Every finding on record at Arrington Living Center

Based on interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from neglect when a Certified Nurse Aide (CNA) inappropriately transferred a dependent resident, resulting in a fractured femur for one (1) of two (2) residents reviewed for accidents, Resident #3. Based on the implementation of the facility's corrective actions on 4/24/25, the deficient practice was determined to be Past Non-Compliance (PNC) with measures put in place to correct the deficiency effective 4/25/25, prior to the State Agency (SA) entrance on 4/29/25. Findings include: Review of the facility's policy, Abuse, Neglect, and Exploitation, revised 10/10/2022, revealed, Policy: This facility's policy is to protect each resident's health, welfare, and rights by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect .Definitions .'Neglect' means the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . A record review of the facility's investigation, dated 4/23/25, revealed that during the 3-11 PM shift on 4/23/25, two Certified Nurse Aides (CNAs) noted Resident #3 had a swollen and painful left hip. The Registered Nurse (RN) supervisor assessed the resident and arranged for transfer to an acute care hospital. The facility was notified that Resident #3 had sustained a fracture. Upon reviewing security footage, the Administrator observed that Resident #3 was assisted with lunch, then later wheeled to her room by her daughter-in-law, who left the resident alone in the room in a geri-chair at 12:53 PM. The assigned CNA (CNA #1) later entered and exited the room between 1:13 PM and 1:18 PM. When questioned, the CNA admitted that no one assisted her with transferring Resident #3 and that she had transferred her by placing one arm under the legs and one under the arms. The CNA was immediately suspended pending the facility's investigation. A record review of the Admission Record revealed the facility admitted Resident #3 on 9/29/17 with diagnoses including Sick Sinus Syndrome. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/25 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated her cognition was severely impaired. Further review revealed Resident #3 was dependent upon staff for assistance with mobility including rolling left to right, moving from sitting to lying position, and getting in and out of the shower. A record review of the Emergency Department's Provider Notes, dated 4/24/25, revealed, .History .Nursing home reports that they noted that patient's left upper leg was swollen and appeared to be painful when they were changing her this evening .Left upper leg is swollen .X-ray hip - complete 2 views LT (Left) .Left hip arthroplasty with significantly displaced angulated overriding comminuted periprosthetic fracture of the proximal femoral shaft along the mid to distal aspect of the femoral stem component. Severe osteopenia. Soft tissue swelling . On 4/30/25 at 1:05 PM, during an interview with the Director of Nursing (DON), she explained that an investigation was initiated after the night shift charge nurse notified her on 4/23/25 that the resident had a knot with bruising on the left hip and appeared to be in pain. The DON instructed staff to contact the nurse practitioner, who recommended sending the resident to the ED (Emergency Department). The DON stated the ED physician questioned the injury mechanism and referred the incident to the Attorney General's office. The DON and Administrator questioned CNA #1 on 4/24/25, and CNA #1 admitted to lifting the resident out of her chair and into bed by herself. The DON stated that CNA #1 should have either used the stand-and-pivot method or a mechanical lift with other staff assistance. She emphasized the expectation that staff follow safe transfer techniques to prevent resident injury. On 4/30/25 at 10:42 AM, during an interview with CNA #1, she stated that on 4/24/25 she lifted the resident from the chair to bed using one hand under the hips and the other under the back. She acknowledged that lifting the resident in that way was inappropriate but felt comfortable doing so because of the resident's small size and her own strength. CNA #1 acknowledged the risk of injury, including broken bones, from improper lifting. On 5/1/25 at 9:20 AM, during an interview with RN #1 (Care Plan/MDS Nurse), she explained CNAs are instructed to use a lift if they are uncomfortable transferring a resident. She confirmed that Resident #3 was recommended for one-person stand-and-pivot transfer at the time of the injury. On 5/1/25 at 9:39 AM, during an interview with the facility's Occupational Therapist, he stated that therapy last saw Resident #3 on 9/9/24 and recommended one-person maximal assistance with a stand-and-pivot method. He stated this method was safest and that improper lifting could result in residents having serious injuries or falls. On 5/1/25 at 10:26 AM, during an interview with the Administrator, she confirmed CNA #1 admitted to lifting the resident inappropriately. The Administrator stated she did not believe the act was malicious and CNA #1 had no prior disciplinary issues, but the CNA was placed on leave pending investigation and later terminated. On 5/1/25 at 12:40 PM, during an interview with Resident #3's Resident Representative (RR), she stated the resident had experienced a recent incident that resulted in a hip fracture. She stated the injury occurred when CNA #1 lifted the resident from a chair to bed. She added that on 4/30/25 at 9:35 AM, the Administrator informed her that CNA #1 admitted to lifting the resident inappropriately. On 5/8/25 at 9:50 AM, during a post-exit interview with the Administrator, she explained that at the time of the inappropriate transfer, Resident #3 had a lift pad under her in the geri-chair because staff earlier in the day had used a mechanical lift to transfer her. She stated that while the resident could typically perform a stand-and-pivot transfer with assistance, her condition varied day to day. The Administrator emphasized that the staff are expected to evaluate transfers and, if a resident appears too weak or unstable to complete a safe pivot, a mechanical lift must be used. She explained that this expectation was reinforced through immediate in-services and education following the incident, which applied not only to residents with established lift orders, but to any resident whose transfer needs may change based on their condition at the time. The facility submitted the following corrective action plan: 1. Address how corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Certified Nurse Aide (CNA) (CNA #1) in question was suspended on April 24, 2025, pending investigation completion. Certified Nurse Aide (CNA) to be terminated week of April 28, 2025, following completion of investigation. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents using the lifts have the potential to be affected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. An Emergency Quality Assurance meeting was called at 9:20 a.m. on April 24, 2025, to discuss injury to Resident. Read and sign immediate education was placed in the In-Service Binder by the Staff Educator on April 24, 2025, regarding: i. Lift Education - Patient Lifts Safety Guide ii. Policy and Procedure for Safe Lifting Program iii. Step-by-step Instructions to find lift orders in the kiosk for residents. iv. Policy and Procedure for Abuse, Neglect, and Exploitation A 100% audit was conducted by the Minimum Data Set (MDS) Nurses of all residents using sit to stand or total lifts to verify sling sizes, care plans, lift evaluations, and orders were correct and accessible to staff through the Electronic Health Record kiosk. A 100% audit was conducted by the Minimum Data Set (MDS) Nurses of all residents diagnosed with osteopenia or osteoporosis to review care plans. All Nurses and Certified Nurse Aides (CNA) will complete one-on-one checkoffs on proper use of the lift beginning April 24, 2025, by Quality Assurance (QA) Nurse, Staff Educator, Registered Nurse Supervisors, or DON. All Nurses and CNAs will continue to complete skills checkoffs for sit to stand lift and total lift bi-annually and on hire. In addition to lift usage review in Quality Assurance and Performance Improvement (QAPI) committee, the committee will review any specific changes or needs for further education of staff beginning during the QAPI meeting on April 30, 2025, and continue for three months. Conducted a directed in-service on April 24, 2025, at 3:00 p.m. with consultant via Zoom on abuse, neglect, and exploitation. Recording of in-service was distributed by Remind to all staff unable to attend to watch prior to working next shift. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. QA Nurse began spot rounds regarding proper use of lifts on April 24, 2025, and will continue every week for four weeks, then every month for three months, and then quarterly. Audit results will be reviewed by the OAPI Committee on April 30, 2025, and monthly for three months until such time consistent substantial compliance has been achieved as determined by the committee. 5. Indicate the date(s) the corrective action(s) will be completed. The corrective action will be completed by April 24, 2025, with audits to continue until substantial compliance is reached. Validation: The State Agency (SA) validated on 5/1/2025, through interview and record review that all corrective actions had been implemented as of 4/24/25, and measures put in place to correct the deficiency effective 4/25/25, prior to the SA's entrance on 4/29/25.

Based on record review, interview, and facility policy review, the facility failed to complete and submit Quarterly Minimum Data Set (MDS) assessments within the required timeframe of no more than ninety-two (92) days from the prior assessment for two (2) of nineteen (19) sampled residents, Resident #21 and Resident #42. Findings Included: A review of the facility's policy, MDS Assessments, revised 2/18/25, revealed, .Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a .standardized assessment of each resident's functional capacity .Types of .Assessments .e. Quarterly Assessment - completed using an ARD (Assessment Reference Date) no >(greater than) 92 days from the most recent prior quarterly or comprehensive assessment . Resident #21 A record review of the Admission Record revealed the facility admitted Resident #21 on 3/19/24 with current diagnoses including Generalized Osteoarthritis. A record review of the electronic health record revealed on the MDS tab that Resident #21 had a Quarterly MDS with an ARD of 3/24/25 with a status of Export Ready. Resident #42 A record review of the Admission Record revealed the facility admitted Resident #42 on 1/29/24 with current diagnoses including Hemiplegia. A record review of the electronic health record revealed on the MDS tab that Resident #42 had a Quarterly MDS with an ARD of 3/24/25 with a status of In Progress. On 5/1/25 at 11:49 AM, during an interview with Registered Nurse (RN) #1/MDS nurse, she explained that the MDS department reviews every resident's MDS, and any issues are generally caught at that time. She confirmed that Resident #21's Quarterly MDS had been completed but not exported and was twenty-two (22) days overdue, and Resident #42's Quarterly MDS was in progress and was twenty-five (25) days overdue. She stated she was not sure how these were missed by the facility. On 5/1/25 at 1:25 PM, during an interview with the Director of Nursing (DON), she stated she expected the MDS to be submitted on time.

Based on record reviews, interviews, and facility policy review, the facility failed to implement a comprehensive care plan intervention for a resident transfer with a stand mechanical lift, resulting in left ankle fractures for one (1) of three (3) resident care plans reviewed. Resident #1. Based on the implementation of the facility's corrective actions on 1/17/24, the deficient practice was determined to be Past Non-Compliance (PNC) and the facility was in compliance effective 1/18/24. Findings include: A review of the facility's policy, Comprehensive Plan of Care, revised 10/10/22, revealed POLICY: It is the policy of this facility to .implement a comprehensive person-centered care plan for each resident .Policy explanation and Compliance Guidelines .3. The comprehensive care plan will describe .a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . A record review of the Care Plan revealed Focus The resident has an ADL (Activities of Daily Living) self-care performance deficit .Interventions .TRANSFER: The resident requires STAND lift X (times) 2 staff for transfers. Date initiated 1/10/24 . A record review of the facility's investigation, dated 1/18/24, revealed that on 1/17/2024, Resident #1 reported she had pain in her left foot and that her foot had hit something while she was being transferred from the wheelchair to the bed the prior afternoon (1/16/24). The resident received x-rays and upon obtaining the images, the Nurse Practitioner gave an order to transfer the resident to an acute hospital. Additional x-rays were obtained which revealed she had fractures. An investigation was completed, and it was found that CNA #4 was transferring Resident #1 and did not use a stand lift, which was what the resident required per her care plan. A record review of the Admission Record revealed the facility admitted Resident #1 on 12/28/2011 with current diagnoses including Chronic Obstructive Pulmonary Disease and Muscle Weakness. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/2023 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. A record review of the Physician's Order Sheet, revealed Resident #1 had a Physician's Order, dated 1/10/24, for Stand lift x (times) 2 persons for transfers. A record review of the local hospital report, dated 1/17/24, revealed Resident #1 had an acute spiral fracture lateral malleolus (outside ankle) and an acute avulsion fracture medial malleolus (inner side of ankle). During an interview on 02/15/2024 at 09:25 AM, Resident #1 revealed a CNA came into the room and assisted her from the wheelchair to her bed and did not use any type of mechanical lift. During an interview on 02/15/2024 at 12:15 PM, with the Director of Nursing (DON), revealed CNA #4 did not use the stand lift as was required per the Physician's Order and plan of care for Resident #1. He stated that he expected the staff to review the resident's care plan to ensure the resident was properly transferred. During an interview on 02/15/2024 at 12:30 PM, with the Administrator, she revealed the resident was not transferred appropriately per the care plan and Physician's Order. She stated that the facility conducted a thorough investigation and reported the fracture to the authorities as required. CNA #4 was placed on leave pending the investigation on 1/17/24 and was terminated on 1/18/24 because she did not come to Human Resources for a meeting as requested. The Administrator said that residents and other staff were interviewed and there were no other instances in which a resident was inappropriately transferred. The facility had an emergency Quality Assurance Performance Improvement (QAPI) meeting on 1/17/24 at 2:40 PM to discuss the injury to the resident. The facility's policies regarding mechanical lifts were reviewed during the QAPI meeting and there were no changes recommended to the current policy. The facility provided immediate education beginning 1/17/24 on Lift Education, Policy and Procedure for Safe Lifting Program, Step by step instruction to find lift orders in the kiosk for residents, and policy and procedure for Abuse, Neglect and Exploitation. She explained that a 100% audit was conducted of all residents using the stand and full body lifts to verify sling sizes, care plans and Physician Orders to ensure all were correct and accessible to staff through the electronic health records. All nurses and CNAs completed one-on-one checkoffs on the proper use of the lift beginning 1/17/24 and no staff were allowed to work until in-service training was completed. Lift skills checkoffs for nurses and CNAs will be completed bi-annually and upon hire. The QAPI committee will review lift usage and the need for further education of staff for the next three months. Based on implementation of the facility's corrective actions on 1/17/24, the deficient practice was determined to be Past Non-Compliance (PNC) and the facility was in compliance effective 1/18/24. Validation: On 2/15/24, the State Agency (SA) validated the following: The SA validated through interviews and record review that the facility completed a thorough investigation and reported the event to the SA and the Attorney General's Office. The SA validated through staff interview and record review CNA #4 was suspended on 1/17/24 pending the facility's investigation and was terminated on 1/18/24. The SA validated through interviews and review of the QAPI sign in sheet the facility held a Quality Assurance Performance Improvement (QAPI) meeting on 1/17/24 at 2:40 PM and the facility's policies regarding mechanical lifts were reviewed. The SA validated through staff interview and in-service sign in sheets that the facility provided immediate education beginning 1/17/24 on Lift Education, Policy and Procedure for Safe Lifting Program, Step by step instruction to find lift orders in the kiosk for residents, and policy and procedure for Abuse, Neglect and Exploitation. The SA validated through staff interview and record review the facility conducted a 100% audit of all residents using the stand and full body lifts to verify sling sizes, care plans and Physician Orders to ensure all were correct and accessible to staff through the electronic health records. The SA validated through staff interview and record review of competency checkoffs, that all nurses and CNAs completed one-on-one checkoffs on the proper use of the lift beginning 1/17/24 and no staff were allowed to work until in-service training was completed.

Based on record reviews, interviews, and facility policy review, the facility failed to ensure a resident was free of accidents and/or hazards during a transfer when a Certified Nurse Aide (CNA) transferred Resident #1 from the wheelchair to the bed without using the required stand mechanical lift, resulting in left ankle fractures for one (1) of three (3) residents reviewed for accident/hazards. Resident #1. Based on the implementation of the facility's corrective actions on 1/17/24, the deficient practice was determined to be Past Non-Compliance (PNC) and the facility was in compliance effective 1/18/24. Findings include: A review of the facility's policy Safe Lifting Program, revised 09/22/2022 revealed, POLICY: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury . Compliance Guidelines .3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs .10. Two staff members must be utilized when transferring residents with a mechanical lift .13. Staff members are expected to maintain compliance with safe handling/transfer practices . A record review of the facility's investigation, dated 1/18/24, revealed that on 1/17/2024, Resident #1 reported she had pain in her left foot and that her foot had hit something while she was being transferred from the wheelchair to the bed the prior afternoon (1/16/24). The resident received x-rays and upon obtaining the images, the Nurse Practitioner gave an order to transfer the resident to an acute hospital. Additional x-rays were obtained which revealed she had fractures. An investigation was completed, and it was found that CNA #4 was transferring Resident #1 and did not use a stand lift, which was what the resident required per her care plan. A record review of the local hospital report, dated 1/17/24, revealed Resident #1 had an acute spiral fracture lateral malleolus (outside ankle) and an acute avulsion fracture medial malleolus (inner side of ankle). A record review of the Physician's Order Sheet, revealed Resident #1 had a Physician's Order, dated 1/10/24, for Stand lift x (times) 2 persons for transfers. A record review of the Admission Record revealed the facility admitted Resident #1 on 12/28/2011 with current diagnoses including Chronic Obstructive Pulmonary Disease and Muscle Weakness. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/2023 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. On 02/15/2024 at 09:25 AM, an interview with Resident #1 revealed a CNA came into the room and assisted her from the wheelchair to her bed. She stated that she bumped her leg on something, but she did not report that her foot was hurt until the next morning. She said the nurse came and looked at her foot and then she was sent to the hospital. She confirmed the CNA transferred her by helping her to stand and did not use any type of mechanical lift. On 02/15/2024 at 10:30 AM, an interview with CNA #1 revealed there was information on the kiosk that indicated how a resident was to be transferred, including if a mechanical lift was required or how many staff were required to complete the transfer. On 02/15/2024 at 12:15 PM, an interview with the Director of Nursing (DON) revealed he assisted with the investigation in which CNA #4 transferred Resident #1 to the bed without using the mechanical lift. He acknowledged that CNA #4 did not use the stand lift as was required per the Physician's Order and plan of care for Resident #1. He stated that he expected the staff to review the resident's care plan to ensure the resident was properly transferred. On 02/15/2024 at 12:30 PM, an interview with the Administrator revealed the resident was not transferred appropriately per the care plan and Physician's Order. She stated that the facility conducted a thorough investigation and reported the fracture to the authorities as required. CNA #4 was placed on leave pending the investigation on 1/17/24 and was terminated on 1/18/24 because she did not come to Human Resources for a meeting as requested. The Administrator said that residents and other staff were interviewed and there were no other instances in which a resident was inappropriately transferred. The facility had an emergency Quality Assurance Performance Improvement (QAPI) meeting on 1/17/24 at 2:40 PM to discuss the injury to the resident. The facility's policies regarding mechanical lifts were reviewed during the QAPI meeting and there were no changes recommended to the current policy. The facility provided immediate education beginning 1/17/24 on Lift Education, Policy and Procedure for Safe Lifting Program, Step by step instruction to find lift orders in the kiosk for residents, and policy and procedure for Abuse, Neglect and Exploitation. She explained that a 100% audit was conducted of all residents using the stand and full body lifts to verify sling sizes, care plans and Physician Orders to ensure all were correct and accessible to staff through the electronic health records. All nurses and CNAs completed one-on-one checkoffs on the proper use of the lift beginning 1/17/24 and no staff were allowed to work until in-service training was completed. Lift skills checkoffs for nurses and CNAs will be completed bi-annually and upon hire. The QAPI committee will review lift usage and the need for further education of staff for the next three months. Based on implementation of the facility's corrective actions on 1/17/24, the deficient practice was determined to be Past Non-Compliance (PNC) and the facility was in compliance effective 1/18/24. Validation: On 2/15/24, the State Agency (SA) validated the following: The SA validated through interviews and record review that the facility completed a thorough investigation and reported the event to the SA and the Attorney General's Office. The SA validated through staff interview and record review CNA #4 was suspended on 1/17/24 pending the facility's investigation and was terminated on 1/18/24. The SA validated through interviews and review of the QAPI sign in sheet the facility held a Quality Assurance Performance Improvement (QAPI) meeting on 1/17/24 at 2:40 PM and the facility's policies regarding mechanical lifts were reviewed. The SA validated through staff interview and in-service sign in sheets that the facility provided immediate education beginning 1/17/24 on Lift Education, Policy and Procedure for Safe Lifting Program, Step by step instruction to find lift orders in the kiosk for residents, and policy and procedure for Abuse, Neglect and Exploitation. The SA validated through staff interview and record review the facility conducted a 100% audit of all residents using the stand and full body lifts to verify sling sizes, care plans and Physician Orders to ensure all were correct and accessible to staff through the electronic health records. The SA validated through staff interview and record review of competency checkoffs, that all nurses and CNAs completed one-on-one checkoffs on the proper use of the lift beginning 1/17/24 and no staff were allowed to work until in-service training was completed.

Based on observations, staff interviews, and facility policy review, the facility failed to sanitize a full body lift between use for two (2) of four (4) observations. Findings Include: A review of the facility's policy, Standard Precautions Infection Control, (undated), revealed, Policy: All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to 'Standard Precautions' to prevent the spread of infection Definitions: Standard Precautions represent the infection prevention measures that apply to all resident care, regardless of suspected or confirmed infection status of the resident, in any setting where healthcare is delivered . On 09/12/2022 at 09:00 AM, the State Agency (SA) observed Certified Nursing Assistant (CNA) #1 retrieve a full body lift directly from the hallway and take it into an unsampled resident's room on the 400 Hall. CNA #1 did not sanitize the lift before use. CNA #3 assisted CNA #1 with transferring the resident inside the resident's room. On 09/12/2022 at 09:19 AM, the SA observed CNA #1 pushing the full body lift out of the same unsampled resident's room and back into the hallway on 400 Hall. CNA #1 did not disinfect the lift after use. CNA #2 immediately retrieved the lift from the hallway and pushed it to the 300 Hall for CNA #4 to use. On 09/12/2022 at 09:34 AM, the SA observed CNA #4 pushing the lift inside the room of an unsampled resident room on the 300 Hall. CNA #4 was assisted in the room by Licensed Practical Nurse (LPN) #2. On 09/12/2022 at 09:40 AM, the SA conducted an interview with CNA #4, who stated that she did not clean the lift and that she did not know it was supposed to be cleaned. She stated that she more than likely had training on it but does not remember because she works PRN (as needed). On 09/12/2022 at 09:42 AM, the SA conducted an interview with LPN #2, who confirmed that she did not clean the lift, but has received training on infection control. On 09/12/2022 at 09:49 AM, the SA conducted an interview with CNA #1, who confirmed that she did not clean the lift and that she should have cleaned it. She stated that it is important to clean it because it can move one contamination from one resident to another resident. On 09/12/2022 at 09:55 AM, the SA conducted an interview with CNA #2, who stated that she was asked to bring the lift to CNA #4, so she grabbed it from the 400 Hall and brought it to the 300 Hall. She stated that she did nothing with it before or after that. On 09/12/2022 at 10:03 AM, the SA conducted an interview with CNA #3 who confirmed that she did not clean the lift and that cleaning the lift slipped her mind. She also confirmed that she was supposed to clean the lift. On 09/13/2022 at 09:14 AM, the SA conducted an interview with the Infection Preventionist Nurse (IP) #1, who stated that the reason it is important to clean the equipment in-between use is to prevent the spread of infection. She confirmed that the lift should have been cleaned between usage and that staff had received training on that matter. On 09/13/22 at 10:36 AM, the SA conducted an interview with the Director of Nursing (DON), who confirmed that it is important to clean the equipment between use to cut down the spread of infection. She verified that the staff has had training and should have cleaned the lift. A record review of the Inservice Sign In Sheet revealed an inservice was conducted with the Topic: Prevention and Control of Infection Standard Precautions Covid 19 protocols with the Date listed as July Inservice All Staff. The inservice sheet included the signatures of CNA #1, CNA #2, CNA #4, and LPN #2 which indicated they had received training on infection control.

Based on observations, interviews, and record reviews, the facility failed to wash a resident's hair, who was dependent on staff for Activities of Daily Living (ADL) for one (1) of two (2) residents reviewed for ADL care. Resident #17 Findings Include: On 09/12/22 at 9:21 AM, during an observation and interview with Resident #17 stated she gets a bath once a week. The resident's hair looked oily and unclean. Resident #17 states that she gets her hair washed sometimes. On 09/13/22 at 8:58 AM, in an observation and interview with Resident #17 said I have not had a bath this week. The resident's hair continues to look oily and unclean. On 09/14/22 at 3:30 PM, in an observation and interview with Resident #17 stated she still has not had a bath this week and has never refused one. The resident's hair continues to look oily and unclean. On 09/15/22 12:06 PM, in an interview with Certified Nursing Assistant (CNA) #2 she stated that a bed bath consists of head-to-toe bath, including washing the resident's hair. On 09/15/22 at 1:02 PM, in an interview with CNA #7 she confirmed that a bed bath consisted of the resident's whole body, including the hair. She verified that Resident #17's hair was oily. On 09/15/22 at 1:05 PM, in an interview with Resident # 17 she stated that her hair needs washing. Resident #17 commented that although she received a bath yesterday, the CNA did not wash her hair. On 09/15/22 at 1:07 PM, in an interview with Licensed Practical Nurse (LPN) #2 she stated that Resident #17's hair usually does not look oily and that Resident #17's hair, Is a little oily. On 09/15/22 at 1:10 PM, in an interview with the Director of Nursing (DON) she stated that Resident #17 just got off of non-weight bearing status this week and could now start receiving showers again. While the resident was on non-weight bearing status she had to receive bed baths. She said she had expected the CNAs to wash her hair when completing a bed bath because a bed bath included a head-to-toe bath. On 09/15/22 at 3:40 PM, in an interview with CNA #5, she stated that baths and showers are documented in the Activities Daily Living (ADL) section in the computer when it is completed. She confirmed that when a resident receives a bed bath, it should include the hair being washed every time, but admitted that she does not wash the resident's hair with every bed bath. CNA #5 said that she washes residents hair probably twice a week. Record review of the Face Sheet revealed the facility admitted Resident #17 on 11/13/18 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/9/22 revealed a Brief Interview for Mental Status score of 11, which indicated Resident #17 has moderate cognitive impairment. Section G indicated Resident #17 required one-person physical assistance with bathing. Record review of the Shower List revealed Resident #17 received a Bed Bath on 9/12/22 and 9/14/22. Record review of the Inservice Sign In Sheet revealed the facility provided training on ADL care from 4/26/22 through 4/28/22.

Based on interviews, record review, and facility policy review, the facility failed to ensure residents received their mail on Saturdays for two (2) of 15 sampled residents. Resident #1 and Resident #22. This had the potential to affect 59 residents. Findings Include: Record review of the facility policy Mail and Telephone Services with a revised date of 11/28/17 revealed Purpose: To facilitate communication between the residents and their significant others via telephone and mail services . On 09/14/22 at 10:11 AM, during the Resident Council meeting, Resident #22 stated that they do not get mail on the weekends. There is no one at the facility to go to the post office to get the mail on Saturday. Resident #22 stated that she has inquired about the mail in the past and nothing was done about it. Record review of the Face Sheet revealed Resident #22 was admitted by the facility on 4/18/16 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/22 revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. On 09/14/22 at 10:35 AM, in an interview with Activities Director, stated that about a year ago, the residents agreed in a resident council meeting to only have their mail delivered Monday through Friday. She said the facility has a Post Office (PO) box and someone, usually the Administrator, must go to the post office to get the mail. She explained that neither herself nor the Administrator works on weekends, so the mail is not picked up at the PO box on Saturdays. On 09/15/22 at 1:38 PM, in an interview with Resident #1, she stated she does not get mail on Saturdays. She receives a lot of mail from family and friends, and also receives catalogs that she enjoys looking through. She would like to get mail on Saturdays. She regularly receives letters from her sister because it is the only way she can communicate with her. She stated that she had been told by the facility that she could not receive mail on Saturdays because no one is at the facility on weekends to get it. Resident #1 commented, I would be thankful if I could get my mail on Saturday. Record review of the Face Sheet revealed Resident #1 was admitted by the facility on 11/15/19 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the quarterly MDS with an ARD of 08/30/22 revealed Resident #1 had a BIMS score of 15, which indicated she was cognitively intact. On 09/15/22 at 2:35 PM, in an interview with the Administrator, she stated residents do not get mail on Saturday. Most of the facility's mail goes to the adjoined hospital's business office and no one is there to get the mail on Saturdays. She confirmed the facility also has a PO box that is checked Monday through Friday, but no one is at the facility to check it on Saturday. She stated that It is the resident's right to receive mail on the weekends.

Based on observations, staff interview, record review, and facility policy review, the facility failed to ensure dishes, pots and pans were sanitized to prevent the possibility of food borne illnesses, staff failed to wash their hands between contact with clean and dirty dishes for three (3) of three (3) kitchen observations. Findings include: Review of the facility's policy titled,(NAME)Washing, dated (MONTH) 2014, revealed: It is the center policy that all dishware and service ware will be cleaned and sanitized after each use. The Food Services Director insures that the nutrition service staff is knowledgeable in proper technique for processing dirty dish ware to clean through the dish machine and proper handling of sanitized dish ware. The Food Services Director ensures that all the dish machine water temperatures are maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. Review of the facility's policy titled, Manual(NAME)Washing, dated (MONTH) 2014, revealed It is the center policy to ensure all service ware and cook ware that is not processed through the dish machine will be manually washed and sanitized. The Food Service Director ensures that the Dining Service staff is knowledgeable in proper technique for washing, rinsing, and sanitizing. An observation, on 08/01/19 at 8:43 AM, during the dishwashing machine process, two trays full of cups were run through the dish machine, the rinse water got to 140 degrees Fahrenheit (F). The dishwash machine was a hot temp machine. Dietary Department Staff (DDS) Staff # 1 staff doing the dishwashing and was observed to touch the dirty dishes and then the clean dishes without washing her hands. DDS#1 handled the clean cups without washing her hands. DDS #2 entered the dishwashing area and also observed DDS #1 touching the clean dishes and then the dirty dishes without washing her hands in between the contacts. In an interview, on 8/01/19 at 1:30 PM, DDS #2 revealed the potential harm of the dishwasher temperature not reaching 180 degrees F was bacteria growth and infectious diseases. DDS #2 revealed the manufacturers temperature recommendations for the rinse water for the dish machine was 180 degrees F. DDS #2 also stated the harm of staff not washing their hands after handling dirty dishes and then handling clean dishes was the potential for contamination. An observation, on 07/30/19 at 10:00 AM, revealed the rinse water's chemical sanitizer level, in the three compartment sink, was required to be 200 to 400 parts per million (ppm). However, on 07/30/19 at 10:00 AM, the chemicals in the rinse water only tested at 20 ppm. An observation, on 08/01/19 at 9:00 AM, revealed, the three compartment, sink's chemical level registered at zero (0) ppm. In an interview, on 08/01/19 at 1:30 PM, DDS #2 revealed the three compartment sink chemical level was supposed to register from 150 to 400 ppm.

Based on record review, facility policy review, and staff interview, the facility failed to revise Resident #18's Comprehensive Care Plan for the use of an anti-coagulate medication, for one (1) of 14 care plans reviewed. Findings include: Review of the facility's policy titled, Comprehensive Plan of Care, dated 11/26/2017, revealed it is the policy of this facility that Plans of Care are developed by the Interdisciplinary Team, to coordinate and communicate care, approaches, and goals for the resident related to clinical [DIAGNOSES REDACTED]. The facility policy stated the plan of care will be reviewed and revised: Quarterly, annually, with significant change of status, and as needed; to enhance the resident's ability to meet his/her objectives. Review of Resident #18's medical record documentation titled, Care Plan, revealed a Problem/Need, with an onset date of 03/08/2018, for the risk of bleeding/bruising related to (r/t) the use of Aspirin and anti-platelet medications. The Care Plan's Approaches included: The Nursing department is to administer medications as ordered, and the nursing department is to Notify Medical Director (MD) as warranted. The Goal and Target Date was 09/18/2019. During an observation, on 7/30/2019 at 9:30 AM, Resident #18 was sitting in the day room area in her wheel chair. Resident #18 had multiple bruise-like areas to her Bilateral Upper Extremities (BUE). Review of Resident #18's medical record documentation titled, (MONTH) 2019 Physician Orders, revealed an order, dated 04/30/18, for the anti-coagulate medication Eliquis (apixaban) five (5) milligrams (mg) to be given by mouth (PO) twice a day (BID). The order also revealed this medication was prescribed for the diagnosis (DX) of [MEDICAL CONDITIONS] of the Bilateral Lower Extremities (BLE). Review of Resident #18's medical record documentation titled, Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/12/2019, revealed section N0410E was coded that Resident #18 had received an anti-coagulate medication for the seven (7) day look back period. During an interview, on 08/01/2019 at 11:30 AM, Registered Nurse (RN) #1/ Care Plan/MDS Coordinator, confirmed the comprehensive Significant Change MDS, for 06/12/2019, was coded to indicate the resident was on an anti-coagulate medication for the seven (7) day look back period. RN #1 stated the Care Plan had not been revised to include the use of the anticoagulant medication. RN #1 stated that was an order for [REDACTED]. During an interview, on 08/01/2019 at 2:15 PM, the Director of Nursing (DON), confirmed the anticoagulant should have been added to Resident #18's current care plan. The DON stated the order for the medication had an order date of 04/30/2018, and was on the Physician order [REDACTED]. Review of the Face Sheet revealed the facility admitted Resident #18, on 03/08/2018 and readmitted Resident #18 on 04/30/2019, with [DIAGNOSES REDACTED].

Based on observation, staff interview, record review and facility policy review, the facility failed to develop a Care Plan related to a resident's behaviors, for one (1) of 18 Care Plans reviewed, Resident #15. Finding include: A review of the facility's policy titled, Care Plan, revised 11/28/17, revealed the care plans would be developed by the interdisciplinary team to coordinate and communicate care approaches and goals for the resident related to clinical [DIAGNOSES REDACTED]. A review of Resident #15's Current Comprehensive Care Plan, with Goal and Target dates of 09/18/19, revealed no care plan for behavioral concerns. Review of the facility's Resident Incident Report, dated 02/17/19, revealed Resident #15's wheelchair was bumped by another resident's wheelchair at the dining room table and Resident #15 kicked the other resident in the ankle under the table. The incident report revealed after the investigation, the facility concluded no injuries were noted, and the residents were separated without any incident before or after. The facility determined that seating arrangements were to be changed during dining, and both residents agreed to the changes. An interview was attempted, on 07/30/19 at 3:58 PM, with Resident #15. However Resident #15 refused to talk to this surveyor related to the incident. Resident #15 was ambulatory with wheelchair in the hallway with a Certified Nursing Assistant (CNA) at her side. Resident #15 said I'm too busy right now. An observation, on 07/31/19 at 9:59 AM, revealed Resident #15 was sitting in the dining room by the TV with other residents without any behaviors noted. A review of the Significant Change Minimum Data Set (MDS) assessment, with an Assessment Reference Dates (ARD) of 04/23/19 and 06/12/19, revealed no behaviors were documented for the review periods. A review of the Resident #15's Nurses Notes revealed no further incidents or behaviors were documented regarding since the incident on 02/17/19. An interview, on 07/31/19 3:57 PM, revealed the Director of Nursing (DON) said Resident #15 had not had any indications of this behavior prior to the incident on 02/17/19. The DON said the resident was very picky as to who she would talk to, but did not show any verbal or physical behaviors towards staff or residents before or after the incident. An interview, on 07/31/19 at 4:42 PM, with Social Service (SS) revealed she would update the care plan for Resident #15 with any behavior issues, but she said that the incident on 02/17/19 was considered a misunderstanding more than a behavior issue, and therefore she would not care plan those. An interview, on 08/01/19 at 9:53 AM, revealed the DON said she thought the facility should have care planned the incident related to behaviors for Resident #15 so staff could be aware of concerns or problems for the resident. Review of the Face Sheet revealed the facility admitted Resident #11, on 03/09/12, with the included [DIAGNOSES REDACTED]. Review of Resident #15's Significant Change MDS, with an ARD of 06/12/19, revealed a Basic Interview for Mental Status (BIMS) score was 12, which indicated moderate cognitive impairment.

Based on staff interview, record review and facility policy review, the facility failed to provide written notification of transfer to the resident or the Resident Representative (RR) for two (2) of four (4) hospitalization s reviewed, Resident #32 and Resident #11. Findings include: Review of the facility's policy titled, Bed Hold Policy Before and Upon Transfer, dated 11/28/17, revealed: Notice Before a Transfer: Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or the resident representative that specifies the nursing facility's policies regarding bed hold periods. Notice at Time of Transfer: The second notice must be provided to the resident, and if applicable the resident's representative, at the time of transfer, or in cases of an emergency transfer, within 24 hours. The notice must provide information to the resident that explains the duration of bed hold, if any, and the reserve bed payment policy. It should also address permitting the return of residents to the next available bed. Resident #32 Review of the Face Sheet revealed the facility admitted Resident #32, on 6/25/19, with the included [DIAGNOSES REDACTED]. Review of the Departmental Notes-Nursing revealed Resident #32 was sent to the hospital on [DATE] and returned to the facility on [DATE]. Review of Nurses Notes, on 07/03/19 at 1:39 PM, revealed Resident #32 was sent out to the emergency room (ER) due to an Illuis related to a small bowel obstruction. The Nurses Note, on 07/15/19 at 8:11 PM, revealed Resident #32 returned to the facility. Nurses Note dated 07/17/19 at 8:49 PM revealed Resident #32 was status [REDACTED]. Today had episodes of nausea and vomiting and elevated temp. Order to send to (Name of Hospital) for evaluation by surgeon. Further review of the Nurses Notes revealed Resident #32 returned to the facility, on 07/19/2019, with [DIAGNOSES REDACTED]. On 07/31/19 at 2:40 PM, an interview revealed the Administrator reported there was no written notification to Resident # 32 or the Resident's Representative regarding the hospital transfers. No documentation was located in Resident #32's medical record of any written notifications regarding the resident's transfers to the hospital were provided to Resident #32 or the Resident's Representative. Resident #11 Review of the Face Sheet revealed Resident # 11 was admitted by the facility, on 03/06/19, with the included [DIAGNOSES REDACTED]. Review of the Department Notes-Nursing, dated 06/17/19 at 9:01 AM, revealed at 8:10 AM Resident #11 was found on the floor on her right side. The resident was assessed and no injuries were found. Resident #11 said she was going over to the roommate's side of the room and tripped on a blanket. Resident. The Department Note-Nursing on 06/17/19 at 9:29 AM revealed Resident #11 was verbalizing suicidal ideation, stated she swallowed hair pins, and she wanted to die. The Nurse Practitioner was notified and Resident #11 was transferred to the hospital for further evaluation. The suicidal ideation was reported to the Emergency Medical staff at the time of the transfer, and the hospital emergency room Resident #11 was transferring to. Further review of the Department Notes-Nursing revealed on 07/02/19 at 12:50 PM, Resident #11 returned to the facility. An interview, on 07/31/19 2:40 PM, revealed the Administrator stated there was no written notification to Resident #11 or the Resident's Representative regarding the hospital transfer. No documentation was located in Resident #11's medical record of any written notifications regarding the resident's transfers to the hospital were provided to Resident #32 or the Resident's Representative.

Based on record review, staff interview, and facility policy review, the facility failed to provide the bed hold policy/agreement to the resident and/or Resident Representative (RR) at the time of transfer to an acute care hospital for two (2) of four (4) hospitalization s reviewed, Resident #32 and Resident #11. Findings include: Review of the facility's policy titled, Bed Hold Policy Before and Upon Transfer, with an effective date 11/28/2017, revealed: Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or the resident's representative that specifies 3. The nursing facilities policies regarding bed hold periods. Resident #32 Review of the Face Sheet revealed the facility admitted Resident #32, on 6/25/19, with the included [DIAGNOSES REDACTED]. Review of the Departmental Notes-Nursing revealed Resident #32 was sent to the hospital on [DATE] and returned to the facility on [DATE]. Review of Nurses Notes, on 07/03/19 at 1:39 PM, revealed Resident #32 was sent out to the emergency room (ER) due to an Illuis related to a small bowel obstruction. The Nurses Note, on 07/15/19 at 8:11 PM, revealed Resident #32 returned to the facility. Nurses Note dated 07/17/19 at 8:49 PM revealed Resident #32 was status [REDACTED]. Today had episodes of nausea and vomiting and elevated temp. Order to send to (Name of Hospital) for evaluation by surgeon. Further review of the Nurses Notes revealed Resident #32 returned to the facility, on 07/19/2019, with [DIAGNOSES REDACTED]. An interview, on 07/31/19 at 2:40 PM, revealed the Administrator stated there was no written notification to Resident # 32 or the Resident's Representative regarding the hospital transfers. No documentation was located in Resident #32's medical record of any written notifications regarding the resident's transfers to the hospital were provided to Resident #32 or the Resident's Representative. Resident #11 Review of the Face Sheet revealed Resident # 11 was admitted by the facility, on 03/06/19, with the included [DIAGNOSES REDACTED]. Review of the Department Notes-Nursing, dated 06/17/19 at 9:01 AM, revealed at 8:10 AM Resident #11 was found on the floor on her right side. The resident was assessed and no injuries were found. Resident #11 said she was going over to the roommate's side of the room and tripped on a blanket. Resident. The Department Note-Nursing on 06/17/19 at 9:29 AM revealed Resident #11 was verbalizing suicidal ideation, stated she swallowed hair pins, and she wanted to die. The Nurse Practitioner was notified and Resident #11 was transferred to the hospital for further evaluation. The suicidal ideation was reported to the Emergency Medical staff at the time of the transfer, and the hospital emergency room Resident #11 was transferring to. Further review of the Department Notes-Nursing revealed on 07/02/19 at 12:50 PM, Resident #11 returned to the facility. During an interview, on 07/31/19 2:40 PM, the Administrator revealed there was no written notification to Resident #11 or the Resident's Representative regarding the hospital transfer. No documentation was located in Resident #11's medical record of any written notifications regarding the resident's transfers to the hospital were provided to Resident #32 or the Resident's Representative.

Based on observation, staff interview,and facility policy review, the facility failed to prevent possible food borne illnesses as evidenced by failure to maintain adequate food temperatures, wet nesting of plastic cups, and failure to ensure all dietary staff was knowledgeable of how to calibrate food thermometers for two (2) of two (2) tray line observations. Findings include: A review of the facility's policy entitled, Storage of Pots, Dishes, Flatware, and Utensils revealed pots, dishes, and flatware are stored in such a way as to prevent contamination by splash, dust, pest, or other means. On 07/10/18 at 9:15 AM, observation during initial tour of the kitchen revealed wet nesting of 10 of 24 brown six (6) ounce (oz) plastic cups stacked on a silver tray. On 7/10/18 at 9:20 AM, interview with Dietary Aide #2 revealed he thought the cups on the tray were dry. On 7/10/18 at 9:25 AM, interview with the Chef Manager revealed there is a problem if the dishes are wet, called wet nesting, which is an infection control issue. She also stated the dishes need to be dry to prevent bacteria from growing on them. On 7/11/18 at 10:55 AM, during a kitchen observation tour, 16 nine (9) oz bowels and 24 six (6) oz cups were observed with spots of water on them. The water spots were approximately two (2) centimeter in diameter. On 7/12/18 at 11:00 AM, observation of meal temperature checks revealed Assistant Cook #1 did not know how to calibrate the thermometer. Observation of the lunch meal temperatures were as follows: Beef soup-145 degrees, pureed sweet potatoes 170 degrees, cream of mushroom soup 163 degrees, pureed green beans 170 degrees, pureed stuffed bell peppers 170 degrees, regular green beans, yellow rice 178 degrees, stuffed bell peppers 181 degrees, pureed peaches 63.5 degrees, and yogurt 57.3 degrees. When the surveyor asked Assistant Cook #1 the importance of checking the food temperatures, she stated, To better serve the residents. On 7/11/18 at 11:05 AM, interview with the Chef Manager revealed the temperatures are checked because of bacteria.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide respiratory inhalation administration in a manner consistent with professional practices for three (3) of five (5) resident medication inhalations observed. Resident #14, Resident #15, and Resident #50. Findings include: Review of the facility's policy, Medication Administration, revised 6/15/18, revealed, Medications shall be administered only upon the order of the physician . Update to medication information shall be available to the individual administering the medication. Available information shall include, but not be limited to: Proper instructions for administration. The individual administering the medication shall verify and be aware of: Precautions. Resident #14: Review of the manufactures Guidelines for Breo Ellipta revealed it can cause serious side effects, including: fungal infection the mouth or throat (thrush). The instructions indicate to rinse the mouth with water, without swallowing, after using Breo to help reduce the chance of getting thrush. On 07/11/18 at 8:28 AM, an observation of the morning medication pass revealed Resident #14 inhaled Breo Ellipta inhaler medication into the mouth. LPN #1 failed to ask Resident #14 to rinse her mouth out with water. Record Review of Resident #14's Physicians Orders revealed to give Breo Ellipta ([MEDICATION NAME]/vilanterol powder inhaler) 100-25 microgram (mcg), one (1) inhalation daily for Asthma; have resident rinse mouth with water and spit out water after use. Review of the Medication Administration Record (MAR) for Resident #14, revealed Breo Elipta 100-25 MCG, one (1) inhalation daily-Asthma have Resident rinse mouth with water and spit out water after use. In an interview, on 07/11/18 at 8:31 AM, LPN #1 confirmed she forgot to ask Resident #14 to rinse her mouth out with water after the inhalation of Breo. A review of the facility's face sheet revealed the facility admitted Resident #14 on 3/12/18, with diagnoses, which included Asthma, Pneumonia and Chronic [MEDICAL CONDITION] Fibrillation. Resident #15 Review of the Manufacturer's guidelines for [MEDICATION NAME] included to rinse the mouth with water after using the [MEDICATION NAME] to help reduce chances of getting thrush. On 07/11/18 at 8:17 AM, an observation of the morning medication pass revealed Resident #15 inhaled two (2) puffs of [MEDICATION NAME] Inhaler. LPN #1 failed to ask Resident #15 to rinse her mouth with water after the inhalation. Review of the current MAR and physician's orders [REDACTED]. During an interview on 07/12/18 at 2:00 PM, LPN #1 confirmed she forgot to ask Resident #15 to rinse her mouth out with water. A review of the facility's face sheet revealed the facility admitted Resident #15 on 4/18/16, with diagnoses, which included Hypertension, Asthma and Gastro-esophagel reflux Disease. Resident #50: On 7/11/18 at 8:10 AM, medication administration was observed for Resident #50, which included the use of the inhaler [MEDICATION NAME]. LPN #1 did not instruct nor assist to rinse the resident's mouth after the [MEDICATION NAME] inhaler was administered. Review of Resident #50's current physician's orders [REDACTED].#50 was ordered [MEDICATION NAME] MDI 80-4.5 mcg, two (2) puffs inhaled twice daily. Have resident rinse mouth with water after use and spit fluid out. On 7/11/18 at 2:00 PM, interview with LPN #1 revealed she forgot to rinse the resident's mouth after the inhaler usage, and stated that could cause a fungal infection. On 7/12/18 at 4:00 PM, interview with RN #1 revealed she expected staff members to follow the physician's orders [REDACTED]. On 7/12/18 at 4:10 PM, interview with RN #2 revealed he does education with the staff as far as going over the facility's policies. He also stated he informs the nurses to rinse the residents' mouth after administering Steroid inhalers. On 7/12/18 at 4:15 PM, interview with the Director of Nursing (DON) revealed she would expect the nurses to follow the doctor's orders and if it's an inhaler that requires the resident's mouth to be rinsed, then she expected their mouth to be rinsed. Review of the Facility's Training Record, titled, Medication Administration Observation, revealed Licensed Practical Nurse #1 was trained on inhaler administration properly/hold breath after puff, rinse mouth after administration if applicable.

Based on staff interview, record review, and facility policy review, the facility failed to follow the comprehensive care plan related to respiratory inhalation medication administration for three (3) of five (5) residents inhalation observations. Residents #14, #15, and #50. Findings include: Review of the facility's policy titled, Comprehensive Plan Of Care, dated 11/28/18, revealed the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being are described. Resident #14 Record Review of the manufactures Guidelines for Breo Ellipta, an inhaled medication, revealed it can cause serious side effects, including: fungal infection the mouth or throat (thrush). Rinse your mouth with water without swallowing after using Breo to help reduce your chance of getting thrush. Review of Resident #14's Comprehensive Care Plan, dated 03/12/18, revealed Problem: At risk for complications related to Hypertension, [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION] and Shortness of breath. Goal: the resident would not have complications related to the diagnoses. Interventions: Administer medications as ordered. Review of Resident #14's Physicians Orders revealed to give Breo Ellipta ([MEDICATION NAME]/vilanterol powder inhaler) 100-25 microgram (mcg), one (1) inhalation daily-asthma, have resident rinse mouth with water and spit out water after use. On 07/11/18 at 8:28 AM, an observation of the morning medication pass revealed Resident #14 inhaled Breo into her mouth. LPN #1 failed to ask Resident #14 to rinse her mouth out with water. During an interview on 07/11/18 at 8:31 AM, LPN #1 confirmed she forgot to ask Resident #14 to rinse her mouth out with water after the inhalation of Breo. During an interview with Registered Nurse (RN) #2, on 07/13/18 at 2:30 PM, she confirmed LPN #1 failed to follow the manufactures Guidelines to rinse Resident #14's mouth with water and spit it out to prevent fungal infections in the mouth or throat. A review of the facility's face sheet revealed the facility admitted Resident #14 on 03/12/20, with diagnoses, which included Asthma, Pneumonia and Chronic [MEDICAL CONDITION] Fibrillation. A review of Resident #14's Quarterly MDS, with an ARD of 05/16/18, revealed Resident #14 had a BIMS score of 15, which indicated the resident is cognitively intact. Resident #15: Review of Resident #15's care plan, initiated 6/6/16, revealed an intervention to administer medications as ordered. Review of Resident #15's physician orders, initiated 11/21/17, revealed [MEDICATION NAME] 160-4.5 mcg inhaler, two (2) puffs inhaled, twice daily. Instruct resident to rinse mouth with water and spit out fluid after each use. On 07/11/18 at 8:17 AM, an observation of the morning medication pass revealed Resident #15 inhaled two (2) puffs of a [MEDICATION NAME] Inhaler. Licensed Practical Nurse (LPN) #1 failed to ask Resident #15 to rinse her mouth out with water after the inhalation. During an interview on 07/12/18 at 2:00 PM, LPN #1 confirmed she forgot to ask Resident #15 to rinse her mouth out with water. A review of the facility's face sheet revealed the facility admitted Resident #15 on 04/18/16, with diagnoses, which included Hypertension, Asthma and Gastro-esophagel reflux Disease. A review of Resident #15's Quarterly MDS, with an ARD of 03/12/18, revealed Resident #15 had a BIMS score of 15, which indicated the resident is cognitively intact. Resident #50: Review of Resident #50's care plan, initiated 12/18/12, revealed an intervention to administer medications as ordered. Review of physician's orders [REDACTED]. On 7/11/18 at 8:10 AM, observation of medication administration for Resident #50, by LPN #1, revealed she did not ask the resident or assist the resident to rinse her mouth after a [MEDICATION NAME] inhaler administration. 7/11/18 at 2:00 PM Interview with Licensed Practical Nurse (LPN) reveals I forgot to rinse her mouth after the inhaler, it could cause a fungal infection. Review of Resident #50's face sheet revealed the facility admitted the resident 12/28/11, with [DIAGNOSES REDACTED]. During an interview on 7/12/18 at 4:00 PM, Registered Nurse (RN) #1 revealed she expected staff members to follow the resident's care plan. During an interview on 7/12/18 at 4:15 PM Interview with The Director of Nursing (DON) reveals she would expect the nurses to follow the doctor's orders and care plans, and if the nurse did not have the resident to rinse their mouth after an inhaled medication was administered, the care plan wasn't followed.

Based on observation, staff interview, inservice record review, and facility policy review, the facility failed to ensure food safety, and prevent the possibility of food borne illness as evidenced by the facility's dietary staff' failure to demonstrate correct food thermometer calibration prior to the tray line food temperature checks for one (1) of two (2) kitchen tours. Findings Include: Review of the facility's policy titled, Thermometer Calibration, effective January 2015, revealed temperatures of food shall be monitored using accurate thermometers. Thermometers should be accurate to +/- 2 (two) degrees Fahrenheit. This policy did not quote safe serving temperatures. An observation on 3/1/17 at 10:30 AM, revealed a salad containing lettuce, tomatoes, cheese, ham, and eggs on top of a portable heated tray line. At 10:45 AM on 3/1/17, Dietary Worker #1 took the portable tray line to the facility's resident dining room to serve the residents. The salad remained on top of the heated portable tray line. Dietary Worker #1 proceeded to check tray line temperatures on the hot foods. Dietary Worker #1 did not calibrate the thermometer prior to checking the tray line food temps. When asked, Dietary Worker #1 was unable to demonstrate the correct method for calibration of the thermometer. After assistance by the Dietary Manager, the hot food temperatures were obtained, and were within the acceptable range; however, the salad temperature was 61 degrees Fahrenheit (F), not the acceptable 41 degrees F or below. The Dietary Manager immediately pulled, and discarded the salad. Interview with the Dietary Manager on 3/1/17 at 10:59 AM, revealed Dietary Staff #1 was not the person that normally takes the food temperatures on the tray line. The Dietary Manager explained the food temperatures are usually obtained by the Dietary Cook. Observation, and interview on 3/1/17 at 11:04 AM, with the Dietary Cook revealed the cook was unable to demonstrate how to calibrate the facility's thermometer, or recite 32 degrees F was the correct temperature for calibration in ice water. The Dietary Cook said the temperature should be 31 to 35 degrees for calibration temperature. The thermometer read 33 degrees F. Interview with the Dietary Manager on 3/1/17 at 11:10 AM, revealed he bought new thermometers about two (2) to three (3) months ago, and had not trained his staff on the new thermometers. He stated that he trains his staff every day but does not remember the last time he trained on safe food temperatures. He explained the dietician may have provided training. Review of the facility's In-Service Training Report revealed an in-service was provided to the dietary staff on 10/27/16 by the Registered Dietician, titled: Correctly Calibration & documentation for food service thermometers. The in-service objectives included correctly calibrating the thermometer. The in-service included materials, and demonstration. The results of the evaluation revealed the team members adequately comprehended calibration and documentation for food service thermometers. Review of the in-service sign in sheet revealed the Dietary Cook's signature was on the sheet dated 9/27/16, but Dietary Worker #1's signature was not on the sheet.

Based on observation, user manual review, progress note review, resident record review, resident tracking forms review, staff interview, and facility policy review, the facility failed to provide assessment, supervision, monitoring, and safety measures for a resident placed in a restraint bed to prevent the risk of entrapment for one (1) of 15 residents reviewed; Resident #7. Findings include: A review of the "Professional User Manual" for the restraint bed revealed, "Improper use of the (name of bed) may lead to serious injury or death. Patient monitoring should be established by hospital protocol. It is important to be familiar with the indications for use, the contraindications for use and in particular, risks associated with entrapment, suffocation, choking, and falls." The facility had no policy related to the use of the restraint bed. The facility had no evidence of staff inservices related to the safety hazards associated with the restraint bed. The facility failed to provide documentation of assessments conducted by Physical Therapy (PT); Nursing Staff; Physicians; and/or Occupational Therapy (OT) for the use of restraints, restraint beds, and/or assistive devices for Resident #7 prior to the application of the restraint bed on 06/25/2013. The facility failed to provide documentation of assessments for the need and/or justification of the restraint bed for Resident #7 prior to implementation on 06/25/2013 and/or after implementation. Interview on 03/06/15 at 4:30 PM with the Director of Nursing (DON) revealed, "We don't have a specific policy for the bed." Record review of Resident #7's March 2015 Cumulative physician's orders [REDACTED]. Review of Resident #7's written physician's orders [REDACTED].#1 dated 06/25/13 which revealed "Use (name of bed) for resident R/T (related to) Hi (high) Risk for falls. Discontinue (D/C) bed alarm." The surveyor attempted three times unsuccessfully to reach Physician #1 for interview. Record review of physician progress notes [REDACTED].#7 while in restraint bed, or reduction attempts for Resident #7's use of the restraint bed. During an interview with Physician #2 on 03/06/15 at 1:00 PM, who was the facility's Medical Director and Resident #7's current physician, revealed he had assumed the care of Resident #7 in January 2015 due to Physician #1 leaving the facility. Physician #2 stated he did not question the use of the bed after assuming Resident #7's care because he had seen this type bed used before. Review of the "Professional User Manual" for the restraint bed , under Warnings and Precautions, "Canopy Gaps: Raising the head of the (name of bed) will create gaps or pockets between the head of the bed and the canopy. These areas pose an extreme risk of serious injury or death from entrapment to certain at-risk patients. Keep the mattress flat with the head of the bed down, when an at-risk patient is unattended." The manual defined at-risk patients as "Patients who, because of mental or physical disability, cannot reposition or remove him or herself from a confined area of the bed." The manual included "Reducing the Risk of Entrapment" which stated to keep the mattress flat and to provide extra monitoring. Review of cumulative physician's orders [REDACTED]." Resident #7 had a physician order [REDACTED]. Review of the "Professional User Manual" revealed "If you need to elevate the head or torso of an at-risk patient, keep the mattress flat and use a cushion to position the patient. If you must leave the head of the bed up while an at-risk patient is unattended, use the (name of bed) cushions." Interview with Registered Nurse (RN) #2 on 03/05/15 at 11:20 AM concerning elevation of the head of the resident's bed during gastrostomy feeding revealed, "We do elevate the head of the bed when she receives her feedings and keep her elevated for at least thirty minutes after. Someone is supposed to be in there during that time. We don't have pillows that came with the bed." CNA #1 explained in an interview on 03/05/15 at 11:10 AM that during tube feedings, the facility elevated the head of bed for about 30 to 45 minutes after the nurse gave the gastrostomy tube feeding. On 03/05/15 at 12:45 PM, CNA #1 was seated at the bedside. Observation revealed Resident #7 lying in the restraint bed with eyes closed and the head of bed elevated to 45 degree with no (name of bed) cushions in place. Observation on 03/04/15 at 9:30 AM, on 03/05/15 at 12:00 PM, and on 03/06/15 at 10:00 AM revealed Resident #7 lying flat supine in the restraint bed that was covered in a tent-like, mesh enclosure zipped on all four sides. The resident was alone in the room and was not in view of the nurses' station. There were no (name of bed) cushions on the bed or in the resident's room. Record review of Resident #7's Medication Administration Record (MAR) revealed no documentation of monitoring following bolus feedings. Review of the Certified Nursing Assistant's (CNA) documentation entitled "CNA-Activities of Daily Living (ADL) Tracking Form" revealed no documentation or instructions to monitor Resident #7, or how to position Resident #7 safely in the restraint bed. Interview on 03/05/15 at 11:10 AM with the Administrator revealed, "We do not have any special pillows. I just never ordered them." Interview on 03/05/15 at 3:00 PM with the DON confirmed there were no orders for specific monitoring of Resident #7, no instructions for documentation of monitoring by the CNA's, as well as no documentation of the safety of Resident #7's positioning in the restraint bed. Review of the facility's face sheet revealed the facility admitted Resident #7 on 10/17/12 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) with an assessment reference date of 12/15/14 revealed a Brief Interview for Mental Status (BIMS) score of three (3), indicating Resident #7 had severe cognitive impairment. Review of Resident #7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/14 revealed Resident #7 was totally dependent on staff for bed mobility, transfer, locomotion, dressing, eating, toileting, and bathing and had range of motion impairment on both sides to upper and lower extremities.

Based on resident care plan review, staff interview, and facility policy review, the facility failed to develop a comprehensive care plan related to a restraint bed device for one (1) of 15 residents reviewed for care plans; Resident #7. Findings include: Review of the facility's policy entitled "Restraint Policy", undated, revealed "The use of restraints must be addressed on the Total Care Plan." Review of the "Professional User Manual" for the restraint bed revealed "The bed must be used in accordance with: The patient's care plan." The manual also revealed "Before allowing a patient to occupy the bed, confirm the following: A current patient care plan is available and followed." Review of the facility's care plan policy entitled, "Care Plan Updates Policy", undated, read, "It is the policy of this facility that care plans will be updated as follows: -To address all problems related to resident care." Review of Resident #7's care plan revealed a two page care plan for "fall risk" dated 10/17/12. On 06/25/13, the facility added "(Name of bed) related to (R/T) high risk for falls" to this fall care plan. The most recent listed approach was "(name of bed) to prevent falls but allow movement." The last care plan revision conference date listed on the care plan was 07/08/13. There was no reference made to the bed being a restraint. There were no interventions developed for monitoring the use of the restraint bed. Interview on 03/04/15 at 9:50 AM with Registered Nurse (RN) #1, the Care Plan nurse, confirmed the fall care plan was the only part of the resident's care plan that the bed restraint was addressed and no restraint care plan was developed because, "It has never been considered a restraint. It was the last resort for someone who had multiple falls to keep her safe." During an interview with the Administration on 03/07/15 at 11:00 AM, the Administrator explained the facility failed to identify the bed as a restraint initially, thus failed to implement assessments, monitoring, and attempts at restraint reduction. On 03/04/15 at 9:30 AM, 03/05/15 at 12:00 PM, and 03/06/15 at 10:00 AM, Resident #7 was observed lying supine in a tent-like enclosure with all four sides zipped closed. She was alone in the room and the room was not in view of the nurses' station. Review of the facility's face sheet revealed the facility admitted Resident #7 on 10/17/12 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/14 revealed a Brief Interview for Mental Status (BIMS) score of three (3) indicating Resident #7 was severely cognitively impaired. The 12/15/14 MDS failed to identify Resident #7 with a restraint device.

Based on observation, record review, staff interview, and professional literature review, the facility failed to maintain the dignity of a resident as evidenced by placing a resident in an enclosed mesh covered restraint bed with limited interaction with other residents, staff, and visitors for one (1) of 15 residents reviewed; Resident #7. Findings include: Review of "Fundamentals of Nursing Care: Concepts, Connections, and Skills (Second Edition)" by Marti A. Burton and Linda J. May Ludwig, Copyright 2015, revealed in "Chapter 3: Nursing Ethics and Law" that "Patients have the right to be treated ethically with advocacy, respect, dignity, honest, and [MEDICATION NAME]. Maintaining a patient's dignity means allowing and honoring the patient's possession of self-respect. Every patient is considered worthy of dignity and self-respect." It also stated "Treat every patient as you would want to be treated yourself or as you would want the most important person in your life to be treated." On 03/04/15 at 9:30 AM during initial tour, the surveyor observed Resident #7 in a dark room, with blinds partially open lying flat in a bed covered with a single sheet. A mesh tent-like covering zipped closed on all four sides covered Resident #7's bed. Resident #7 was alone in the room and the room was not in view of the nurse's station. A television was playing; however, the resident's eyes were closed. Resident #7 had little or no visibility from inside the enclosed restraint bed that was observed to look like a tent covering the bed. On 03/05/15 at 12:00 PM, Resident #7 was again observed in the restraint bed lying on her right side with her eyes closed. The room was dark and blinds closed. There was no television or radio playing. There was no activity and/or interaction with others provided for the Resident during this observation. On 3/6/15 at 10:00 AM, the surveyor observed Resident #7 lying in the meshed covered bed, awake and pushing her feet against the side of the enclosed bed mesh crying. Observation on 03/06/15 at 12:30 PM revealed Resident #7 seated in a geri-chair in the facility day room with staff and other residents in attendance. The surveyor spoke to the resident and Resident #7 responded by nodding and smiling at the surveyor. After a birthday song was sung to the resident, Resident #7 responded in a low voice to the staff and surveyor, "That was nice." Interview on 03/06/15 at 4:30 PM with the Director of Nursing concerning Resident #7's dignity while in the mesh enclosed restraint bed revealed,"Dignity wasn't something we considered an issue because her family has been pleased with the bed. Also, Resident #7's cognitive status is very low." Interview on 03/06/15 at 4:30 PM with Registered Nurse #4, Quality Assurance Nurse, revealed "I don't think that (dignity) was a concern because Resident #7 really isn't aware of her surroundings." Review of the facility's face sheet revealed the facility admitted Resident #7 on 10/17/12 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/14 revealed a Brief Interview for Mental Status (BIMS) score of three (3) indicating Resident #7 was severely cognitively impaired.

Based on observation, facility statement review, resident record review, restraint bed user manual review, staff interview, and facility policy review, the facility failed to ensure a resident was free from restraints as evidenced by a resident being placed in a restraint bed on 06/25/13 without assessment, monitoring, restraint reduction attempts, or scheduled releases from restraints for one (1) of three (3) residents reviewed for restraints; Resident #7. Findings include: Review of the facility's policy entitled "Restraint Policy", undated, revealed "Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal assess to one's body." The policy also stated "Restraints will be checked every thirty minutes and loosened and released every two hours for ten minutes. An initial assessment must be completed prior to the application of the restraint." Review of the "Professional User Manual" for the restraint bed revealed, "Because the bed is a restraint, it's use must be prescribed by a licensed physician. Anyone interacting with the bed must complete the (name of bed) In-Service Training Program which includes proficiency in the use of this manual." The user manual also revealed, "As with any less restrictive restraint system, it is important to be familiar with the indications for use, the contraindications for use and in particular, risks associated with entrapment, suffocation, choking, and falls." The user manual also read, "Because the bed is a restraint system, anyone who cares for a patient in the bed must be properly trained according to their facility's policy." During initial tour of the facility on 03/04/15 at 9:30 AM, the surveyor observed a frail, thin, emaciated Resident #7 lying supine on a flat mattress in a bed covered in a tent-like mesh enclosure that was zipped on all four sides. Resident #7's bedroom was not within view of the nurse's station, and the resident was alone in the room. Observation on 03/05/15 at 12:00 PM revealed Resident #7 lying flat in the mesh, tent-like enclosure restraint bed. No television or radio was playing. The resident's room was dark with blinds closed. No activity and no interaction with others was noted during the observation of Resident #7 on 3/5/15 at 12:00 PM and no staff monitoring of Resident #7 was observed at this time. On 03/05/15 at 12:45 PM, observation revealed Resident #7 lying in the restraint bed with eyes closed and the head of bed elevated to 45 degrees without additional cushions. CNA #1 was seated at the bedside and stated she was at bedside due to elevated head of bed post gastrosomy feeding. Observation, on 03/06/15 at 10:00 AM, revealed Resident #7 again lying on her right side with the mesh, tent-like enclosure covering the restraint bed. The restraint bed was flat. Resident #7 was awake pushing her feet against the side of the enclosure crying. Resident #7 was observed to be alone in the room. During an incontinent care observation on 03/06/15 at 10:10 AM, Resident #7 was rolled to her side by staff and repositioned after the care by staff. The resident required staff assistance with positioning. After restraint concerns were discussed with the facility, observation on 03/06/15 at 12:30 PM revealed Resident #7 up in the dayroom of the facility in a gerichair. Review of the Medication Administration Record [REDACTED]. Review of the facility's physician's orders [REDACTED].#7 revealed an order by Physician #1 written on 06/25/13 which stated "Use (name of bed) for resident R/T (related to) HI (high) Risk for falls. D/C (Discontinue) Bed alarm." The order was signed by Physician #1. The surveyor attempted unsuccessfully to reach Physician #1 for an interview by telephone three times during the survey process. Interview on 03/06/15 at 1:00 PM with Physician #2, who was also the Medical Director and current physician for Resident #7, revealed he began caring for Resident #7 in January 2015 due to Physician #1 leaving the facility. Physician #2 stated the Resident was already using the bed when he assumed care and he did not have a problem with it. Review of all progress notes for Resident #7 following the above order for restraint bed revealed no justification for the use of the bed, how long the bed was to be used, the need for increased monitoring regarding the restraint bed, or when to attempt a restraint reduction. Review of a statement submitted to the survey team during the survey and signed by the Administrator read, "Administrator discussed with Resident #7's Responsible Party (RP) about the use of a (name of bed) for Resident #7 in June of 2013. The use of this device was discussed as an intervention to prevent further episodes with the potential of harm to the patient including but not limited to falls, skin tears, fractures, etc ... It was discussed via telephone and a verbal consent was given by the patient's RP to Administrator. Other methods had been tried prior to this intervention unsuccessfully. An order was given by patient's physician on 06/25/13. Since it's installment, the (name of bed) has completely reduced the harm risk incurred with prior methods." The Administrator revealed during an interview on 03/04/15 at 10:15 AM, "It (restraint bed) has never been considered a restraint because she is not ambulatory anyway. She could not get up on her on. She is total care. It was looked at as more of a safety device." Interview on 03/07/15 at 11:00 AM with the Administrator revealed, "In discussion of the bed from the beginning, it was considered more of a parameter because she had full range of motion (ROM) and she had no capability of ambulation. Due to her cognitive status also, it was considered more of a safety canopy." On 3/30/15, the State Agency contacted the Administrator by email and requested any additional documentation of restraint/ device assessment performed prior to placing Resident #7 in any device or restraint. The facility failed to provide documentation of restraint assessment, release, or supervision of the resident. The facility failed to provide evidence of staff training for the use of the restraint bed. Review of the facility's face sheet revealed the facility admitted Resident #7 on 10/17/12 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) with an Assessment Reference Date of 12/15/14 revealed a Brief Interview for Mental Status (BIMS) score of three (3), indicating Resident # 7 had severe cognitive impairment. Review of Resident #7's most recent Minimum Data Set (MDS) with an assessment reference date( ARD) of 12/15/14 revealed Resident #7 was coded as having no restraints in use, requiring total staff assistance for bed mobility, and had impaired range of motion (ROM) on both sides/upper and lower extremities. The facility failed to provide documentation of assessments for any assistive devises or restraints by Physical Therapy (PT); Nursing Services, Physicians; or Occupational Therapy (OT). There were no documented assessments provided for the use of restraints or assistive devices prior to the introduction of the restraint bed on 06/25/13. The facility failed to provide documentation and/or evidence of the monitoring of the restraint bed or the reduction of the restraint bed. Interview on 03/04/15 at 9:50 AM with Registered Nurse (RN) #3, who was the MDS nurse, revealed, "She is in a (name of bed) for her safety. We have never called it a restraint." Interview on 03/04/15 at 11:00 AM with the Director of Nursing (DON) revealed, "We would not have the usual things in place like monitoring and release because it was never considered a restraint. We did try other methods before going to the bed, but nothing since then." Interview with Resident #7's son (Responsible Party) on 03/05/15 at 1:50 PM revealed the Administrator called him about placing his mother in the enclosed bed. The resident's son explained the bed was not described as a restraint and would be the best alternative to prevent accidents. The resident's son stated he did not like seeing his mother in the enclosed bed but believed it was for her safety. Interview on 03/05/15 at 3:00 PM with the Director of Nursing (DON) revealed, "No, there was no formal training on the bed that I know." On 03/05/15 at 11:10 AM, an interview with Certified Nursing Assistant (CNA) #1 confirmed, "There really wasn't training (on the restraint bed)."