Every finding on record at Westlake Health Campus

Based on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: On 1/5/26 at approximately 9:40 a.m., during the initial tour of the kitchen, the following concerns were observed with cook F. Multiple single portioned condiments with an expired use by date (UBD) of 12/25/25 were observed in the reach in refrigerator. Two bags of refrigerated boiled eggs were observed without a UBD. A single serving portioned container of barbeque sauce was observed without any received or used by dates. an uncovered/cooked turkey breast was observed in a pan without any labeling on it indicating a used by date or a cooked date. An opened to air bag of frozen fried chick was observed in the freezer without a UBD or a received date. Two pans of pureed broccoli and green beans were observed without any labeling. A bag of frozen chicken breast was observed in the freezer, open to air and unsealed. Four portable containers of carbon dioxide were observed to be freestanding and unchained/unsecured. A pile of single and stale marshmallows was observed unsealed in an open container that had no dating. Dried grease spillage was observed on the racks and in the bottom flooring in the mealtime express warmer. On 1/5/26 at approximately 10:06 a.m., the concerns were reviewed with cook F and they indicated they would have to throw away the items that were past the UBD and the unlabeled food items. [NAME] F indicated they would have to get the racks and flooring of the warmer cleaned and would throw away the marshmallows. On 1/7/26 at approximately 10:17 a.m., the concerns noted in the Kitchen on 1/5/26 were reviewed with the Food Service Director B (FSD B). FSD B reported that they had gone over all the items of concern with cook F and they were starting to provide in-servicing/education to the kitchen staff on the identified concerns. A review of the 2022 Food and Drug Administration (FDA) Food Code revealed the following: refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observation, interview and record review, the facility failed to ensure Physician orders and a comprehensive plan of care was in place for one resident (R77) on oxygen therapy of one resident reviewed for respiratory care. Findings include: On 1/05/2026 at approximately 10:52 a.m., R77 was observed in their room, up in their wheelchair. R77 was observed to have oxygen infusing at 2 LPM (liters per minute). R77 was asked if they know how much oxygen they should be receiving and they reported they did now know. On 1/6/26 at approximately 2:05 p.m., R77 was observed in the common area, up in their wheelchair. R77 was observed to have a portable E-tank of oxygen infusing via nasal canula at 2.5 LPM. On 1/6/26 at approximately 2:30 p.m., R77 was observed in their room, laying in their bed. R77 was observed to have oxygen infusing at 2 LPM. On 1/6/26 the medical record for R77 was reviewed and revealed the following: R77 was initially admitted to the facility on [DATE] and had diagnosis including Chronic obstructive pulmonary disease, and Anxiety disorder. A review of R77's Physician orders was conducted and did not reveal any orders from the Physician that indicated how many liters per minute of oxygen therapy R77 was supposed to be provided. A review of R77's care plan was reviewed and revealed the following: No baseline care plan or comprehensive care plan was present in the record addressing R77's use of oxygen therapy. On 1/6/26 at approximately 2:32 p.m., Nurse D was queried regarding how many liters per minute R77 should be provided and they indicated it should be 1-2 liters per minute. Nurse D was then observed reviewing R77's medical record and indicated R77 did not have a current order for oxygen and that they would have to put one in. Nurse D was queried if R77 had been on oxygen therapy for a long time and they reported they had and thought that there used to be an order for them. Nurse D was observed reviewing old Physician orders and they indicated that R77 had a previous oxygen order, but it had been discontinued, and nobody had placed a new order in the record. On 1/6/26 at approximately 2:40 p.m., MDS (minimum data set) Coordinator G was queried regarding the location of baseline care plans for R77 who was a newly admitted residents on oxygen therapy. MDS Coordinator G reviewed R77's medical record and indicated that R77 did not have a plan of care for oxygen therapy and that they would have to ensure one was placed in the record. On 1/7/26 at approximately 9:02 a.m., during a conversation with the Director of Health Services (DHS), the DHS was queried regarding the clinical process for residents on oxygen therapy and they reported that the resident needs a Physician's order and a plan of care to be provided oxygen. A facility document titled Oxygen Administration was reviewed and revealed the following: OVERVIEW Guidelines to properly Administering Oxygen and any Respiratory procedure. SOP (standard operating procedure) 1. Verify physician's order for the procedure .

Based on observations, interviews and record reviews the facility failed to ensure nutritional supplements were provided as ordered, failed to ensure timely assistance was provided for meals and failed to modify the plan of care to the resident current needs for one (R8) of three residents reviewed for Nutrition. Findings include:On 1/5/26 at 9:30 AM, R8 was observed lying on their back in bed and did not wake with verbal stimuli. Observed against the wall was R8's breakfast tray with a bowl of dry rice cereal, a sliced banana, yogurt and coffee unopened. Utensils wrapped in a navy color cloth napkin was observed to be unopened. There was no staff present in the room.Review of the meal ticket on the breakfast tray noted the following in part, . Magic cup. Peach Oatmeal. Diced Peaches. Resident Notes: [NAME] Krispies, Diced Banana, Yogurt. decaf coffee. The magic cup was not observed on the resident's tray.On 1/7/26 at 9:04 AM, R8 was observed laying on their back in bed waving their arm with their eyes unopened. Observed against the wall was R8's breakfast tray- a fruit cup, peach yogurt, a bowl of dried rice Krispies, coffee and two white Styrofoam cups- all untouched. Utensils wrapped in a navy color cloth napkin was observed untouched on the tray. There was no staff present in the room.Review of the meal ticket on the breakfast tray noted the following in part, . Magic cup. Yogurt. [NAME] Krispies. Cranberry Juice. Decaf Coffee. The magic cup was not observed on the resident's tray.On 1/7/26 at 9:20 AM, Certified Nursing Assistant (CNA) E (the aide assigned to R8 on 1/7/26-dayshift) was interviewed and asked if R8 was able to feed themselves and CNA E stated . No, she requires to be fed by staff. When asked whose responsibility it was to feed R8 their breakfast, CNA E replied the aides or the nurses.A review of the medical record revealed R8 was admitted to the facility on [DATE], with diagnoses that included: dementia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, psychotic disorder with hallucinations, gastro esophageal reflux, cognitive communication deficit, protein calorie malnutrition, contracture to the left hand and gastrostomy status. R8 was noted to have severely impaired cognition and was dependent on staff assistance for all Activities of Daily Living (ADLs).A review of a physician order noted the following, . Fortified Foods, Pre-cut meats. Special Instructions: Magic cup with breakfast and lunch. Further review of the physician orders revealed no directive on the assistance level needed by staff for R8 meals.A review of a physician order discontinued on 7/8/25, documented the following in part . Fortified. Meats cut-up, 1:1 (one on one) assistance with meals, Magic cup with breakfast and lunch.A review of the Resident Profile documented in part . Diet: Feeding tube. Fortified foods. Regular, Regular Texture, Thin Liquids. Meats cut up. Sit upright (90 degrees) when eating and drinking and for 30 minutes after eating. Styrofoam cup for all liquids due to hand tremors. The profile gave no directive on the assistance level needed for meals.A review of the care plans revealed the staff's failure to modify the care plan to reflect the current needs of R8's assistance levels needed for meals and the failure to provide supplements as ordered.On 1/7/26 at 11:10 AM, an interview was conducted with the Director of Nursing (DON). A review of the electronic medical record was conducted with the DON. The Physician order for R8's diet and the resident profile was reviewed with the DON. The DON was asked what level of assistance is needed for R8's meals and the DON was unable to verify what assistance level was needed. The DON was then asked whose responsibility it was to ensure all supplements (magic cup) was provided to the resident at breakfast and lunch and the DON stated it was the responsibility of the kitchen staff. The DON stated they would follow up on the concerns. At 11:48 AM, the DON returned and stated they were following up on updating R8's plan of care.No further explanation or documentation was provided by the end of the survey.

This citation has two deficient practices. Deficient practice #1 Based on observation, interview and record review the facility failed to ensure a Physician's order was obtained for a wound dressing for one resident (R75) of one resident reviewed for non-pressure wounds. Findings include:R75 On 1/05/2026 at approximately 10:36 a.m., R75 was observed in their room, laying in their bed. R75 was observed to have multiple foam dressings on their left forearm that were undated and had dried blood showing through. R75 was asked how they got the wound and they reported they had fragile skin and ripped their skin getting out of bed the day before. On 1/6/26 at approximately 11:42 a.m., R75 was observed in their room, up in their bed. R75 was observed to have to multiple foam bandages on their left forearm. The bandages were both dated 1/5/26. R75 was queried regarding the bandages and reported they had been changed by the Nurse the previous night (1/5/26). On 1/7/27 at approximately 8:50 a.m., R75 was observed in their room, up in their wheelchair. R75's left forearm was observed to have a foam dressing on it with a date of 1/6/26. On 1/5/26 the medical record for R75 was reviewed and revealed the following: R75 was initially admitted to the facility on [DATE]. A review of R75's Physician orders revealed no orders for the dressings on R75's left forearm. A review of R75's progress notes and observations did not reveal any documentation of R75 sustaining a skin tear to their left forearm including no Physician notification or assessment of the skin tear. On 1/7/26 at approximately 8:58 a.m., Nurse D was interviewed regarding the dressing on R75's left forearm and was asked what the dressing order was. Nuse D was observed reviewing R75's medical record and reported that there was no Physician's order for the dressing, but they had applied new dressing the previous night due to the dressing being soiled. Nuse D indicated they would contact the Physician and get an order for R75's left forearm wound. On 1/7/26 at approximately 9:02 a.m., during a discussion with the Director of Health services (DHS), the DHS was asked about R75's skin tear and why there was not any documentation regarding it and why there were no Physician orders for the wound, and they reported there should have an order for the dressing and they would look into the concern. On 1/7/26 at approximately 11:10 a.m., during a follow up conversation with the DHS, the DHS was asked about R75's left forearm wound and they reported there was no documentation done at that time and no order for the dressing. The DHS reported they had to provide in-service education to R75's Nurse regarding obtaining a Physician's order and documenting new skin impairments in the medical record. ON 1/7/26 a facility document titled Bruise, Rash, Lesion, Skin Tear, Laceration Assessment Guidelines was reviewed and revealed the following: Purpose Statement-The purpose of this policy is to: Utilized to describe and monitor bruises, rashes, lesions, skin tears, and lacerations .Procedure: Skin Tear laceration-1. If skin alteration is noted upon admission, admitting nurse should complete the template/assessment progress note. IDT should review this timely and wound nurse or designee complete an assessment in wound management or Wound Zoom. 2. If skin alteration occurs post admission, follow the below steps: a. Complete Skin Tear/Laceration Incident in EHR (electronic health record) by an RN/LPN along with the template/assessment progress note. IDT should review this timely and wound nurse or designee complete an assessment in wound management or Wound Zoom . b. Continue to monitor weekly in wound management. c. Must review for at least 1 week in wound management. Once the wound nurse/designee determines that the wound is healing as expected, resolved or becomes a chronic skin condition this wound nurse/designee may heal the wound in wound management or Wound Zoom. Deficient Practice #2 Based on observation, interview and record review, the facility failed to ensure appropriate transportation arrangements were provided for one resident (R79) of one resident reviewed for transportation/appointments. Findings include: R79 On 1/05/26 at approximately 11:07 a.m., R79 was observed in their room, lying in bed with visitor H at the bedside. R79 was queried if they had any concerns regarding their care and visitor H reported that R79 was not provided any transportation to their Orthopedic doctor appointment that day and their appointment was at 10:45 (AM) and as a result, they had missed the appointment. On 1/5/26 the medical record for R79 was reviewed and revealed the following: R79 was initially admitted to the facility on [DATE]. A Physician's order with a start date of 1/5/26 revealed the following: Follow up appointment w/orthopedic surgeon [Name of Surgeon] D/D (Discontinue) ONCE COMPLETE Once A Day 06:30 AM - 10:00AM A hospital Transition of Care Form dated 12/26/25 revealed the following follow-up appointments: Specialists in Orthopedic Surgery on 1/5/26 at 10:45 AM. On 1/7/26 at approximately 9:02 a.m., during a conversation with the DHS, the DHS was queried regarding R79's missed Doctor's appointment and why the facility had not assisted R79 in arranging transportation for them. The DHS reported they would look into the concern. On 1/7/26 at approximately 11:10 a.m., during a follow up conversation with the DHS, the DHS indicated there was a miscommunication between Nursing and R79's family regarding the needs for transportation to their appointment. The DHS reported the Nurse who was aware of the appointment never clarified with R79's family who was going to provide transportation to the appointment, so the appointment was missed. The DHS indicated the family member did not ask about transportation and that they just informed the facility about the appointment date and time and the Nurse who received the information and implemented the order never clarified with the family regarding who would be providing transportation. On 1/7/26 the facility policy titled transportation that pertained to how transportation was scheduled and arranged was reviewed and revealed the following: OVERVIEW-Transportation is provided from the hospital to a campus, to medical appointments by bus or car, for campus outings and various trips. We are committed ta doing aur best to accommodate transportation wherever the residents wish to go, such as shopping, restaurants, museums, parks etc, A successful transportation program has defined expectations and guidelines regarding scheduling, pricing and team responsibilities Suggested 'Steps for Communication': 1. Nursing should fill out all necessary sections of the transportation request form and submit to the TA (transportation associate) and or LED (Life Enrichment Director) at least 48-72 hours in advance of an appointment Noted changes to appointments, whether by campus or family, should be communicated, by Nursing, to the family, and to the TA DHS (Director of Health Services) Role-1. Educate the Nursing team on the process for requesting and scheduling transportation. Educate on notifying the responsible party of the medical appointment and asking them to transport their loved one first, before using in-house services .

This citation pertains to intake #2623642Based on interview and record review, the facility failed to conduct accurate assessments, complete wound treatments per Physician orders, implement interventions in a timely manner and have new wounds regularly assessed by medical providers for one resident (R901) of two residents reviewed for pressure ulcers, resulting in R901 developing two unstageable pressure ulcers on the left and right buttock that worsened into an infection which required an acute care transfer. Findings include:On 10/7/25 a concern submitted to the State Agency was reviewed that alleged R901 developed multiple pressure ulcers that became infected while at the facility. On 10/7/25 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] with diagnoses including Displaced intertrochanteric fracture of left femur, Osteomyelitis (bone infection) unspecified and was discharged to the hospital on 7/14/25. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 6/24/25 revealed R901was dependent on facility staff with most of their activities of daily living. R901's BIMS score (brief interview for mental status) was 14 indicating intact cognition. Section M (skin condition) documented R901 was at risk for developing pressure ulcers and had no unhealed pressure ulcers/injuries. A review of R901's admission careplans revealed the following: Problem Start Date: 06/19/2025 Category: Skin Integrity At risk for skin breakdown r/t (related to) decline in functional mobility, bladder incontinence .Approach- Approach Start Date: 06/19/2025. Keep resident as clean and dry as possible. Minimize skin exposure to moisture. A Nursing admission assessment dated [DATE] revealed R901 had a braden scale score (a tool used to predict risk of skin breakdown) of 17 which indicated they were at risk of developing pressure ulcers. Further review of the assessment did not document any pressure ulcers present on R901's body. A progress note dated 6/26/25 revealed the following: MASD (moisture associated skin damage) noted to both but <sic> cheeks, skin open, bruise to right buttock, family & NP (Nurse Practitioner) & wound care, [Nurse B] made aware, Triad paste per order, applied, continue to monitor. A progress note dated 6/26/25 revealed the following: Resident observed with a bruise measuring approx. (approximately) 7x1cm (centimeters) on the R (right) buttock. Bruise is dark purple/red in color and is linear. Resident uses the bed pan frequently and bruise is due to sitting on the bed pan. Resident receives anticoagulant therapy and is at risk for easy bruising. Resident also noted with widespread MASD in the gluteal cleft area. Area was cleansed and Triad cream applied. Surrounding skin with blanchable redness. Intervention for bruising is to encourage resident to use the toilet as opposed to the bedpan. A progress note dated 7/2/25 revealed the following: .Two pressure ulcers noted on the coccyx present from admission, see wound management for measurements. New orders placed to cleanse with WC/NS (wound cleanser/normal saline), apply medihoney, apply foam dressing daily.A Nursing Wound Details assessment dated [DATE] completed by Nurse B revealed the following: Wound Type-Pressure Ulcer.Wound Location-Left buttock.Length-4 centimeters (cm). Width-2 cm. Can depth be measured? [No]. Exudate Amount Light Exudate color and consistency-Serosanguineous (pale red to pink, thin and watery) Stage-Stage II .Tissue Type-Epithelial Tissue. Skin surrounding wound: Assess within 4cm of wound edge. Erythema (redness)/blanchable. Present on Admission/Re-entry: Yes.A second Nursing Wound Details assessment dated [DATE] completed by Nurse B revealed the following: Wound Type-Pressure Ulcer.Wound Location-Right buttock.Length-4 centimeters (cm). Width-7.5 cm. Can depth be measured? [No]. Exudate Amount: Light Exudate color and consistency Serosanguineous. Wound odor present? No. Stage-Unstageable - Slough and/or Eschar. Tissue Type-Necrotic Tissue Present on Admission/Re-entry: Yes.A Nursing Wound Details assessment dated [DATE] revealed the following: Wound Type-Pressure Ulcer.Wound Location-Left buttock.Length-6 centimeters (cm). Width-2 cm. Can depth be measured? [No]. Exudate Amount-Light. Exudate color and consistency-Seropurulent (yellow or tan, cloudy and thick) Stage-Unstageable - Slough and/or Eschar. Tissue Type-Slough. Present on Admission/Re-entry: Yes. A second Nursing Wound Details assessment dated [DATE] revealed the following: Wound Type-Pressure Ulcer.Wound Location-Right buttock.Length-4 centimeters (cm). Width-7.5 cm. Exudate Amount-Light. Exudate color and consistency-Seropurulent. Stage-Unstageable - Slough and/or Eschar. Tissue Type-Slough. Present on Admission/Re-entry: Yes. A review of R901's Physician ordered enhanced barrier precautions (EBP) (precautions used to prevent infection) revealed no EBP orders were implemented to protect R901's wounds from infection until 7/10/25.A progress note dated 7/12/25 revealed the following: Foul odor noted in coccyx wound, recent lab results show WBC (white blood cell count) 10.51. [medical provider group] on-call notified and lab results faxed. New order for Doxycycline 100mg BID (twice a day) x 7 days and wound culture reflected in EMAR (electronic medication administration record) per Dr. recommendation. Additional order for Vitamin C 500mg bid updated to EMAR for iron absorption per recommendation.A progress note dated 7/14/25 revealed the following: NP (Nurse Practitioner) [NP A] is here, evaluated resident condition, resident is in pain to left thigh, neuro WNL (within normal limits), coccyx wound not improving, infection present, NP ordered resident to be sent to hospital.A progress note dated 7/14/25 revealed the following: IDT (interdisciplinary team) Review: Infection-- Resident's wound assessed this morning due to diagnosis of infection. S/sx (signs/symptoms) of infection include: surrounding skin erythema, pain at the site, moderate amount of serous (clear) drainage. Resident also noted with a functional decline and she experienced a fall on 7/13/25. Resident meets Mcgreer's McGeer criteria for infection. She started on Doxycycline 7/12-7/19 for treatment of infection. Due to severity of her symptoms, she was transferred to the ER (emergency room) on 7/14.A Nurse Practitioner evaluation note dated 7/15/25 with a date of service of 7/14/25 revealed the following: was evaluated today due to concerns about coccyx wound infection, extreme pain, and post-fall. Resident fell in her room yesterday; no new obvious injuries were detected; at this time, the resident was resting in bed, weeping, and complaining of acute discomfort in her bottom (9/10) (pain scale rating 1-10). To treat the resident's pain, the nurse administers oxycodone. Resident had an infected wound on her coccyx; she is currently getting doxycycline, which was ordered by on-call yesterday. On-call also ordered a wound culture, which is still pending. After inspecting the wound, the family was advised to either take the patient to the hospital or make an appointment with the wound clinic. Due to the patient's suffering and discomfort, the family consented to send her to the hospital. Staff phoned 911 and transported the patient to the hospital with her prescription list. Assessment and Plans.Risk of Complications and/or Morbidity or Mortality of Patient Management: undefined.Local infection of the skin and subcutaneous tissue, unspecified: Coccyx wound infection, painful.Acute pain due to trauma: Acute and severe pain at the resident <sic> but to due to worsening wound.Further view of R901's medical record did not reveal any documentation that the development of R901's pressure ulcers were unavoidable or any medical provider's complete assessment/presentation of the skin impairments for the identified MASD on the bilateral buttocks on 6/26 or the Bilateral buttocks pressure ulcers identified on 7/2 as well as the foul odor noted on the coccyx on 7/12 until 7/14 when R901 was sent to the hospital for an infected coccyx wound.A Physician's order dated 6/26/25 revealed the following: Triad Wound Dressing (wound dressings) [OTC] (over the counter) paste; - ; amt (amount): 1 application; topical Special Instructions: apply to both butt cheeks until healed-Twice A DayA Physician's order dated 7/2/25 revealed the following: - Ulcers on coccyx: Cleanse with wound cleaner/NS, apply medihoney, cover with allyven dressing Special Instructions: Contact provider for s/sx of infection-Once A Day.A Physician's order with a start date of 7/12/25 revealed the following: Vitamin C (ascorbic acid (vitamin c) tablet; 500 mg; amt: 1 tab; oral Twice A DayA review of R901's July 2025 Medication administration record/Treatment administration record (MAR/TAR) revealed no documentation of R901 receiving their Triad treatment on the morning of 7/11/25. Further review of the MAR/TAR revealed R901 did not receive their Medihoney treatment to their ulcers on their coccyx on 7/3/25 with the documented reason being No Medihoney. In addition, their evening Vitamin C administration on 7/12/25 with the documented reason being Drug/Item Unavailable.A review of R901's careplan revisions for the identification of their new pressure ulcers identified on 7/2/25 revealed R901's careplan was not updated to reflect the new pressure ulcers until 7/7/25, furthermore R901 did not have a careplan for enhanced barrier precautions initiated.Two additional Physician orders dated 7/14/25 revealed the following: 1.- Pressure reducing cushion to w/c (wheelchair)-Three Times A Day and 2. Order Set PS- Pressure reducing mattress. (12 days after the identification of the pressure ulcers)On 10/7/25 at approximately 12:32 p.m., during an interview with Clinical Support Nurse C (CSN C), CSN C was queried why no wound assessments documenting the presentation of R901's wounds were completed by any medical providers in the facility and they indicated they did not know, but that the medical providers should be assessing wounds in the facility to determine the appropriate treatment orders. CSN C was queried regarding the pressure relieving devices ordered on 7/14/25 including the wheelchair cushion and mattress and they indicated that there was a delay in getting orders into the chart. CSN C indicated that R901 was provided a standard pressure reduction mattress and a wheelchair cushion upon admission, but that the Physician orders for the specialized mattress and wheelchair cushion were not added until 7/14/25. CSN C reported the facility did add a specialized cushion roho(specialized pressure reduction cushion) to the care plans five days after the pressure ulcers were identified on 7/7/25 and that a work order was made on 7/3/25 for a specialized mattress. CSN C was queried regarding the wound detail assessments completed by Nursing staff that indicated R901's pressure ulcers were present upon admission, and they indicated they believed they were not and that not accurate. CSN C was queried regarding the progression of R901's skin impairments from having nothing identified on their coccyx area upon admission, to having multiple infected and unstageable pressure ulcers upon transfer to the hospital on 7/14, and they acknowledged the concern and indicated that the medical providers should have completely assessed and evaluated the wounds.On 10/7/25 at approximately 1:24 p.m., Nurse Practitioner A (NP A) was queried regarding the progression of R901's wounds and if they had ever assessed their wounds while they were in the facility. NP A reported they never conducted a thorough assessment of the wounds that included measuring/staging etc. NP A indicated they did not assess any wounds in the facility but had looked briefly at R901's wound on the day they were sent to the hospital and that it had become infected. NP A reported they had talked to a family member that day about going to the hospital or the wound clinic. NP A reported that the Nursing staff write out their own treatment orders, and they just sign off on them on a later date. NP A was queried if the Nursing staff ever call them to discuss the orders for treatment of the wounds and they indicated they did not and left that decision to the Nurse to decide and would sign off on the order later. NP A reported that if a resident needed antibiotics they would order those or other medications for them.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included education to the providers, new wound nurse and nursing staff. A new order set was set up with guidelines depending on the resident's risk of skin break down. Current residents were reviewed by the provider. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake: MI002570414. Based on observation, interview and record reviews the facility failed to consistently maintain an ongoing Infection Control Surveillance system and ensure to consistently follow the facility's policy for the Infection Prevention and Control Program. This deficient practice had the potential to affect multiple residents residing in the facility, (including R's 902 and 905) two of three residents reviewed for Infection Control Surveillance. Findings include:R902A review of a complaint submitted to the State Agency (SA) documented concerns of the facility's timeliness to treat R902's bilateral conjunctivitis. The complaint also noted multiple concerns with the facility's Infection Control Surveillance. On 9/9/25 at 11:22 AM, R902 was observed lying on their back in bed. An interview was conducted with the resident at that time. A review of the medical record revealed R902 was re-admitted to the facility on [DATE] with diagnoses that included: acute and chronic respiratory failure, hemiplegia and hemiparesis following cerebral infarction affect left non-dominant side, dysphagia (difficulty swallowing) and required staff assistance for all activities of daily living. R902 was their own responsible party. A review of the progress notes revealed the following: A Nurse Practitioner (NP) note dated 6/17/25 at 12:16 AM, documented in part . DATE OF SERVICE: Jun, 16, 2025. Left eye discharge, Right eye discharge. Left exudate, Left eyelid swelling, Right exudate, Right eyelid swelling.A nursing note dated 6/17/25 at 11:29 AM, documented new order for bilat (bilateral) eye conjunctivitis ordered, pharmacy was called, awaiting to deliver it.A nursing note dated 6/17/25 at 11:52 PM, documented Changed order start and stop dates for eyes drops to coordinate with pharmacy delivery. Should come in between 2-3am, to start at 4am.An Infection Event note dated 6/19/25 at 10:19 AM, documented IDT Review: Infection-Resident with bilateral eye conjunctivitis. S/sx (signs/symptoms) of infection include: bilateral eye redness, itchiness, yellow discharge. Resident meets Mcgreer's criteria for infection. Order is for Polymyxin eye drop. for treatment of infection. Contact precautions initiated due to diagnosis. Nursing to monitor for effectiveness of antibiotic and for adverse effects r/t (related to) abt (antibiotic) therapy.A nursing note dated 7/23/25 at 12:36 PM, documented in part . Patient's daughter expressed concern to provider regarding a possible double eye infection, noting redness in both eyes. Following the assessment, the on call provider prescribed new order for Polymyxin ophthalmic drops. The patient and her daughter were informed about the treatment plan, including the correct administration of the eye drops and the importance of adhering to the medication regimen. (This order was documented as a late entry and created on 7/30/25 at 11:46 AM.)A nursing note dated 7/24/25 at 7:58 AM, documented in part . IDT (interdisciplinary team) Review: Resident assessed with bilateral eye purulent drainage, redness on the surrounding skin and sclera and c/o (complaint of) itching to bilateral eyes. Resident meet Mcgreer's criteria for eye infection. Discussed with NP and resident started on Polymyxin 7/23-8/2 for treatment of bilateral conjunctivitis. Resident placed on contact precautions. Nursing to monitor for effectiveness of abt and for adverse effects r/t abt therapy. Goal is for the infection to clear without complication.A NP note dated 7/24/25 at 11:56 AM, documented in part . was evaluated today for bilateral eyes conjunctivitis. Bilateral eyes redness, yellow crusty discharge, watery, and itchiness. Resident states she has been complaining of itcy <sic> eyes couple days ago. Resident has a history of eye conjunctivitis couple weeks ago and she finished the course of antibiotic. Will order polymyxinB-sulfa trimethroprin antibiotic eyes drop q (every) 4 hours needed 8/2. Encourage resident to clean her eyes with room temp clean clothes, and maintain proper hygiene.A review of the June 2025 Medication and Treatment Administration Record (MAR/TAR) revealed the following: Polymyxin B sulf-trimethoprim drops; 10,000 unit- 1mg (milligram)/mL (milliliter); Apply 1 drop in each eye for conjunctivitis. Start date 6/17/25 and End date 6/17/25. Multiple nursing notes documented waiting to arrive. This indicated the pharmacy had not delivered the medication which caused a delay in treatment. A second order for the above eye drops was implemented and started at 4:00 AM on 6/18/25. Two days after the assessment and identification by the NP of the bilateral conjunctivitis for R902 on 6/16/25. The medication was noted to have been completed on 6/27/25. A review of the progress notes revealed no re-evaluation of the effectiveness of the antibiotic eye drops, nor a reassessment of R902's eyes after the completion of the antibiotic eye drop treatment on 6/27/25. A review of the Infection Control Surveillance documentation for June 2025, noted the identification of R902's eye infection, however contained no documentation on whether the infection had resolved or the re-evaluation of the contact precautions for R902. Review of the complaint submitted to the SA documented in part . resident has been waiting with double eye infection to be seen by facility dr (doctor). Upon my arrival to visit (Wednesday 7/23/24) my mother's eyes are so red, crusty and swollen she can barely keep them open. Resident was told on Friday she had to wait to see dr until Monday. The complainant states she spoke to the social worker and the social worker called the doctor and she assessed and treated the resident.The social worker involved in the incident was identified during the survey as the Assistant Director of Social Services (ADSS) C. On 9/9/25 at 1:06 PM, ADSS C was interviewed and asked about the interaction they had with R902's family on 7/23/25 regarding R902's eye infection. ADSS C replied they remembered the incident. ADSS C stated they remembered R902's family member approaching them and stated . her eyes was getting gross and I called the NP. ADSS C went on to explain the NP was in the facility and had come to assess the resident and started treatment. ADSS C was asked if they had informed R902's assigned nurse that day regarding R902's family concerns and ADSS C stated they informed the nurse after they had contacted the NP. ADSS C went on to say, The family was very upset and so I felt it was best to contact the nurse practitioner.The above interview corroborated the reported complaint submitted to the SA and differed from the late entry nursing note created on 7/30/25 and back dated to 7/23/25. R905On 9/10/25 at 10:18 AM, R905 was observed lying on their back sleeping. R905 did not awake with verbal stimuli. A review of the Infection Control Surveillance for July 2025 revealed the following: R905 was treated for an and eye infection with a start date of 7/2/25. Contact precautions were noted and the end date was documented as 7/13/25.There was no documentation of the reassessment of the effectiveness of the medication, reassessment of the eye infection or the reassessment of the need for contact precautions. Further review of the July 2025 Infection Control Surveillance documented on 7/29/25 the resident was again prescribed antibiotic eye drops for an eye infection. The end date was documented as 8/9/25. A review of the progress notes revealed the following: A nursing note dated 7/2/25 at 2:55 PM, documented Resident observed with increased drainage /pus from her left eye. Resident has this infection recurring every month. There is a pocket filled with pus under her eye lid. Resident has been prescribed the same medications for her eye by her eye doctor that has been clearing the infections. NP notified new ordered received to start the resident on Doxycycline (antibiotic) 50 mg BID (twice a day) x 10 days, Diflucan (antifungal) x 10 days and moxifloxacin and Polymycin <sic> (antibiotic combination) eye drops. Orders noted.Further review of the progress notes revealed no documentation of the reassessment of the effectiveness of the above treatment, the reassessment of the resident eyes or the reassessment of the need for contact precautions after the treatment was noted to be completed on 7/13/25. A review of a nursing note dated 7/30/25 at 2:10 PM, documented in part . IDT Review: Infection-Writer assessed resident this morning due to new orders for antibiotics for eye infection. Resident's L (left) eye assessed with purulent drainage and crusting on the eyelid. new orders received. Nursing to monitor for effectiveness and for adverse effects r/t abt therapy. Resident placed on contact precautions due to drainage from eye and diagnosis conjunctivitis. Goal is for the infection to clear without complication.The progress notes again, revealed no documentation of the reassessment of the effectiveness of the treatment, the reassessment of the resident eyes or the reassessment of the need for continued and/or discontinuation of the contact precautions implemented, after the completion of the treatment on 8/9/25. A review of a facility policy titled Infection Prevention and Control Program dated 11/10/17, documented in part . The purpose of this policy is to: To establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The campus has a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. Evaluates implementations and effectiveness of recommended actions.INFECTION SURVEILLANCE PROGRAMA review of the July 2025 Infection Control Surveillance revealed an increase of eye infections from one identified resident (in June 2025) to three identified in July 2025. There was no documentation of additional education provided to the facility staff regarding hand hygiene and/or any other additional education. A review of the August 2025 Infection Control Surveillance revealed two residents documented to have eye infections. This did not include or identify R's 902 or 905 who were both identified from their medical records to have been treated for eye infections for the month of August 2025. A review of the August 2025 mapping of infections in the facility failed to identify any of the residents with eye infections in the facility. A review of the August 2025 analysis failed to note any of the residents' treated for eye infections in the facility. On 9/9/25 at 1:12 PM, the facility's Infection Control Preventionist (ICP) D was interviewed and asked about the multiple eye infections for R902 & R905 and whose responsibility it was to monitor the effectiveness of the treatment, reevaluation of the resident eyes/infection and the reevaluation of the implemented contact precautions and ICP D replied the assigned nurses to the resident. On 9/10/25 at 11:15 AM, an interview was conducted with the interim Director of Nursing (DON) and the facility's Clinical Support (CS) B. When asked whose responsibility it was to monitor the effectiveness of the prescribed antibiotic and reassess the resident eyes after the treatment is completed the DON replied they would expect the nurse that administered the last dose to re-evaluate the resident. The DON was asked if the assessment should be documented in the residents record and the DON replied that it should. On 9/10/25 at 1:01 PM, a follow up interview was conducted with ICP D. ICP D was asked who re-evaluates the resident on Contact Precautions to ensure it can be discontinued or the need to be continued, ICP D stated they ordered the precautions to be in place as long as the prescribed antibiotic. The precautions are scheduled to discontinue after the last day of treatment. ICP D was then asked about the lack of education provided to the facility staff during the months of June and July when the Infection Surveillance program revealed an increase in eye infections in the facility. ICP D stated during those months they were verbally educating the staff. ICP D was then asked about the resident identified to have eye infections and to have been treated for eye infections in the month of August 2025 that was not identified on the Infection Surveillance, mapping and the analysis of the facility's infections for the month of August 2025. ICP D explained they only count the facility acquired and not the community acquired infections. ICP D was then asked about both R's 902 and 905 who were facility acquired infections and ICP D stated they did not document it because the infection had carried over from the previous month. Further record review for R902 revealed they were diagnosed with a third eye infection on 8/27/25 and again prescribed antibiotic eye drops. Further review of the facility's policy titled Infection Prevention and Control Program dated 11/10/17, documented in part . a member of the clinical team to monitor the campus IPCP program to perform surveillance to identify, investigate, control and prevent the spread of infection and reporting for the IPCP. Reviews and adopts the corporate Infection Prevention and Control guidelines, recommending additions or revisions as necessary (Hand Hygiene, Standard Precaution, Contact Precautions etc.). Surveillance activities to identify, investigate, control and prevent the spread of infection. Infections shall be tracked per hall/unit, type of infection. Reviews and critiques infection surveillance reports and statistics, recommending appropriate action for Healthcare Associated Infections (HAI) and Community Acquired Infection (CAI). Not limited to, documentation in resident's Electronic Health Record. Involvement in campus QAPI by participating in meetings and reporting resident infections.No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake: 2599423. Based on interviews and record reviews the facility failed to ensure a physician order was followed for one (R903) of two residents reviewed for catheter care. Findings include: A review of a complaint submitted to the State Agency (SA) noted that R903 was admitted to on 8/15/25 with a foley catheter due to urinary retention. On the morning of 8/21/25 the resident was . eating in the dining room, and he did not feel good. (R903) looked pale, dizzy, and he did not seem like himself. The complainant stated they requested the nurse to check for a UTI (urinary tract infection). The complainant stated the nurse talked to the doctor who stated . (R903) would have to get blood drawn first, and that it would take two days for the results to come back. The complainant then requested to speak to the doctor and was told the doctor was gone for the day. The complainant stated . felt that they had no choice but to take (R903 name) to the hospital at that point. The resident was admitted to the hospital on intravenous antibiotics. A review of the medical record revealed that R903 was admitted to the facility on [DATE], with diagnoses that included : dementia and benign prostatic hyperplasia with lower urinary tract symptoms, urine retention and a foley catheter. A review of a progress note dated 8/21/25 at 10:34 AM, documented . The resident stated being cold and have chills, VSs (vital signs) are WNL (within normal limits), afebrile, denied pain at this time. Family is present in the room. (Doctor name) informed order for CBC (complete blood count), CMP (comprehensive metabolic panel) Stat (immediate) received, Blood collected, lab called for pick up, samples is waiting for pick up. The writer coming back to the floor, informed by (nurse name) that family took resident to the hospital for evaluation. This note was documented by Registered Nurse (RN) E .A review of a nursing note dated 8/21/25 at 3:22 PM, documented . The writer was informed by resident's daughter, that resident was admitted to (hospital name) with UTI diagnosis. This note was also documented by RN E. A review of R903's physician orders revealed the following order:8/15/25 - May dip urine is <sic> s/s (signs/symptoms) of UTI, then may send urine for C&S (culture and sensitivity) if positive for leukocytes. The review of the record revealed no documentation of a dip stick to have been completed or urine obtained for testing. On 9/10/25 at 12:48 PM, RN E was interviewed and asked about the incident of R903 to have been transferred to the hospital by their family. RN E explained the family had approached them and informed them that R903 didn't feel good. RN E stated they went to do vitals on R903 and it was okay and the resident stated he was chilly. RN E explained they contacted the doctor (Physician F) who informed them to do STAT labs. When asked why they had not completed the dip stick order for analysis of the resident's UA to rule out a UTI as the physician order directed, RN E stated they planned to complete the dip stick order when they had returned from their break. RN E went on to explain that when they returned from their break the family had already left to take the resident to the hospital. On 9/10/25 at 2:52 PM, a telephone interview was conducted with Physician F. Physician F was asked during that interview if they were aware of the family to have observed the resident to have been .pale, dizzy, and he did not seem like himself. on the morning of 8/21/25 when the nurse contacted them. Physician F stated it was their understanding that the resident had chills. During the interview Physician F stated if they felt like the resident was going septic and had a change of condition they would have definitely treated the resident. On 9/10/25 at 10:53 AM the interim Director of Nursing (DON) and Clinical Support (CS) B were both interviewed. When asked about the dip urine orders reviewed for R903, the DON explained the facility had a urine order set for all residents. The DON stated if signs/symptoms are observed the nurses are to complete the urine dip stick as ordered. If the dip stick is positive for leukocytes the urinalysis is sent out for testing and to have a culture and sensitivity completed. The DON was asked why RN E had not carried out the order as implemented by the Physician for R903 and the DON stated they could not say why RN E did not complete the order, however their expectation would have been for the nurse to follow the physician orders and the physician directive. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake: 2570414. Based on observation, interview and record review the facility failed to follow their policy regarding the follow up of concerns for one (R902) of four residents reviewed for quality of care. Findings include: A review of a complaint submitted to the State Agency (SA) documented multiple concerns verbalized to the facility's staff with no resolution. On 9/9/25 at 11:22 AM, R902 was observed lying on their back in bed. An interview was conducted with the resident at that time. A review of the medical record revealed R902 was re-admitted to the facility on [DATE] with diagnoses that included: acute and chronic respiratory failure, hemiplegia and hemiparesis following cerebral infarction affect left non-dominant side, dysphagia (difficulty swallowing) and required staff assistance for all activities of daily living. R902 was documented to be their own responsible party. On 9/9/25 at 11:45 AM, the facility's Administration was asked to provide all concerns/grievances filed on the behalf of R902 from January to current. A review of the grievances provided revealed the following: On 7/23/25 a family member of R902 was angry and noted Residents daughter had concerns about doctor visit schedule and other medical concerns. The resolution was entered on 7/28/25 that noted Satisfactorily- Provider saw resident and was notified of residents preferences regarding physician visit schedule and got all questions answered.On 7/24/25 a family member of R902 was upset and noted Grooming- Family Member expressed concern regarding the shower schedule and dressing for her mom. The resolution was dated 7/25/25 that noted Satisfactorily- Family and Resident preferences updated, nursing notified and provider notified. Staff educated. SW (social worker) spoke to resident about concerns. Resident pleased with care and no further concerns with showers at this time.A review of a facility policy titled Resident Concern Process review date 12/16/24, documented in part . The facility will provide an open and customer friendly atmosphere for residents and their families and representatives to voice concerns and problems with the assurance that their concerns will be heard and acted upon. All concerns should be entered electronically. The department leader will investigate and discuss the concerns with the team and will implement, or educate to prevent further concerns. the department leader will document the resolution on the concern form. and will follow up with the person reporting the concerns to explain the resolution.The facility staff failed to follow up with the family member that verbalized and reported the above concerns. On 9/10/25 at 1:18 PM, the family member to R902 (FM G) was interviewed. FM G verbalized multiple concerns reported to the facility's SW and Administration staff. FM G explained an incident they reported to the SW regarding a delay in treating an eye infection for R902. FM G also stated they reported an incident to the SW and Administration staff on how they had dressed their mother in a night gown one evening for bed. FM G' stated they returned to the facility the next afternoon for a visit and the resident had on the same night gown that was notably dirty. FM G stated the staff never followed up with them or communicated any resolutions to their concerns. On 9/10/25 at 2:11 PM, the Administrator, Director of Nursing (DON), Clinical Support (CS) and Assistant Director of Social Services (ADSS) C were all interviewed together and asked about the concerns for R902. The documented concerns were reviewed and they were asked why no one had followed up with the family member that reported the concern to discuss and/or inform them of the resolutions. ADSS C stated they followed up with R902 because . the resident is her own person. The facility policy was reviewed regarding the guidance of the follow up to be conducted with the person(s) who verbalized the concern and the Administration staff acknowledged the concern. No further explanation or documentation was provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to provide dignified care for one Resident (R500) of four residents reviewed for dignity. Findings include: On 7/23/25 at 12:38 p.m., R500 was observed in their hospital bed wearing a gown. On 7/23/25 at 12:39 p.m., R500 reported earlier in the day Nurse Aide, (NA) C, checked their incontinence brief when they told NA C they did not want to be checked or changed, as their brief was dry. R500 stated NA C checked their brief anyways and said they felt harassed by NA C, as this was intrusive. R500 explained it was their right not to be checked against their wishes, since their brief was dry. On 7/23/25 at 1:21 p.m., NA C was asked what occurred when they checked R500's incontinence brief earlier on 7/23/25. NA C reported they asked R500 if they could check their brief for incontinence, and R500 responded they did not want their brief checked. NA C stated they still checked R500's brief for incontinence, and the brief was dry. When asked why they continued, NA C said they were trained to check a resident's brief every two hours. NA C clarified their job responsibility was to check every resident's brief every two hours as a standard of care. NA C stated, I just wanted to double check (the brief was dry). Review of R500's Minimum Data Set (MDS) assessment, dated 5/13/25, revealed R500 was admitted to the facility on [DATE], with diagnoses including arthritis, depression, and anxiety. The assessment revealed R500 required maximal assistance for transfers and was dependent for toileting. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed R500 was cognitively intact. The assessment showed no behaviors. Review of R500's Care Plan, accessed 7/23/25, revealed R500's goal was for their preferences were to be honored, with approaches which included Encourage resident to participate in decision making by offering choices.Encourage resident to actively participate in care plan and decision making. The interventions were dated 7/14/25. On 7/23/25 at 5:05 p.m., the concerns related to undignified care by NA C towards R500 were reviewed with the Nursing Home Administrator (NHA), with Clinical Nurse Consultant A, as reported when discovered earlier in the survey. Both reported they understood the concerns related to undignified care and had reeducated NA C regarding dignified care provision and resident rights. Review of the policy, Resident Rights Guidelines, reviewed 12/17/24, revealed, Purpose Statement: The purpose of this policy is to: To ensure resident rights are respected and protected and provide an environment in which they can be exercised. Policy Resident Rights Guidelines Procedure 1. Residents shall not leave their individual personalities or basic human rights behind when they move to a health campus. The following is a list of rights recognized by staff at (the provider): 2. Our residents have a right to. a. Be treated with dignity and respect b. Be given the information necessary to participate in decisions which affect them both individually and corporately.f. Be treated fairly, courteously and with respect by all staff.

Based on observation and interview, the facility failed to maintain the exterior dumpster area in a sanitary manner. This deficient practice had the potential to affect all residents in the facility. Findings include: On 10/7/24 at 9:05 AM, 8-10 trash bags were observed on the ground next to the dumpster. There was a brown liquid leaking out onto the ground from one of the bags. Dietary Manager (DM) D stated that the dumpster was probably full, so staff put the bags on the ground. DM D further stated that the dumpster was emptied this morning, but the bags had not yet been transferred into the dumpster.

Based on observation, interview and record review, the facility failed to ensure coordination of behavioral health services for five (R4, R17, R35, R32 and R145) of five residents reviewed for behavioral health care, resulting in delayed and/or unmet mental and psychosocial care needs and staff unaware of individualized approaches and targeted behaviors. Findings include: R145 On 10/07/24 at approximately 10:01 a.m., R145 was observed in the hallway/common area sleeping on the couch and was difficult to arouse. On 10/08/24 at approximately 9:25 a.m., R145 was observed in their room, laying in their bed with a nasal cannula that was infusing oxygen at two liters per minutes. R145 appeared to be confused when asking questions regarding the staffing levels in the facility was and providing nonsensical responses. On 10/7/24 the medical record for R145 was reviewed and revealed the following: R145 was initially admitted to the facility on [DATE] with diagnoses that included vascular dementia, unspecified severity, without behavioral disturbance; psychotic disturbance; mood disturbance; and anxiety. A review of R145's MDS (minimum data set) with an ARD (assessment reference date) of 9/18/24 revealed R145 needed assistance from staff with most of their activities of daily living. R145's BIMS score (brief interview for mental status) was eight, indicating moderately impaired cognition. A review of R145's active Psychotropic medications revealed the following: Rexulti (brexpiprazole) (antipsychotic medication) ICD-9 Diagnosis: N/A with a start date of 9/12/24 and Lexapro(escitalopramoxalate) tablet; 5 mg (milligram); amt (amount): 1tab (tablet); oral Special Instructions: Anxiety with a start date of 9/29/24. A review of R145's social service assessment dated [DATE] revealed the following: Psychiatric/Mood/Other Diagnosis: [None of the above] (checked) .Resident's mood is addressed in the plan of care: [No] (checked) .Potential Indicators of Psychosis-Check all that apply-[None of the above] (checked) . A progress note dated 9/29/24 revealed the following: Resident wife informed provider resident was taken Lexapro 5mg Daily at home for anxiety. Writed <sic> contacted [Physician] and okay with resident (taking) medication while at facility. Provider request resident to be seen by Psych. Writer placed new order into EMAR (electronic medication administration record). A review of R145's comprehensive care plan failed to identify the specific resident centered behaviors and symptoms of their individualized behavioral health disease process that would warrant the prescribed antipsychotic and antidepressant medications as well as resident specific monitoring of their identified behaviors. On 10/08/24 at approximately 10:15 a.m., during an interview with Social Worker A (SW A), SW A was Informed of the medical record review for R145 that did not include any documentation of focuses on R145's potential mood or psychosis symptoms as well as no individualized targeted behaviors or resident specific interventions that were not present in record that warranted administering antipsychotic and antidepressant medications. SW A was also queried why R145 did not have a diagnosis for their antipsychotic medication. SW A responded by indicating that they did not have a diagnosis for the medication due to R145 declining facility psychiatric services. SW A then reported that when a resident declined psychiatric services, the attending Physician had to do the evaluation and put in the appropriate diagnoses. SW A was queried who was responsible for talking with the family and the resident to identify the resident's specific behaviors and interventions to appropriately address their behavioral health needs while at the facility and they indicated it was the interdisciplinary team that did them together. At that time, SW A was queried for any further documentation that R145 had resident specific interventions and targeted behaviors for their psychotropic medications and behavioral health needs. No additional information was received before the end of the survey. 48680 R32 On 10/7/24 at 10:20 AM, R32 was observed in the hall way in a wheel chair. R32 went to their room so they could be asked about their stay at the facility the R32 stated their were no issues with the facility and that they enjoyed it here. A record review revealed that R32 was admitted to the facility on [DATE] with the diagnosis of muscle weakness, dysphagia and personal history of behaviors and mental disorders. With a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. Further review revealed that R32 was prescribed Clonazepam (an antianxiety medication) 0.5mg and sertraline (an antidepressant medication) 100mg. A medication regimen review was completed on 9/26/24 with the recommendation to conduct a gradual dose evaluation for sertraline and clonazepam. The care plan was reviewed and there was no targeted behaviors specific to the resident as to what staff should look for and there were no non-pharmacological interventions in place for the resident. On 10/8/24 at 10:17AM an interview was held with SW A. She was asked when R32 was last evaluated by psychiatric services since the MRR (Medication Regimen Review) stated they (the facility) would obtain an evaluation. SW A said that R32 had refused psychiatric services and the attending physician was supposed to cover and review the medication recommendations. SW A was then asked how would the frontline staff (nurses/certified nursing assistants) know the targeted behaviors were and what are the non pharmalogical interventions in place for R32 to determine whether they need to be medicated. SW A explained that there were no patient specific behaviors documented in the medical record or care plan that would alert the frontline staff of targeted behaviors. 41415 R17 On 10/7/24 at 9:22 AM, R17 was observed in the community room sitting in their wheelchair with their eyes closed. R17 did not respond to verbal stimuli. A review of the medical record revealed R17 was admitted to the facility on [DATE] with diagnoses that included: dementia, restlessness, agitation, and adjustment disorder with anxiety. A Minimum Data Set (MDS) assessment dated [DATE] documented a BIMS score of 3 which indicated severely impaired cognition. Review of the physician orders included the following medications: Buspirone 15 mg (milligram) three times a day for anxiety Lorazepam 0.5 mg every 4 hours as needed for anxiety Seroquel 25 mg for increased behaviors and delusions Trazodone 50 mg once a day and 100 mg at bed time for increased behaviors A review of the care plans failed to identify the resident's behaviors, resident specific monitoring of their identified behaviors and resident centered interventions to address the behavioral needs of the resident. R4 On 10/7/24 at 9:36 AM, R4 was observed lying in bed on their back. A review of the medical record revealed R4 was admitted to the facility on [DATE] with diagnoses that included mood disorders. Review of the physician orders revealed the medication of Trazodone 150 mg. There was no indication for use noted. Review of a Social Services note dated 8/25/24 at 12:06 PM, documented in part . DX (diagnosis): delusional disorders, insomnia, mood disorder . Target behavior are in place for depression . Review of the care plans failed to identify the resident's behaviors, resident specific monitoring of their identified behaviors and resident centered interventions to address the behavioral needs of the resident. R35 On 10/7/24 at 9:01 AM, R35 was observed seated on a couch in their room with the lights off. R35 was watching an electronic device on their table. A review of the medical record revealed R35 was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease, Dementia, Anxiety disorder, and Depression. Review of the physician orders revealed the following medications: Buspirone 10 mg for anxiety three times a day Escitalopram oxalate 20 mg once a day for depression Risperdal 0.5 mg twice a day for behaviors Wellbutrin XL 450 mg once a day for depression Review of the care plans failed to identify the resident's behaviors, resident specific monitoring of their identified behaviors and resident centered interventions to address the behavioral needs of the resident. On 10/8/24 at 10:13 AM, the Social Worker (SW) A was interviewed and asked what resident specific behaviors were being monitored for R's 17, 4, & 35 and what resident centered interventions were implemented for the behaviors. SW A stated they would review the medical record and follow back up. At 10:27 AM, SW A returned and acknowledged they were unable to provide additional information or documentation. SW A confirmed the facility utilized a generic physician order to monitor residents on psychotropic medications, however the orders were not resident specific. No further information or documentation was provided by the end of the survey.

Based on interview and record reviews the facility failed to implement an effective antibiotic stewardship program for three (R302, 192, & 193) of five residents reviewed for infections. Findings include: Review of the Center for Disease Control's (CDC) The Core Elements of Antibiotic Stewardship for Nursing Homes, dated 2015: .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority.Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics when followed over a year .studies have shown that40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic- resistant organisms .Infection prevention coordinators have key expertise and data to inform strategies to improve antibiotic use. This includes tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections .Identify clinical situations which may be driving inappropriate courses of antibiotics such as asymptomatic bacteriuria or urinary tract infection prophylaxis and implement specific interventions to improve use . Review of the April, May, & June 2024 infection surveillance logs revealed the following: April - R302 was documented to have a Urinary Tract Infection (UTI) that did not meet McGeer's criteria (a tool utilized to determine if antibiotics are being utilized appropriately). Macrobid (an antibiotic) was prescribed to the resident from 4/4/24 until 4/9/24. May - R192 was documented to have a UTI that did not meet McGeer's criteria. Bactrim DS (an antibiotic) was prescribed to the resident from 5/7/24 until 5/11/24. June- R193 was documented to have a UTI that did not meet McGeer's criteria. Cephalexin (an antibiotic) was prescribed to the resident from 6/25/24 until 7/1/24. Review of the medical records for R's 302, 192 & 193 revealed no documentation that either antibiotic was reviewed for appropriateness. On 10/8/24 at 1:50 PM, a meeting was held with the facility's interim Infection Control Nurse (ICN) B (who also served as the facility's Infection Preventionist). ICN B stated they had recently obtained the duties as the ICN for the last few weeks as an interim. ICN B confirmed when asked that the facility followed the McGeer's criteria for all infections. ICN B was asked the facility's protocol for residents who are admitted with an antibiotic or recently prescribed an antibiotic for an infection that did not meet criteria. ICN B stated they probably should be notifying the providers, however they stated they have not notified the providers of the residents who did not meet criteria. ICN B stated moving forward they would ensure the providers are notified of the residents that did not meet criteria and ensure documentation is kept in the medical records. ICN B was asked about R's 302, 192 & 193 and asked how they ensured the appropriateness of each antibiotic prescribed to the residents if they did not meet criteria of an infection and ICN B stated they would review the records and follow back up. At 2:52 PM, ICN B returned and stated they were unable to provide any additional information or documentation. Review of a facility policy titled Antibiotic Stewardship Guideline reviewed 12/31/23, documented in part . PURPOSE - Optimize the treatment of infections by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic . New orders for antibiotic usage will be reviewed . including antibiotics on new admissions from the community .

Based on interview and record review, the facility failed to notify, in writing, the reason for a discharge out of the facility to a representative of the State Long term Care Ombudsman for one (R40) of one residents reviewed for discharges. Findings include: On 10/8/24 the medical record for R40 was reviewed and revealed the following: R40 was initially admitted to the facility on [DATE] and was transferred to the hospital on 8/4/24 and did not return. A review of R40's MDS (minimum data set) with an ARD (assessment reference date) of 7/26/24 revealed R40 needed assistance from facility staff with their activities of daily living. A progress note dated 8/04/2024 at 11:19 a.m., revealed the following: Writer received resident resting in bed with eyes open. Resident is A&O x1(alert and oriented to themselves) with some confusion. Resident vital signs WNL (within normal limits), denies pain. CRCA (Certified Nursing Assistant) informed writer resident refused to let CRCA get her dressed and said she is not going anywhere, and leave her alone. While writer went in room to discharge resident she became very agitated with writer and her husband, stating 'Get my ex-husband out of here', 'I'm not going anywhere'. Resident was to be discharge <sic> home today with husband , she keep saying 'I am not going anywhere' and 'Don't touch me.' Writer contacted provider to inform of resident condition, provider order <sic> resident to be sent out EMS (Emergency Medical System) for further evaluation, due to increase <sic> confusion and agitation. Resident husband and son present at the time. Writer printed and gave CCD (Continuity of Care Document,) and Face sheet to EMS. Further review of R40's medical record revealed no documentation that notification of the transfer to to hospital was provided to the Long term care Ombudsman. On 10/8/24 at approximately 2:47 p.m., the Administrator was informed that the documentation of notification to the Ombudsman was unable to be found in the record and was requested from the facility. On 10/08/24 at approximately 2:59 p.m., Social Worker A (SW A) was queried regarding the documentation of the bed hold notification and ombudsman notification of transfer for R40. SW A. reported that the resident was supposed to discharge home with their family that day but was instead transferred to the hospital from the facility. SW A indicated that the way the information was entered into the medical record was that they were discharged and it did not trigger them to send the notices, so they were not sent. SW A indicated that after reading the notes in the record that the notices of bed hold provision and the transfer for the ombudsman for R40 should have been provided due to R40 being transferred to the hospital from the facility. On 10/9/24 a facility document titled ombudsman notification was reviewed and revealed the following: OVERVIEW-CMS (Centers for Medicare & Medicaid Services) Requirements of Participation, this SOP (standard operating procedures) will detail expectations on communication of facility initiated transfer or discharges to the State Long-Term Care Ombudsman. SOP DETAILS-Federal regulation requires that the facility sends a copy of the notice of transfer or discharge to a representative of the Office of the State Long-Term Care Ombudsman. This applies to facility-initiated discharges. The Director of Social Services, or designee, will email a copy of the notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman at least 30 days before the resident is transferred or discharged . The Director of Social Services, or designee, will complete the Ombudsman Notification Observation in the electronic health record as evidence that the notice was sent to the State Long-Term Care Ombudsman. Exceptions to the 30-day requirement apply when the transfer or discharge is because- 1. The resident's welfare is at risk, and his or her needs cannot be met in the facility (i.e., emergency transfer to an acute care facility); or 2. The health or safety of others in the facility is endangered. In these cases, the Director of Social Services, or designee, will instead send a list of transferred and discharged residents that were exempt from the 30-day requirement on a monthly basis. The Director of Social Services, or designee, will then complete the Ombudsman Notification Observation in the electronic health record as evidence that the notice was sent to the State Long-Term Care Ombudsman. If the Director of Social Services is not present or available, the Executive Director should delegate this task to another team member to assure these notices are sent to the State Long-Term Care Ombudsman within the required time frame and the Ombudsman Notification Observation in the electronic health record is completed.

Based on interview and record review, the facility failed to provide a written copy of the bed hold notification to the resident/resident's representative, upon acute transfer to the hospital for one (R40) of one residents reviewed for transfers/discharges. Findings include: On 10/8/24 the medical record for R40 was reviewed and revealed the following: R40 was initially admitted to the facility on [DATE] and was transferred to the hospital on 8/4/24 and did not return. A review of R40's MDS (minimum data set) with an ARD (assessment reference date) of 7/26/24 revealed R40 needed assistance from facility staff with their activities of daily living. A progress note dated 8/04/2024 at 11:19 a.m., revealed the following: Writer received resident resting in bed with eyes open. Resident is A&O x1(alert and oriented to themselves) with some confusion. Resident vital signs WNL (within normal limits), denies pain. CRCA (Certified Nursing Assistant) informed writer resident refused to let CRCA get her dressed and said she is not going anywhere, and leave her alone. While writer went in room to discharge resident she became very agitated with writer and her husband, stating 'Get my ex- husband out of here', 'I'm not going anywhere'. Resident was to be discharge home today with husband , she keep saying 'I am not going anywhere' and 'Don't touch me'. Writer contacted provider to inform of resident condition, provider order resident to be sent out EMS (Emergency Medical System) for further evaluation, due to increase confusion and agitation. Resident husband and son present at the time. Writer printed and gave CCD (Continuity of Care Document,) and Face sheet to EMS. Further review of R40's medical record revealed no documentation that a copy of the bed hold notification was provided to the resident or residents representative when transferred to the hospital. On 10/8/24 at approximately 2:47 p.m., the Administrator was informed that the documentation of notification that the bed hold provision to R40 was unable to be found in the record and was requested from the facility. On 10/08/24 at approximately 2:59 p.m., Social Worker A (SW A) was queried regarding the documentation of the bed hold notification and the ombudsman notification of transfer for R40. SW A reported that the resident was supposed to discharge home with their family that day but was instead transferred to the hospital from the facility. SW A indicated that the way the information was entered into the medical record was that they were discharged and it did not trigger them to send either of the notices so they were not sent. SW A indicated that after reading the progress notes in the record, that the notices of bed hold provision and transfer to the to the ombudsman for R40 should have been provided due to R40 being transferred to the hospital from the facility. On 10/9/24 a facility document titled Bed hold notification was reviewed and revealed the following: OVERVIEW -Residents and Responsible Parties have a right to be notified verbally and in writing on reserve bed payment policy per the state plan when someone goes out to the hospital or on a therapeutic leave. Before a nursing facility transfers a resident to a hospital or the resident goes on a therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies the duration of the state bed hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; the reserve bed payment policy in the state plan if any; the nursing facility's policies regarding bed-hold periods permitting a resident to return. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed hold policy SOP (standard operating procedures)-Before transferring a resident to a hospital or allowing a resident to go on a therapeutic leave, the Nursing designee or other designated staff member should provide written information to the resident and a family member or legal representative of the bed hold and admission policies .In cases of emergency transfers, the notice of bed hold policy under the state plan and facility's bed hold policy should be provided to the resident or resident's representative by nursing designee within 24 hours of the transfer. This may be sent with other papers accompanying the resident to the hospital .During the daily census reconciliation when transfer/discharge information is identified, the BOM will place a phone call to the Responsible Party notifying them of the bed hold policy and the room reserve rate allowing them to direct facility to hold the bed or not .Medicare A and Managed Care Primary - Payers do not cover bed holds when Resident is on a hospital or therapeutic leave over 24 hours. BOM will place a phone call to the Responsible Party. If the Resident/Responsible Party elects not to hold the bed, a discharge census event will be entered. Follow census event guide for instructions. Medicaid primary - If the hospital leave or therapeutic leave extends longer than the state allowed Medicaid bed hold days, BOM will contact the Responsible Party to see if they would like to pay to continue to hold the bed at the Medicaid per diem rate. If they elect not to hold the bed, they will be subject to the next available bed and Responsible Party should make arrangements to remove belongings from the room. IN Only: There will be a 10-day courtesy bed hold per hospital and therapeutic leave. When updating census in MatrixCare, make sure to choose non-billable for both hospital and therapeutic leaves with a status code of 30 still patient to ensure Level of Care is not terminated Once phone call is placed, BOM will make note of conversation and outcome in the Progress Notes section in MatrixCare and complete Resident Bed Hold Authorization Form. Progress Note should be detailed and include person spoken with and notification of whether or not they elected to hold the bed. Resident Bed Hold Authorization form should be completed and Resident/Responsible Party signature obtained by fax, e-mail scan or mailed and returned. Bed Hold Policy should be sent with authorization form .When Resident Bed Hold authorization form is signed it should be scanned in to Resident documents in MatrixCare and filed in the resident AR file. Follow census event guide to enter the correct census event in MatrixCare .

Based on observation, interview, and record review, the facility failed to ensure food in the kitchen was stored in a sanitary manner, food items were labeled and dated when opened or prepared, and prepared food and condiments were discarded by their use by dates. This had the potential to affect all residents who eat food from the kitchen. Findings include: On 9/12/23 at 8:50 AM, an observation of the kitchen was conducted with Director of Food Service (DFS) 'K'. The following was observed in the walk-in refrigerator: 1. Corn with a use by date of 9/11/23. 2. Tuna salad prepared by the facility with a use by date of 9/11/23. The following was observed in the reach-in refrigerator that contained beverages: 1. Watermelon juice with a use by date 9/11/23. DFS 'K' reported that all items should be removed and discarded by their use by date. The following was observed in the reach-in refrigerator that contained condiments: 1. 10 single portion cups of mustard with use by date of 9/7/23. 2. 27 single portion mustard with use by date of 9/10/23 3. 8 single portion cups of sour cream with use by date of 9/10/23 4. 4 single portion cups of tartar sauce with no use by date 5. 1 single portion cup of raspberry vinaigrette with a use by date of 9/10/23 6. 1 gallon container of teriyaki Sauce with a use by date of 9/3/23 7. 1 gallon container of Asian ginger sauce with a use by date of 9/11/23 18. 9 single portion cups of french salad dressing with use by date of 9/10/23 At that time, DFS 'K' reported condiments had a three day window after they were removed from the original packaging. The following was observed in the prep station that contained chopped vegetables, cheeses, and meats: 1. 1 green pepper and 1 onion that was cut and not wrapped or contained and was placed loose inside of the prep station At that time, DFS 'K' reported the cut vegetables should not be loose in the prep station. Review of a facility policy titled, Food Labeling and Dating Policy, revised on 4/26/22, revealed, Any food item must have .the use by date for the product .Foods in production need BOTH a production date AND a use by date. Foods are considered to be in production when they have been taken out of the original container AND the seal has been broken .All food items must be properly covered (not exposed to air) prior to being labeled and dated .

Based on observations, interviews, and record reviews the facility failed to consistently ensure the pharmacist findings documented whether an irregularity was identified or not and failed to ensure the physicians review, action and rationale of the identified medication irregularity was documented and maintained in the resident's medical record for five (R's 12, 8, 6, 35 & 27) of five residents reviewed for unnecessary medications. Findings include: R8 On 9/12/23 at 10:40 AM, R8 was observed sitting in their high back wheelchair in the community room in front of the television. R8 was observed picking at a blanket that covered the lower portion of their body. R8 was dressed appropriately and was observed to be well kept. Review of the medical record revealed R8 was admitted into the facility on [DATE] with a readmitted [DATE] and diagnoses that included: dementia, type 2 diabetes mellitus, hypertension, and falls. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 00 (which indicated severely impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of the Medication Regimen Reviews (MRR) conducted by the facility's pharmacist consultant revealed the following: July 2023- No documentation in the medical record from the physician regarding a review, action or rationale of a recommendation made by the pharmacist consultant and the facility staff could not provide any documentation of the pharmacist consultant to have documented that no irregularities were identified for this month. 6/17/23- HYDROXYZINE. There are multiple purposes for which this medication can be given. Please specify the reason for use of each order to assist with proper use, monitoring, and care planning. 5/3/23- . currently ordered Humalog and it is non-preferred with insurance. Please consider changing to formulary preferred Novolog . 4/7/23- . LORAZEPAM TAB 0.5MG which has been active since 3/30. Federal regulations require that all PRN (as needed) psychoactives (non-antipsychotics) initially be limited to 14 days . ranolazine for mild pain. This medication is only indicated for angina. It is also typically dosed routine. Please review . 3/7/23 . Please provide/clarify diagnosis in the ICD-10 list for: ranolazine PRN - specify type of pain . 2/14/23 . Instead of the current order of oral diphenhydramine for skin allergies and/or itching, recommend switching diphenhydramine capsule to topical diphenhydramine . Resident is receiving the antipsychotic agent: QUETIAPINE, but lacks an allowable diagnosis to support its use . January 2023- No documentation in the medical record from the physician regarding a review, action or rationale of a recommendation made by the pharmacist consultant and the facility staff could not provide any documentation of the pharmacist consultant to have documented that no irregularities were identified for this month. Review of the medical record revealed no documentation from the physician regarding the review, action, or rationale of the pharmacist consultant's recommendations for February, March, April, May, or June of 2023. Review of the physician orders revealed an order for Gabapentin with no documented indication for use. R6 On 9/12/23 at 10:13 AM, R6 was observed laying on their back in bed. The resident was observed sleeping with their mouth opened. With verbal stimuli, R6 opened their eyes however quickly closed them shortly after. Review of the medical record revealed R6 was initially admitted in the facility on 7/24/19 with diagnoses that included: dementia, anxiety, hypertension, major depressive disorder, and type 2 diabetes mellitus. A MDS assessment dated [DATE], documented a BIMS score of 3 (which indicated severely impaired cognition) and required staff assistance for all ADLs. Review of the MRR's completed by the facility's pharmacist consultant documented the following in part: July 2023- No documentation in the medical record from the physician regarding a review, action or rationale of a recommendation made by the pharmacist consultant and the facility staff could not provide any documentation of the pharmacist consultant to have documented that no irregularities were identified for this month. 6/17/23- . FENTANYL . 50MCG/HR. Appropriate administration of a patch is to remove the old one before applying the new one and place new patch in a dry, clean, hair free area . being sure to rotate appropriate sites and document date of application on the patch. Please consider adding these instructions to the order . May 2023- No documentation in the medical record from the physician regarding a review, action or rationale of a recommendation made by the pharmacist consultant and the facility staff could not provide any documentation of the pharmacist consultant to have documented that no irregularities were identified for this month. 4/19/23- . has an order for quetiapine less than 50mg daily. The starting dose of quetiapine in older adults is usually 50mg/day, increasing at 50mg intervals based upon clinical RESPONSE . If the order is to continue as ordered, please provide rationale as well as the risk/benefits of continuing therapy . March, February, & January 2023- No documentation in the medical record from the physician regarding a review, action or rationale of a recommendation made by the pharmacist consultant and the facility staff could not provide any documentation of the pharmacist consultant to have documented that no irregularities were identified for this month. Review of the medical record revealed no documentation from the physician regarding the review, action, or rationale of the pharmacist consultant's recommendations for June and April 2023. R27 On 9/12/23 at 10:07 AM, R27 was observed lying on their back in bed. The sheet was pulled up to the resident's neck area. R27 was observed with their eyes wide open looking at the ceiling. R27 would glance at the surveyor when spoken to, however continued to stare at the ceiling. R27 did not verbally respond to any of the questions asked. Review of the medical record revealed R27 was initially admitted to the facility on [DATE], with a readmitted [DATE] and diagnoses that included: dementia, atrial fibrillation, type 2 diabetes mellitus, hypertension, and unspecified sequelae of cerebral infarction. A MDS assessment dated [DATE], documented a BIMS score of 00 (which indicated severely impaired cognition) and required staff assistance for all ADLs. Review of the MRR's completed by the facility's pharmacist consultant documented the following in part: July 2023- No documentation in the medical record from the physician regarding a review, action or rationale of a recommendation made by the pharmacist consultant and the facility staff could not provide any documentation of the pharmacist consultant to have documented that no irregularities were identified for this month. 6/17/23- . Please update the target behavior(s) of the following psychoactive medications, since the current behavior may not be measurable: insomnia symptoms treated with trazodone . May 2023- No documentation in the medical record from the physician regarding a review, action or rationale of a recommendation made by the pharmacist consultant and the facility staff could not provide any documentation of the pharmacist consultant to have documented that no irregularities were identified for this month. 4/11/23- . Recommend assessing the PRN (as needed) antipsychotic, HALOPERIDOL TAB 2MG . active order for this medication since 3/27. Federal regulations require that all PRN antipsychotics, regardless of indication, be limited to 14 days . 3/2/23- . now receiving hospice services. Due to change in status, certain medications may no longer be necessary . Please review the following order and if possible, discontinue any of the following to decrease medication load/needle sticks and increase patient comfort: 9/22/22 lab order for CBC (complete blood count), CMP (comprehensive metabolic profile), and TSH (thyroid stimulating hormone), aspirin 81mg, rosuvastatin, trazodone, sertraline, amlodipine, losartan PRN . Please make sure a diagnosis (reason for giving) is added to the MARs . for ALL PRN medications . 1/17/23- . Recommend assessing the psychotropic PRN medication, lorazepam 0.5mg which has been active since 12/15 . Federal regulations require that all PRN psychoactives . be limited to 14 days . Review of the medical record revealed no documentation from the physician regarding the review, action, or rationale of the pharmacist consultant's recommendations for June, April, March, and January 2023. Review of the physician orders revealed no documented indication for use for the Trazodone 100mg at bedtime and Zoloft 50 mg once a day medications. On 9/13/23 at 2:38 PM, the Director of Nursing (DON) was interviewed with the facility's Regional Clinical Support (RCS) E personnel in attendance. The DON was asked why there was no documentation to provide for R's 8, 6, & 27 to show that the pharmacist had reviewed their medications monthly and had no identified irregularities and no recommendations from the pharmacist consultant, the DON explained the facility is able to provide documentation of any identified irregularities by the pharmacist consultant however could not provide documentation for the months when the pharmacy consultant reviewed the resident medications and did not identify any irregularities. The DON was then asked why the physician documentation in response to the pharmacist consultant's recommendations were not maintained in the medical record. The DON explained they would usually call the physician with the pharmacist consultant's recommendations and note the physician response on a separate document that is not apart of the resident's medical record. The RCS E stated they are in process of changing their MRR process to adhere to the federal regulations. The DON was then asked why R's 27 and 8 did not have a documented indication for use for each medication prescribed and the DON stated they would follow up immediately and fix the concern. No further explanation or documentation was provided by the end of the survey. 32568 R12 Review of R12's complete active electronic medical record revealed R12 was admitted into the facility on [DATE] with diagnoses that included: pulmonary embolism. Review of a Pharmacy Review dated 8/10/23 revealed a MRR was completed on this date, but it did not document whether the pharmacist identified any irregularities or that the review included a review of R12's medical record. Review of a Pharmacy Recommendation dated 8/10/23 provided by the facility and not accessible in R12's electronic medical record revealed the pharmacist documented, (R12) was admitted on apixiban (a medication used to prevent blood clots) .10 mg (milligram) BID (twice a day) without a stop date. Hospital records (MAR - Medication Administration Record) indicate resident should be on the 10mg BID dose through 8/11 and reduce to 5mg (milligrams) BID on 8/12 which aligns with recommended dosing. Please clarify .(R12) has an order for hydralazine TID (three times a day) PRN (as needed). Please 1). add specific parameters for administration and 2) Add a separate order to monitor BP (blood pressure) TID as the current order will DC (discontinue) on 8/11. The form indicates the physician was notified and that they agreed with the recommendation but was not made a part of R12's medical record. 48680 Resident #35 On 09/14/23, a record review for R35 revealed a pharmacy review. There was a check box that stated that the Medication Regimen Review (MRR) was completed. The recommendation section was left blank. The information was not accessible (weather there were or were not any recommendations made) within the medical record. The box was checked for yes the MMR are was completed, but no information was included in the medical record for the months of May, June, July and August.

Based on observation, interview, and record review, the facility failed to prevent recurrent skin tears during mechanical lift transfers for one (R40) of two residents reviewed for accidents. Findings include: On 9/12/23 at 9:45 AM, R40 was observed lying in bed. A fall mattress was observed on both sides of the bed. At that time, R40 did not wish to answer questions. Review of R40's clinical record revealed R40 was admitted into the facility on [DATE] with diagnoses that included: hydrocephalus, Type 2 diabetes mellitus, and dementia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R40 had severely impaired cognition, no behaviors, required extensive physical assistance from at least two staff members for bed mobility, and was totally dependent on at least two staff members for transfers. On 2/19/23 at 11:27 AM, the following was documented in a Nursing progress note: During the morning patients care, while resident was transferring by 2 staff members from the bed to the wheelchair by the (mechanical lift), the residents arm touch the (mechanical lift), and scratch the skin off in 3 small areas . On 7/27/23 at 8:22 PM, the following was documented by Registered Nurse (RN) 'H' in a Nursing progress note: During the transferring resident from wheelchair to the bed, residents arm contacted with the (mechanical lift) handles and tear the skin on the right elbow . On 9/5/23 at 4:23 PM, the following was documented by RN 'H' in a Nursing progress note: During the transferring resident from the wheelchair to the bed, residents arm toughed <sic> the (mechanical lift) handle and tear the skin at this area. Skin tear 1cm (centimeter) x 1 cm is located on the left forearm, small amount of fresh blood are noted around at this time . On 9/12/23 at 2:55 AM, all incident reports and associated investigations for R40 were requested from the Administrator for the past six months. Review of an Event Report (incident report) for R40 dated 7/27/23 at 8:18 PM revealed, R40 sustained a skin tear to the right elbow that measured 1 cm in length by 1 cm in width with a small amount of bleeding and mild pain. It was documented that skin tear occurred during transferring. In the notes section, it was documented in an Interdisciplinary Team (IDT) note on 8/10/23 that During the transferring resident from wheelchair to bed, residents arm contacted with the (mechanical lift) handles, tearing skin on right elbow .Intervention is to keep resident's arms close to chest when in (mechanical lift) sling. There was no additional information about who was transferring R40 or how it was determined that R40 sustained a skin tear during a mechanical lift transfer. Review of an Event Report for R40 dated 9/6/23 at 6:03 PM completed by RN 'L' (the progress note was completed the day before by a different nurse, RN 'H' on 9/5/23 at 4:23 PM) revealed, R40 sustained a skin tear to the left forearm that measured 1 cm x 1 cm. The Notes section was blank. The Evaluation section documented, Event still open. On 9/13/23 at 8:46 AM, R40 was observed lying in bed eating breakfast. R40 was asked if he had ever fallen and he reported he fell the previous day. When asked if staff used a mechanical lift to transfer him to and from the bed, R40 reported they did. When queried about whether one or two staff members assisted with the transfers, R40 reported only one person. When queried about how his arms kept getting bumped and sustaining skin tears, R40 stated, It's not their fault. On 9/13/23 at 1:01 PM, a telephone interview was conducted with RN 'H'. When queried about R40 sustaining skin tears during mechanical lift transfers on 7/27/23 and 9/5/23, RN 'H' did not remember who transferred R40 on those dates, but reported R40 impulsively grabbed onto the mechanical lift at times because he became impatient. RN 'H' explained R40's skin was very fragile. When queried about any interventions that were implemented to prevent further skin tears while transferring R40 in the mechanical lift, RN 'H' was not sure. On 9/13/23 at approximately 1:30 PM, a review of R40's care plans revealed no care plans that addressed interventions to prevent injury during mechanical lift transfers based on R40's history. On 9/13/23 at 1:34 PM, an interview was conducted with the Director of Nursing (DON). The DON explained she began working in the facility as the DON on 7/31/23. When queried about what the facility would do if a resident sustained a skin tear during a transfer, the DON reported they would tend to the resident, alert family and the physician, and the nurse would open an event (incident report) that would include measurements of the skin tear, and enter orders to care for the wound. When queried about how the facility would identify the root cause of a skin tear sustained during a transfer, the DON reported they would interview the resident and interview any witnesses. The DON was queried about the Event Reports for R40 dated 7/27/23 and 9/6/23 that indicated R40 sustained a skin tear during a transfer. When queried about who transferred R40 on 7/27/23 and 9/6/23 when he sustained the skin tears, the DON stated, The person who opened the event is who was transferring. When queried about who else was assisting with R40's transfer on 7/27/23, the DON did not know and reported she did not work at the facility on 7/27/23 and she was not in the room on 9/6/23. The DON reviewed the event report and confirmed it did not document who was involved in R40's transfer. When queried about what the facility did to investigate the root cause of why R40 sustained skin tears during transfers on 7/27/23 and 9/6/23, the DON explained that if it was witnessed, they knew what happened and they do not have to look into it. At that time, the DON was asked to provide any additional information that showed any education provided as a result of the incidents, any interventions put into place, or any investigation that was conducted. On 9/14/23 at approximately 1:30 PM, the DON followed up regarding R40's injuries sustained during mechanical lift transfers on 7/27/23 and 9/5/23. The DON provided a sign in sheet for education provided on 8/24/23 titled, CNA (Certified Nursing Assistant) Competency which was explained to have included transfers/mechanical lift education. The education was not provided as a result of R40's injuries on 7/27/23 and 9/5/23. When asked how R40 sustained skin tears if the staff were transferring him appropriately, the DON stated, I have no reason to believe the way they transferred him was incorrect. When queried about how she knew that without investigating their transfer technique, the DON did not offer a response. The DON referred to the Event Report on 7/27/23 and explained that the intervention at that time was to keep R40's hands close to his body while transferring. When asked how that was determined to be an effective intervention without an investigation into the root cause, especially since R40 was injured again on 9/5/23 in the same way and also on 2/19/23 according to the progress notes, the DON did not offer a response. At that time, the Regional Clinical Support Nurse 'E' reported a root cause analysis had to be determined in order to implement appropriate interventions to prevent further injuries during mechanical lift transfers. At that time, R40's care plans were reviewed and did not include any interventions to prevent injury during mechanical lift transfers. On 9/14/23 at 2:06 PM, former interim DON 'I, Regional Clinical Support Nurse 'E' and the DON followed up and reported they did not have any additional information to provide and they understood the concern. Review of an Event Report dated 2/19/23 revealed R40 sustained three skin tears to right forearm during a transfer. An IDT Review dated 2/24/23 documented, .Resident becomes agitated during transfers and will try to grab and bumped his arm . No interventions to address the document behaviors were documented. Review of a facility policy titled, Guidelines for Episodic Event and/or Soft File Investigation, last reviewed 8/22/23, revealed the following, When an incident or area of concern occurs, the following steps should take place: .The investigation should begin immediately .If an incident is deemed to be an Episodic Event .Efforts should be made to begin the process of correcting the incident by the completion of the Episodic plan of action which includes .Establish a root cause .Analyze the root cause .Plan of action which should include .What did you do to ensure correction for the effected resident .What did you put in place for this resident to prevent re-occurrence .Care plan update .Identify all like residents who had the potential to be effected by the .event. Like resident should be re-assessed and care plans updated to ensure safety .

Based on observations, interviews, and record reviews the facility failed to consistently educate and offer residents the option to formulate an advance directive and failed to implement an Advance Directive policy that required the facility staff to provide information to the resident and/or resident representative on their rights to formulate an advance directive resulting in the potential for missing information or incorrect wishes for resident's advance directives. Findings include: Review of the facility's policy titled Guidelines for Advance Directives (with a review date of 12/31/22) revealed no documentation to provide information to the resident or resident representative about their rights to formulate an advance directive. On 9/14/23 at 8:50 AM, the facility's Director of Social Work (DSW) C was interviewed and asked about the facility's process in providing new admissions with information and offering them the opportunity to formulate an advance directive and if they choose to formulate an advance directive, what is the facility's protocol. DSW C stated they do confirm the code status of every newly admitted resident, however stated there was no specific document that they would review with the new admissions regarding offering the resident and/or resident representative the option to formulate an advance directive and was unsure of what to do if the resident and/or resident representative wished to formulate an advance directive. DSW C stated they only review the code status with the residents and/or resident representatives. DSW C stated if they already had an Advance Directive in place upon admission the facility's admission personnel would put a copy of it on their desk. When asked if newly admitted residents and/or resident representatives did not already have an Advance Directive in place what is done with those residents, DSW C replied their department does not provide advance directive information or offer the residents and/or representatives to formulate an advance directive. On 9/14/23 at 9:49 AM, the Customer Service Representative (CSR) D (who also serves as the facility's admission personnel) was interviewed and asked their role in providing information to residents and/or resident representatives regarding advance directives and offering them the option to formulate an advance directive and the CSR D replied the facility currently did not have documentation on advance directives and what they would review or educate with the resident and/or representatives. CSR D was asked how are they informing the resident and/or resident representatives on what an advance directive is and their right to formulate an advance directive and the CSR D replied they have discussed it with their team that something has to be in place for the advance directives and stated the facility's team is in the process of trying to put something in place. The CSR D then stated they would have to get their nursing team involved if the resident requested information on formulating an advance directive on admission. CSR D was asked to provide a copy of the advance directive information they currently review with newly admitted residents and/or their representatives and CSR D stated they had no documentation to provide. On 9/14/23 at 10:56 AM, the facility's Director of Nursing (DON), Regional Clinical Support (RCS) E and both Administrators (Administrator and Administrator A) were interviewed and asked about the facility's process in providing residents and/or resident representatives with information on what an advance directive is and if the staff are offering the residents and/or resident representatives the opportunity to formulate an advance directive and the Administrator acknowledged that the facility does not have anything currently in place, however the clinical team is working on it immediately to put something in place to provide information for residents and/or resident representatives regarding advance directives. No further documentation was provided by the end of the survey. 48680 On 9/14/23 at 08:50AM, the Director of Social Services (DSW C) was interviewed and asked how does the facility get Advance Directives from residents and stated that on admission, the team gets the Advance Directives and the code status and explained they also go over it at a meeting (with the family). DSW C stated, If a person has one (an Advance Directive) it's normally left on my desk but who offers it (an explanation of), I'm not sure. On 9/14/2023 at 09:49AM, Customer Service Representative D was interviewed and asked how does the facility get Advance Directives from residents. Customer Service Representative D explained that when a resident gets admitted to the campus, Either myself or someone else will go down to the resident to do the paper work. If they do not have an Advance directive in place, then we educate them and ask if they would like help to get one (an Advance Directive) if they do have one, I give it to the clinical team. But, we currently do not have an observation for this. It's discussed between the teams . On 09/14/2023 at 11:10AM the Director of Nursing, Regional Support Nurse E and Administrators (administrator and administrator A'') were interviewed. The Administrator stated that the process is to document, but its not clear on where it is documented. When asked what system is in place to prove that the education and Advance Directives have been offered? The Administrator stated, First we ask do they have one, if not, we ask if we can get family involved. If not, we go through Guardianship and discuss it. We do not have anything in place to show that its been done or completed but we are discussing it now.

Based on observations, interviews, and record reviews the facility failed to ensure professional standards of practice was consistently implemented by the facility nursing staff (medication administration for R35, R41, R45). Findings include: Medication Administration Observation On 9/13/23 at approximately 8:55 AM, Registered Nurse (RN) L was observed preparing the morning medications for R41. RN L was observed to have administered R41's medications and exited the room. RN L discarded a few needles in the sharps and then stated they were going to obtain the blood pressure of another resident. Review of R41's September 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed RN L did not sign R41's morning medications as administered. On 9/13/23 at 10:59 AM, RN L was interviewed and shown R41's September 2023 MAR and TAR and asked why they failed to document the morning medications as administered. RN L stated they didn't know what happened but would follow up immediately. On 9/13/23 at 11:16 AM, the Director of Nursing (DON) was interviewed and informed of the medication administration observation conducted with RN L and shown the September MARs and TARs for R41 that revealed no initials documented for the morning medications for R41. The DON stated they would provide additional education to RN L on the facility's documentation process after the administration of medications. The DON stated the nurse should have signed for all of the medications they administered after the administration of the medications. No further explanation was provided by the end of the survey. 48680 R45 On 09/12/23 at 09:59 AM, a cup of pills was observed left in a room. Observed in the cup was an oblong shaped light blue-green pill, a small circle burnt yellow pill, two circle shaped white pills and an oblong white pill. On 09/12/23 at 03:18 PM, Nurse O was asked if R45 can administer medications to himself and stated they would have to look at his assessments, but yes he can, he is alert and can talk. Nurse O stated, He told me that he would take the pills when he was ready. I went back to theroom to check to see if he had taken them. On 09/12/23 at 03:25 PM, the DON was asked to review where the self-administration assessment for R45 was. The DON confirmed there is no observation done for him (to self administer medications) at this time. R35 On 09/13/23 at 09:39 AM, R35 was observed with a nebulizer treatment running while the nurse was rendering care to room [ROOM NUMBER] (a different room than R35). On 09/13/23 at 01:36 PM, Nurse I was asked what the protocol was for residents who self-administer medications? Nurse I read the policy and stated, It's an observation I take of the resident self-administering medications, I give it (the assessment) to the Medical Director and then they write an order based off my observation . On 9/14/23 at 09:32 AM, the DON and Nurse E were asked that if the assessment was not completed, then R45 and R35 should not be self adminstering medications and stated that was correct (they should not be self administering medication).

Based on observation, interview, and record review the facility failed to ensure the proper disposal of a controlled medication was completed (for R35) by one (Licensed Practical Nurse - LPN) M of four nurses observed for the medication administration observation. Findings include: On 9/13/23 at 9:18 AM, LPN M was observed preparing the morning medications for R35. LPN M was followed into the unit 100 hallway to obtain a medication from the units' medication storage room. LPN M obtained the needed medication from the storage room and was observed to have dropped four pills from R35's medication cup. The four pills identified were tolterodine 4 mg (milligram) extended-release capsule, potassium chloride 10 mEq ER (extended release) tab, gabapentin 100 mg capsule and docusate sodium 100 mg capsule. LPN M was observed to discard all four medications into the medication cart sharp container and proceeded to obtain another tolerodine capsule, potassium chloride tab, gabapentin capsule and docusate sodium capsule from the medication cart and controlled medication storage. LPN M was observed to have administered R35 their medications shortly after. The gabapentin capsule is classified as a controlled medication and therefore should have been disposed of per the facility's controlled medication disposal policy. Review of a facility policy titled Disposal of Medications and Medication-Related Supplies . revised 11/18 documented in part . Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations . When a dose of a controlled medication is removed from the container for administration . or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed facility personnel as permitted by regulations, and the disposal is documented on the accountability record/book on the line representing that dose. The same process applies to the disposal of unused partial tablets . and doses of controlled substances wasted for any reason . On 9/14/23 at 9:34 AM, the Director of Nursing (DON) was interviewed with the Regional Clinical Support (RCS) E in attendance and informed of the observation of the controlled medication disposal made by LPN M and the DON stated they were aware of the observation and have already started educating their staff. The DON confirmed that any controlled medication disposal should be conducted by two nurses and documented on the controlled medication form.

This citation has three deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to thoroughly assess and obtain treatment in a timely manner after a fall for one (#26) of three residents reviewed for quality of care, resulting in a delay in [DIAGNOSES REDACTED]. Findings include: On 7/10/18 at 8:32 A.M., R#26 was observed lying in bed. R#26 was interviewed at that time. When asked if R#26 had been transferred to the hospital or emergency room recently, R#26 stated, I broke my hip and my ribs. I was going to take my shower and I'm pretty independent about that and I slipped and fell . I ended up going to the hospital. They kept telling me there was nothing wrong with me. I was in so much pain. My daughter finally took me to the hospital and I found out I broke my hip. On 7/11/18 at 10:22 A.M., an investigation regarding an incident reported to the State Agency by the facility was reviewed. A summary of the investigation documented, .4/25/18 at 3:58 PM, (R #26) was heard calling out from her room by (Nurse W) .entered (room number) observed resident laying on her left side near bench in room. When (Nurse W) asked where she was attempting to (go), (R#26) reported that she was 'getting up to use bathroom and lost her footing, falling to the floor.' (Nurse W) stated that (R#26) told her she had hit her head and complained of shoulder and rib pain. CENA (Certified Nursing Assistant - CNA) D stated, 'I went into room and she was laying on her left side with body facing bathroom door, near entrance to bathroom'. (Nurse I) assessed resident and she was free from apparent injury. Pain was indicated by resident in left shoulder and left upper quadrant near ribs. ROM (Range of Motion) was completed without resistance. CENA and nurse reported in statements that the resident did not appear to be in pain during ROM . .Per (CNA D's) statement, 'I toileted her an hour prior to fall and I saw her in her room [ROOM NUMBER]-15 minutes before fall and she did not have concerns.' (Nurse I) stated that she had been in room '5 minutes prior and offered toileting, resident declined.' Resident has a history of [MEDICAL CONDITION] and [DIAGNOSES REDACTED] although is A+O x 3 (alert and oriented to person, place, and time) and well conversing. BIMS (Brief Interview of Mental Status) score of 15 (which indicates intact cognition) .recently diagnosed with [REDACTED]. (R#26) is impulsive and aware that the call light needed to be triggered but does not always do so per interview with staff . .(Physician X) notified and order for X-ray of left shoulder and ribs obtained. Resident's daughter, (name redacted) notified via phone. X-ray were completed and negative fracture. Resident's daughter and physician notified no new orders at that time. Resident complained of intermittent pain to left upper quadrant/left rib relieved with Tylenol. According to staff statements and ADL (Activities of Daily Living) documentation, resident continued to require 1A for ADLs. Progress notes report that resident continued complaining of intermittent pain although it was in location of ribs, LUQ (left upper quadrant). Per (Nurse Y), resident's pain was relieved after Tylenol was given. Resident did not request Tylenol the remainder of the shift . .Outside consult obtained 5/1/18, revealing a non-displaced intertrochanteric (IT) fracture ([MEDICAL CONDITION] - upper part of femur/thigh bone). Per daughter (name redacted), fracture was noted to be directly below where pain was indicated by resident. Hospital would not release any medicals records to facility citing hospital policy. Resident denied falling at any other time after fore mentioned fall although staff report resident is non-compliant with call light. Per resident and family required, a room change closer to nursing station will occur and frequent checks will continue . .(R#26) had an un-witnessed fall 4/25/18. Resident complained of left shoulder and rib pain. X-rays obtained and negative for fracture. Resident continued to function as normal and transfer with 1A. Intermittent pain continued. Outside consult obtained 5/1/18, revealing a non-displaced intertrochanteric fracture. Facility investigation revealed that resident's care plan was being followed at time of fall and the pain the residents was describing was referred pain from fracture caused by [MEDICAL CONDITION]. Resident will return to facility for rehab . Signed statements from staff members included in the facility's investigation revealed the following: A statement signed by CNA D on 5/3/18 documented, (Nurse W) .yelled out in to the hallway for me to come to (room number redacted) while she got (R#26's) assigned nurse for the day. I went in to room and (R#26) was laying on her left side with body facing bathroom door, near entrance to bathroom. I asked (R#26) what hurts and she said 'I landed on my side and my head and hip hurts.' Nurse entered room, assessment was done, and (R#26) implied her side hurt. She did not appear in pain during ROM and she did not have her normal exaggerated reaction to pain. I toileted her an hour prior to fall and I saw her in her room [ROOM NUMBER]-15 minutes before fall and she did not have concerns. A statement signed by Nurse W on 5/3/18 documented, On 4/25/18, I heard someone calling out 'I need some help'. I checked a few rooms before I found that it was (room number redacted), (R#16's) room. I observed her lying on her left side. I asked the resident if she was ok and asked her not to move. (Nurse I) arrived and assessed resident and completed fall event and notifications. I had last seen (R#26) in her room sitting on her bed within 45 minutes of fall. Resident walked and acted as normal while I was here the next day (Thursday). A statement signed by Nurse I on 5/2/18 documented, (Nurse W) came to get me because I am (R#26's) nurse. (R#26) was on the floor next to the bench on her side. Resident stated that she hit her head and had pain in shoulder and ribs. ROM complete and no concerns with her hip. (Nurse I) and aide training in room less than 5 minutes prior and offered toileting. Resident declined, but requested shower. Aide in training went to get (CNA C). Resident stated that she was getting up to use bathroom and lost her footing, falling to the floor. Fall happened on 1st shift around 2 PM. A statement signed on 5/9/18 by Clinical Support Nurse (CSN) G documented, On 4/30/18, SS (Social Services) director asked me to come to (R#26's) room because she called to police. Upon entering room resident stated that she wanted to go to the hospital because she was in pain. Resident pulled up her shirt and touched her lateral left upper quadrant on the last rib. I asked her if she had pain anywhere else and she stated, no. I asked how she hurt it and she said it was from her fall a week before. I pulled her X-rays and found they were both negative for fracture. I asked (Nurse Y), the nurse to call (Physician Z). I called (R#26's) daughter and explained situation. Daughter stated that she visited over the weekend and her mom was complaining of rib pain although it was intermittent and after Tylenol, she seemed fine. She also noted her mother was walking as normal with walker. Daughter stated 'I think it is just one of her crys for help' she did not 'want to speak badly about mother' but (R#26) was 'manipulative'. She asked for the results of X-ray and I read them to her with resident's permission. Daughter is a nurse in the ER at (hospital name redacted) and understood medical background and cognition. She asked that the resident be kept at facility if possible because she had been more delusional lately and confabulating situations. The nurse (Nurse Y) was briefed on conversation so that (Physician Z) could be notified when he called back. Resident received Tylenol per (Nurse Y), just prior to my conversation with her. On 7/11/18 at 11:41 A.M., R#26's clinical record was reviewed and revealed the following: R#26 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Hospital records indicated R#26 had a [MEDICAL CONDITION] rib on the left side, in addition to the [MEDICAL CONDITION]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#26 had intact cognition and required extensive assistance for bed mobility, transfers, dressing, toilet use, and bathing. Progress notes from 4/2018 through 5/2018 were reviewed and revealed the following: A Late entry written by Nurse AA on 4/22/18 for 4/21/18 documented, Another nurse informed this writer that the resident was on the floor in her bathroom. Resident stated that she slipped and that she hit her head on the wall. Vitals within normal limits (under vitals.) Neuro checks within normal limits. C/O headache, Tylenol given. MD and family notified. Will endorse to next shift and continue to monitor. A noted dated 4/23/18 documented, Resident yell for help, the writer rushed into the room, she was observed lying on the floor face down closer to the bed. On assessment, no injury noted at the time. She stated 'I wanted to go to bed and in the process I slide out of bed, I have pain on my left cheek, but I would be alright'. PRN (ass needed) pain medication given as ordered. (Physician X) notified via voicemail, awaiting his call back. The family notified as well, the daughter stated 'I'm working at the emergency room close to your facility, if there is any changes, you can call to let me know' Continue to monitor. A note dated 4/25/2018 at 4:56 P.M. written by Nurse I documented, Resident observed on the floor in laying positron on the left side of body. Resident stated I was trying to go to the bathroom and lost my footing and just fell on the floor. Resident stated her head, ribs, and left shoulder hurt X-rays were ordered. ROM performed when lifting left arm there was some pain and in head. Res. (resident) is currently in rm (room) in bed safety is being maintained. A progress note dated 4/30/2018 at 3:42 P.M. written by Nurse Y documented, Resident c/o (complained of) pain on rib area, PRN Tylenol given. A progress note dated 4/30/2018 at 4:30 P.M. written by the Social Services Director (SSD) documented, SS asked to take a call from (name of police department redacted). Res. apparently has called 911 four times today asking for help. SS and a nurse mgr. (manager) visited Res. who was observed lying in bed, crying, stating she was in pain. Res. recent x-ray showed negative results. Nurse mgr. calling dtr. and (Physician Z) to discuss sending Res. to hospital. A Late entry progress note written by CSN G dated 5/8/18 for 4/30/18 documented, On 4/30/18, SS director asked this nurse to come to (R#26's) room because she called to police. Upon entering room resident room, (R#26) stated that she wanted to go to the hospital because she was in pain. Resident pulled up her shirt and touched her left lateral upper quadrant on the last rib. I asked her if she had pain anywhere else and she stated no. Resident reported it hurt since her fall last week. I pulled her x-rays and found that they were both negative for fracture. Nurse (Y) called (Physician Z). This nurse called daughter and explained situation. Daughter stated that she visited on the weekend and her mom was complaining of mild rib pain although it was intermittent and after Tylenol, she seemed fine. Daughter thought it was just cartilage pain. She also noted that her mother was walking as normal with walker. Daughter stated, 'I think it is just one of her cry's for help' she did not 'want to speak badly about mother' but she (has) done things like this before and had had an increase in behaviors starting in March. She asked for the results of the X-rays and with resident's permission, they were shared over phone. Daughter is a nurse in the ER at (hospital name redacted) and understood medical background and cognition. She asked that the resident be kept at facility, if possible, because she had been more delusional lately and confabulating situations. Nurse (Y) was briefed on conversation so that (Physician Z) could be notified when he called back. Resident received Tylenol per (Nurse Y), just prior to my conversation with her. A progress note dated 5/01/18 at 4:50 P.M. documented, Resident received in bed alert and verbal with c/o pain to left hip, writer attempted to assist resident with repositioning but refused, PRN Tylenol 650 mg x two dosage given per ordered with no effect. Daughter asked that her mother be send to (name redacted) Hospital d/t increased pain per resident. (Physician X) notify, said to notify (Physician Z). (Physician Z) notify of daughter request, said it was okay. Call place to (name redacted) ambulance, arrived at 4:15 PM. Resident transfer to (hospital name) at 4:20 PM. A progress note dated 5/01/18 at 6:30 P.M. documented, Resident daughter call with update on mother status and said that resident fracture her left hip in two places. Resident will not be returning tonight . A progress note dated 5/9/18 at 3:00 P.M. documented, Resident arrived to facility via ambulance .Resident has 13 staples totals (7 staples in left hip) (5 staples in left lateral femur) and ( 2 staples at left lateral knee) .Resident has Foley cath (indwelling urinary catheter) in place . A progress note dated 5/22/18 by the PM&R (Physical Medicine and Rehabilitation) doctor documented, Patient presented to (facility name) on (MONTH) 9, (YEAR) after being transferred from (facility name) to (hospital name redacted) Hospital (MONTH) 1, (YEAR) after a fall in the bathroom. The patient had actually 2 unwitnessed falls that same week. X-rays were done at (facility) and were initially read as normal. She continued to complain of pain in the left hip and was transferred to the emergency department where she was diagnosed with [REDACTED]. She was evaluated by orthopedics and was taken to the operating room on (MONTH) 2, (YEAR) for an IM (intramedullary) nailing (a surgical procedure where a metal rod is inserted into the bone cavity) with (name redacted). Her hospital course was Located by postoperative [MEDICAL CONDITIONS] requiring transfusion . On 5/23/18 at 7:51 P.M., a progress note written by (Physician Z) (14 days after R#26 was readmitted into the facility) documented, .presented to (hospital) on 5/2 with c/o fall and left hip pain. She was found to have a left IT fracture and a left 9th rib fracture (this progress note was the first date the rib fracture was documented in R#26's clinical record). On 5/2 she had left IM nailing by (hospital physician) . A Radiology Report dated 4/25/18 (completed at the facility) documented, .No acute rib fracture identified .No rib fracture evident. Consider follow up or further imaging is symptoms continue . On 7/11/18 at 2:00 P.M., CNA D was interviewed via the telephone. CNA D reported she typically worked first and second shift and is not assigned to a particular unit. When queried about R#26's fall on 4/25/18, CNA D stated, I was not assigned to her, but I was training. I entered the room to stay with her while the nurse on the hallway went to go get her assigned nurse. They only thing I can recall was that I asked her if anything hurt and she complained about her head and her hip. I told the assigned nurse and she then assessed the resident. CNA D stated, (R#26) was not crying. She has a very exaggerated way of expressing things, it wasn't her normal exaggerated self, she just said she was in pain. On 7/11/18 at 2:30 P.M., Nurse I (the nurse assigned to R#26 on 4/25/18) was interviewed via the telephone. Nurse I reported she typically worked the day shift on the 200 hall. When queried about R#26's fall on 4/25/18, Nurse I stated, That day I worked on the 100 hall but they had a nurse on the 200 hall that could not work with this resident. The nurse from that hall came and got me off the hall to come over to do an assessment. She said she lost her footing. She said her ribs were hurting and hit her head. I did ROM on legs both, arms, neurochecks, got off the floor, did vitals. Did not complain of any pain other than her ribs. Got an xray for skull, shoulder, and ribs. Came back and told me her hip was broken. Nurse I was asked how R#26 was lying on the floor. Nurse I stated, There was a seat next to her (bench) she was trying to hold her elbows up on floor, lying on her left side. When asked if CNA D reported R#26's complaints of hip pain, Nurse I stated, No she didn't report anything to me. On 7/11/18 at 3:13 P.M., and interview was conducted with the SSD regarding R#26 and the progress note that documented the resident called the police and 911 on 4/30/18. SSD stated, She has horrible delusions. She calls her daughter and makes stuff up. She has been deemed incompetent. When queried about the reason R#26 contacted the police, the SSD stated, She was in pain and we sent her out. We wanted to send her out and her daughter said no and then she wanted to send her the next day. When asked why the daughter did not want to send R#26 to the hospital, SSD stated, Because she is constantly lying. On 7/11/18 at 3:22 P.M., an interview with CSN G was conducted. CSN G was asked how R#26's hip pain was addressed. CSN G stated, She had hip pain according to (CNA D), but when the nurse assessed her and when I assessed her she didn't have any pain and was ambulating normally. Called the physician and told him where the pain was and he ordered xray of skull, shoulder and ribs. She only complained of pain in the left upper quadrant. When queried about what was done when R#26 continued to complain of rib pain, CSN G stated, The PM&R doctor and (Physician X) saw her and she received Tylenol. The day we were going to transfer her out, her daughter didn't want to because she thought she was lying and being manipulative. Pain was intermittent until close to the end when we decided to look at her. The CSN was asked how pain was assessed in the facility. CSN G stated, Pain is assessed per orders. We use a one through 10 pain scale. The Medication Administration Record [REDACTED]. There was no documentation of a pain scale used to assess R#26's pain when PRN Tylenol was given to determine R#26's level of pain before and after administration of the pain medication. There was no physician's order to assess pain. The MAR indicated [REDACTED].M. (no pain scale used and marked as effective) and on 4/30/18 at 3:40 P.M. (no pain scale used and marked as effective). The reason for administration was documented as rib pain. CSN G was queried about the day R#26 called the police and 911 asking for help and complaining of pain (4/30/18) and stated, The day she called, we called her daughter who said she was just there and said she complained about rib pain but thinks she just pulled a muscle. The daughter asked me to look at the x-rays and the nurse talked to (R#26) and she said she had left upper quadrant pain. Tylenol was given and effective. It's not unusual for (R#26) to have outbursts. Her daughter said she thought she was trying to attention seek. By the weekend, the daughter wanted her to go to the hospital. We did follow up eventually. CSN G was asked if the physician evaluated R#26 during the time between the fall on 4/25/18 and the hospital transfer on 5/1/18. CSN G stated, We talked to Physician Zon the phone. He reviewed the X-rays and was notified about the fall. When asked why further imaging was not completed per the radiology report when R#26's symptoms continued, CSN G reported that it was completed at the hospital (6 days after the first complaint of rib pain). On 7/11/18 at 4:00 P.M., Hospital Records for R#26 were reviewed and revealed the following: An X-ray of the left hip with pelvis on 5/1/18 revealed, .non-displaced intertrochanteric fracture of left femur . An X-ray of the chest and left rib dated 5/2/18 documented, .Nondisplaced fracture involving the lateral aspect of the left ninth rib . A History and Physical dated 5/2/18 documented, .presented to (hospital) from nursing home with c/o L (left) hip pain. Daughter at bedside reports pt fell Tuesday and Thursday of last week .Upon arrival, workup revealed nondisplaced L 9th rib fx (fracture) and non-displaced IT fx of L femur. Currently reports pain with deep inspiration (breathing) .Still with pain at L hip with attempted movement . An Operative Report dated 5/2/18 documented, .Operative Procedure: Cepha-medullary nail of left intertrochanteric fracture . On 7/12/18 at 10:00 A.M., a Physical Therapy Plan of Care dated 5/9/18 was reviewed and documented, .presents with a decline in strength, balance, mobility and safety following admit from hospital for left intertrochanteric femur fx due to fall s/p (status [REDACTED].and an increased need for assistance . Deficient Practice #2 Based on observation, interview, and record review, the facility failed to address and implement interventions for [MEDICAL CONDITION] for one (#26) of two residents reviewed for [MEDICAL CONDITION], resulting in resident complaints of discomfort and the potential for undiagnosed or worsening health conditions. Findings include: On 7/10/18 at 8:46 A.M., R#26 was observed lying in bed. R#26 was interviewed about any concerns she had at that time. R#26 reported swelling in her left ankle. R#26's left ankle was observed to be slightly swollen. R#26 stated, It swells very bad every day, sometimes all the way up my leg from my foot. I am diabetic and I have problems with my heart so it scares me and nothing is ever addressed. When asked if she voiced her concerns to anyone in the facility, R#26 stated, I have talked to the nurse. I talk to everyone about the swelling. They don't do anything. When asked if she had seen the physician regarding the swelling, R#26 stated, The doctors come, but, not very often. It scares me that something is going to happen to me because I didn't have any of these problems when I first came here. On 7/10/18 at 1:50 P.M., R#26 was observed seated in a wheelchair. R#26's left ankle appeared significantly more swollen than in the morning. R#26 reported it swelled up as the day progressed and that it recently started doing that. On 07/10/18 at 3:32 P.M., R#26's clinical record was reviewed and revealed the following: R#26 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Hospital records indicated R#26 had a [MEDICAL CONDITION] rib on the left side, in addition to the [MEDICAL CONDITION]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#26 had intact cognition and required extensive assistance for bed mobility, transfers, dressing, toilet use, and bathing. There were no nursing progress notes, no care plans, and no physician's orders for monitoring or treatment of [REDACTED]. On 7/10/18 at 3:45 P.M. an observation of R#26's left foot was conducted with CSN (Clinical Support Nurse) G. R#26's left foot was observed to be covered with a sock. When the sock was removed, indentations from the sock were observed around R#26's ankle and on her foot. R#26 stated, That foot recently gets swollen. It gets really bad. It never did that before. CSN G stated, She's independent and gets up and walks and is up in the wheelchair. The swelling might be worse during the day. She always had the swelling and it's non-pitting. If both (feet) were swollen we would be more concerned. She is active now and was seen two weeks ago by the PA (Physician Assistant). On 7/10/18 at 4:30 P.M., R#26's clinical record was reviewed with CSN G. When asked where R#26's [MEDICAL CONDITION] would be documented if it had been present since admission, CSN G stated, I didn't see anything documented about the [MEDICAL CONDITION]. She has always had it. On 7/10/18 at 4:45 P.M., Progress Notes from 5/9/18 through 7/10/18 were reviewed for R#26 and they revealed the following: A Skilled Charting report dated 5/18/18 documented, .left lower leg [MEDICAL CONDITION], non-pitting .right lower leg [MEDICAL CONDITION], non-pitting . A PM&R (Physical Medicine and Rehabilitation) Conference Note dated 5/15/18 documented the physician, Nurse Practitioner, Therapies, Nursing, and Social Worker were present at the conference. The note documented, .Cardiovascular: LLE (left lower extremity) [MEDICAL CONDITION] 1-2+ (barely to slight pitting/indentation) .abnormal . On 5/16/18, Physician Z documented, .No [MEDICAL CONDITION] noted . On 5/17/18, the PM&R Progress Note documented, .Cardiovascular: LLE [MEDICAL CONDITION] trace -1 (minimal swelling) .abnormal . On 5/18/18, 5/21/18, PA BB documented, .No [MEDICAL CONDITION] noted . On 5/21/18, a PM&R Conference Note (held with the facility Interdisciplinary team including the physician and nursing) documented, .Cardiovascular: LLE [MEDICAL CONDITION] 1-2+ .abnormal . On 7/10/18 at 5:14 P.M., CSN G reported she called the physician (Physician X) and he told her to email her the question. According to CSN G, Physician X reported R#26 had non [MEDICAL CONDITION] since admission. When asked if it was documented or care planned in the clinical record, Avery stated, We can do a care plan, but really everyone here has non [MEDICAL CONDITION]. There were no documented interventions to monitor or treat R#26 [MEDICAL CONDITION] to the LLE in the clinical record. On 7/12/18, CSN G provided a document which was explained to be the Admission Assessment from 5/9/18 that documented, .left lower leg [MEDICAL CONDITION], non-pitting .right lower leg [MEDICAL CONDITION], non-pitting . The facility's policy regarding [MEDICAL CONDITION] management was requested. According to the CSN, the facility does not have a policy specific to [MEDICAL CONDITION]. Deficient Practice #3 Based on observation, interview, and record review, the facility failed to assess and obtain a physician's orders for a surgical incision on admission for one (#159) of one resident reviewed for surgical wounds, resulting in the potential for improper care and worsening condition of the incision. Findings include: On 7/9/18 at 3:12 P.M., R#26 was observed sitting up in bed. A dressing dated 7/9/18 was observed on R#26's right knee. Blood was observed soaking through the dressing. R#26's knee appeared swollen with bruising around the knee and on the back of R#26's calf and thigh. R#26 was asked about his knee and reported he recently had a total knee replacement. R#26 stated, I think I have an infection or something. It's been bleeding and swollen. The doctor looked at it today and he is having me stop therapy for the time being. I hope I don't have to have surgery again. When queried about how often the dressing to his knee was changed, R#26 stated, I think they are supposed to do it a few times a day, but that doesn't happen. On 7/10/18 at 12:28 P.M., R#159's clinical record was reviewed and revealed the following: R#159 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Physician's orders were reviewed since admission and revealed no orders for the monitoring or treatment of [REDACTED]. On 7/10/18 a physician's order documented, Clean incision to right knee with NS (normal saline), pat dry, apply TAO (triple antibiotic ointment), cover non-adhesive pad and ABD pad, wrap with kerlix twice a day. an order for [REDACTED]. On 7/10/18 at 3:05 P.M., R#159 was observed lying in bed. R#159's right Knee was wrapped in with a gauze dressing dated 7/10/18. R#150 stated, They tried to do some light therapy today. There was minimal bleeding. I have an appointment with the orthopedic surgeon to figure out the next steps. On 7/12/18 at 11:20 A.M., an interview was conducted with Clinical Support Nurse (CSN) G. CSN G was asked what the facility's process was to monitor and treat a surgical incision when a resident was newly admitted . CSN G stated, We open an incision event and order a treatment. When queried about whether or not R#159 had an incision event and a treatment order, CSN G reviewed R#159's clinical record and stated reported there was an incision event, but it was not filled in until 7/10/18. CSN G stated, It was opened by the nurse on 6/29/18, but nothing was entered until 7/10/18. CSN G was asked how it was known what the surgical incision looked like at the time of admission and CSN G did not offer a response. When queried about what was put in place for R#159 upon admission for the surgical incision, CSN G reviewed the hospital records and stated, I don't see a discharge summary. We wouldn't be able to monitor the site because usually it would be covered with (a foam dressing) that stays on until the follow up with the surgeon, but we could make sure the dressing was in place. I don't see anything regarding the surgical dressing in the hospital records. I will look to see if I can find a discharge summary from the hospital to see if he even needed a dressing or if we just dropped the ball. On 7/12/18 at 12:34 P.M., CSN G stated, (Hospital) will not release the medical records without a release. When queried about whether or not the orders should have been clarified upon admission CSN G reported they should have and stated, It should have been entered into (the electronic medical record.) On 7/12/18 at 12:41 P.M., Skilled Charting was reviewed. There was no mention of the surgical incision site until 7/9/18. CSN G was queried about a care plan for R#159's surgical incision and stated, It wouldn't have triggered because the incision event was not completed until 7/10/18. On 7/12/18 at 1:00 P.M., R#159's clinical record was further reviewed. Progress notes were reviewed from admission on 6/29/18 through 7/12/18 and they documented the following: On 7/2/18 at 1:48 P.M. a progress note written by Physician Z documented, .Incision site over right knee appears to be healing well . On 7/6/18 at 11:31 A.M., Physician Assistant (PA) BB documented, .Incision site over right knee appears to be healing well . On 7/9/18 at 2:02 P.M., PA BB documented, .His only complaint is that the incision site on his right knee has started oozing .Incision site over right knee appears to be healing well .small amount of blood oozing from incision site .Apply dressing to right knee . On 7/11/18 at 1:16 P.M., Physician Z documented, .Incision site over right knee appears with mild bruising and approx. 1 cm of outer layer of skin peeling lateral to incision site. Small amount of blood oozing from incision site .Apply dressing to right knee . On 7/12/18 at 9:41 A.M., a PM&R (Physical Medicine and Rehabilitation) Progress note documented, .He reports that he is having some left knee pain .He is also having some bleeding from the surgical site. He reports, along with his nurse who was present, that he has had about 3-4 dressing changes in the last 24 hours .There is a small area at the mid distal end of the surgical site where a small amount of dried drainage is noted. The surgical area appears slightly [DIAGNOSES REDACTED]tous and [MEDICAL CONDITION] .There is a notable area at the mid-proximal aspect of the incision that appears dark and as if there is almost a collection of old blood. Slight increased temp to right knee vs. left knee .I ordered steri-strips to be placed to mid-distal end of surgical site where bleeding is .Nursing to monitor (his) surgical site and provide dressing changes as app(TRUNCATED)

This Citation Pertains To MI 627 Based on observation, interview and record review, the facility failed to ensure the main entrance doors and wander guard system were simultaneously properly functioning, which allowed one resident (#501) of two residents reviewed as having wandering and/or exit seeking behavior to exit the facility, without knowledge of the facility staff. That resulted in an Immediate Jeopardy when Resident #501 was observed standing outside in the parking lot near the 100 Hall of the facility. Resident #501's wander guard was determined dysfunctional. This deficient practice had the potential to result in serious harm and or injury and required immediate corrective action. The Administrator was notified of the Immediate Jeopardy (IJ) on 7/20/17 at 1:15 p.m. A plan to remove the immediacy was requested. Immediate Jeopardy was identified: 7/20/17 at approximately 12:00 p.m. The immediacy was removed on 7/20/17 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with the potential for harm that is immediate jeopardy. Findings include: On 7/20/2017 at approximately 9:00 am, Resident #501's clinical record was reviewed and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The minimum Data Set ((MDS) dated [DATE] revealed a brief mental status of 4, indicating severe cognitive impairment. The care plan dated 3-08-2017 identified Resident #501 as at risk for elopement and a wanderguard was to be placed on his wheelchair. Placement and function of the wanderguard was to be checked each shift and as needed. A review of the treatment administration record revealed check function of wandering alert bracelet/device twice daily and was signed off as done for 7-07-2017 and 7-08-2017. A review of the nurses notes dated 07-01-2017 revealed in part .combative behavior, tried to open exit doors . A review of the facility Event Report dated 7-08-2017 revealed Resident #501 was last seen on 7-08-2017 at around 6:50 am and was found in the facility parking lot on 7-08-2017 at approximately 7:15 am. further review of the event report read in part Did the resident exhibit any of the following behaviors prior to exit seeking? The following had a checked box in front of the statement 1.Exit seeking attempts in past-unsuccessful. 2. Verbalizing statements about leaving. According to the facility's investigation of Resident #501's elopement dated 7-13-2017 The Administrator watched the campus video that showed Resident #501 exit the facility unaccompanied through the facility's main door, and was outside for approximately 11 minutes. At which time Licensed Practical Nurse (LPN) B and Certified Nursing Assistant (CNA) C escorted Resident #501 back into the facility. Further review of the investigation revealed the Administrator tested all exit doors on 7-08-2017 with a wanderguard bracelet and the tester, which concluded the main door would not lock and or sound the alarm consistently. The investigation further identified a lightening storm on 7-06-2017 spontaneously caused alarms on the doors to sound and the system was reset by staff. Which the facility concluded as the root cause. The alarm company provided a service call on 7-10-2017 and added a second antenna to the main door. On 7-20-2017 at 9:15 am, during an interview with CNA C she reported she was caring for a resident in the 100 hallway, and when she looked out the window she observed Resident #501 outside in the parking lot walking behind his wheelchair. She then stated she told LPN B and they went outside and brought Resident #501 back inside the facility On 7-20-2017 at 9:30 am during a phone interview with LPN B she reported she was notified on 7-08-2017 at approximately 7:15 am by CNA C that Resident #501 was in the parking lot. LPN B further stated that after she and CNA C brought Resident 501 back into the facility, she assessed him for injury (none found) then checked the wanderguard bracelet with the tester device kept on the med cart. The wanderguard did not work with the tester, I replaced the wanderguard bracelet immediately. On 7-20-2017 at 9:45 am, a review of the work order from the alarm company dated 7-10-2017 reflected Site had elopement, wants system checked. Health center entrance door needed aux antenna to completely cover doorway. On 7-20-2017 at 9:50 am, during a telephone interview with the alarm door company's technician E that serviced the facility on 7-10-2017 he reported the upon his testing of the door lock and alarm system Equipment worked exactly the way it was supposed to. Best solution was to add another antenna. The Administrator was interviewed on 7-20-2017 at 10:45 am an observation of the door alarm/locking system was done with the tester device. The Administrator reported that upon his arrival to the facility on [DATE] he tested the exit doors with a testing device and a wanderguard bracelet and found sometimes the door would lock, sometimes it wouldn't, sometimes the alarm would sound and sometimes it wouldn't. At that time the Administrator assigned a person to stand guard at the doors until Maintenance Director F could digitally enter codes for entering and exiting the facility. The facility submitted the following acceptable plan including supporting documentation to remove the immediacy on 7/20/17: Element #1: On July 8, 2017 the campus Executive Director (ED) checked the main health campus entrance door for appropriate functioning. The ED used the Name of alarm company wander guard tester and a wander guard bracelet. During the checks, it was identified that the door would not lock and/or alarm consistently. A dedicated invididual was placed at the door to monitor. The campus entrance door was then placed in a locked mode where individuals will need to enter a code to enter and exit. This was done to ensure the doors were secure to residents with a wander guard bracelet. (The 15-second fire egress is still in place to remain in compliance with Life Safety Code.) Name of alarm company was notified of the concern with the entrance door on July 8, 2017. An on-site assessment was completed by their company on Monday, July 10, 2017. At this assessment, it was confirmed that the system was not reacting appropriately on a consistent basis. An additional attena was added to the health campus entrance door to increase the ability of the system to pick up the wanderguard bracelet, thus alarming and/or locking the door. On the morning of July 8, 2017, resident Resident #501 was assisted back into the campus at approximately 7:15am by staff. The licensed nurse completed an assessment and observed no signs or symptoms of injury or harm. The resident was noted to be fully clothed with shoes on. The weather was reported to be warm and sunny. Per campus video, the resident was identified to be outside of the campus for approximately 11 minutes. The resident's wife and physician were notified of the event on July 8, 2017. Element #2: On July 8, 2017 healthcare residents were assessed for elopement risk. Residents identified as being at-risk for elopement were verified to have their wander guard bracelets on and that they were functioning as appropriate. The campus elopement books were reviewed and deemed up to date and appropriate. Wander guard doors are checked Monday thru Friday by the campus Director of Plant Operations and by the manager on duty on Saturday and Sunday. Residents with a wander guard bracelet were verified to have orders for checking of placement and functioning per campus policy. During the investigation, it was identified that the campus was potentially hit by lightening during a thunderstorm earlier in the week. Various staff report that during the storm, they heard a loud clap of thunder, lightening, and felt the campus shake. Wander guard and door alarms sounded. They re-set the alarms and notified the Director of Plant Operations. Element #3: The root cause of the incident was identified as the Door System not responding to bracelets appropriately on a consistent basis. Re-education to licensed nursing staff has begun and includes notifying the Director of Plant Operations, Director of Health Services, and the Executive Director of any unusual occurrences, such as lightening or power loss, etc. potentially affecting the alarm system. Element #4: The Director of Plant Operations will be notified of any unusual occurrences that could potentially affect the alarm system. The DPO and/or the ED will advise the charge nurse to place the campus doors in a secure locked mode until the DPO/designee can assess the system for any change in function. Once time per week, random audits/interviews will be completed with licensed nurses regarding their understanding of the notification process of any unusual occurrences potentially affecting the campus alarm systems. Element #5 The Executive Director is responsible for continued compliance.

Based on observation, interview and record review, the facility failed to prevent, identify and treat a facility acquired pressure ulcer in 2 sampled residents (#601, #603) out of three residents reviewed for facility acquired wounds out of a total sample of 15 residents resulting in discomfort, pain and a decline in general health. Findings include: Resident #601 Resident #601 was a [AGE] year old female who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. This resident was identified by the facility as having a facility acquired wound. On 5/17/17 at 9:20 AM, during wound care for Resident #601, the wound was observed. The wound edges were pink and the center of the wound had a deep induration which was packed with maxsorb Ag+. The old dressing had a moderate amount of seerous drainange on it. There was no odor. The last measurement of the wound as documented on 4/20/17 was 2.6 cm x 1 cm x 0.8 cm. On 5/18/17 at 1:30 PM, a record review of the progress notes in the electronic medical record was done. According to the documentation, on 11/6/16, the wound originally was thought to be a nodule and was treated with an antibiotic. The nodule progressed from a flat red circle measuring 0.5 cm in diameter on 11/6/16 to a wound measuring 7 x 8 cm on 11/15/16. On 11/15/16, the wound was treated with an [MEDICATION NAME] dressing but continued to enlarge and progress. On 12/16/16, an order was received for [MEDICATION NAME] Ag+ , an antimicrobial dressing, used for fluid absorption and the reduction of odors. The wound continued to progress and became covered with blue/black necrotic tissue which had to be debrided on 1/5/17. * On 11/6/16 at 2:09 PM, a progress note stated observed nodule on resident's L (left) gluteal area. It is appears as a flat red circle (approx 0.5 cm diameter) with the dark blue circle in the middle (2 cm diameter). The center area is hard and warm to the touch. * A physician's orders [REDACTED]. * A progress note on 11/15/16 indicated the left gluteal wound care area of discoloration became larger; the hard to touch area is now 7 X 8 cm; the redness is 6 X 5 cm; the blue/black dark area in the center is 3 X 3 cm. * A physician order [REDACTED]. * On 11/17/16 at 3:00 PM, the progress note stated Resident was seen by NP (nurse practitioner) to assess wound L buttock. No new orders received. * Documentation on 11/23/16 indicated entire surface of wound covered with blue/black necrotic area with hard density (7 cm x 5 cm), small amount sero-sanguinous drainage. Covered with [MEDICATION NAME]. * Progress note on 11/25/16: seen by wound care nurse, wound necrotic with erythremic ring and induration on the border, the center is blue/black, 6 cm x 4 cm, moderate sero-sanguinous drainage. * On 12/14/16 at 9:38 AM, a progress note by wound care nurse A stated after a surgical consult for the wound to the left gluteal area the surgeon's impression is that this is a necrotic decubitus ulcer and would require extensive debridement creating a large open wound requiring dressing changes 2 - 3 x per day. * On 12/16/16, a physician's orders [REDACTED]. * On 12/23/16, a physician's orders [REDACTED]. * A progress note, dated 1/5/17, stated With the resident in bed and on her right side surgical debridement was performed to remove necrotic cap of wound. * Progress note on 2/9/17 indicated Stage 4 wound is healing. On 5/18/17 at 2:00 PM, a record review of the skin integrity care plan was done. On 11/17/16, the following interventions were added to the care plan: assess the pressure ulcer for location, stage, size, presence/absence of granulation tissue and epithelization weekly. Conduct a systematic skin assessment weekly. Report signs of further breakdown. Keep bony prominences from direct contact with one another with pillows. Keep clean and dry as possible. On 12/2/16 the following was added to the care plan Use low air loss for pressure reduction when resident is in bed. Use ROHO cushion for pressure reduction when resident is in chair. On 12/16/16 the following intervention was added Avoid friction and shearing force during transfer and position change. On 4/26/17, the following was added to the care plan: Treat area per MD order. On 5/18/17 at 2:20 PM, a record review of the Pressure Ulcer Prevention, Management and Staging Policy and Procedure, revised on 12/2015 and approved on 2/2005, revealed the following information: Procedure #1. Interventions will be implemented promptly to prevent or treat pressure ulcers. Procedure #3 - an individualized care plan will be developed to address prevention, care, and treatment of [REDACTED]. On 5/18/17 at 2:45 PM, in an interview with the Director of Nursing (DON), she was unable to give any background regarding the wound to Resident #601 because the DON began working at the facility in January 2017. Resident #603 On 5/16/17 at 8:55 AM, during initial tour an observation of Resident #603 was made. Resident #603 was observed in the room sitting up in gerichair asleep. Resident #603 had oxygen infusing via nasal cannula (N/C) at 2 liters per minute via concentrator located at the bedside. A review of Resident #603's clinical record was conducted on 5/16/17 at 10:45 AM and revealed that Resident #603 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #603's MDS dated [DATE] documented that the resident was severely impaired cognitively and required extensive to total staff assistance for all ADLs (activities of daily living). A review of a nursing progress note by Wound Nurse 'A' dated 4/6/17 was conducted on 5/17/17 at 9:00 AM. Wound Nurse 'A' documented: Nurse on unit notified writer that resident has a skin breakdown to coccyx area. Pressure ulcer is noted measuring 1cm x 0.3cm x 0.1cm- wound is full thickness, defined, wound bed is yellow slough with no exudate. On 5/18/17 at 11:00 AM, an interview was conducted with Resident #603's family member. Resident # 603's family member indicated that she visited the resident daily. Resident #603's family indicated that the resident developed a wound while at the facility in the beginning of April. When queried regarding if staff had been turning Resident # 603 every two hours, Resident #603's family member stated: I really don't think so. One time my mom was not changed and was soiled for 17 hours. The mattress and room was so smelly. I left for lunch at 1:00 PM and returned the next day. When I returned the next day, the room was really smelly, so I assume that mom was not changed until the next day. They did not change her until I said something. The mattress was soiled and they threw away the mattress. Resident # 603's family member indicated that this occurred a month and a half ago. She had reported her mom being soiled for an extended time as well as the soiled mattress to the Assistant Director of Nursing (ADON) 'A'. An interview was conducted with Wound Nurse 'A' on 5/18/17 at 12:00 PM. When queried regarding Resident #603's wound development and documented note of 4/6/17, Wound Nurse 'A' indicated that that the wound to coccyx originally displayed as a stage II. When queried further regarding how the wound developed, Nurse 'A' stated: attributed to resident having a decline, was having dentures repaired and incontinent. Wound Nurse 'A' further explained that wound was assessed and measured: On 4/27/17- 0.5cm (length) x 0.4cm (width) x 0.1cm (depth) with scant exudate. Then 5/4/17 0.4cm x 0.3cm x 0.1cm. On 5/11/17 saw 0.5cm x 0.4cm x 0.1cm. An interview was conducted with ADON 'V' on 5/18/17 at 12:40 PM. When queried regarding Resident #603 wound which developed in April and the soiled mattress, the ADON stated: That was probably 3 months ago. I think from day to midnight shift and the mattress was soiled. When queried further, the ADON stated: I don't recall anything with her (referring to Resident #603). The ADON indicated that the Environmental department would have been responsible for removing the mattress. An interview was conducted with Environmental Director/ Director of Plant Services 'S' on 5/18/17 at 1:20 PM. When queried regarding removal of Resident #603 soiled mattress and if a log was kept, Environmental Director 'S' stated: Mattresses are removed all the time. Do not keep a record. Housekeeping let us know if mattresses are un-cleanable and I remove them. An interview was conducted with the Director of Housekeeping 'E' on 5/18/17 at 1:25 PM. When queried regarding Resident #603, Director of Housekeeping 'E' stated: Yes, I recall about a month ago. Was asked to come and clean mattress as well as sterilize. After close observation, we decided to remove it. Observed that it was soiled with urine. Certified Nursing Assistant (CNA) 'W' was aware of our going to replace it. Resident #603's family member was here that morning. I felt that it needed to be replaced. It smelled strong urine. An interview was conducted with CNA 'W' on 5/18/17 at 1:26 PM. When queried regarding Resident #603, CNA 'W' stated: I had asked housekeeping to take it out and get a new one (referring to soiled mattress). I thought that only the mattress cover was soiled with urine but it was the foam or mattress itself. It happened about a month - two and a half ago. I could not put her back to bed with it like that. CNA 'W' indicated that Resident #603's room smelled of strong urine and that the previous shift (midnights) had gotten the resident out of bed to the wheel chair and put clean linen on the bed. An interview was conducted with the Director of Nursing (DON) on 5/18/17 at 1:30 PM. When queried regarding Resident #603's wound which was documented as developed while in the facility on 4/6/17, the DON responded that the wound was acquired and observed when the resident returned on 4/26/17 after being hospitalized . When queried further regarding documentation of 4/6/17, the DON stated: I'll check on that. When queried regarding Resident #603's urine soiled mattress, the DON stated: There was a request from housekeeping and mattress removed due to old or did not smell good.

Deficient Practice #1 This deficient practice pertains to Intake MI 795 Based on observation, interview and record review, the facility failed to activate a newly applied wander guard and check to ensure proper functioning, which allowed one resident (#702) of two residents reviewed as having wandering and/or exit seeking behavior to exit the facility, without knowledge of the facility staff, from a total of nine sampled residents. That resulted in an Immediate Jeopardy when Resident #702 was observed standing outside of a door on the 400 Hall of the facility. Resident #702's wander guard was determined to be dysfunctional. This deficient practice had the potential to result in serious harm and or injury and required immediate corrective action. The Administrator was notified of the Immediate Jeopardy on [DATE]. A plan to remove the immediacy was requested. The immediacy was removed on [DATE] based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings Include: On [DATE] at 1:30 p.m. Resident #702 was observed to be out of her room and off the unit. When queried her whereabouts, Registered Nurse (RN) 'C' stated, (Name) Resident #702 is usually wandering around. She likes sitting on the couch on the 400 Hall. She's confused. On [DATE] at 1:50 p.m., Resident #702 was observed relaxing on the couch with her shoes off. Resident #702 was wearing a wander guard bracelet on her left wrist. When queried about going outside of the facility, Resident #702 stated, No! I don't know. That was a long time ago. When asked if she knew where the 400 Hall exit door was, Resident #702 looked out of the window and pointed to the lobby entrance door. The 400 Hall exit door is at the end of the 400 Hall near resident rooms 410 and 413. It is an Emergency Exit Only door with a sign the reads Push until alarm sounds, door can be opened in 15 seconds. The 400 Hall door leads to the side of the facility's parking lot. On [DATE] at 2:00 p.m., a review of the facility's clinical record revealed Resident #702 was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of a quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 7, which indicated Resident #702 was severely cognitively impaired for decision-making. Resident #702 required supervision - oversight, encouragement or cueing with ambulation/locomotion on and off the unit with a walking cane. A review of a physician's orders [REDACTED]. A review of a physician's orders [REDACTED]. The facility's care plan revealed Problem Start Date: [DATE]. Category: Safety will remain safe from elopement. Edited: [DATE] On [DATE] at 2:15 p.m., a review of the facility's investigation report dated [DATE], revealed the following: On [DATE] at approximately 7:10 p.m., (resident's name) was observed outside the 400 hall exit door . Her wander guard bracelet, which was on her ankle, was checked for functioning and placement and deemed to be in good working condition . On [DATE], Director of Plant Operations 'D' checked all door alarms and wander guard alarms for appropriate functioning. There was a noted concern with the Assisted Living (AL - attached separate campus) main entrance door . On [DATE] upon further investigation of the resident's wander guard, it was noted that the date of the bracelet was [DATE]. It was also noted that the device was not activated . (Resident's name) . ambulates independently with a cane throughout the campus. She has been at risk for elopement since her admission due to her cognition and independence in ambulation and has had a wander guard since . Wander guard door alarms were checked on the morning of [DATE] to ensure proper functioning. The wander guard attached to the Assisted Living main entrance was noted to not be functioning appropriately . The root cause of the incident was identified as lack of education to licensed nurses regarding how to 1) activate a wander guard signaling device, and 2) checking the device for placement and functioning correctly . On [DATE] at 4:20 p.m., during an interview, the Administrator stated, the Director of Maintenance 'D' checked the doors the morning of [DATE]. The resident went outside the door the evening of [DATE]. When Maintenance checked the doors the morning of [DATE], that's when it was discovered the AL door was not working. When queried if he knew what door Resident #702 eloped, the Administrator stated, I don't really know. It was discovered Resident #702's wander guard was never activated when it was first applied. When asked who was responsible for activating the residents' wander guards in the facility, the Administrator stated, The nurses. On [DATE] at 10:35 a.m., an interview was conducted with Licensed Practical Nurse (LPN) 'E' who stated, I was in another resident's room. My aide (Certified Nurse Assistant-CNA) came pulled me out of the room, and pointed out to me that (resident's name) was outside. I saw (resident's name) standing on the outside of the emergency exit door at the end of the 400 Hallway . I immediately ran outside, and asked (resident's name) to come back inside with me. I walked her around to the lobby entrance door. LPN 'E' further stated, She (Resident #702) was cold and seemed a little unsteady . At that same time, LPN 'E' was queried if Resident #702's wander guard alarm was sounding when she entered through the lobby doors. LPN 'E' stated, No, there was no alarm sounding. On [DATE] at 10:45 a.m., during an interview, Director of Operations 'D' stated, The nurses are supposed to keep tabs on the bracelets (wander guards), and report any problems to 'TELS' (building maintenance system). The nurses have a tester to check wander guard bracelets and doors. When asked about the functionality of the facility's wander guards and who was responsible for maintenance, Director of Operations 'D' stated, I test the doors daily. I checked the doors the morning of [DATE], and they passed. When queried why the door did not alarm when Resident #702 exited the facility, Director of Operations 'D' stated, It (wander guard) was expired as far as I know. On [DATE] at 1:00 p.m., a review of the TAR (Treatment Administration Record) dated [DATE], revealed Resident #702's right ankle bracelet (wander guard) was signed as checked by LPN 'F'. On [DATE] at 2:20 p.m., an interview was conducted with LPN 'F'. When queried about the technique used to check Resident #702's wander guard, LPN 'F' stated, When it was on the ankle. I didn't know how to check for functionality. I was only checking for placement. I thought that placement was enough. A review of the facility's policy titled Elopement Risk Reduction revised [DATE] documented the following: PURPOSE To prevent elopements by appropriately assessing resident risk factors, observing resident patterns, .identifying the significance of risk factors, implementing prevention interventions and making environmental adaptations. PROCEDURES Elopement Overview: Elopements occur when a resident leaves the premises or a area without authorization (i.e., an order for [REDACTED]. The resident does not necessarily need to be off the campus property for it to be considered an unsafe area. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. These policies assist to define the mechanisms and procedures for monitoring and managing residents at risk for elopement help to minimize the risk of a resident leaving a safe area without authorization and/or appropriate supervision. Procedure . 6. Facilities with door alarms should place a wander guard bracelet on the resident and have the alarms activated at all times. 7. a check will be completed of alarmed doors and resident alarms to ensure proper functioning . The facility's policy titled Alarm Checks revised [DATE] documented the following: PURPOSE to ensure resident and door alarms are properly functioning to protect the safety of campus residents. PROCEDURES 1. All door alarms should be checked for proper functioning. a. Each facility shall develop a door alarm check schedule and designate a person and alternate to complete the alarm check task. 2. Resident wander guard alarms . should be checked for proper functioning. a. Frequency of individual alarm checks should be daily for function and every shift for placement or based on the resident's individual plan of care. i. Alarms for these residents should be evaluated for continued appropriateness . The facility submitted the following acceptable plan including supporting documentation to remove the immediacy on [DATE]: Element #1: In the early morning of [DATE] the Director of Plant Operations checked all door alarm and wander-guard alarms for appropriate functioning. There was a noted concern with the Assisted Living (attached separate campus) main entrance door. Name of Local Company, the manufacturer of the wander-guard system was contacted and a replacement part was shipped over-night to the campus. A dedicated individual was assigned to watch the assisted living entrance door until the replacement part was installed. Name of Local Company, completed an on-site assessment of all campus wander guard and alarm doors on [DATE] at 10:30am. Once the resident returned inside the campus, the licensed nurse (per her statement on [DATE] at 3:30pm) completed an event form on the incident. She assessed the resident and observed no signs or symptoms of injury or harm. She noted that the resident was fully dressed with a sweatshirt, long pants, and shoes. She notified the residents physician on [DATE] at approximately 7:30pm. Element #2: On [DATE] the Director of Health Services, (DON), reviewed all residents assessed to be at risk for elopement. Residents identified were verified to have their wander guard bracelet on and that they were functioning as appropriate. Any bracelets observed to be expired/out of date would be removed and discarded. No issues were identified. The campus elopement book was reviewed and deemed to be appropriate and up to date. Wander guard door alarms are checked weekly by the Director of Plant Operations; no issues have been identified. Wander guard door alarms were checked on the morning of [DATE] to ensure proper functioning. They were last checked by the Director of Plant Operations on [DATE] and noted to be functioning appropriately. The wander guard attached to the Assisted Living main entrance was noted to not be functioning appropriately during the [DATE] check. An individual was assigned to monitor the entrance door continuously until the door panel was repaired. On [DATE] a replacement part for the main entrance on the assisted living was installed and is functioning appropriately. On [DATE] Name of Local Company, arrived at the campus and reviewed all locks and wander guard systems for functionality. Element #3: On [DATE] the campus QAPI committee met ad hoc. The policy and procedure for Elopement Risk Reduction dated [DATE] was reviewed and deemed to be appropriate. The policy and procedure for Alarm Checks dated [DATE] was also reviewed and deemed appropriate. The root cause of the incident was identified as lack of education to licensed nurses regarding how to 1) activate a wander guard signaling device, and 2) checking the device for placement and functioning correctly. Re-education to campus staff has begun and includes reviewing the two above policies and staff acknowledging understanding of the same. It also includes re-education to nursing staff regarding the Name of Local Company, wander guard/signaling device manufacturer's guidelines regarding activating the device and checking it correctly utilizing the Wander guard ID System Universal Tester. Element #4: The Director of Health Services/designee initiated an audit tool that will track all current and future residents assigned a wander guard bracelet. This tracking tool will monitor placement of the device, activation date, 90-day bracelet replacement date, care plan intervention date, and MAR/TAR addition as well as other interventions deemed appropriate. This audit tool will be on-going. The audit tool will be reviewed monthly at the campus QAPI committee for tracking, trending, and any edits or changes needed to the tool. Deficient Practice #2 This deficient practice pertains to Intake MI 159. Based on interview and record review, the facility failed to advise one resident (#707) of risks associated with electrical stimulation treatment out of one resident reviewed for electrical stimulation treatment from a total sample of nine sampled residents, resulting in Resident #707 receiving burns to her back. Findings include: Resident #707 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A record review of the Brief Interview for Mental Status reveled Resident #707 scored 15 out of 15 points which indicated this resident had no issues with her mental cognition (ability to think). At the time of the investigation, the resident was no longer living in the facility. On [DATE] at 3:00 PM, an interview with PTA (physical therapy assistant) A was done. According to PTA A, she had done electrical stimulation to Resident #707 on [DATE] without any adverse effects. On [DATE], PTA A performed a second electrical stimulation treatment on Resident #707. PTA A stated she placed 4 electrodes on Resident #707's back and started the treatment. The strength of the treatment was a default and was not changed during the treatment. The treatment lasted 20 minutes and, according to PTA A , Resident #707 did not complain of discomfort during the treatment. At the end of the treatment, after removing the electrodes from Resident #707's back, PTA A noted white blisters to Resident #707's back. When PTA A touched the blisters, they were hard to the touch. PTA A stated there were more than 5 blisters. PTA A was asked if she prepped Resident #707's skin before the treatment and PTA A said she did not as she could see that Resident #707 did not have any lotion on her back. The prep would have consisted of using an alcohol pad to cleanse the area. PTA A was asked for a copy of the policy and procedure for using the Intelect Legend XT, the machine used to provide electrical stimulation to Resident #707 and PTA A said there was no such policy. PTA A provided the user manual for the Intelect Legend XT machine for review. A record review of the user manual revealed the following statement burns beneath the electrodes have been reported. PTA A was asked if she was aware that there was a potential for burns when using the Intelect Legend XT machine and she stated she was unaware that this could occur. PTA A was asked if she explained the risks of electrical stimulation treatment with Resident #707 and PTA A said she did not and was unaware of any risks. PTA A was asked to produce the machine for review and PTA A stated the manufacturer had taken the machine from the facility in order to check it for defects so it was no longer in the facility. On [DATE] at 3:20 PM, a record review of Resident #707's electronic medical record revealed, on Monday [DATE], Resident #707 had the following burned areas to her back which were reddened and had irregular edges. All wounds were unopened. #1. Left lower back - 1 cm X 0.5 cm X <0.1 cm #2. Left lower back - 1.5 cm X 0.5 cm X <0.1 cm #3. Left lower back near areas #1 and #2 - 1.5 cm X 0.5 cm X <0.5cm #4. Right lower back - 1 cm X 1 cm X<0.1 cm #5. Right lower back below #4 - 0.3 cm X 0.3 cm X <0.3 cm #6. Right lower back beneath #4 and #5 - 0.5 cm X 0.5 cm X <0.1 cm A physician's orders [REDACTED]. On [DATE] at 5:00 PM, a record review of the physician's orders [REDACTED]. There was no explanation why the electrical stimulation was done to the lower back when the order indicated the electrical stimulation was to be done to the left hip area only.

This citation has two deficient practices. Deficient practice #1: Based on observation, interview, and record review, the facility failed to provide adequate supervision, and consistently implement and ensure that safety devices were functional for eight (#'s 502, 503, 504, 505, 509, 510, 513, and 517) of 10 sampled residents reviewed for accidents from a total of 17, resulting in bruises, hematomas, lacerations, skin tears, intracranial hemorrhage, fractures, emergency hospitalization s, and the potential for further accidents/injuries. Findings include: Resident #509- During the initial tour on 6/30/15 at 9:55 AM, resident #509 was observed sitting in a wheelchair alone in his room with the door closed. The resident was alert and spoke in a slow, flat tone. The resident was sitting on a safety alarm (motion) sensor pad. The light on the alarm's control box was not flashing to indicate that it was operational. Nurse 'E' was immediately asked to check the alarm. The control switch was observed to be set to the off position. The nurse turned on the alarm and said that it should have been on. As the room was being exited, the resident said, Close the door when you leave. The resident's room was located at the end of the hall far away from the nurses station. On 7/1/15 at 11:45 AM, resident #509 was alone in his room in the wheelchair. The alarm control box was not flashing. The Director of Nursing (DON) and the resident's assigned nurse aide('B') entered the room to check the alarm. Aide 'B' said, It's turned off. The DON and the aide did not respond why it was off. The resident was observed to have a large skin tear, approximately 4 inches in diameter, on the left lateral forearm that was actively bleeding. A dressing that was covering the skin tear, was pulling away from the wound and sticking to the wheelchair armrest. Nurse 'C' entered the room and removed the dressing which was covered with fresh blood and detached skin. When informed that the alarm was turned off, nurse 'C' said, He likes to keep the door closed. When I'm here, I tell him that he cannot stay in here with the door closed because if the alarm sounds, we won't be able to hear it. On 7/1/15 at 12:20 PM, nurse 'E' was queried about a Skin Impairment Circumstance Investigation form that she wrote dated 6/30/15 about resident #509's arm injury. Nurse 'E' said, (Aide 'B') told me that she was transporting (resident #509) out of the bathroom after toileting him and he hit his arm on the door frame. At 1:40 PM, when asked about the arm injury, aide 'B' said, We were coming out of the bathroom and turning the corner. He tends to hold his elbows out and hit his arm. Aide 'B' did not respond when asked why she did not ensure that the resident's arms were safely positioned during transport. At 2 PM, the resident was sitting in the wheelchair alone in his room. On 7/2/15 at 8:40 AM, resident #509 was alone in his room with the door closed. At 2 PM, the resident's clinical record, care plans, and Accident/Incident (A/I) Reports were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Minimum data sets ((MDS) dated [DATE] and 4/13/15 noted that the resident had moderate cognitive impairment, was non-ambulatory, had unsteady balance, and required extensive assistance when transferring on and off the toilet. There was no documented Falls care plan for resident #509. An ADLS (activities of daily living) care plan dated 10/4/14 noted: I am a fall risk, I have a sensor alarm on my wheelchair and bed at all times. A/I reports for resident #509 revealed the following: 1. 6/28/14-Found on the floor near the bathroom door and stated he was trying to stand and open the door; complained of pain to the lower back area and skin tear to the right lower leg; no indication that an alarm sounded to alert staff of an attempt to self-transfer; measures taken to prevent reoccurrence-call light in reach and toilet every two hours. An X-ray report of the lumbar spine dated 6/28/15 showed: Mild compression deformity at the L1 (first lumbar vertebrae) level, age indeterminate. Per a physician progress notes [REDACTED]. Patient has some recent back pain A Pain Circumstance Assessment form dated 8/12/14 noted that the resident was almost constantly experiencing low back pain over the last five days and was prescribed a Fentanyl (pain) patch. There was an order dated 8/14/14: Pad (sensor) alarm on wheelchair and bed at all times. Check function every shift. An X-ray of the spine for Pain, low back pain dated 8/18/14 noted that the No gross fracture, but exam was limited. There was no repeat X-ray. 2. 9/8/14-On the floor in his room; the alarm sounded; complained of pain to the left buttock; measure taken-place items in reach. A CAT scan of the abdomen and pelvis dated 10/11/14 noted: Severe compression deformity of L1 and L4 (first and fourth lumbar vertebrae) are new since the prior exam on 3/15/14. 3. 11/11/14-On the floor in his room and stated he was trying to reach the phone; bruises to the left buttock and left knee; no indication that the alarm sounded; measure taken-reminded to ask for assistance and keep phone within reach. Per a nurses note dated 11/13/14: Resident complaining (of) pain in vertebrae area, thinks that it is due to fall. Per a note dated 11/18/14: Resident is complaining pain in lower back (vertebral area). Per PM&R (Physical Medicine and Rehabilitation) Conference Notes dated 10/23/14, 11/13/14, 11/20/14, and 11/25/14, the resident complained of low back, bilateral hips, and thigh pain and had a functional decline. On 12/4/14, PM&R noted: Decline in function right foot drop-new etiology consider MRI lumbar spine/hips. There was an order dated 12/4/14: CAT scan lumbosacral spine regarding low back pain and right foot drop. On 12/15/14 the physician noted: Follow-up back pain and foot drop (inability to lift the toes due to weakness or paralysis commonly caused by a pinched/compressed nerve in the spine) a recently noted foot drop on the right back exam unremarkable A CAT scan report to the lumbar spine dated 12/18/14, ordered for low back pain and right foot drop, was reviewed. The report noted that this CAT scan was compared to a previous scan to the abdomen and pelvis performed on 10/11/14 with the following results: Severe compression fracture at L1 and L4 There is a comminuted (broken, splintered, or crushed) appearance of L4 There is a (bone) spur protruding in the right with possible impingement on the L5 nerve posterior displacement of the fracture fragment (in) the spinal canal at L4. There was no documentation in notes, CAT scans, or X-rays, that the resident had osteoporosis (brittle bones). There was an order dated 12/19/14 for a serum protein electrophoresis blood test to rule out [DIAGNOSES REDACTED] (bone marrow cancer). The results of the blood test dated 12/29/14 noted: No paraprotein detected (negative for [DIAGNOSES REDACTED].) There was no documented investigation that addressed how the compression spinal injuries may have occurred. There were no further available documented progress notes from 12/15/14 until 1/29/15 by the resident's primary care physician (PCP, who was also the Medical Director). None of the PCP's notes from 6/2014 thru 6/2015 mentioned the compression spinal fractures. Continued review of resident #509's A/I reports revealed the following: 4. 3/1/15-A nurse came to the resident's room and was told by his daughter that he was placed on the toilet by her and left him alone on the toilet. The nurse then heard resident sliding off toilet and was almost to floor, but the fall was blocked; There was no mention whether the nurse also allowed him to remain on the toilet alone before he began to slide; no documented injury; measure taken-none noted, such as educating the family and/or nurse. The resident's ADLS care plan noted on 10/4/14: Please do not leave me on the toilet alone as I may decide to transfer myself. 5. 3/12/15-A large hematoma (swelling) was discovered to the left humerus; measure taken-none noted; Per the Skin Impairment Investigation, there was a bruise, wound, and treatment implemented. Per a nurses note dated 3/12/15: large bruise on inside of left arm was discovered with large hematoma 7 cm (centimeters) by 8 cm. A Pain Circumstance Assessment form dated 3/16/15 noted that the resident complained of pain to the left arm. An X-ray to the left arm was negative for fracture. There was no documented conclusion or physician statement regarding how this injury may have occurred. 6. 3/23/15-The resident was taken to the bathroom by his son using a walker and was lowered to the floor after becoming weak while standing and holding on to a bathroom bar; no documented injury; measure taken-resident instructed to use wheelchair instead of walker There was no mention of educating the family or ensuring that staff toileted the resident. 7. 6/30/15-(Aide 'B') was wheeling resident out of bathroom and arm caught on door frame; Skin tear to left forearm; measure taken-Remind resident to keep arms inside wheelchair while being transported. There were no measures, such as educating aide 'B' on her responsibilities when transporting residents. On 7/2/15 at 3:30 PM, the DON was queried about resident #509's accidents/injuries. The DON did not respond why the resident was left alone on the toilet and why safety devices (alarms) were not consistently implemented. She did not offer a response why other interventions, such as proper supervision, a room closer to nurses station, or discouraging closing the door when out of bed, were not care planned. Regarding the skin tear from the door frame, the DON said, The resident was reminded to keep his arms inside the wheelchair. Are you saying that you wanted the staff educated too? When queried about resident #509's injuries of unknown origin not being fully documented and investigated, the DON said, I know where you are going with this. It is pretty consistent. We are going to have to hire somebody. Resident #513- On 7/1/15 at 4 PM, resident #513 was observed sitting near the nursing station in a wheelchair with a sensor alarm. The resident was confused and two staff were observed pivoting the resident from the wheelchair to a nearby sofa. On 7/2/15 at 9:30 AM, the clinical record and A/I reports for resident #513 were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS also noted that the resident was cognitively intact at that time, was non-ambulatory, and required extensive assistance for transfers and bed mobility. The resident's Nursing Admission assessment dated [DATE] noted: The resident was admitted with 24 staples to the left hip from surgical repair and required a tab alarm for safety, however, there was no documented order for a tab alarm. A/I reports for resident #513 noted the following: 1. 4/18/15 (day after admission)-Answered the call light and found sitting on floor in room in front of wheelchair; no documented injury; no indication that an alarm sounded; measure taken-Tab alarm on wheelchair. There was no documented order for a tab alarm. 2. 5/5/15-Found on floor next to bed with blankets wrapped around wheelchair; No documented injury; no indication that an alarm sounded; measure taken-Tab alarm. There was an order dated 5/5/15 for a tab alarm. 3. 5/6/15 2 AM-Found lying on stomach in front of toilet; two lacerations to right forehead measuring 2.1 cm by 0.6 cm and 1.9 cm by 0.1 cm resident returned to wheelchair not responding to nurses right pupil sluggish ; steri-strips applied to forehead; no indication that an alarm sounded; measure taken-discontinue tab alarm, pad alarm ordered to bed and wheelchair. The A/I report noted that when the resident was observed on the floor, the tab alarm was on floor not attached and concluded resident removed, however, the report indicated that the incident was not witnessed. Resident #513 was transported to the hospital on [DATE] at 3:30 AM and returned at 7:15 AM with 7 sutures on right forehead per nurses notes. 4. 5/7/15-Found on floor in room next to wheelchair; no new injury documented, but blood pressure noted at 196/110 while laying; no documented indication that an alarm sounded; measure taken-Continue using 'tab' alarm, not a sensor alarm. 5. 5/23/15 9:45 AM-Nurse answered alarm and found resident on bathroom floor attempting to self transfer; no documented injury; no indication regarding if the alarm had a tab or a sensor; measure taken-resident to stay at nurses station except during therapy and meals, resident forgets to use call light. 6. 5/29/15 1:15 PM-Observed on bathroom floor after answering sounding alarm, needed to go to bathroom and did not need help; no documented injury; measure taken-resident needs to stay at nurses station when not at meals or in therapy because of cognitive impairment resident forgets to use call light for assistance. On 7/2/15 at 3:30 PM, when queried, the DON did not respond why the resident was not adequately supervised and safety devices were not consistently implemented. Resident #504- On 7/1/15 at 4 PM, resident #504 was observed asleep in a wheelchair in her room with a sensor alarm on the wheelchair. On 7/2/15 at 10 AM, resident #504's clinical record and A/I reports were reviewed. The resident was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] noted that the resident was cognitively intact, was non-ambulatory, and required extensive assistance for transfers and bed mobility. There was an order dated 1/6/13 for a sensor pad alarm to the bed and wheelchair for resident #504. There was no documented order to discontinue it. A/I reports for resident #504 noted the following: 1. 12/10/14-Observed on the floor in her room; no documented indication that an alarm sounded; sustained a hematoma and a 5 cm by 4 cm abrasion to the left forehead; measures taken-none documented. The resident's Falls care plan noted: 12/11/14 I am at risk for falls Place a personal sensor alarm on my bed/chair 2. 1/6/15-On floor in room and stated that she slid out of the wheelchair; no noted injury; no documented indication that an alarm sounded; measure taken-frequent room checks and pad alarm. The resident's care plan noted on 1/7/15 that a dycem (non-skid) pad was added to the wheelchair. 3. 2/27/15-Alarm sounded, staff found resident on floor by bathroom door with skin tear and redness near left eye and complaints of pain to right hip and knee; measure taken-remind resident to use call light and ask for assistance. 4. 3/20/15-Found on floor in room near wheelchair by the visitor of another resident who reported it to staff; no noted injury; no documented indication that alarm sounded; measure taken-none noted. 5. 4/29/15 2:45 AM-Resident refused to sleep in her bed after several attempts to convince her , fell asleep in wheelchair, slipped out, and fell on floor in her room, but no documented witness to the incident; sustained a skin tear and abrasion to the right elbow; no documented indication that alarm sounded; measure taken-none noted. There was no mention of the dycem non-skid pad that was care planned following the fall on 1/6/15. 6. 5/1/15 7:30 PM-Found face down on the floor near wheelchair, resident's head was touching corner of dresser with blood on floor and stated that she fell forward reaching for an object on the floor; laceration visible on left side of scalp; no documented indication that alarm sounded; measure taken-none noted. Per nurses notes dated 5/1/15, the resident was transported to the hospital at 8 PM and returned at 11:50 PM with 3 staples to laceration on back of head. 7. 5/22/15 11:30 PM-Resident was calling for help found resident hanging on to the sink with her buttocks on the floor; no noted injury; no documented indication that an alarm sounded; refused to go to bed on afternoon and midnight shifts and stated she was trying to go to the bathroom; measure taken-none noted. There was no documented indication that the resident was evaluated for possible sleep disorder following this fall or the fall on 4/29/15. Per nurses notes dated 5/25/15, the resident complained of pain to the left hip and knee. On 7/2/15 at 3:30 PM, when queried regarding safety devices not being consistently implemented, and safety interventions/adequate supervision not provided for resident #504 leading to injuries and hospitalization , the DON did not respond. A facility policy on safety interventions was requested. The facility provided a policy dated 10/19/07 on Procedure Guidelines Alarm Checks, reviewed on 7/2/15 at 3 PM that noted: Resident bed/chair alarms should be checked for proper functioning; Residents with a history of removing alarms should be checked more frequently; Alarms for these residents should be evaluated for continued appropriateness; Alarm checks should be part of routine daily care. ( ) Resident #503. On 6/30/15 at 3:00 p.m. Resident # 503 was observed in a wheelchair without leg rest in place at the nurse's station. She was alert and oriented and able to answer questions appropriately. Both feet were on the floor. She stated she was able to move her wheelchair herself with her feet. On 6/30/15 at 2:00 p.m., a review of the clinical record for Resident #503 revealed her to be a [AGE] year old female, originally admitted into the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. According to the 11/17/14 and the 2/6/15 Minimum Data Set Assessments Resident #503 required extensive assistance of two persons for bed mobility, transfer, toileting and bathing. She had a 15 on her cognitive test indicating she was cognitively intact. Further review of Resident #503's clinical record revealed current Care Plan's which included the following: Activities of daily living (undated) I am non ambulatory. I have not walked for a long time. I am a two person assist with transfers using a mechanical sit to stand (lift). I am a two person assist for bed mobility, toileting and bathing (transferring). I have mobility and standing impairments. I am a fall risk. 3/5/15, I have osteoporosis and am at high risk for fractures. Use cation when you are assisting me to turn/reposition, transfer, dress etc.I have anxiety related to changes in caregivers and a fear of falling. A physician's orders [REDACTED]. On 7/1/15 at approximately 11:00 a.m., the facility provided the following accident and incident (A/I) reports for Resident #503: 1. An A/I dated 8/24/14 at 5:00 a.m., Description of what happened: Resident was transferred from bed to wheelchair via one person assist.Certified Nursing Assistant (CNA) said she heard a 'pop' and when resident asked if she was ok, resident complained of discomfort. Description of injury 'Fracture, hip.' . Measures taken to prevent reoccurrence, Resident should have been transferred via sit to stand or 2 person. An attached statement from CNA R documented .8/24/15 at 5 a.m., .I took my place as usual in front of (Resident #503) to transfer to the wheelchair from the bed.I heard a pop. (No mention of a mechanical lift). The Nurse's note dated 8/24/14 at 12:00 p.m., documented Resident complained of left hip pain and said her hip 'popped' during transfer from bed to wheelchair this a.m. Nurse's note at 5:55 p.m., X-ray result for left hip/pelvis reveals acute left intertrochanteric fracture.(Physician) notified. Orders to transfer Resident #503 to (acute care hospital). The x-ray report dated 8/24/14 documented Left acute intertrochanteric fracture with varus angulation. (displaced left hip fracture). A Multidisciplinary team note dated 9/4/14 documented Resident #503 was post fall with left hip ORIF (surgical repair of hip fracture). 2. An A/I dated 6/9/15 at 9:50 p.m., Description of injury, right calf below the knee large bruise with swelling.Measures taken to prevent reoccurrence, Educated resident to call for help/assistance and report any injury as it happens. A Nurse's note included on the A/I documented Summonsed to resident (#503) room by CNA Resident (#503) observed with large purple swollen bruise to her right leg calf. An addendum dated 6/11/15 documented Staff interview, bumped leg during hoyer transfer-staff educated to have co-worker help during transfer. 3. An A/I dated 6/23/15 at 9 a.m., Resident's (#503) right leg hit wheelchair.Type of injury, hematoma lower leg.measures to prevent reoccurrence, treatment started. No Nurse's note related to the incident was found in Resident #503's clinical record or provided by the facility when requested. On 7/1/15 at 11:50 a.m., Resident #503 was questioned about the injuries to her right leg. She stated I got bumped on the front of the leg when they were getting me out of bed. I don't recall who or when. The back of the leg they bumped on the wheelchair it was (Certified Nursing Assistant (CNA) Staff P). I didn't lift my leg up enough and it got hit with the wheelchair. When queried about a broken hip in August of 2014 Resident #503 stated Somehow how I fell against the bed. I don't really remember what happened exactly. On 7/1/15 at 1:15 p.m., Resident #503 was observed during a transfer to bed by CNA's Staff CC and DD using a gait belt and pivot transfer (Per the care plan a lift was required). Once in bed an observation of Resident #503's skin revealed an area on the front medial calf with a large approximate 2.5 by 2.5 centimeter (cm) raised gray/purple color hematoma (localized collection of blood outside the blood vessel) with light gray discoloration (bruising) above the area (still visible from the 6/9/15 incident ). A dressing was observed to an area on the back of the right calf. Staff Nurse G removed the dressing to the back of the calf to reveal an approximate 3 by 3 cm area with black eschar (slough or dead tissue) in the center and gray discoloration (bruising) surrounding the area. A scant amount of drainage was noted on the old dressing. (still visible from the 6/23/15 incident). Wheelchair leg rests were observed on the floor in Resident #503's room. Both Staff CNA's CC and DD were queried as to Resident #503's transfer status and stated she was a two person assist. (Neither CNA mentioned the mechanical lift). When asked how they are made aware of the resident's transfer status both stated Ask the Nurse. CNA DD stated The wound on the back of her leg is where a CNA bumped her with the wheelchair. On 7/1/15 at 3:10 p.m., CNA Staff P was queried regarding the injury to the back of Resident #503's right calf. CNA P stated I was not her assigned CNA .I was taking her (in her wheelchair) from the dining room through the court yard. She holds her feet close (the CNA demonstrated by holding her legs up, with her feet off the floor crossing her feet at the ankles and tucking them close under the chair). She (Resident #503) dropped her feet during the transfer. The area on the wheelchair where the leg rests would have been attached banged into her leg. She said ouch. When I looked (at her leg) it was a big bump sticking up and was bleeding. I put wet paper towel and covered it. I got the Nurse. When asked why no leg rests were used on the wheelchair for transport, CNA P stated, (Resident #503) doesn't like the foot rests.She usually holds her feet up. On 7/2/15 at 11:35 a.m., Resident #503 was observed self propelling her wheelchair in the hall of the facility using her feet. When queried about staff using leg rests when they push her in the wheelchair she stated No, because it is easier for me to move without them. When asked if staff ever puts the leg rests on when they are pushing her in her wheelchair she stated NO. When asked if she finds it difficult to hold her legs up while staff are pushing her in her wheelchair, she stated Yes, it is. That's what happened, I couldn't hold it (leg) up and the wheelchair hit the back of my leg. That is how I got the sore. On 7/1/15 at 4:05 p.m., the facility Director of Nursing was unable to identify the CNA who was interviewed on the 6/9/15 I/A. I should have done a 1:1 education on hoyer lift transfers with staff. I don't know if it was done. I have no documentation. On 7/2/15 at 3:10 p.m., the facility DON was queried as to Resident #503's current transfer status and reviewed the Care Plan and stated Sit to Stand (lift) with two persons. When asked about the physician order [REDACTED]. When asked what Resident #503's transfer status was on 8/24/14 the DON stated The same, two person with a lift. It (the 8/24/14 transfer) was not done per the care plan. The DON was informed of an observation on 7/1/15 of two CNA's transferring Resident #503 from her wheelchair to bed with a gait belt and pivot. The DON shook her head and stated It should have been a lift. When queried regarding leg rests for Resident #503's wheelchair during staff assisted transfer/propelling. The DON stated She likes to self propel and sometimes pushes herself backwards.She normally holds her legs up. I verbally talked to (Staff P) about it, but have no documentation. The DON stated It's clear where you are going with this. It is consistent on all the A/I's that interviews, investigations should have been done and documented on the A/I's. They are going to have to hire someone else. A review of the facility provided policy's revealed the following: Guidelines for Resident Transfers (Undated) Purpose: To ensure the safety of residents and staff when performing mobility/transfer tasks. Procedure: 1. Upon admission the admitting nurse and/or therapy department shall determine the type of transfer device, amount of assistance required to assist with safe mobility based on assessments in the areas of: a. Cognition-ability to follow simple instructions. b. Weight bearing status-full, partial, toe touch, non. c. Resident's weight. d. Upper and lower body strength. e. Trunk stability. f. Skin condition. g. Mobility status-supervision, limited, extensive, dependent. Guidelines for 'SWAT- We've got your back' program (undated) 1. (same as in 'Guidelines for Resident Transfers') .3. The lifting requirements and appropriateness of the type of device used to assist with mobility should be reviewed quarterly and as needed with change in condition. 4. The type of equipment to be used for the resident should be reflected on the individual care plan and the nursing assistant assignment sheet. 5. Type of handling devices available are: a. Dependent Mechanical Lift. b. Sit to Stand Mechanical Lift. c. Steady- transfer assist. d. maxislide sheets. All devices are safe to be used by one staff member per manufactures guidelines. Staff should seek the assistance of a second person for those residents' care planned for assistance of two with the lifting device or as needed for safe handling. 7. The Dependent Mechanical Lift shall be used for individuals who cannot bear weight, have poor trunk stability and require extensive assistance or total dependence with transfers. ( ) Resident #510 On 7/1/15 at 1:30 P.M., Resident #510's family member was overheard talking with the nurse on the unit and reported that Resident #510 had been in a lot of pain, had a huge bruise on her back and asked if an X-ray had ever been done. On 7/1/15 at 3:30 P.M., the radiology log book and physician's orders [REDACTED].#510. On 7/2/15, multiple observations were made of Resident #510 from 8:25 A.M. until 11:15 A.M. During this time, Resident #510 was observed to be in pain and distress, as evidenced by tearfulness, verbalizations of pain in her back, rubbing her back, placing her head in the palms of her hands, facial grimacing and shifting her weight in her wheelchair. Throughout this time frame, Nurse J was observed with her back to Resident #510, standing at the medication cart. A Radiology Report was reviewed on 7/2/15 at 9:00 A.M. and documented that on 7/1/15, Resident #501 had an X-ray of her lumbar spine. The results documented, .Age-indeterminate mild to moderate L1 Compression fracture . At 10:25 A.M., Resident #510 was observed self propelling her wheelchair to the couch located in the common area. Nurse J was standing at the medication cart with her back to Resident #510. Resident #510 attempted multiple times to stand up from the wheelchair and position the wheelchair so that she could transfer to the couch. It was immediately brought to Nurse Js attention to observe Resident #510 trying to self transfer to the couch. At this time, Resident #510 told Nurse J that she would like to lay down in her bed. On 7/2/15 at 11:55 P.M., an Accident/Incident (A/I) Report completed by Nurse EE was reviewed which documented that on 6/27/15 at 9:15 A.M., Resident (#510) stood up from w/c (wheelchair) to transfer self without locking brakes and lost balance and fell into table and then onto floor on bottom. The description of the injury was documented as a bruise deep in color to Resident #510's left side of back. In the section labeled, What measures were taken to prevent this from happening again?, Pad alarm to w/c was documented as an intervention. A Fall Circumstance, Assessment and Intervention form dated 6/27/15 documented that a fall occurred on 6/27/15 at 9:15 A.M. and was witnessed in the 200 unit living area. The Injury location was left blank. Activity at time of fall was documented as Transferring self. In the section titled equipment inspection, it was documented that safety equipment was not in place and functioning at the time of the incident and the wheelchair brakes were not locked. Resident #510's clinical record was reviewed on 7/1/15 at 3:30 P.M. and 7/2/15 at 2:00 P.M. and revealed the following: Resident #510 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #510 had severely impaired cognition and required extensive assistance with transfers and ambulation. A Care Plan (undated) for Falls was reviewed and documented, I am at risk for falls r/t (related to) arthritis, pain, h/o (history of) falls, weakness and dementia .Lock the brakes .Place a PSA (sensor pad alarm) on my bed/chair to remind me to ask for assist with transfers and to alert you if I don't . A Nursing Admission Assessment & Data Collection form dated 4/17/15 documented Pad alarm to bed and w/c in the safety section. It was also documented that Resident #510 had cognitive impairment that effects safety/judgement, had a history of [REDACTED]. Nurse EE was interviewed on 7/2/15 at 2:55 P.M. via the telephone regarding Resident #510 ' s fall on 6/27/15. Nurs

Based on observation, interview, and record review, the facility failed to thoroughly document, care plan, and ensure appropriate and timely implementation of preventive interventions for three (#'s 501, 505, and 517) of seven sampled residents reviewed for wounds from a total of 17, resulting in the development of pressure sores. Findings include: On 6/30/15 at 10 AM, resident #505 was observed sitting in a geri-chair by the nurses station with her legs elevated. Her heels were placed on the footrest. At 2:15 PM and 4 PM, the resident was lying in bed with her heels on the mattress. On 7/1/15 at 1:30 PM, per review of an Accident/Incident report dated 6/28/15 for resident #505, a stage II (partial skin thickness) pressure sore was discovered that day on the resident's coccyx area. A foam dressing was applied that day and was documented on a treatment record. Resident #505's skin was then observed with nurse 'C' for any other skin issues. The resident was lying in bed with heels on the mattress. An unstageable (necrotic-dead skin) pressure sore was discovered to the left heel that nurse 'C' measured at 3 centimeters (cm) by 2 cm in diameter. The pressure sore was surrounded by a red, swollen, nonblanchable (skin that does not change color when pressed) area measured at 7 cm by 4.5 cm representing a stage I pressure area. Nurse 'C' said, Oh. I was not aware of this area. The left heel pressure sore was not noted on the treatment record. There were no pressure relief devices, such as heel protectors or foam boots, observed in resident #505's room. On 7/2/15 at 9 AM, the clinical record for resident #505 was reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS had not yet been completed, however, the resident was non-ambulatory, was observed being fed by staff, and was incontinent of bladder and unable to turn/reposition herself during the wound observation. The resident was placed under hospice services on 6/23/15. An Individual (care) Plan Report for resident #505 noted: Skin (undated): observe my skin during routine caregiving for acute changes. Provide me with pressure redistribution products for my bed and chair My goal is maintain intact skin 6/24/15 I have an alteration in my skin integrity related to thin, dry, fragile skin Provide me with pressure redistribution products for my bed/chair 6/28/15 stage 2 pressure ulcer on coccyx There was no mention of the pressure sore on the left heel. On 7/2/15 at 3:30 PM, when the pressure sore on resident #505's left heel was discussed with the Director of Nursing, she did not offer a response. ( ) Resident #501- On 6/30/15 at 2:30 p.m., the clinical record for resident #501 was reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set ((MDS) dated [DATE] indicated her cognition was moderately impaired and required extensive assistance for repositioning. A Pressure Ulcer assessment dated [DATE] noted the resident was admitted with a stage II (partial skin thickness) ulcer to her left outer heel measuring 2 centimeters (cm) by 1 cm. She also had a stage IV (full thickness down to underlying bone/tendons) pressure ulcer to the coccyx. Physician orders [REDACTED].>4/3/15-float heels while in bed; wound care daily to the left foot and wrap with bulky gauze protective dressing. 4/9/15-weekly skin assessments. 4/13/15-pressure relief boot on left lower extremity when in bed only. 4/22/15-float heels in bed. Per review of follow-up visit notes dated 4/18/15 with a hospital-based Infectious Disease specialist, the resident was seen for treatment of [REDACTED]. Per review of an Accident/Incident (A/I) report dated 5/27/15- Aide found pressure sore on right heel measuring 3 cm by 3 cm and unstageable. On 5/27/15, wrap right heel every day, float heel in bed, was ordered and on 5/28/15: Off load pressure to heels while in bed; discontinue the dressings. The resident's Skin care plan related to the right heel pressure ulcer, dated 5/27/15, did not mention floating the heels or pressure relief devices for the heels. According to the resident's weekly Clinically at Risk Individual Monitoring Sheets, documentation was to include: Wound exhibits signs/symptoms of healing/not exhibiting signs/symptoms of healing or appears to be worsening. On 5/2715, the Monitoring Sheet did not document discovery of the new right heel ulcer. An A/I report dated 6/1/15 noted: During wound measurements nurse observed new skin impairment. Necrotic (black, dead ) tissue on left foot measuring 5 cm by 4 cm and unstageable. The following new orders were reviewed: 6/1/15-cleanse right and left heel with normal saline; pat dry; cover with a thick pad and wrap with gauze daily. 6/2/15-heel protectors on bilateral feet at all times except for bathing. On 6/23/15, the order for the thick pads and gauze wraps, was changed. Instead of applying them daily, they were ordered to be applied on an as needed basis. On 7/1/15 at 2 PM, resident #501's skin was observed with nurse 'E'. The resident was alert, lying in bed, and had to be turned by staff. The left heel pressure ulcer, that measured 1 cm by 2 cm on admission, was a necrotic cap of black tissue covering the heel. The right heel was covered with a necrotic black cap. When asked if the resident's wounds were being overseen by a wound specialist, nurse 'E' said that she did not know. On 7/2/15 at 11:05 a.m., Shower Skin assessments dated 6/2/15, 6/6/15, 6/9/15, 6/16/15, 6/23/15, 6/27/15, and 6/30/15 were reviewed with the Director of Nursing (DON). The assessments noted that there were no areas of concern with the resident's skin on the right and left foot. The DON stated, Areas of concern should have been documented on the Shower Skin Assessment. At 3 PM, when asked why resident #501 developed pressure ulcers on the heels, the DON said that there was no wound care nurse at the facility and that care was provided by the staff nurses and the facility physician. She was asked if there were any treatment modifications or referrals for a wound consultation to promote healing and prevent worsening of the heel wounds. The DON said that because of the resident's insurance, she did not qualify to be seen by a wound specialist. When asked if the Medical Director was made aware, the DON said, We could probably do that. Resident #517- On 7/8/15 at 11:20 AM, resident #517's was observed to be alert and wearing a pressure relief boot on the left foot. There was none on the right foot. At 3 PM, the clinical record and Accident/Incident (A/I) reports for resident #517 were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission MDS, which was not completed until 6/4/15, noted that the resident had moderately impaired cognition, was non-ambulatory, and required total assistance for repositioning. A Nursing Admission assessment dated [DATE] noted that the resident had a callous lateral- right great toe on admission and the left heel pressure sore. There was an order dated 5/1/15: Float heels while in bed; Bilateral waffle (pressure relief) boots-remove every shift; check skin for color, [MEDICAL CONDITION], breakdown. An A/I report dated 5/3/15 noted the following: While assisting, (nurse aide) with (incontinent) brief change observed stage II (partial skin thickness) pressure ulcer on right foot pad below big toe. The measure taken to prevent reoccurrence-air loss (pressure relief) mattress and boots in bed and wheelchair. There was an order dated 5/3/15 for wound treatment and a dressing to the pressure sore on the pad of the right foot under the great toe. The resident's Inividual (care) Plan Report noted however, that this pressure sore was present on admission. There was no documentation why the wound care was not implemented upon admission. Per review of a Pressure Ulcer Letter of Unavoidablility dated 5/3/15, the facility deemed the right foot pressure sore to be unavoidable due to poor skin turgor. The care plan noted that the resident had [MEDICAL CONDITIONS] making the lower extremities at risk for complications, but [MEDICAL CONDITION] was not checked off on the Letter as a contributing factor. (A physician progress notes [REDACTED].) There were no documented measurements for the right foot pressure sore on the resident's Clinically at Risk Individual Monitoring Sheet dated 5/5/15. There was an order dated 5/14/15 to wrap the right foot with a pad and a bulky protective gauze dressing. On 6/9/15, the Monitoring Sheet noted that the sore measured 1.3 centimeters (cm) by 1.7 cm and was unstageable (the depth could not be observed due to a covering of dead tissue). On 6/16/15, the Sheet noted the sore was 1.8 cm by 2.5 cm in diameter. From 5/5/15 thru 6/16/15, the right foot wound was monitored and measured weekly on the Monitoring Sheet, but no further documented weekly measurements. An A/I report dated 6/29/15 noted: Observed pressure ulcer on right lateral foot while changing other dressings: measure taken-Waffle boots to both feet. There was no documented indication that the boot was still being applied to the right foot after the 5/14/15 order for the bulky dressing. On 7/2/15 at 4 PM, the facility's undated General Wound and Skin Care Guidelines, was reviewed and noted: Evaluate the need for a pressure reduction surface for bed/chair and the need for heel floats. ( )

Based on observation, interview and record review, the facility failed to adequately evaluate and treat pain for one (#510) of seven sampled residents reviewed for pain from a total sample of 17 resulting in delayed assessment of a fractured back and the resident crying, feeling anxious, complaining of back pain and exhibiting signs of distress. Findings include: On 7/1/15 at 1:30 P.M., Resident #510's family member was overheard talking with the nurse on the unit and reported that Resident #510 had been in a lot of pain, had a huge bruise on her back and asked if an X-ray had ever been done. On 7/1/15 at 3:30 P.M., the radiology log book and physician's orders [REDACTED].#510. On 7/2/15 at 8:25 A.M., Resident #510 was observed in the main dining room, seated in a wheelchair. Resident #510 gestured that she needed help and appeared anxious, was tearful, and stated that she would like to go to her room. Resident #510 repeatedly reached into the front of her shirt and adjusted her bra and reported that it was uncomfortable. A staff member took Resident #510 to Nurse J on the unit. Resident #510 was heard asking Nurse J for medication. Nurse J told Resident #510, I have to check, but I think you already got something for anxiety. Resident #510 continued to reach into her shirt and pull at her bra. Nurse J stood at the medication cart that was facing the nurse's station with her back to the residents in the common area, including Resident #510. From 8:35 A.M. until 8:55 A.M., Resident #510 observed with facial grimacing, shifting her weight in the wheelchair, tearful, and anxious. At 8:45 A.M., Resident #510 was interviewed and asked if she was ok. Resident #510 was crying and stated, My whole body. It feels awful. I don't know what is going on. Resident #510 was asked if she hurt herself or had a fall. Resident #510 stated, I seem like I did, but I don't remember. I don't remember anything and placed her head down on her hands. At 9:00 A.M., Nurse J was asked if Resident #510 was okay. Nurse J stated, I'm waiting for the doctor to call back to give him the X-ray results. He hasn't called back yet. When queried about what she had called the doctor for, Nurse J reported that Resident #510 had an X-ray on 7/1/15 and had a L1 (lower back) compression fracture. Nurse J stated, She is anxious, but she already had her medication for anxiety. When queried about whether or not Resident #510 had been assessed for pain, Nurse J stated, I will see if she had her medication yet. I'm waiting for the doctor. A Radiology Report was reviewed on 7/2/15 at 9:00 A.M. and documented that on 7/1/15, Resident #501 had an X-ray of her lumbar spine. The results documented, .Age-indeterminate mild to moderate L1 Compression fracture . At 9:05 A.M., Nurse J walked over to Resident #510 and asked her if she was in pain. Resident #510 was grimacing, tearful, and pointed to her lower back area. The Medication Administration Record (MAR for July 2015) was reviewed at this time and documented that Resident #510 had an order for [REDACTED]. It was documented in the MAR that Resident #510 received the Tylenol #3 on 7/1/15 at 4:15 P.M. and 11:15 P.M., but had not received any PRN pain medication on 7/2/15. An additional order for [MEDICATION NAME] (a non-narcotic pain medication) 50 milligrams (MG) three times a day (TID) PRN was documented on the MAR. No doses had been given. At 9:30 A.M., Resident #510 remained in the common area, seated in a wheelchair. Resident #510 was observed coughing, holding her head in her hands, tearful and anxious and stated, My back. It hurts. I don't know what to do. When asked about how she hurt her back, Resident #510 stated, I don't know. Resident #510 put her head on her hands and fell over into a slumped over position in the wheelchair. Nurse J was standing at the medication cart with her back to Resident #510. Nurse J was informed that Resident #510 was slumped over in her wheelchair and stated, She just had her pain meds. I'm waiting for the doctor to call back. At 10:15 A.M., Resident #510 remained seated in a wheelchair in the common area of the unit, shifting her weight in the wheelchair. Resident #510 told Nurse J, It hurts. I don't know what to do. At 10:25 A.M., Resident #510 was observed self propelling her wheelchair to the couch located in the common area. Nurse J was standing at the medication cart with her back to Resident #510. Resident #510 attempted multiple times to stand up from the wheelchair and position the wheelchair so that she could transfer to the couch. It was immediately brought to Nurse Js attention to observe Resident #510 who was trying to transfer to the couch. At this time, Resident #510 told Nurse J that she would like to lay down in her bed. At 10:30 A.M., Nurse J was observed calling Resident #510's physician on the telephone. Nurse J gave report of the X-ray results of an L1 compression fracture, but did not mention anything about the pain Resident #510 had been experiencing for the past two hours. Nurse J was asked about what the physician said. Nurse J stated, He said he'd be in to see her later today. He didn't give any orders. At 10:35 A.M., Physical Therapy Assistant (PTA) L came to the unit where Resident #510 was. After telling Nurse J that she wanted to lay down because of her back, the nurse did not intervene when PTA L approached Resident #510 and stated, I'm going to take you to therapy like you do every day. At 10:40 A.M., PTA L brought Resident #510 into the therapy room. Resident #510 was grimacing, holding her head with her hands, lifting up her legs and shifting weight in the wheelchair. At 10:45 A.M., PTA L brought in some wheelchair leg rests and attempted to attach them to Resident #510's wheelchair. Resident #510 was observed to be crying, rubbing her head, and anxious. At 10:48 A.M., PTA L stated to Resident #510, I'm just going to get you a different wheelchair. I don't know where the leg rests are for this chair. At 10:55 A.M., Resident #510 remained tearful and was rubbing her back. PTA L assisted Resident #510 to a standing position with a gait belt and had her hold on to the therapy bar while another therapy staff member replaced the wheelchair with another one. Resident #510 was assisted back into the wheelchair. PTA L had Resident #510 stand a second time to place the wheelchair alarm sensor pad back on the seat of the new wheelchair, even though they were there at the time actively supervising the Resident and she was still visibly in distress. PTA L then took Resident #510 back to her room after telling the resident that she seemed to be in too much pain today. Resident #510 asked to be laid down on her bed. PTA L transferred her and Resident #510 was observed to fall asleep almost instantly after being laid down in her bed. PTA L was asked why Resident #510 was brought to the therapy room while in distress. PTA L stated, She needed leg rests in her wheelchair. She normally doesn't use leg rests because she self propels in the wheelchair. The last couple of days she has been in a lot of pain though so we thought it might make her more comfortable. PTA L was asked about her knowledge of the origin of the back pain Resident #510 had been experiencing. PTA L stated, I know she has an L1 compression fracture. That's what I was told in morning report and that she did not have any restrictions. PTA L was queried about Resident #510's participation in physical therapy. PTA L reported that on Monday (6/29/15), Resident #510 was placed back under therapy services after she had a fall on Sunday (6/28/15). PTA L explained that she thought Resident #510 participated in physical therapy on 6/29/15 and 6/30/15, but she did not work that day. PTA L reported that on Wednesday 7/1/15, she worked with Resident #510 with some standing exercises and stated, She wasn't in as much pain yesterday. She just complained of knee pain. Apparently her daughter was here and told them she had increased pain and so they ordered an X-ray last night. At 11:20 A.M., an observation of Resident #510's back was made with Nurse J. Resident #510 was observed to have an approximately 10 inch wide by 4 inch deep, dark purple bruise on the left side of her lower back toward the waist line of her pants and another dark, almost black colored bruise approximately 5 to 6 inches in diameter on her mid-back to the left of her spine. On 7/2/15 at 11:45 A.M., Nurse J was interviewed and asked why she did not report anything to the physician over the telephone about the pain Resident #510 had been experiencing all morning. Nurse J stated, I didn't purposely not tell him that. He didn't give any orders. I can give him a call back and tell him about her (Resident #510) pain. On 7/2/15 at 11:50 A.M., Resident #510's family member was interviewed about the pain Resident #510 had been experiencing. Resident #510's family member reported that Resident #510 had a fall in the day room and Nurse EE witnessed it. Resident #510's family member explained that she was waiting to hear from the doctor because they took X-rays of her back yesterday. Resident #510's family member reported that before the weekend, Resident #510 did not complain much of pain, but that it got really bad yesterday (7/1/15) and she requested X-rays. On 7/2/15 at 11:55 P.M., an Accident/Incident (A/I) Report completed by Nurse EE was reviewed which documented that on 6/27/15 at 9:15 A.M., Resident (#510) stood up from w/c (wheelchair) to transfer self without locking brakes and lost balance and fell into table and then onto floor on bottom. The injury was noted as a bruise deep in color to Resident #510's left side of back. The A/I also documented there was no visible injury. In the Treatment Required section, it was documented that X-rays were not ordered. In the Notification/Orders section, it was documented that the physician was notified on 6/27/15, however, the physician's statement/orders section was left blank. The A/I was not signed by the Medical Director to indicate it was reviewed. On 7/2/15 at 12:00 P.M., a PRN Medication Tracking form for June 2015 was reviewed and documented that from 6/2/15 through 6/25/15, Resident #510 scored between 5 and 8 on the pain level scale (1 being the least and 10 being the worst) prior to being administered PRN Tylenol #3 (narcotic). The pain levels following the fall on 6/27/15, were as follows: 6/27/15 at 5:00 P.M., pain scale = 9 6/28/15 at 4:00 P.M., pain scale = 9 6/28/15 at 9:00 P.M., pain scale = 8-9 6/29/15 at 7:00 A.M., pain scale = 9/10 6/29/15 at 11:30 A.M., pain scale = 9/10 6/29/15 at 8:00 P.M., pain scale = 8 6/30/15 at 11:30 A.M., pain scale = 10 6/30/15 at 6:00 P.M., pain scale = 9 However, a Fall Circumstance, Assessment and Intervention form, 72-hour Assessment, dated 6/28/15 and 6/29/15 documented that the resident did not experience pain. Physical Therapist (PT) K was interviewed on 7/2/15 at 12:30 P.M. about any PT Resident #501 had received in the past week. PT K reported that he received an order for [REDACTED].#510 as having a more difficult time walking and toileting. PT K stated, It was pain in her knee. She has always had it, but I guess it was hurting her more and she wasn't able to do as much. PT K was queried about whether or not he was aware that Resident #510 had a fall on 6/27/15. PT K stated, I didn't know about a fall. Nobody told me that. I was more involved with her knee pain. PT K reported that on 6/30/15, he worked with Resident #510 on walking and transferring. PT Daily Treatment Notes indicated that Resident #510 was evaluated on 6/30/15 by PT K and performed therapeutic exercises and activities, neuromuscular re-education, and gait training. On 7/1/15, PTA L documented, Patient performed the exercise x 30 reps with mod/max verbal cues for participation. Patient stated that her right knee and right side was hurting. Nursing notified and pain medicine given . Nurse EE was interviewed via the telephone on 7/2/15 at 2:55 P.M. regarding Resident #510's fall on 6/27/15. Nurse EE was queried about the process for monitoring Resident #510 for pain following the fall. Nurse EE stated, I worked the next day. I didn't notice any increased amount of pain. She was in a normal amount of pain. Her back and right knee always bother her. Nurse EE was queried about the documentation by her of increased pain on the PRN Medication Tracking form on 6/29/15 day shift that indicated Resident #510 experienced pain at level 9 out of 10 and if the physician was notified. Nurse EE reported that she did not notify the doctor of Resident #510's increased pain and thought it was just her usual amount of pain. The Director of Nursing (DON) was interviewed on 7/2/15 at 3:15 P.M. regarding the process for assessing residents' pain. The observations of Resident #510 being in visible distress and pain from 8:25 A.M. until 11:15 A.M. when she was assisted to bed, and the lack of reporting of pain to the physician from Nurse J were discussed with the DON. The DON not offer any explanation. Resident #510's clinical record was reviewed on 7/1/15 at 3:30 P.M. and 7/2/15 at 2:00 P.M. and revealed: The Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #510 had severely impaired cognition and required extensive assistance with transfers and ambulation; and experienced frequent, moderate pain within the five days prior to the assessment. Nurse's notes were reviewed since the admission date of [DATE] and there was no documentation of the fall that occurred on 6/27/15 or any nurse's notes since 5/1/15. An Individual Plan Report (Care Plan) for Pain Management documented, I have potential for pain .Listen to me when I tell you I am in pain. Observe my facial expressions and body language for indications of pain as well .Report any unrelieved pain to my doctor . physician's orders [REDACTED]. An order dated 6/30/15 for PT eval and tx .Dx: (diagnoses): General weakness, difficulty walking . An order dated 7/1/15 for STAT x-ray lower back (lumbar). The facility's undated policy titled, Guidelines for Pain Assessment and Management was reviewed on 7/2/15 at 3:00 P.M. and documented the following: .If there is a change in pain indicators or verbalizations from resident, a pain circumstance form will be completed to indicate changes and are plan update .Assess the resident for a condition that would indicate that pain may be expected (injury .) Assess for behaviors that may be indicators of pain or activities that increase indicators of pain . .Implement the care plan approaches to assist with pain management . .Evaluate the effectiveness of pain management interventions and modify as indicated . ( )

THIS CITATION HAS MULTIPLE DEFICIENT PRACTICES: DEFICIENT PRACTICE #1 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE TIMELY MONITORING AND SUPERVISION TO PREVENT ELOPEMENT AND INJURIES FOR ONE (#610) OF FIVE RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 12, RESULTING IN AVOIDABLE ELOPEMENT, INJURIES AND HARM. FINDINGS INCLUDE: ON 6/19/12 AT 2:55 P.M. DURING INITIAL TOUR OF UNIT 300 WITH NURSE "C," IT WAS OBSERVED THAT RESIDENT # 610 WAS LYING IN HER BED WITH A LEFT BLACK EYE. WHEN NURSE "C" WAS QUERIED REGARDING HOW RESIDENT #610 ACQUIRED THE BLACK EYE, SHE STATED, "SHE fell on FRIDAY, 6/15/12, TRIED TO ELOPE, THEY REPORTED THAT SHE WAS FOUND ON HER SIDE AND SO WAS HER WHEEL CHAIR, THE DOOR ALARM WAS GOING OFF (ON THE 300 DOOR AT THE END OF THE HALLWAY THAT LEADS TO THE DIRECT OUTSIDE)."IT WAS REPORTED THE RESIDENT WAS INJURED AND SUSTAINED ABRAISIONS TO THE SKULL, LEFT HIP, LEFT 2ND LITTLE TOE AND LEFT KNEE. ON 6/20/12, AT 12:00 P.M., DURING RECORD REVIEW, RESIDENT #610 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #610'S MINIMUM DATA SET ((MDS) dated [DATE] RATED THE RESIDENT'S COGNITIVE STATUS AS SEVERELY IMPAIRED. ADDITIONALLY, RESIDENT #610 HAD A LONG STANDING HISTORY OF ATTEMPTS TO ELOPE AS DOCUMENTED IN THE BEHAVIOR DETAIL REPORT PROVIDED BY THE FACILITY DATED 6/22/12. THE REPORT REVEALED SEVERAL ELOPEMENT ATTEMPTS WITH DATES ENTERED FROM 10/11 TILL 4/12 WITH NO FURTHER DOCUMENTATION CONCERNING ELOPEMENT IN THE BEHAVIORAL DETAIL REPORT. DOCTOR'S ORDERS FOR WANDERGUARD TO RIGHT WRIST WAS INITIATED ON NOVEMBER 11, 2011. FURTHER RECORD REVIEW REVEALED DOCUMENTATION IN THE NURSING NOTES OF MULTIPLE ATTEMPTS TO ELOPE FROM THE FACILITY AS FOLLOWS: "5/11/12 8 P.M.- RESIDENT CONTINUES TO EXHIBIT INCREASE IN ANXIETY/AGITATION...AGGRESSIVE WANDERING WITH NUMEROUS ATTEMPTS TO LEAVE BUILDING..." "6/15/12 10:00 A.M. RESIDENT WAS IDENTIFIED OUTSIDE LAYING ON HER LEFT SIDE ON THE PAVEMENT WITH HER WHEELCHAIR..." "6/18/12 6:50P.M., RESIDENT ATTEMPTED TO ELOPE, THE DOOR ALARM OF 300 HALL. DOOR SOUNDED AND STAFF MEMBERS WERE ABLE TO REDIRECT RESIDENT." ON 6/21/12, AT APPROXIMATELY 8:55 AM, THE FACILITY'S INVESTIGATION REPORT WAS REVIEWED. ON JUNE 15, 2012, THE STAFF REPORTED HEARING AN ALARM SOUNDING, THE CERTIFIED NURSING STAFF RESPONDED FROM THE 200 HALL AFTER IDENTIFYING THE LOCATION OF THE ALARM AS THE EXIT DOOR ON THE 300 HALL. IT REPORTEDLY TOOK THE CERTIFIED NURSING ASSISTANT LESS THAN FOUR MINUTES TO DISCOVER RESIDENT #610 OUTSIDE," 30 FEET AWAY FROM THE BUILDING, LAYING ON THE GROUND INJURED. THE INVESTIGATION REPORT IDENTIFIED THAT THE ASSIGNED NURSE FAMILIAR WITH THE RESIDENT AND CLOSEST TO THE ALARM DOOR FAILED TO RESPOND TO THE ALARM AT ALL. ON 6/21/12 AT 9:10 A.M., REVIEW OF THE CARE PLAN TITLED, "WANDERING," DATED 5/14/2012, REVEALED THE FOLLOWING UPDATE ON 6/15/12 FOR ELOPEMENT: 1) STAFF TO MONITOR RESIDENT'S WHEREABOUTS FREQUENTLY THROUGHOUT THEIR SHIFT, 2) STAFF TO KEEP DOOR ALARMS ON AS PER FACILITY POLICY AND, 3) REDIRECT RESIDENT WHEN RESIDENT APPROACHES EXIT DOORS. THERE WAS NO EVIDENCE THAT FACILITY STAFF WERE FREQUENTLY MONITORING THE WHEREABOUTS OF RESIDENT #610 WHILE IN THE FACILITY. ON 6/22/12 AT 10:30 A.M., THE DIRECTOR OF NURSING WAS QUERIED CONCERNING THE EXIT SEEKING BEHAVIOR OF RESIDENT #610, SHE STATED, "THE RESIDENT HAS A LONG HISTORY OF EXIT SEEKING BEHAVIOR" AND WHEN THE DIRECTOR OF NURSING WAS ASKED WHY THE INTERVENTION OF THE STAFF TO MONITOR THE RESIDENTS WHEREABOUTS WAS NOT IMPLEMENTED UNTIL 6/15/12, AFTER THE ELOPEMENT, SHE STATED, "WE MONITOR ALL OF OUR RESIDENTS CLOSELY" WHEN ASKED IF SHE COULD PRODUCE ANY EVIDENCE THAT COULD VERIFY DOCUMENTATION OF ANY TYPE OF CLOSE MONITORING, NONE COULD BE PRODUCED. ON 6/22/12 AT 1:30 P.M., DURING A CONCURRENT INTERVIEW WITH THE ADMINISTRATOR AND OBSERVATION OF THE FACILITY'S DOOR ALARM UNIT AND OPERABILITY, THE DOOR OF THE 300 UNIT WAS OPENED AND WAS EXPLAINED BY THE ADMINISTRATOR THAT THE DESIGN WAS TO ALARM IMMEDIATELY AND UNLOCK AFTER 15 SECONDS WHILE BEING PRESSED. WHEN THE ADMINISTRATOR WAS QUERIED WHY THE ASSIGNED UNIT NURSE DID NOT RESPOND TO THE ALARM, SHE STATED THAT, "SHE DIDN'T RESPOND THE WAY SHE WAS SUPPOSED TO." BASED ON THE FACILITY'S POLICY TITLED "PROCEDURE GUIDELINES ELOPEMENT RISK REDUCTION" REVISED 10/19/2007 UNDER PROCEDURE #1. STATES, "EACH RESIDENT WILL BE ASSESS UPON ADMISSION, MONTHLY AND WITH CHANGE IN CONDITION FOR FACTORS THAT MAY IMPACT THEIR OFF GROUNDS PRIVILEGES OR RISK FOR GOING TO AN UNSAFE AREA AND TO DETERMINE THE SUPERVISION REQUIRED TO LEAVE THE FACILITY GROUNDS. THE FACILITY FAILED TO FOLLOW ITS OWN POLICY ( ) DEFICIENT PRACTICE #2 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE ADEQUATE SUPERVISION AND ASSISTANCE DEVICES WERE USED TO PREVENT ACCIDENTS FOR ONE (#603) OF FIVE RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL OF 12 SAMPLED RESIDENTS, RESULTING IN A FALLS WITH INJURIES. FINDINGS INCLUDE: ON 6/20/12 AT 1:30 P.M., REVIEW OF THE ADMISSION FACESHEET FOR RESIDENT #603 DOCUMENTED THE RESIDENT WAS readmitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. PER REVIEW OF THE SIGNIFICANT CHANGE MINIMUM DATA SET ((MDS) dated [DATE], AND THE MOST RECENT QUARTERLY MDS dated [DATE], RESIDENT #603 WAS COGNITIVELY INTACT AND REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS AND AMBULATION, WITH ONE PERSON PHYSICAL ASSIST. REVIEW OF NURSING NOTES DATED 3/9/12, DOCUMENTED THE FOLLOWING: - AT 10:45 A.M.,"WHILE BEING TRANSPORTED IN A WHEELCHAIR TO THE HAIR SALON, RESIDENT #603's FEET GOT CAUGHT UNDERNEATH THE WHEELCHAIR AND THE RESIDENT fell FORWARD OUT OF THE CHAIR AND LANDED ON HER LEFT KNEE, HIP AND SIDE OF HER FACE. FACILITY STAFF FAILED TO ENSURE THAT THE RESIDENT WAS POPERLY POSITIONED FOR TRANSPORT IN THE WHEELCHAIR. THE RESIDENT COMPLAINED OF PAIN AND STAT X-RAYS WERE ORDERED FOR HER BILATERAL KNEES AND HIPS. THERE WAS A SMALL ABRASION AT THE TEMPORAL AREA OF THE LEFT SIDE OF THE RESIDENT'S HEAD." THERE WAS NO DOCUMENTATION OR EVIDENCE THAT WHEELCHAIR FOOT REST WERE IN USE FOR SAFETY. - AT 1:00 P.M., RESIDENT "COMPLAINED OF SORENESS TO LEFT KNEE, LEFT KNEE BRUISING NOTED." -AT 8:30 P.M., DOCUMENTED "XRAY NO ACUTE FRACTURE OR DISLOCATION." (THERE WERE NO NURSING NOTES, POST FALL ASSESSMENTS, VITAL SIGNS OR NEUROCHECKS DOCUMENTED AFTER 3/9/12). REVIEW OF THE FACILITY'S INCIDENT AND ACCIDENT REPORT (I/A) DATED 3/9/12 AT 10:40 A.M., DOCUMENTED- "TRANSPORTING RESIDENT TO HAIR SALON, RESIDENT FOOT GOT CAUGHT UP AND UNDER WHEELCHAIR. RESIDENT fell OUT OF CHAIR ON BILATERAL KNEES AND HANDS AND LEFT SIDE OF FACE SCRAPPED THE FLOOR." INJURY: ABRASION, REDNESS, BRUISE-SMALL IN SIZE LOCATION: SKULL/SCALP, BILATERAL KNEE. PREVENTION UPDATE: FOOT PEDALS ON WHEELCHAIR DURING TRANSPORTING. REVIEW OF THE FACILITY'S "FALL CIRCUMSTANCE, ASSESSMENT AND INTERVENTION" CHECK OFF FORM DATED 3/10/12-3/12/12, - WAS "LEFT BLANK" FOR ASSESSMENTS, VITAL SIGNS, AND NEUROCHECKS. ON 6/21/12 AT 2:30 P.M., DURING AN INTERVIEW AND RECORD REVIEW WHEN QUERIED, THE DIRECTOR OF NURSING (DON) WAS UNABLE TO EXPLAIN WHY THE RESIDENT WITH A HISTORY OF DIFFICULTY WALKING WAS BEING TRANSPORTED IN A WHEELCHAIR WITHOUT USING WHEEL CHAIR FOOT PEDALS FOR SAFETY. ( )