res. sent to Mercy ER." The incident report, dated 03/28/12 at 3:00 a.m., documented the resident was found on the mat beside bed. The resident was attempting to get out of bed. It documented the resident's condition before the incident was confused with a [DIAGNOSES REDACTED]. The incident report, dated 03/28/12 at 2:35 p.m., documented the resident's personal alarm was sounding. The CNA was responding to the alarm when she found the resident on the floor. It documented the resident's condition before the incident was confused. The interventions taken were to educate the resident on the use of the call light and the importance of wheelchair safety. **The clinical record documented the resident sustained [REDACTED]. The incident report, dated 08/15/12 at 9:30 a.m., documented the resident was found on the floor in her room. It documented prior to the incident the resident was oriented to self. It did not document interventions to be taken, the area was blank. **The clinical record documented the resident sustained [REDACTED]. There was no documentation the staff had assessed the effectiveness of interventions developed for the falls. The nursing staff provided no documentation the resident's ability to utilize the interventions had been assessed. The care plans for falls were not developed and individualized for this resident's dementia and state of confusion. On 08/21/12, the resident was observed wearing a seat belt while in her w/c. On 08/21/12 at 8:40 a.m., the resident was observed eating the morning meal in the dining room. At 9:30 a.m., she was transferred to the activities room and remained there through 11:00 a.m. She was transferred to the dining room from the activities room. At 12:20 p.m., she was returned to her room from the dining and left alone. She said, "They said they would be right back. I need to potty." At 1:00 p.m., two CNAs returned from the dining room, they were pushing a resident in a geri-chair. They walked past the resident's room. They did not perform a visual check. The resident was rolling her w/c in circles in her room. She was attempting to stand up by pushing against the arms of her w/c with her hands. The restraint was preventing her from rising. The call light was coiled on the far side of the bed. It was not within reach of the resident. At 1:15 p.m., one of the CNAs came out of the other resident's room and walked past resident #7's room. No visual check was performed. At 1:20 p.m., CNA #4 entered her room and asked her if she needed to use the bathroom. She was assisted to the restroom where a wet brief was removed and she was toileted. On 08/23/12 at 12:30 p.m., she was asked if she could use her call light. She said, "I don't know. Where is it?" She was staring off into space and made no attempt to locate the call light. She was pushing her w/c around in circles. Her speech became garbled and she was unable to be understood. The call light was clipped to the wall on the far side of the bed. It was not within her reach. At 2:00 p.m., CNA #3 entered the resident's room. The resident was asked if she needed to potty." She replied, "No, not now." The CNA stated she was going to toilet her anyway because she was not toileted after lunch. The resident was transferred to the restroom, her wet brief was removed, and she was toileted. The resident was asking if the golf tournament had started? The CNA was asked if the resident ever used the call light. She said, "I don't think she can remember." The call light was not within reach. Visual checks were not performed while the resident was left alone in her room. At 4:50 p.m., in the presence of the director of nursing (DON) the resident was asked if she could use the call light. The resident attempted two times to reach out in the direction of the bed then she appeared to forget what she was doing and stared into space. The DON was asked if reminding the resident to use the call light was a useful intervention for this resident. She said, "Well, no. She couldn't find it then she forgot what she was doing. I've talked with my staff about relying on the call light for this type of resident." She was asked if staff was available on the hall during meal service. She stated one staff member was left on the hall to answer call lights. She was asked if the same staff person was responsible for providing feeding assistance was also responsible for answering call lights and conducting visual checks. She stated she would have to check on that. On 08/24/12 at 3:00 p.m., the DON was asked for copies of the resident's fall assessments, since 09/07/11. No information was provided.

Based on observation, record review and interview, it was determined the facility failed to ensure potentially hazardous chemicals were stored behind locked doors or in locked cabinets. The DON (director of nursing) identified four residents who wandered the facility. Findings: The Housekeeping/Laundry Safety Procedures policy documented, "...Never leave chemicals or cleaning products unattended in a location accessible by residents...Never leave equipment (e.g., cords, ladders, chemicals) unattended in areas that are accessible to residents. When not in use, store equipment in a locked closet, cupboard, cabinet, or storage area..." On 10/08/2012 at 4:35 p.m., the shower room between hall 200 and hall 300 was entered. A plastic storage cabinet was observed against the wall. The padlock was open on the cabinet door. Inside the cabinet the following was observed: ~ a can of shaving cream, ~ a container of shampoo and body wash. The label documented, "For external use only," ~ a container of Bath Additive and Skin Conditioner. The label documented, "For external use only," and ~ a container of Classic Whirlpool Disinfectant Cleaner. The label documented, "Danger...Keep out of Reach of Children...If swallowed call a poison control center immediately for advice. Do not induce vomiting...Do not give any liquids to this person..." At 4:40 p.m., the shower room between hall 300 and hall 400 was entered. A plastic storage cabinet was observed against the wall. The padlock was locked but was only through one door of the cabinet. The cabinet doors would open. Inside the cabinet the following was observed: ~ one container of hair conditioner, ~ two cans of shaving cream, ~ one spray bottle of Virex disinfectant/deodorizer. The label documented, "Keep out of reach of children," ~ one gallon of Freesia Shampoo/Body Wash. The label documented, "For External Use Only," and ~ two containers of Bath Additives Skin Conditioner. The label documented, "For External Use Only." At 4:45 p.m., the shower room between hall 500 and hall 600 was entered. A plastic storage cabinet was observed against the wall. The padlock was locked but was only through one door of the cabinet. The other doors hole for the lock placement was broken. The cabinet doors would open. Inside the cabinet the following was observed: ~ one gallon container of Freesia Shampoo/ Body Wash. The label documented, "For External Use Only," ~ two spray bottles of Crew Multi-Purpose Restroom Cleaner. The label documented, "Keep Out Of Reach Of Children." When one of the bottles was picked up, the lid came off and the bottle fell to the floor, spilling liquid on the floor. ~ one spray bottle of Febreeze, ~ two bottles of Smooth & Silky hair conditioner, ~ one bottle Treseme shampoo, ~ three cans of shaving cream, ~ one container of Shampoo/Body Wash, with no lid. The label documented, "For External Use Only," ~ three containers of bath additive. The label documented, "For External Use Only," and ~ a container of whirlpool disinfectant cleaner. On 10/08/12 at 4:50 p.m., the corporate RN (registered nurse) was taken into the shower room on the 500/600 hall. She was told about and shown the spill on the floor from the multi-purpose bathroom cleaner. She stated, "Those doors have always been locked. They are checking them daily on their rounds." She was then taken to the shower room for the 300/400 halls. She was asked if the cabinet was locked. She pulled on the cabinet doors and they opened. She stated, "It should have been. They have been checking them." She was then taken the the shower room for the 200 hall. She was asked if the cabinet was locked. She looked at the open lock and sighed. She stated, "They have been being closed." On 10/09/12, the administrator stated the cabinet in the halls 300/400 shower room had been fixed on 10/08/12. At 6:42, a.m., the cabinet in the shower room of hall 300/400 was observed. The lock was bolted but the doors were easily opened. At 6:45 a.m., the administrator was accompanied to the shower room on 300/400 halls. She was asked if the cabinet was locked. She tugged on the doors and they opened. She stated she had checked the cabinet before leaving the building on the evening of 10/08/12 and it had been locked. At 6:52 p.m., the bath aide reported she had left the cabinet doors unlocked in the shower room for the 300/400 halls. She stated she was transferring supplies from the shower room on the 500/600 halls to this shower room. She stated she did no know she needed to lock the cabinet if she was in and out of the room. She was asked if any of the residents in the facility were "wanderers." She stated, "Yes." She was asked how quick she thought a resident could gain access to the chemicals. She stated, "Pretty quickly." At 2:40 p.m., the maintenance supervisor was asked about the locks on the shower room cabinet doors.. He stated he had put a hinge on the hall 200 cabinet doors and this was the second time he had drilled holes for the lock in the 300/400 shower room cabinet because the staff kept breaking it to get the doors opened. He stated, "They just keep breaking them."

Based on observation, record review and interview, it was determined the facility failed to: ~ provide supervision to prevent falls for a resident with 22 falls which resulted in injury and actual for one (#7) of 10 sampled residents for whom falls were reviewed. The facility's Roster/Sample Matrix, dated 08/20/2012, documented 36 residents had triggered for falls. ~ ensure potentially hazardous chemicals were stored behind locked doors or in locked cabinets. The DON (director of nursing) identified five residents who wandered the facility. ~ ensure safe hot water temperatures were maintained in two of three shower rooms. The DON identified 118 residents utilized the shower rooms. The Census and Condition, dated 08/20/12, documented 120 residents resided in the facility. Policy The facility's, "Falling Leaves Prevention Program Form," documented, "Policy Statement: It is the policy of this facility to promote resident safety and decrease the risk of injury from falls. Procedure: 1. A Fall Risk Assessment will be performed: a. On admission/readmission b. Quarterly c. Annually d. Significant Change 2. If a resident's Fall Risk Assessment is determined to be high, they will be identified to the staff by placing multi-colored leaves at the resident's door and other significant areas as needed. 3. The Interdisciplinary Team will identify appropriate interventions to prevent falls when a resident is identified as "High Risk" and note those on the care plan. 4. The Safety Committee will meet monthly and review all incident reports and make monthly documentation of all falls for trending. If a resident's fall history is indicative of frequent falls and/or their plan of care needs to be re-evaluated for interventions, the following steps can be initiated, as indicated: i. A Frequent Fall Assessment to determine causative factors. ii. Notify physician of frequent fall history and request a review of any possible treatable medical conditions or problems. iii. Physical Therapy / Restorative Nursing Screening. iv. Consultant Pharmacists review of medications. v. Assessment of possible issues. vi. Vision screening. 5. From the Safety Committee's monthly fall documentation the QA Committee will identify all potential problems to be addressed. 6. The "Falling Leaves" designation will mean: a. Upon each pass down the hallway, staff will look into all "Falling Leaves" rooms to ensure that the resident is not attempting to get up without assistance, or has fallen. b. If a resident is attempting to get up without assistance, staff will assist resident with the task and will redirect resident to ask for assistance. c. Staff will be responsible for monitoring each resident with a "Falling Leaves" designation on their wheelchair more closely for any attempts at getting up without assistance. d. Staff will notify the Charge Nurse of resident's attempts or of resident falling per policy for incident reports. 7. Staff will be inserviced during orientation and as needed to the Falling Leaves Fall Prevention Program. 8. Quality Assurance will evaluate this policy as needed." Findings: 1. The resident's score on the Fall Risk Assessment for resident #7, dated 09/07/11, was a 12. A score greater than ten indicated the resident was a high risk for falls and should be placed on the Falling Leaves program. The resident had [DIAGNOSES REDACTED]. The resident's quarterly assessment, dated 07/18/12, documented she was not on a restorative program and required staff to propel her wheelchair; and required extensive assistance with one staff member for transfers and dressing. She was continent of bowel and occasionally incontinent of bladder. She had functional range of motion impairment in all four extremities, her vision was highly impaired, and she wore no glasses during this testing. The resident's care plan, dated 12/08/11, documented: "Problem: (Name deleted) has a hx (history) of falls d/t (due to) impaired mobility, poor eyesight r/t (related to) Parkinson's Disease with potential for self-injury. Goal: (Name deleted) will be free of self-injury r/t falls QD (every day) Approach:...Remind/encourage (Name deleted) to ask for or wait for assistance with transfer and/or ambulation... Keep call light in reach at all times when in room... Keep adaptive device: wheelchair in reach at all times and remind (name deleted) to use.... Monitor (Name deleted) frequently for fall risk... Assess for need of restorative nursing to increase independence in mobility... Keep room free of clutter to prevent tripping hazards... Soft buckle belt while up in chair related to leaning forward. Comment: 07/18/12 Cont current plan of care... Problem:...Resident is on scheduled toileting program... Goal: (Name deleted) will regain bowel and bladder control AEB maintenance of continence thru target date Approach:...Assess for ability to participate in program ( E.G. some awareness of toileting needs...)... Encourage (Name deleted) to hold urine until next scheduled time but do assist to toilet if requested... Encourage (name deleted) to perform Kagel exercises... Comment: 07/18/12 Cont current plan of care... Problem:...Limited abilities and potential for injury d/t highly impaired vision and Parkinson's Disease... Approach:...Provide adaptive devices: glasses clean and on QD (every day) when awake... Comment: 07/18/12 Cont current plan of care..." The resident's care plan, dated 03/29/2012 documented: "Problem (The area named the Problem had a line drawn through it and the word resolved was written under it.)...(Name deleted) has a Maxillary fracture and laceration of face r/t fall Goal:...(Name deleted) will be free from infection r/t facial injuries sustained from fall. Approach:...Remind/encourage (Name deleted) to ask for or wait for assistance with transfer and/or ambulation... Keep call light in reach at all times when in room... Keep adaptive device: in reach at all times and remind (Name deleted) to use... Low bed with mat on floor beside bed with bolster pillows. Keep floor clean and free of debris and other items... Apply bed alarm and remind (Name deleted) not to get up without assistance... Monitor (name deleted) Q 2 hours for safety and comfort... Comment: (This area was left blank)." The Care Plan Fall Log documented she had 22 falls between 09/05/11 and 08/15/12. All the falls occurred while the resident was alone in her room. "Fall: 09/05/11 Res.(resident) was observed sitting on floor mat by her bedside @ (at) 0500 (5:00 a.m.). No injuries noted. Intervention(s): Instructed to call for assistance. 09/15/11 Res. was observed on the floor on her L (left) side over the floor mat. States she fell out of the bed and hit her nose. Intervention(s): Res. to be monitored Q (every) 2 hours for bed alarm placement; to be offered toileting PRN (as necessary) and Q 2 hrs. 09/20/11 Res. was found to be sitting on floor on bottom next to bed, upright. Res. still had alarm attached; no injuries noted Intervention(s): Frequent visual checks, Keep necessary items within reach. 09/25/11 Res. found sitting on floor on bottom next to bed. no injuries present. Intervention(s): Res. to be monitored Q 2hrs (hours) For Bed alarm placement. Scheduled toileting PRN and Q 2 hrs. 10/25/11-Res. was found on floor beside her w/c (wheelchair), states that she slid out of her w/c. Intervention(s): Res. evaluated for new w/c for decreased) risk of falls, by P.T./O.T. (physical therapy and occupational therapy). 10/26/11-Res. found on floor in front of w/c. No c/o (complaints of) pain. Intervention(s): Res. received new w/c with pommel cushion device to reduce risk of sliding out of w/c. 10/26/11 11:40 p.m. Res. stated she toileted herself and as she tried to sit back down in her chair, she fell on to floor. Intervention(s): Toileting schedule in place, Res. to be toileted Q 2 hrs./PRN by staff. 10/28/11 Res. tried to get out of w/c while toileting and fell forward and hit right side of head. Intervention(s): Res. to wear shoes c (with) rubber sole. Toileting Q 2 hours/PRN Toileting schedule. 11/24/11 Resident climbed out of low bed and was sitting on mat. Intervention(s): Res. cont. (continue) to be re-oriented on use of call light. Res. monitored Q 2 hrs/PRN. 12/08/11 Res. found on her knees on floor mat by bed. Intervention(s): Res. placed on toileting schedule Q 2 hrs / PRN. 12/26/11 Resident found sitting on safety mat by bedside. Res. stated 'I got out of bed, I wanted to be in drivers seat.' Intervention(s): Res. encouraged to use call light. Bed alarms are checked and working properly. 01/01/12 Res. found on her bottom on bathroom floor. Res. stated she needed to void. Intervention(s): Initiated visual checks. 01/17/12 Resident found resting on floor in front of w/c with alarm personal alarming. Intervention(s): Res. to be monitored with visual checks Q 2 hours. 01/29/12 CNA (certified nurse aide) found resident on bottom beside her bed. Denies hitting head. Res. states she slid out of her chair. Intervention(s): (This space was blank. There were no interventions documented). 03/17/12 Resident was found sitting on safety mat on floor beside bed. No injury. Intervention(s): Res. encouraged to use call light for all assistance. 03/28/12 Res. noticed sitting on bedside mattress by bedside stating that she slid out of bed while trying to get up. Intervention(s): Res. toilets Q 2hrs/PRN 03/28/12 1435 pm (2:35 p.m.) Res. alarm sounding off. CNA entered room and found resident lying face down on floor in res room. Intervention(s): Res. sent to Mercy Hosp. 04/22/12 CNA found resident sitting on safety mat by bed. Res. say I was trying to go home. No injuries noted. Intervention(s): Toileting schedule Q 2hrs to be done by staff. 06/17/12 found on floor. Abrasion noted on head. Intervention(s): Continue frequent visual checks. 07/06/12 Found sitting on floor beside bed. No injuries noted. Intervention(s): Encouraged to use call light for assistance. 07/30/12 Found sitting on floor on bottom beneath w/c. No injuries noted. Intervention(s): Continue frequent visual checks. Encourage resident to participate in activities outside of room. 08/15/12 Found on the floor in room c bleeding laceration to forehead. Tx (treatment) to ER (emergency room ). Intervention(s): Res. sent to Mercy ER." **The incident report, dated 03/28/12 at 3:00 a.m., documented the resident was found on the mat beside the bed. The resident was attempting to get out of bed. It documented the resident's condition before the incident was confused with a [DIAGNOSES REDACTED]. The incident report, dated 03/28/12 at 2:35 p.m., documented the resident's personal alarm was sounding. The CNA was responding to the alarm when she found the resident on the floor. It documented the resident's condition before the incident was confused. The interventions taken were to educate the resident on the use of the call light and the importance of wheelchair safety. The clinical record documented the resident sustained [REDACTED]. **The incident report, dated 08/15/12 at 9:30 a.m., documented the resident was found on the floor in her room. It documented prior to the incident the resident was oriented to self. It did not document interventions to be taken, the area was blank. The clinical record documented the resident sustained [REDACTED]. On 08/20/12 at 8:00 a.m., the resident was observed during the morning meal. She had a laceration with sutures to her right forehead. She was not wearing a restraint. A pre-restraint assessment, dated 08/20/12 at 5:00 p.m., documented the resident's son had given verbal permission for the use of a seat belt. It documented the seat belt was necessary due to frequent falls because the resident attempted to transfer without assistance. The resident was forgetful and only sometimes able to follow directions. On 08/21/12 at 8:40 a.m., the resident was observed eating the morning meal in the dining room. She was wearing a seat belt attached to her w/c. At 9:30 a.m., she was transferred to the activities room and remained there through 11:00 a.m. She was transferred to the dining from the activities room. At 12:20 p.m., she was transferred to her room from the dining room and left alone. She said, "They said they would be right back. I need to potty." At 1:00 p.m., two CNAs walked past her room while pushing a resident in a geri-chair. They did not perform a visual check as they walked past her room. The resident was rolling her w/c in circles in her room. She was attempting to stand up by pushing against the arms of her w/c with her hands. The restraint was preventing her from rising. The call light was coiled on the far side of the bed. It was not within reach of the resident. At 1:15 p.m., one of the CNAs came out of the other resident's room and walked past resident #7's room. No visual check was performed. At 1:20 p.m., CNA #4 entered her room and asked her if she needed to use the bathroom. She was assisted to the restroom where a wet brief was removed and she was toileted. On 08/23/12 at 10:30 a.m., the resident was observed in the activities room. At 11:00 a.m., she was transferred to the dining room. At 12:30 p.m., she was transferred to her room. She was not toileted before being left alone in her room. She was attempting to stand. She said, "I have to potty. Can you undo this belt?" The resident was asked if she could undo the belt. She said, "I don't believe I can." She was asked if she could use her call light. She said, "I don't know. Where is it?" She was staring off into space and made no attempt to locate the call light. She was pushing her w/c around in circles. Her speech became garbled and she was unable to be understood. The call light was clipped to the wall on the far side of the bed. It was not within her reach. At 1:00 p.m., the resident was still attempting to stand and pushing her w/c around her room. CNA #5 was the only staff member on the hallway. She was in a resident's room feeding a resident. She was asked about the staffing of the hall during meal service. She stated she stayed behind to feed the hall trays while the other two CNAs went to the dining room. She stated she was the only one responsible for feeding hall trays on two halls. She stated that normally only two CNAs work this hall, but surveyors are here so there are three of us. At 2:00 p.m., CNA #3 entered the resident's room. The resident was asked if she needed to potty. She replied, "No, not now." The CNA stated she was going to toilet her anyway because she was not toileted after lunch. The resident was transferred to the restroom, her wet brief was removed, and she was toileted. The resident was asking if the golf tournament had started? The CNA was asked if the resident ever used the call light. She said, "I don't think she can remember." The call light was not within the resident's reach. Visual checks had not been performed while the resident was left alone in her room. At 4:50 p.m., in the presence of the DON the resident was asked if she could use the call light. The resident was seated in her w/c with the seatbelt attached. She attempted two times to reach out in the direction of the bed, then she stopped and stared off into space. The DON was asked if reminding the resident to use the call light was a useful intervention for this resident. She said, "Well, no. She couldn't find it then she forgot what she was doing. I've talked with my staff about relying on the call light for this type of resident." She was asked if staff was available on the hall during meal service. She stated one staff member was left on the hall to answer call lights. She was asked if the same staff person was responsible for providing feeding assistance, answering call lights and conducting visual checks. She stated she would have to check on that. On 08/24/12 at 3:00 p.m., ADON (assistant director of nursing) #2 was asked about the resident's cognition on the most recent resident assessment. She was asked if the resident scored a "12" which would have indicated the resident had moderately impaired cognition. The ADON stated sometimes she is cognitive. Maybe 50-50. She also stated the resident definitely had memory problems. 2. The Housekeeping/Laundry Safety Procedures policy documented, "...Never leave chemicals or cleaning products unattended in a location accessible by residents... Never leave equipment (e.g., cords, ladders, chemicals) unattended in areas that are accessible to residents. When not in use, Store equipment in a locked closet, cupboard, cabinet, or storage area..." On 08/20/12 at 11:50 a.m., the corporate maintenance supervisor was observed at the janitor closet on hall 400. He was observed to push the door open, pull it until it latched and then push the door until it reopen without using the door handle. He was observed repeating this process four times. At 3:00 p.m., the clean work room on hall 400 was entered. The following was observed: ~ a bottle of Diversy Lemon Furniture Polish was on the lower shelf of a desk in the room. The shelf had no door. The label documented, "...Keep out of reach of children..." ~ A bottle of Gelrite Instant Hand Sanitizer was located on the cabinet countertop. The label documented, "...Keep out of reach of children. If swallowed, get medical help or contact a Poison Control Center right away..." At 3:05 p.m., the janitor closet door on hall 400 was observed to open when the center of the door was pushed on. Inside the closet the following was observed: ~ A spray bottle of Virex 256 One Step Disinfectant Cleaner and Deodorant. The label documented, "...Avoid contact with skin and eyes. In case of contact, immediately flush with water...Keep out of reach of children..." This bottle was sitting on the floor at the back of the closet. ~ Carpet Extract Cleaner Concentrate and Multi Purpose Restroom Cleaner Concentrate were located in a dispenser on the wall. At 3:15 p.m., a bottle of Gelrite Instant Hand Sanitizer was observed in an unlocked cabinet above the sink in the hall 400 kitchenette area. On 08/21/12 at 9:05 a.m., a bottle of Shine-Up Lemon Furniture Polish was observed in an unlocked cabinet above the sink in the soiled work room on hall 500. The workroom door was left unlocked. At 1:00 p.m., the shower room between hall 200 and hall 300 was entered. A plastic storage cabinet was observed against the wall. A padlock was locked and in place; however when you pulled on the cabinet door it opened. The area on the door where the padlock would have attached was broken. Inside the cabinet the following was observed: ~ a jug of Bath Additive and Skin Conditioner. The label documented, "...For external use only..." and ~ a can of shaving cream. At 1:10 p.m., the door to the janitor closet on hall 400 was pushed and opened without the use of the handle. Inside the closet on the floor beside the door the following was observed: ~ a jug of Glance HC Glass and Multi Surface Cleaner concentrate. The label documented, "...Danger: Corrosive, causes skin and eye burns..." and ~ a jug of Virex II 256 concentrate. The label documented, "...Precautionary Statements: Hazardous to humans and domestic animals...Causes irreversible eye damage and skin burns...Harmful if swallowed..." At 5:10 p.m., the main dining room was entered. In the back left corner of the room an industrial buffing machine was observed. Two residents were seated at a table awaiting supper within 8-10 feet of the buffer. The following chemicals were observed in the immediate area: ~ A bottle of Comet with Bleach hung on the buffer handle. The label documented, "...Keep out of reach of children...eye irritant...Avoid contact with eyes..." ~ two jugs of Snapback Spray Buff were sitting on the floor beside the buffer. The label documented, "...Avoid contact with eyes and skin. In case of contact, immediately flush with water..." On 08/24/12 at 2:30 p.m., the corporate and facility maintenance supervisors were asked to examine the janitor closet on hall 400. The corporate maintenance supervisor stated he was aware the door had been not been locking and it had been fixed this morning. He stated they had also found where the staff had placed tape on several other door latches in the facility to keep the doors from locking. They were asked about the chemicals in the janitor closet on hall 400. The corporate maintenance supervisor stated hazardous chemicals should be kept behind a locked door or in a locked cabinet. They were then shown and asked about the plastic cabinet in the shower room between hall 200 and hall 300. The corporate maintenance supervisor stated the cabinet had been replaced before, but the staff rebroke the area where the padlock was to be placed. When the corporate maintenance supervisor opened the cabinet doors, he stated there were chemicals stored in the cabinet. When leaving the shower room, the corporate maintenance supervisor pointed to two cans of shaving cream and a jug of body soap in the shower stall and stated, "Here are chemicals, too. We've talked about this too." 3. During an environmental tour of the facility on 08/20/12, the following hot water temperatures were obtained: ~ 3:30 p.m., in the shower room on 300 - 400 halls was 126 F, ~ 4:05 p.m., in the shower room hall 200 was 118.7 F. ~ 4:20 p.m., in the shower room on 500 - 600 halls was 119.6 F On 08/24/12 at 2:30 p.m., the corporate maintenance supervisor and the facility's maintenance supervisor were asked to check the hot water temperatures in the shower rooms on 300 - 400 halls and 500 - 600 halls. The following temperatures were obtained: ~ hall 300 - 400 was 124 F, ~ hall 500 - 600 was 118 F. The corporate maintenance supervisor stated, "Those are too hot. They should not be that hot." He then told the facility's maintenance supervisor that he had not shown him how to regulate the temperatures yet, but the hot water should be under 115F. On 08/25/12 at 1:25 p.m., the administrator was asked if the facility had a policy on hot water temperatures. She presented the Preventative Maintenance Schedule and stated temperatures are taken weekly. The Preventative Maintenance Schedule documented, "...All items will be inspected at the times specified, if not more often... Weekly...Hot water supply..." She was then asked if there was a policy on where the temperatures should be set. She stated the regulator takes care of that. She stated the policy was what the regulations stated but did not believe there was a written policy. At 2:20 p.m., the water temperature log book was reviewed with the administrator. The following was documented: ~ 08/06/12: 300 - 400 hall shower room...116 F 500 - 600 hall shower room...127 F, ~ 08/13/12: 300 - 400 shower room...117 F 500 - 600 hall shower room...120 F and ~ 08/20/12: 300 - 400 hall shower room...118 F 500 - 600 hall shower room...121 F. The administrator was shown the temperatures and made no comment.