Every finding on record at Atkins Nursing and Rehabilitation Center

Number of residents sampled: Number of residents cited: Based on record review and interviews it was determined the facility failed to send a written notice of transfer or discharge to the Ombudsman for one (Resident #59) of one resident, upon discharge. The findings include: Review of Resident #59's admission Record revealed the facility admitted Resident #59 on 02/10/2026 from a local hospital. Review of Resident #59's Medical Diagnosis report revealed Resident #59 had diagnoses which included acute kidney failure, encephalopathy, hypothyroidism, dementia, hypertension and congestive heart failure. Review of Resident #59's discharge, return anticipated Minimum Data Set with an Assessment Reference Date of 02/12/2026 revealed the discharge status was discharged to an inpatient rehabilitation facility. The MDS coded the discharge as a planned discharge. Review of Resident #59's Care Plan dated 02/12/2026 revealed Resident #59 wished to discharged . Review of Resident #59's Progress Notes dated 02/12/2026 at 10:57 PM revealed Resident #59 had discharged to a local rehab. Review of a facility Ombudsman Notification Report dated February 2026, provided by the Administrator, did not include Resident #59. During an interview with the Business Office Manager (BOM) and the BOM Consultant on 04/15/2026 at 2:20 PM, the Business Office Manager (BOM) stated she was responsible for notifying the Ombudsman at the end of each month of emergency discharges. The BOM stated the Ombudsman should be notified when there was an emergency transfer or discharge. The BOM stated she did not notify the Ombudsman of Resident #59's discharge and she was not aware of anyone else at the facility notifying the Ombudsman. The BOM reviewed the Emergency Transfer Report dated February 2026 and confirmed the list was the report sent to the Ombudsman for residents who had discharged in February 2026. The BOM stated they, did not notify the Ombudsman of non-emergency discharges. The BOM Consultant stated the purpose of notifying the Ombudsman was to let the Ombudsman know about a resident's discharge so the Ombudsman could call and talk to the resident if the Ombudsman had any concerns. The BOM Consultant stated they had been notifying the Ombudsman of the emergency discharges. During an interview on 04/15/2026 at 3:02 PM, the Administrator stated Resident #59 had been discharged to a local rehab facility. The Administrator stated the facility should be notifying the Ombudsman of all discharges to ensure they were aware a resident had left the facility and if there were any needed services, as the patient advocate, and so the Ombudsman would know the location of the discharged resident. During an interview on 04/15/2026 at 3:07 PM, the Director of Nursing (DON) stated Resident #59 admitted to the facility from the local hospital with plans to return to that same local hospital's rehabilitation unit for rehabilitation [therapy]. The DON stated Resident #59 discharged to the local hospital rehabilitation unit on 02/12/2026. During an interview on 04/16/2026 at 8:30 AM, the Ombudsman stated they had not been notified regarding Resident #59's discharge from the facility. This surveyor requested a facility policy regarding notification of the Ombudsman. The facility provided an Admission, Transfer and Discharge of Resident policy dated 11/22/2016, but did not have a policy covering notification of the Ombudsman.

Based on observations, record review, interviews and facility policy review, the facility failed to ensure an indwelling catheter was stored off the floor to reduce the risk of infection, cross contamination and injury for one (Resident #3) of one resident reviewed. The findings include:Review of Resident #3's Medical Diagnosis revealed Resident #3 had diagnoses which included urine retention, overactive bladder, chronic kidney disease, tubulointerstitial nephritis (inflamed kidney tubules) and anxiety.Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date of 03/30/2026 revealed, Resident #3 had a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. The MDS also revealed Resident #3 had a catheter and had not had a UTI in the last 30 days. Review of Resident #3's Care Plan revealed Resident #3 had potential/actual impaired skin integrity related to catheter, poor mobility, and use of anticoagulant with an initiated date of 03/31/2026. Care Plan interventions included to keep the residents' nails short, and encourage no scratching, prevent excessive moisture to body parts and to provide [name brand indwelling catheter] care with soap and water.Review of Resident #3's Physician Orders dated 03/30/2026, revealed staff were to check [name brand indwelling catheter] [name brand securement device] for placement every shift related to benign prostatic hyperplasia with lower urinary tract symptoms.Review of Resident #3's Physician Orders dated 03/25/2026 revealed Resident #3 had an order for an anticoagulant to be given twice a day related to stroke.Review of a Urinary Analysis (UA) dated 04/10/2026, revealed results of a positive urinary tract infection (UTI) with blood in the urine and was positive for gram-negative bacteria.Review of Resident #3's Progress Notes on 04/13/2025 at 7:21 PM, revealed the physician was notified of worsening confusion, blood in urine and Resident #3 was started on antibiotics for 10 days. Review of Resident #3's Physician Orders dated 04/13/2026, revealed an order for an antibiotic to be given for 10 days.Review of Resident #3's Physician Orders dated 04/14/2026 revealed an order for contact isolation for gram-negative bacteria in the urine, may discontinue when antibiotics are complete. Review of Resident #3's lab results from [local hospital] dated 04/14/2026 revealed low hemoglobin and hematocrit levels. On 04/13/2026 at 10:43 AM, Resident #3 was observed sitting in a wheelchair on the left side of the bed facing the open door. The front right wheel had rolled over the covered catheter bag hanging below the right arm of Resident #3's wheelchair. Red urine was observed in the catheter tubing. This surveyor observed Resident #3 wearing a leg strap in place on the right leg and the catheter tubing was stretched. Resident #3 stated I do not know why my pee is red and did not know if the catheter tubing had been pulled. This surveyor exited the room, stood in the hallway and observed Resident #3 rolling back and forth over the catheter bag with the wheelchair. Resident #3 was visible to two staff walking in the hallway.During an interview on 04/13/2026 at 10:56 AM, Certified Nursing Assistant (CNA) #1 stated Resident #3 had a UTI and pneumonia in the past but not at this time. CNA #1 stated Resident #3's catheter was resting on the floor and urine appeared red with sediments in the tubing.During an observation and concurrent interview on 04/13/2026 at 11:31 AM, CNA #1 confirmed Resident #3 had red urine in the catheter tubing and stated, Licensed Practical Nurse (LPN) #3 told me it was caused by Resident #3's medicine. CNA #1 stated catheter bags were not supposed to be on the floor because it was dirty and an infection risk. This surveyor observed CNA #1 put on a yellow gown, wash their hands, put on gloves, and hung the catheter bag under the wheelchair, off of the floor. CNA #1 revealed there was an infection control in-service in February or March of 2026.During a telephone interview on 04/13/2026 at 1:30 PM, Resident #3's family member stated the resident had gotten a sore around the penis and an unknown nurse applied cream and changed out the catheter and it improved rapidly. The family member stated Resident #3 had a UTI, was going to see a urologist and felt that the facility was doing everything they could to help Resident #3 heal from the UTI. The family member also stated someone called today and notified them a culture had come back and Resident #3 may be starting an antibiotic. On 04/14/2026 at 1:17 PM, Resident #3 was observed resting quietly. Turbid, red urine with sediment was observed in the catheter tubing draining in a blue covered catheter bag. A lunch tray with fluids were sitting on the over bed table, untouched. Resident #3's roommate had been moved out of the room, contact precautions were in place with signage and Personal Protective Equipment (PPE) was stored outside the door. During an interview on 04/14/2026 at 2:24 PM, LPN #3 stated Resident #3 had a UTI positive for gram-negative bacteria and Resident #3 had increased urine with blood in the catheter. LPN #3 stated blood was discovered in the catheter tubing yesterday morning and Resident #3 had been on a pain reliever that treated urinary symptoms. LPN #3 stated, Antibiotics were started last night, and the gram-negative bacteria is new. LPN #3 stated a catheter should be in a privacy bag and stored off the floor. LPN #3 indicated no CNAs had told her that Resident #3 was rolling over the catheter bag while it rested on the floor. LPN #3 stated it was all around bad because, it could have pulled on the tube and created more bacteria and Resident #3 could have gotten a hole in the catheter bag. LPN #3 stated again If a CNA sees a resident with bloody urine in the catheter tube and the resident was rolling on it with the wheelchair the CNA should have reported that to the nurse.During an interview on 04/15/2026 at 9:39 AM, LPN #2 stated that he worked on 04/14/2026 and the Medical Director (MD) was called about red urine, a culture was taken during the night and the MD stated to wait for results. LPN #2 stated there was a hook under Resident #3's wheelchair to hang the catheter bag from and it would not be appropriate for the catheter bag to be on the floor. LPN #2 stated, I would have changed out and assessed the entire catheter system since Resident #3 was rolling over the bag to check for holes, pulling and injury. Resident #3 stated a 10 [on a pain scale of 1-10] when asked by LPN #3 if the resident was in pain, and LPN #3 stated he would give Resident #3 a non-steroidal anti-inflammatory for the pain.During an interview on 04/15/2026 at 2:15 PM, with the Director of Nursing [DON] and Administrator, the DON stated her expectation was that catheters would be stored under wheelchairs and off the floor when the resident was not in bed. The Administrator confirmed that there was a place to hang the catheter under the wheelchair. The DON and Administrator confirmed catheter bags on the floor being rolled over by residents would not be appropriate because it could cause pulling. The DON revealed that staff made her aware of Resident #3's catheter bag being on the floor and confirmed Resident #3 had been diagnosed with gram-negative bacteria in the urine and was placed on contact precautions and started on antibiotics. The DON revealed if a CNA found a resident sitting in their wheelchair and noticed red fluid in the catheter tubing, or a resident rolling on the catheter tubing, they expected the CNAs to tell a nurse. Review of a facility in-service document dated 02/17/2026 revealed a handwritten subject as mandatory in-service, with multiple areas of reference of which included infection control. LPN #2, LPN #3 and CNA #1's signature indicated they attended the mandatory in-service. This surveyor did not locate infection control training in this document. Review of a facility policy titled Catheter Care, Urinary revised on 11/22/2016, revealed staff are to report any abnormal findings to the charge nurse.Review of a facility policy titled Infection Prevention and Control Program dated 11/22/2017, revealed the facility must have a surveillance program to identify infections before they can spread. Nursing staff monitors residents for signs and symptoms that suggest infection and will report suspected infections to the charge nurse as soon as possible. Surveillance includes monitoring, documentation, reporting, education, data analysis, and antibiotic review. Charge nurse will notify the doctor and infection control nurse as soon as possible.

Based on observation, record review, and interview, the facility failed to ensure hot foods were served hot to maintain palatability and encourage adequate nutritional intake for 1 of 2 meals observed. The findings are: 1. On 10/14/24 at 11:12AM, Resident #51 stated food is cold when served. 2. On10/15/24 at 8:11 AM, a food cart that contained 8 meal trays for breakfast was delivered to the 500 Hall by Certified Nursing Assistant (CNA) #3. At 8:22 PM, the temperature of the food items on the last resident tray, was taken and read by the District Dietary Manager. The temperatures were as follows: a. Scrambled eggs - 98 degrees Fahrenheit. b. Sausage - 84 degrees Fahrenheit. c. Pan cake - 100 degrees Fahrenheit. d. Gravy - 102 degrees Fahrenheit. 3. On 10/15/24 at 8:11 AM, the first breakfast meal tray for the 300 Hall was placed in an unheated food cart in the hall outside the kitchen window by Certified Nursing Assistant (CNA) #4, who left it open while loading the meal trays. When the staff began removing the meal trays, there were 7 trays in the food cart to be delivered to the residents who ate in their rooms. At 8:21 AM, Certified Nursing Assistant (CNA) #5 delivered the same unheated food cart with 3 remaining breakfast trays in it to the 300Hall. At 8:29 AM, the temperature of the food items on the test tray after the last residents was served in their room was taken and read by the District Dietary Manager. The temperatures were as follows: a. Sausage - 80 degrees Fahrenheit. The District Dietary Manager stated it was just warm. b. Scrambled eggs - 112 degrees Fahrenheit. c. Pureed oatmeal - 110 degrees Fahrenheit. d. Pureed eggs - 110 degrees Fahrenheit. e. Pureed sausage - 114 degrees Fahrenheit. 4. On 10/15/24 at 11:52 AM, when asked during an interview Certified Nursing Assistant #4 who loaded the breakfast meal trays into the food cart stated he was instructed to leave the food cart open during the loading process. CNA #4 stated that leaving it open while loading would cause the food to cool down.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure dietary employees washed their hands or changed gloves before handling food items and clean equipment when contaminated; expired food products were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria. The findings are: 1. On [DATE] at 9:42 AM, Dietary [NAME] (DC) #1 wore gloves on her hands while using scissors to cut open a bag of shredded cheese which contaminated the gloves. Without washing her hands, she removed shredded cheese from the bag and sprinkled it on top of enchiladas to be baked and served to the residents for lunch. 2. On [DATE] at 9:52 AM, an opened box of fish was on a shelf in the walk-in refrigerator. The box was not covered or sealed 3. On [DATE] at 9:56 AM, the following observations were made in the storage room: a. One box with 24 count of probiotics drink, was on a shelf with an expiration date of [DATE]. b. On bag of butter fingers was on a shelf with an expiration date of [DATE]. c. One bag of hamburger buns was on the bread rack in the storage room with an expiration date of [DATE]. 4. On [DATE] at 10:28 AM, the following observations were made in the kitchen cabinet: a. One container of whole celery with an expiration date of [DATE]. b. One container of sage rub with an expiration date of or [DATE]. On [DATE] at 11:04 AM, the following observations were made on a shelf in the refrigerator: a. An opened bottle of chicken sauce. There was no open date on the bottle. b. An opened bottle of nutritional drink. There was no received date or name listed on it. c. An opened cup of vanilla ice cream with a straw in it. The cup was not covered. d. An opened container of sherbet was in the freezer. The sherbet appeared discolored. The Dietary Manager stated it had thawed and refrozen, with all the layers of the sherbet mixed as one shade. 5. On [DATE] at 07:19 AM, Dietary Aide (DA) #2 picked up a rag from the counter with food stains on it and dried inside a pan. Without washing his hands, DA #2 attached a clean blade at the base of the blender to be used in pureeing food items to be served to the residents. DA #2 stated he should have washed his hands. 6. A review of facility policy titled, Handwashing and Glove Usage in Food service, initiated 2016, provided by the Dietary Manager on [DATE] indicated employees must wash their hands after starting work and after touching dirty equipment.

Based on observation, record review, and interview, the facility failed to ensure lint traps for two of two dryers located in the facility laundry room were cleaned to prevent the potential for fire hazard. The findings are: During a tour of the facility laundry room on 10/16/2024 at 9:04 AM, two clothing dryers used to launder resident clothing were observed. The Housekeeping/Laundry Supervisor was asked to provide the surveyor with access to the dryer's lint traps. The lint trap of one dryer was found to contain what appeared to be five white pieces of paper, a dryer sheet, and a buildup of lint. The lint trap of the second dryer contained what appeared to be ten dryer sheets and a buildup of lint. During an interview on 10/16/24 at 9:04 AM, the Housekeeper/Laundry Supervisor explained that the lint area of dryers are cleaned every hour. Upon further observation of the dryer lint traps, it appeared to not be cleaned recently in either dryer. The Housekeeper/Laundry Supervisor explained that laundry was told to clean the lint screens every hour instead of every two hours as described on the schedule. Last time Housekeeper #12 verbalized cleaning the dryer lint traps was 7:40 am. A document titled, Lint Cleaning Schedule for the month of October was reviewed on 10/16/24 and revealed that it was signed off as being last cleaned at 6:00 AM. During an interview on 10/16/2024 at 9:45AM, the Housekeeper/Laundry Supervisor and Housekeeper #12 stated that they dried three or four loads of laundry between 6:00AM-9:00AM. On 10/17/2024 the Administrator provided two documents: a. A Laundry Cleaning Schedule which indicated that staff should clean the lint under the dryer with each use. b. A Lint Log Sheet that indicated the lint trap should be emptied after each load of laundry dried.

Based on observation, interviews, and record review, it was determined that the facility failed to ensure dignity was maintained while performing Activities of Daily Living (ADL) for 1 resident (Resident #56) of 1 receiving incontinent care. Findings included: 1. Review of a facility policy titled, Resident Rights, (not dated), indicated, Each resident has the right to be treated with consideration, respect and full recognition of dignity and individuality. Review of an Admission Record, indicated Resident #56 was admitted with a diagnosis of dementia and anxiety disorder. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/8/2024 revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated Resident #56 was moderately cognitively impaired. On 10/15/2024 at 07:14 AM, observed Certified Nursing Assistants #6 and #7 performing incontinent care on Resident #56 without pulling the privacy curtain. On 10/15/2024 at 9:50 AM, Certified Nursing Assistant (CNA) #6 was asked if the privacy curtain should have been pulled completely. CNA #6 stated the curtain should have been closed all the way. On 10/15/2024 at 9:55 AM, Certified Nursing Assistant (CNA) #7 was asked if the privacy curtain should have been pulled completely. CNA #6 stated the curtain should have been pulled to provide privacy. Review of Resident #56's care plan with a revision date of 06/21/2024 showed the resident had bowel incontinence and had limited physical mobility related to dementia. Interventions with revision date of 09/05/2024 included that the resident was dependent on 2 staff for transferring and toileting. During an interview on 10/15/2024 at 11:00 AM, the Director of Nursing (DON) was asked if the privacy curtain should have been pulled completely. She stated the curtain should have been pulled to ensure privacy and dignity were provided to the resident.

Based on interviews, record review, and document review, the facility failed to ensure a Significant Change in Status Minimum Data Set (MDS) comprehensive assessment was completed within 14 calendar days from the determination that a significant change has occurred for one (Resident #2) of one resident reviewed for assessments. The findings are: Upon review of the residents Admission Record, it showed Resident #2 was admitted on [DATE], with a primary diagnosis of encephalitis (inflammation of the brain). The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 07/25/2024 documented the resident scored 03 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status. Upon review of Resident #2's (R#2) scanned documents, hospice care was ordered on 5/11/24. Upon review of all completed MDS assessments, R#2 did not have a significant change in status MDS comprehensive assessment completed within 14 calendar days following readmission on 05/11/2024. On 10/16/2024 at 10:30 AM, interviewed the MDS Coordinator regarding the MDS and care plan for R#2. She confirmed she was aware R#2 was currently receiving hospice care and was aware this was a change that took place upon the readmission on 05/11/2024. During the interview, the MDS Coordinator was asked to review the completed MDS assessments. Upon review, she confirmed a significant change MDS was not completed within 14 calendar days following the resident's readmission to the facility with hospice care ordered on 5/11/2024. Upon review of the most recent care plan, last updated 8/24/2024, the MDS Coordinator confirmed R#2 was no longer taking an anticoagulant, montelukast (medication used to control asthma and inflammation in the lungs), mirtazapine (a medication used to treat depression), or hydrocodone (a medication used to treat pain), however the medications remained on the care plan. In addition, she confirmed the care plan does not contain any new interventions addressing that the resident was receiving hospice care provided by named hospice provider. Under the Activities of Daily Living (ADL) section of the care plan, the MDS Coordinator confirmed it does not address the level of care needed during mealtimes. When asked about the importance of completing a significant change in status MDS assessment, the MDS Coordinator confirmed the MDS and care plans guide everyone providing care to the resident, and if the information is incorrect, this could have a negative impact on the resident.

Based on observation, interviews, record review, and document review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to reflect the resident's needs, and failed to ensure it was accurate to represent the resident's current health status for one resident (Resident #2) of one resident reviewed for comprehensive care plans. The findings are: On 10/14/2024 at 12:55 PM, observed Resident #2 (R#2) sitting in a geriatric chair in the designated dayroom/dining area for the memory unit with Certified Nursing Assistant (CNA) #10 assisting R#2 with lunch. CNA #10 continued to offer each bite of food, and each drink of fluid to R#2. After the meal, CNA #10 was interviewed regarding care for R#2. When asked how much assistance R#2 requires for during meals and for fluids, and she confirmed R#2 requires full assistance with all food and drinks. Upon review of the residents Admission Record, it showed Resident #2 (R#2) was admitted on [DATE] with a primary diagnosis of encephalitis (inflammation of the brain). Upon review of Resident #2's scanned documents, R#2 was readmitted to the facility on [DATE] with a significant change where hospice care orders were completed on 5/11/2024. The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 07/25/2024 documented the resident scored 03 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status. Under section GG regarding eating, it is documented R#2 requires Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity, however the care plan last updated 08/21/2024 does not address the assistance required for meals or fluids for R#2. The current level of care needed for R#2 is fully dependent on staff for eating meals and drinking fluids per staff interview and observations. Upon further review of the resident's physician orders and the care plan, the diet ordered stated: Regular diet, Mechanical Soft texture, Regular consistency. The diet in the care plan stated: Regular diet, Pureed texture, Regular consistency. There is a discrepancy between the orders and the care plan not stating the same diet. Confirmed with dietary staff that R #2 is receiving a Regular diet, Mechanical Soft texture, Regular consistency. Interviewed the MDS Coordinator on 10/16/2024 at 10:30 AM regarding R #2 and the MDS assessments and care plans. She confirmed she was aware R #2 is currently receiving hospice care and was aware this was a change that took place upon the readmission on 05/11/2024. During the interview, the MDS Coordinator was asked to review the completed MDS assessments. Upon review, she confirmed a significant change MDS was not completed within 14 calendar days following the resident's readmission to the facility with hospice care ordered on 5/11/2024. Upon review of the most recent care plan last updated 8/24/2024, the MDS Coordinator confirmed R#2's medications had changed, and the resident was no longer taking an anticoagulant, montelukast (a medication used to control asthma and inflammation in the lungs), mirtazapine (a medication used to treat depression), or hydrocodone (a medication used to control pain), however the medications remain on the care plan. The care plan did not include atropine (a medication used to control secretions) as a current medication which is ordered for this resident. In addition, she confirmed, under the Activities of Daily Living section of the care plan did not address the level of care needed during mealtimes. The MDS Coordinator confirmed the care plan did not address the changes regarding the significant change in status including new interventions related to hospice care. When asked about the importance of completing a significant change in status MDS assessment, the MDS Coordinator confirmed the MDS and care plans guide everyone providing care to the resident and if the information is incorrect, this could have a negative impact on the resident.

Based on observation, record review, and interview, the facility failed to ensure staff followed Enhanced Barrier Precautions to reduce the potential risk of infection for 1 (Resident #41) sampled resident who was reviewed for Enhanced Barrier Precautions. The findings are: Review of the Admission Record revealed Resident #41 was admitted with a diagnosis of pressure ulcer of right heel, stage 3 (Stage 3 pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed). The quarterly 5 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/13/2024 revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 01, which indicated the resident had severe cognitive impairment. Review of Resident #41's care plan, completed 8/21/2024, revealed the resident had a stage 3 pressure ulcer to the right foot. Interventions included but were not limited to: Low Air Loss Mattress to bed for pressure relief as tolerated. Ensure functional and operational and encourage good nutrition and hydration in order to promote healthier skin. Review of Resident #41's physicians orders revealed the resident was on Enhanced Barrier Precautions related to wound to right heel and coccyx start date of 9/27/24. Review of the CMS (Centers for Medicare & Medicaid Services) Center for Clinical Standards and Quality/Quality, Safety and Oversight Group Memorandum, Subject, Enhanced Barrier Precautions [EBP] in Nursing Homes. provided by the Administrator revealed on page 1 that EBP recommendations now include use of EBP for residents with chronic wounds and on Page 3 Chronic wounds include, but are not limited to, pressure ulcers. During an observation on 10/14/2024 at 11:30 AM CNA #8 and CNA #9 witnessed incontinent care and a transfer with a lift. No PPE (Personal Protective Equipment) was used during incontinent care or transfer of Resident #41. During an interview on 10/14/2024 at 12:26 PM CNA #9 stated, Wound is healed up on resident's bottom so no longer on barrier precaution. During an interview on 10/16/24 at 11:06 AM the Wound Consultant and the Treatment Nurse were asked if the pressure ulcer of the right heel of Resident #41 was considered current with treatment. The Wound Consultant and the Treatment Nurse stated yes, and that the resident would be under enhanced barrier precaution and that PPE (personal protective equipment) was in the room for staff to use.

Based on observation and interview, the facility failed to ensure leftover food items were used to maintain food quality; 1 ice machine and 1 scoop holder were maintained in clean and sanitary condition to prevent contamination of airborne particles; foods stored in the dry storage area refrigerator, and freezer were covered, and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen, expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of I kitchen; failed to ensure foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; cold foods on ice were maintained at a temperature at or below 41 degrees Fahrenheit while awaiting service to prevent potential bacteria growth; hot food items on the steamtable were maintained at a temperature at or above 135 degrees Fahrenheit while awaiting service, to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 58 residents who received meals from the kitchen, (total census: 59) as documented on a list provided by the Dietary Supervisor on ,d+[DATE] /2023 at 09:00 AM The findings are: 1 On [DATE] 09:45. A zip lock bag that contained leftover sausage was on a shelf in the refrigerator. On [DATE] at 07:58 AM the surveyor asked Dietary Employee (DE) #3 what do you use leftover sausage for? She stated, we use it for the pureed meal the next morning. 2. On [DATE] at 09:52 AM, an opened box of bacon was on a shelf in the walk-in refrigerator. The box was not covered or sealed. 3. On [DATE] at 09:53 The ice scoop holder on the wall by the ice machine had gray residue at the bottom of it. The ice scoop was in direct contact with the gray matter residue. The surveyor asked the DE #1 to wipe the inside of the ice scoop holder. She did so and stated, it was gray residue. The surveyor asked DE #1 how often they clean the scoop holder. She stated, I clean it every day. 4. On [DATE] at 09:54 AM the top panel of the ice machine in the room between the dining room and the kitchen window had wet black residue on it. The surveyor asked DE #1 to wipe the top panel. The wet residue easily transferred to the tissue. DE #1 stated, that was black matter on it. I clean it every day. The Surveyor asked the Dietary Supervisor, who uses the ice from the ice machine from the ice machine? She stated, that's the ice the CNAs (Certified Nursing Assistants) use for the water pitchers in the residents' rooms and the residents' beverages at the mealtimes. 5. On [DATE] at 09:55 AM an opened box of biscuits was on a shelf in the walk-in freezer. The box was not covered or sealed. 6. On [DATE] at 11:19 AM a box of crackers was on top of the freezer in the nourishment room on 200 Hall had best used by [DATE] on it. 7. On [DATE] at 11:40 AM DE #2 removed a carton of nectar cranberry juice from the refrigerator and placed it on the counter. Without washing his hands, he picked glasses by their rims and poured beverages in them to be served to the residents on nectar thickened liquid diets. 8. On [DATE] at 11:48 AM the temperatures of the food items on the steam table were checked by DE #3 were: a. Potato salad 50 degrees Fahrenheit. b. Pureed potato salad 50 degrees Fahrenheit. c. Baked beans 115 degrees Fahrenheit. The baked beans were not reheated before being served to the residents. 9. On [DATE] at 11:50 AM DE #1, picked up the water hose with bare hands, used it to spray leftover food from inside of the blender. DE #1 placed the blender, a blade and the lid in the dirty racks and pushed the rack into the dish washing machine to wash. After the dishes stopped washing, DE #1 moved to the clean side of the dishwasher area and picked up a clean blade and attached it to the base of the blender to be used in pureeing foods to be served to the residents who received pureed diets for lunch. DE #1 then picked up clean dishes and stacked them in a rubber container on the cart to be used in portioning food items to be served to the residents for lunch. The Surveyor asked what you should have done after touching dirty objects or before handling clean equipment? DE #1 stated, I should have washed my hands. 10. On [DATE] at 12:43 PM DE #2 was on the tray line assisting with lunch meal service, picked up condiments, cartons of milk, shakes, cans of soda and placed them on the trays. Without washing hands, DE #2 picked up glasses that contained beverages by their rims and placed them on the meal trays to be served to the residents for lunch. At 01:00 PM the Surveyor asked DE #2 what should you have done after touching dirty objects or before handling clean equipment? DE#2 stated, I should have washed my hands. 11. On [DATE] at 01:22 PM DE #4 removed onion from the walk-in refrigerator and placed it on the counter. DE #4 peeled off the papery layers from the onion, turned on the 3-compartment sink faucet and rinsed it. DE #4 then turned off the faucet with bare hands, therefore. DE #4 then placed the onion on the cutting board and held it with his hands while he sliced it with a knife. DE #4 then transferred slices of onion into a pot on the stove to be used in cooking cabbage to be served to the residents for supper. The surveyor asked DE #4 what should you have done after touching dirty objects or before handling clean equipment? DE #4 stated, I should have washed my hands. 12. On [DATE] at 02:50 PM a bag of hamburger buns that contained 8 buns was on the rack in the walk-in refrigerator. The bag showed best used by [DATE]. Six bags of hamburger buns with 8 buns in each bag were on the bread rack in the walk-in refrigerator. Each bag showed best used by [DATE]. 13. On [DATE] at 3:00 PM DE #5 removed a tray that contained glasses of beverages from the walk-in refrigerator and placed it on the counter. DE #5 removed cartons of grape juice from the refrigerator and placed them on the counter. Without washing hands, DE #5 picked up glasses by the rims and poured beverages, then placed them on the trays to be served to the residents for supper. The surveyor asked what you should have done after touching dirty objects or before handling clean equipment? DE #5 stated, I should have washed my hands. 14. The facility policy on hand washing provided by the Dietary Supervisor on [DATE] at 09:00 AM documented, After engaging in other activities that contaminate the hands.

Based on Observation, Interview and Policy Review the facility failed to remove expired medications from 1 of 2 medication carts. The Findings include: On 9/6/23 at 2:15 PM observed the following medications on medication cart # 2. a. one vial of Novolin R insulin with an opened date of 6/3/23. b. one Albuterol Inhaler with an opened date of 7/21/03. c. one ProAir Inhaler with an opened date of 7/2/23. d. one Albuterol Inhaler with an opened date of 6/13/23. e. one Albuterol Inhaler with an opened date of 10/31/22. f. four bottles of Artificial Tears with an opened date of 6/20/23, 7/20/23, and 7/26/23 and 1 was not dated. g. one bottle of Dorzolamide eye drops with an opened date of 7/28/23. h. one bottle of Timol Eye drops with an opened date of 7/27/23. i. one Albuterol Sulfate Inhaler with an opened date of 6/15/23. j. one bottle of Latanoprost eye drops with an expiration date of 6/30/23. k. one bottle of Xalatan eye drops not dated. l. one bottle of Latanoprost eye drops with an opened date of 4/21/23. During an interview on 9/6/23 at 2:40 PM, Licensed Practical Nurse (LPN) #1 stated insulin is good for 28 days after it is opened. On 9/6/2023 at 4:19 PM, the Director of Nursing provided a policy titled, Storage of Medications IN THE FACILITY. This policy documented, H .Outdated .medications .are immediately removed from inventory, disposed of according to procedures for medication disposal . J. Medication storage conditions are monitored on a monthly basis by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified .

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. This failed practice had the potential to affect 12 residents who received pureed diets and 13 residents who received mechanical soft diets and 33 residents who received regular diets from 1 of 1 kitchen, according to a list provided by the Dietary Supervisor on 09/06/2023 at 9:00 AM. findings are: 1. The menu for the dinner meal showed the residents who received pureed diets were to receive 2 #8 scoop (1 Cup) of fish sandwich with 2 slices of cheese, residents on mechanical soft diets were to receive 3 ounces of hamburger patties with 2 slices of cheese and residents on regular diets were to receive 2 slices of cheese. 2. On 8/05/23 at 3:28 PM during the supper meal preparation Dietary Employee (DE) #4 placed 4 breaded fried fish cod pieces into a blender, ground and poured it into a pan. He covered the pan with foil and placed it in the oven to be served to 13 residents on mechanical soft diets. At 5:09 PM DE #4 used a 2-ounce spoon to serve a single portion of ground breaded fish cod with a slice of cheese to the residents on mechanical soft diets. instead of 3 ounces of ground breaded fish cod. 3. On 09/05/23 at 3:32 PM DE #4 placed 4 breaded fish cod pieces into a blender, then added 2 more breaded fish cod pieces, added 2 cartons of whole milk and pureed. DE #4 added 2 more cartons of milk and pureed. At 3:38 PM DE #4 poured the pureed fish into a pan, covered with foil, and placed it in the oven to be served to 12 residents on pureed diets. At 5:03 PM DE #4 used a 4-ounce spoon to serve a single portion of pureed fish to the residents on pureed diets, instead of 2 #8 scoop of pureed fish sandwich with cheese. At 5:25 PM the surveyor asked DE #4 the reason residents on pureed diets did not receive any type of bread or cheese. He stated, I forgot to puree bread and cheese. 4. On 9/05/23 5:11 PM DE #4 served a single slice of cheese to the residents on regular diets. 5. On 9/06/23 at 8:02 AM the surveyor asked DE #4 how many servings of fish he prepared for the residents on pureed diets and residents on mechanical soft diets. He stated, I did 6 servings for the pureed dets and 4 servings for the mechanical soft diets. He was asked how many residents you have on pureed diets and on mechanical soft diets. He stated, We have 12 residents on pureed diets and 13 on mechanical. I thought that would be enough when I used milk. 6. On 9/06/23 at 11:23 AM the surveyor asked the Dietary Supervisor to weigh a slice of cheese. She did and stated, it weighed 0.5 ounce. She was asked to weigh 2 slices. She did and stated, it weighed 1 ounce.

Based on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 12 residents who received pureed diets, as documented on the list Dietary Supervisor provided by the Food Service Supervisor on 09/06/2023 The findings are: On 09/05/23 at 11:48 AM, the following observations were made on the steam table: a. A pan of pureed potato salad was on the cold side of the steam table. The consistency of the pureed potato salad was lumpy and was not smooth. Pieces of potatoes were visible in the mixture. b. A pan of pureed barbeque chicken was on the steam table. The consistency of the pureed barbeque chicken was lumpy and not smooth. On 09/05/23 at 12:55 PM The surveyor asked Dietary Employee (DE) #3 to describe the consistency of the pureed foods served to the residents on pureed diets. She stated, pureed barbeque chicken has little pieces of chicken in it. Pureed potatoes have lumps in it. On 09/05/23 at 03:14 PM DE #4 placed 75 tater tots into a blender, added 2 cartons of whole milk and pureed. At 03:18 PM DE #4 poured the pureed tater tots into a pan; he covered it with foil and placed it in the oven. The consistency of the pureed tater tots was lumpy and not smooth. 09/05/23 03:32 PM DE #4 placed 4 breaded fish pieces into a blender, then added 2 more breaded fish pieces, added 2 cartons of whole milk and pureed. He added 2 more cartons of milk and pureed. At 03:38 PM DE #4 poured the pureed fish into a pan, covered with foil, and placed it in the oven. The consistency of the pureed fish pieces was lumpy and not smooth. On 09/05/23 at 03:40 PM pureed cabbage in a pan in the oven to be served to the residents for supper was runny. On 09/05/23 at 05:27 PM the surveyor asked the Dietary Supervisor to describe the pureed food items served to the residents on pureed diets at the dinner meal. She stated, pureed cabbage was too runny, pureed fish and pureed tater tots had lumps.

Based on observation, record review and interview, the facility failed to ensure a Continuous Positive Airway Pressure (CPAP) and mask were properly changed and bagged in a closed container to prevent infections for 1 of 1 sampled resident (Resident # 8) who had a physician's order for the use of a CPAP. The findings are: On 9/05/23 at 11:22 AM Resident #8 was sitting in the resident room with a CPAP on the bedside table with no date on the tubing. The tubing and mask were not bagged. On 9/06/23 at 10:56 AM, observed the mask and tubing on a bedside table. The CPAP was not bagged or dated. On 9/06/23 at 3:35 PM observed the CPAP was not in a bag or dated and the mask was lying on the bed. Review of a Physician's order dated 8/13/23 for Resident #8 showed the oxygen tubing for the CPAP machine to be changed every Sunday night. Review of a care plan with an initiated date of 6/30/23, for Resident #8 for oxygen therapy showed the Resident wears CPAP at night, and the nurse to assist with putting it on at night and removing it in the morning. On 9/7/23 at 8:30 AM Certified Nurse assistant (CNA) #1 confirmed there was no date on the tubing, and it was not stored in a bag. During an interview on 9/7/23 at 8:38 AM, Licensed Practical Nurse (LPN) #3 stated the tubing should be changed weekly and stated Resident #8 tubing was dirty. LPN #3 confirmed there was no date on the tube, and it was not stored in a bag. During an interview on 9/7/23 at 12:20 PM the Director of Nurses (DON) stated the tubing should be changed weekly on Sunday night. On 9/8/23 at 10:32 AM the DON provided a manufactures guideline Titled Cleaning and Maintaining your [Brand] headgear .For best Performance, remember to clean your headgear on a weekly basis .

Based on observation, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessment accurately reflected the resident's status to for Hospice for 1 of 1 (Resident #29) sample resident reviewed. This failed practice had the potential to effect 5 residents who received hospice services according to a list provided by the Assistant Director of Nursing (ADON) on 06/23/22 at 1:00 PM. The findings are: Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/06/22 documented the resident scored 00 (0-7 indicates severe impairment) on a Brief Interview for Mental Status and did not receive Hospice. The Admission MDS with ARD of 02/04/22 did not document the resident received Hospice. a. A Hospice form documented a Hospice admitted [DATE]. b. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 06/21/22 at 3:00 PM, Resident # 29's Power of Attorney stated the resident received Hospice Services. d. On 06/23/22 at 11:40 AM, the ADON was asked, When did the hospice services started? She stated, [Resident # 29] was admitted to the facility on hospice services. She was asked to look at the admission MDS with ARD of 02/04/22 Block O and if the hospice services were documented there. She said it documented, No. The DON and ADON was asked, Should it be documented in section O of the Admission MDS with ARD of 02/04/22? They both stated, Yes, it should be there. e. On 06/23/22 at 1:38 PM, the DON was asked if the hospice services should be documented on the Quarterly MDS? The DON stated, Yes f. On 06/23/22 at 1:45 PM, the Facility Resident Assessment policy and procedure provided by the Administrator on 06/23/22 at 12:36 PM was reviewed and documented, . The comprehensive assessment shall include all information specified in the State-approved resident assessment instrument and all other evaluations and assessments completed by health care professionals treating the resident .

Based on record review and interview, the facility failed to ensure Hospice services were documented on the care plan for 1 of 1 (Resident #29) sampled resident who received hospice services. This failed practice had the potential to effect 5 resident's that receive hospice services according to a list provided by the ADON [Assistant Director of Nursing] on 06/23/22 at 1:00 PM. The findings are: Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/06/22 documented the resident scored 00 (0-7 indicates severe impairment) on a Brief Interview for Mental Status and did not receive Hospice. The Admission MDS with ARD of 02/04/22 did not document the resident received Hospice. a. A Hospice form documented a Hospice admitted [DATE]. b. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 06/21/22 at 3:00 PM, Resident #29's Power of Attorney stated the resident received Hospice Services. d. On 06/23/22 at 11:40 AM, the ADON was asked, When did the hospice services started? She stated, [Resident # 29] was admitted to the facility on hospice services. The ADON was asked to look at Resident # 29's care plan and asked if the hospice services were documented on the care plan. She stated, No, it is not. The ADON was asked if the hospice services should be documented on the care plan? The ADON stated, Yes, it should be documented on the care plan. e. On 06/23/22 at 1:38 PM, the DON was asked if the hospice services should be documented on the care plan? The DON stated, Yes f. On 06/23/22 at 1:45 PM, the Facility Resident Assessment policy and procedure provided by the Administrator on 06/23/22 at 12:36 PM was reviewed and documented, . A comprehensive care plan will be developed for each resident using the results of the comprehensive assessment. Each resident's care plan shall include measurable objectives and timetables to meet the needs identified in the comprehensive assessment .

Based on observation, record review and interview, the facility failed to ensure toenail care was consistently provided to prevent potential complications for 1 (Resident #43) of 5 (Residents #43, #42, #16, #46 and #26) sampled mix residents who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #43 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/22 documented the resident scored 00 (0-7 indicates Severe impairment) on the Brief Interview for Mental Status, required total assistant of two-person assist for transfers, extensive assistance of two-person assistance for bed mobility and personal hygiene, and extensive assistant of one-person assist with bathing. a. The Initial Care Plan dated 11/26/21 documented, [Resident #43] has Diabetes Mellitus . Refer to pediatrist/foot care nurse to monitor/document foot care needs and to cut long nails. b. The Physicians Order dated 6/21/22 documented, Check diabetic feet every day shift every Sat [Saturday] . trim diabetic nails every day shift starting on the 15th and ending on the 15th every month . c. On 6/20/22 at 11:40 AM, the resident was resting in bed, and both feet were visible from under the sheets. Her husband stated, It's been a long time since they trimmed her toenails, they are long and need to be trimmed. The resident's toenails had on a pink polish that covered half of the toenails. The toenails were approximately 1/8 inch from the tip of the toes and the right and left big toenail and left third toe was uneven and jagged. d. On 6/21/22 at 3:03 PM, Licensed Practical Nurse (LPN) #1, was asked, Who performs the nail care of trimming and filing on the diabetic residents? She replied, I do their nail care on the 15th of every month and the RN [Registered Nurse] on the weekends checks the diabetic's feet on Saturday for care and skin issues. The LPN was accompanied the surveyor to the resident's room. The LPN was asked, Can you describe her toenails? She stated, They are long, uneven, and a few are jagged. Her toenails have been polished but that's been awhile. I'm going to file and trim them right now. The LPN was asked, What could happen if her toenails are not kept trimmed and filed? She stated, She could get a skin tear or tear off her toenail. e. On 6/23/22 at 10:25 AM, the Director of Nursing (DON) was asked, How often is nail care, including trimming and filing the toenails, completed? She stated, For the diabetics they are trimmed once a month on the 15th. The DON was asked, Who is responsible for trimming the resident's nails? She replied, The diabetics the treatment nurse, weekend RN and/or the floor nurses as needed. The DON was asked, Who is responsible to ensure the nail care is being completed as needed? She stated, me and the Assistant Director of Nursing (ADON). f. On 6/23/22 the Policy of Nail, Care of [Finger and Toe] from the DON documented, . NOTE: Toenails of Diabetic patients and patients with [CONDITION(S)] are to be cut by the podiatrist or licensed nurse .

Based on observation and interview, the facility failed to ensure dietary staff wore hair restraints while in the kitchen to prevent contamination of food items in 1 of 1 kitchen. This failed practice had the potential to affect 47 residents who received meals from the kitchen according to the Resident Census and Conditions of Residents form dated 04/13/2021. The findings are: 1. On 04/14/2021 at 8:07 A.M., Dietary Employee (DE) #2 had a hair net on that did not completely cover her hair leaving approximately 3 inches of hair exposed in the back of her head and approximately 1 inch of hair above her ears exposed. The Dietary Supervisor (DS) had a hair net on that did not completely cover her hair leaving approximately 3 inches of hair exposed at the back of her head and approximately 1 inch of hair above her ears exposed. 2. On 04/14/2021 at 10:28 A.M., DE #2 had a hair net on that did not completely cover her hair leaving approximately 3 inches of hair exposed in the back of her head and approximately 1 inch of hair above her ears exposed. The DS had a hair net on that did not completely cover her hair leaving approximately 3 inches of hair exposed at the back of her head and approximately 1 inch of hair above her ears exposed. 3. On 04/14/2021 at 12:36 P.M., during meal service in the kitchen, DE #3 entered the kitchen with a hair net on that did not completely cover her hair leaving approximately 2 1/2 inches of hair exposed at the back of her head and approximately 1/2 inch of hair exposed above her ears. 4. On 04/14/2021 at 12:43 P.M., the DS was asked, Are staff required to wear hair nets? She stated, Yes. She was asked, How much of your hair should be covered by the hair net? She stated, All of it. She was asked, How much hair is exposed on [DE #2]. She stated, At least 3 inches in the back. She was asked, How much hair is exposed on [DE #3]? She stated, At least 2 1/2 inches. She was asked, How much of your hair is exposed? She stated, It better not be. while reaching and pulling down her hair net. 5. A Hair Nets policy provided by the Administrator on 04/15/2021 documented, .Food service employees will wear a hair net covering that covers all hair completely .

Based on observation, record review and interview, the facility failed to ensure residents received physician ordered nutritional supplements to prevent further weight loss for 2 (Residents #32 and #38) of 21 (Residents #5, #8, #10, #11, #13, #15, #17, #18, #23, #24, #26, #27, #32, #34, #36, #38, #40, #41, #43, #45, #46) sampled residents who were to receive nutritional supplements. This failed practice had the potential to affect 33 residents, who required nutritional supplements at one or more meals according to a list provided by the Administrator on 04/15/2021. The findings are: 1. Resident #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . . a. The April 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date 05/14/2020 . b. The Plan of Care documented, .is at nutrition risk significant weight changes, unavoidable weight loss, within last 180 days. She is on the green card alert list. Revision on: 08/08/2019 . Add enhanced foods to diet. Date Initiated: 09/18/2020 . Offer supplements on meal trays and PRN [as needed] .Provide diet as ordered. Revision on: 06/27/2019 Current diet, regular, mechanical soft, enhanced, regular liquids .Revision on: 02/05/2019 . c. The Dietary Card dated April 14, 2021 documented, .Lunch .Diet order: Mech [mechanical], Soft, *Regular Diet, Chopped Meats, Enhanced Foods .Adap. [adaptive] Equip [equipment]: Hot Risk Cup with Lid .Notes: red milk and chocolate milk . coffee . fortified hot chocolate .alerts: chopped meat, weigh loss . Standing orders: house shake .dislikes: green leafy vegetables (green beans) . d. On 04/14/2021 at 12:27 P.M., Resident #32's lunch tray was taken to room and set up by Certified Nursing Assistant (CNA) #1 with the following Chocolate milk, Whole milk, Super pudding, Mechanical soft salad, Ranch dressing, 2 packs of crackers, Cottage cheese, Chili, 1 ounce shredded cheddar cheese, Mixed fruit, Grape juice, Baked potato with butter, no sour cream. The tray card documented, .mechanical soft, regular diet with chopped meats and enhanced food, house shake, fortified hot chocolate (hot risk apply lid) Alerts: chopped meat, weight loss, Dislikes green leafy vegetables and green beans . There was not a Strawberry Mighty Shake and Grapes as ordered by the physician on the lunch tray. 2. Resident #38 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 03/05/2021 documented the resident scored 3 (0 - 7 indicates severely impaired) per a BIMS and required a mechanically altered and therapeutic diet while a resident and no or unknown weight loss. a. The April 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Plan of Care documented, .has potential for nutritional problem r/t [related to] past hx [history] adult failure to thrive and low BMI [Body Mass Index] Date Initiated: 10/07/2019 . add super cereal to breakfast Date Initiated: 09/03/2020 . power potatoes at lunch Date Initiated: 04/02/2021 . Provide, serve diet as ordered. Current diet Regular, enhanced foods, mechanical soft texture, regular liquids . Date Initiated: 07/09/2019 c. The Dietary Tray Card documented, .Diet order: Puree, *Regular Diet, Enhance Foods . Notes: regular consistency liquids . magic cup at noon . mighty shake . Fortified hot chocolate . coke float . super pudding . power potatoes . d. On 04/14/2021 at 12:15 P.M., Resident#38 was sitting up in her recliner in the hallway with a tv tray in front of her. Her lunch tray included the following Chocolate milk and whole milk both with a straw .Pureed green beans, Power potatoes- thick, Chili, Super pudding, Fruit, Ranch dressing-no salad . There was not a Mighty Shake, Fortified Hot Chocolate and a Coke Float and there were straws in the Chocolate Milk and the Whole Milk on the lunch tray. e. On 04/14/2021 at 12:45 P.M., the Dietary Supervisor (DS) was asked, Who is responsible to ensure all ordered weight loss interventions or supplements are put on the resident's tray? She stated, Cooks help. She was asked why [Resident #38] didn't get all of the ordered and or recommended weight loss supplements on her lunch tray. She stated, I thought she had some of those discontinued due to having so many ordered but guess I wrong since they still show all of them on her tray card. 3. On 04/14/2021 at 1:12 P.M., Certified Nursing Assistant (CNA) # 1 was asked, Are residents on the secure unit receiving the supplements with their meals? She stated, Yes. She was asked, How do you know what supplements they are supposed to be getting? She stated, By looking at the dietary cards. She was asked, Do you compare what is on the tray to what is listed on the dietary card? She stated, Yes. She was asked, What do you do if everything is not there? She stated, Notify dietary. 4. On 04/14/2021 at 1:19 P.M., CNA #2 was asked, Are residents receiving the supplements with their meals? She stated, There was one missing today. She was asked, How do you know what supplements they are supposed to be getting? She stated, Looking on the card. She was asked, Do you compare what is on the tray to what is on the dietary card? She stated, Yes. She was asked, If the supplements are not on their tray, what do you do? She stated, We go to dietary and git it, we ask for it through the window. 5. On 04/15/2021 at 10:15 A.M., Dietary Employee (DE) #2 was asked, Whose responsibility is it to make sure the diet orders and dietary orders are followed? She stated, .The cooks help, we are supposed to check for enhancements, specialty drinks like coke floats. I'm checking the tray to make sure the food is correct. She was asked, If someone has on their dietary card enhanced hot chocolate should they receive that? She stated, I didn't make that yesterday. It's also a miscommunication, the CNAs tell us they don't want something . 6. On 04/15/2021 at 10:44 A.M., the Director of Nursing was asked, Should a resident be provided with the diet and supplements ordered and or what is listed on the dietary card. She stated, Yes. 7. On 04/15/2021 at 2:29 P.M., the Administrator was asked for a policy on tray preparation. The Administrator stated, .No policy for that, but, the process is; trays are filled by cook, passed down the line and at the end of the line the helper puts in supplements and makes sure all items on the diet card are on tray. Then the tray is passed through the window to the hostess. The hostess then checks the diet card to the items on the tray to verify it is correct, then the CNAs pick up the trays and deliver and set them up to the residents .

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned written menu and quantified recipes were consistently utilized for preparation of altered consistency diets to meet the nutritional needs of the residents for 1 meal observed. This failed practice had the potential to affect 7 residents who received pureed diets received from the kitchen, according to the list provided by the Administrator dated 04/16/2021. The findings are 1. The Dietary Menu provided by the Dietary Supervisor on 04/14/2021 documented the menu items for Wednesday as, chili, baked potato, mixed green salad, Saltine crackers, Margarine, dressing of choice, sour cream, fruit cup, coffee or tea, garnish grated cheese. The pureed menu documented, Chili PU[Puree], BKD POT PU [baked potato puree], PU Vegetable, Crackers Pu, Marg Spread, Sour Cream, Fruit Cup Pu, Coffee/Tea. 2. On 04/14/2021 at 10:31 A.M., Dietary Employee (DE) #1 was pureeing food items for lunch. She stated, I only have 2 things, green beans and chili. She pureed the green beans and chili with no concerns in the puree process of these items. At 10:55 A.M., she stated, That's all I had today. 3. On 04/15/2021 at 10:13 A.M., the Dietary Supervisor (DS) was asked, Was pureed crackers provided for the residents who received a pureed lunch on 04/14/2021? She stated, I'll have to find out why. 4. On 04/15/2021 at 10:14 A.M., DE #1 was asked, Did you puree crackers for the lunch service on 4/14/21? She stated, No, I just overlooked it. 5. On 04/15/2021 at 10:43 A.M., the Director of Nursing was asked, Should the menu be followed and should a resident who receives a pureed diet receive all the items on the menu? She stated, Yes. 6. On 04/15/2021 at 2:29 P.M., the Administrator was asked, If crackers are on the menu, should they be pureed? She stated, If it's on the regular menu we provide the pureed also.

Based on record review and interview, the facility failed to ensure the necessary assessments and monitoring were conducted and documented when a resident exhibited signs and symptoms of a Urinary Tract Infection and consulted with the physician when the resident exhibited increased confusion and had decreased urine output and dark red urine with sediment, which resulted in a delay in treatment for 1 (Resident #34) of 2 (Residents #23 and #34) case mix residents who had indwelling urinary catheters. The failed practices resulted in actual harm for Resident #34, who exhibited signs/symptoms of a Urinary Tract Infection [MEDICAL CONDITION] that went untreated for [REDACTED]. Resident #34 had [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set with an Assessment Reference Date of 9/10/18 documented the resident scored 3 (0-3 indicates cognitively intact) on a brief interview for mental status, required extensive assistance of one person for transfers, toilet use, and personal hygiene, was frequently incontinent of bowel and required an indwelling urinary catheter. a. Nurse's Notes dated 8/18/18 at 6:14 a.m. documented, res (resident) had very little output and what was in foley bag was dark yellow and red, sediment with a very strong odor, will pass on to next nurse to try and push fluids. Res also had a fall yesterday, if odor and unsteadiness cont (continue) will call PCP (Primary Care Physician) about a poss (possible) UA (urinalysis). There was no documentation the resident's vital signs, including temperature, were checked. There was no further documentation in the Nurse's Notes of any follow-up assessments or monitoring of urine output, urine characteristics, or other signs/symptoms related to a possible UTI, until 8/19/18 at 6:21 a.m. b. Nurse's Notes dated 8/19/18 at 6:21 a.m. documented, res (resident) cont (continue) to have little output and is very dark and has a very strong odor, res also cont to be more confused than res norm (normal), res was up most of the night and kept stripping the bedding, will cont to monitor and attempt to encourage fluid. There was no documentation the physician was consulted at this time or of any further attempt to assess / monitor the resident's condition until 1:38 p.m. c. Nurse's Notes dated 8/19/18 at 1:38 p.m. documented, (Ambulance service) here to transport to (Hospital). Sent non emergent ems (Emergency Medical Service) sheet with (Ambulance service), sent SBAR (Situation - Background - Assessment - Recommendation) and transfer paperwork with resident, face sheet. (Daughter's name) aware and DON (Director of Nursing) aware. This was a period of over 30 hours after the changes in the resident's urine output and characteristics were initially identified and documented. d. The hospital History and Physical dated 8/19/18 documented, History of Present Illness: The patient is a [AGE] year-old white female who is sent from the nursing home today for mental status changes. It appears over the last 2 days her mental status has gotten worse, she was sent from the nursing home for evaluation as to the cause. After laboratory x-rays were done, it appears that the patient does have significant urinary tract infection noting that she has leukocyte esterase positive, [MEDICATION NAME] positive, and 10-19 WBCs (White Blood Cells) in her urine. The patient does have a chronic foley in place and is also noted at this particular time, she has a white count as 15,000. The patient is unable to give an adequate history secondary to her underlying mental state. She does have history of Alzhiemer's as per grandson who is in the room with her, but she states she has been more so confused over the past 2 days. The patient does state when asked she has no complaints other than asking me not to mash on her legs when I was checking her for [MEDICAL CONDITION] .Laboratory Data: Abnormal. White count is 15,000. Troponin is 0.056. BNP (Brain Natriuretic Peptide) is elevated 8697. Urine is mentioned in the chief complaint. She is noted to have a BUN (Blood Urea Nitrogen) of 24. Chest x-ray shows no signs of pneumonia. Impression: 1. SIRS (Systemic [MEDICAL CONDITION] Response Syndrome) syndrome as patient has an elevated white count and [MEDICAL CONDITION] 2. Urinary tract Infection. 3. Leukocytosis . e. On 10/10/18 at 1:58 p.m., the DON was asked, was the Physician notified of the resident's decreased urine output and red urine with the strong odor? She stated, .was told in report that the Doctor was notified and to monitor and let him know if it got any worse. That's not documented anywhere. I cannot prove we notified the Physician until it got worse. f. On 10/10/18 at 3:25 p.m., the DON was asked, do you have a structured process for identifying and addressing residents' changes in condition? She stated, Yes, assess the patient and notify the physician of any significant change of condition. g. The facility policy titled, Change of Condition or Status, provided by the DON on 10/10/18 at 3:28 p.m., documented, This facility, specifically, the DON, Charge Nurse, or designee, will promptly notify the resident, the physician, and the resident's legal representative or responsible party . when: .there is a significant change in the resident's physical, mental or psychosocial status, defined as: .A major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both . or . A deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. c. There is a need to alter the resident's treatment significantly, defined as a need to discontinue an existing form of treatment, or to commence a new form of treatment .Documentation: 1. The DON, Charge Nurse or designee will record any changes in the resident's medical condition or status in the resident's medical record, along with all nursing actions, including resident assessments, physician contacts, and responsible party contacts. 2. Documentation of physician notification will include time and response .

Complaint # was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to provide sufficient fluid intake to maintain proper hydration and health for Resident #1. The facility failed to conduct and document ongoing monitoring of the resident's hydration status and assess for increased fluid needs when the resident was diagnosed with [REDACTED].#1) of 2 (Residents #1 and #2) case mix residents who were at risk for dehydration. The failed practice resulted in actual harm for Resident #1, who was subsequently hospitalized with Severe Dehydration and Acute Kidney Injury, and had the potential to affect . 10 residents who were at risk for dehydration according to the Director of Nursing on 2/6/13 at 5:00 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 1/7/13 documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment of Mental Status, had a feeding tube and was totally dependent on staff for nutrition. a. A Physician order [REDACTED]." b. The Plan of Care dated 1/18/13 documented, "Nutrition/Hydration via PEG tube due to severe oropharyngeal dysphagia... Administer tube feeding and water flushes as ordered, monitor for tolerance... monitor for fluid and skin turgor." c. Nurse Notes dated from 1/17/13 through 1/20/13 documented the following: 1/17/13 at 12:15 a.m.: "T (Temperature) 101.2, P (Pulse) 85, R (Respirations) 20, B/P (blood pressure) 131/78. O2 (oxygen) sat (saturation) 97% with O2 at 4 L/m (liters per minute)... slight wheezing noted to bilateral upper lobes. (Physician) notified...1:30 a.m. - Recheck temp (temperature) 100.5... 3:30 a.m. - Temp 100.6..." 1/18/13 at 12:30 a.m.: "T 100.9... 3:40 a.m. - ...T 100.8...Will continue to monitor..." 1/18/13 at 7:00 p.m.: "...O2 at 4L/m... able to answer question... Skin w/d (warm and dry) to touch... VS (vital signs) 139/82, 83, 24, 100.6..." 1/19/13 at 5:15 p.m.: "...Continues on [MEDICATION NAME] 500 mg...VS 160/100, 92, 100.7, 38, 96%." 1/20/13 at 12:30 a.m.: "T 100.8, P 96, R 17, B/P 150/90. O2 sat 97% with O2 at 4 L/m... Lung sounds with ronchi to upper bilateral lobes, continues on antibiotic therapy for URI (upper respiratory infection)... 1:30 a.m. - Recheck temp 100.2..." 1/20/13 at 10:10 a.m.: "VS 138/90, 98, 46, 100.2, 94%. O2 at 4L/min via NC (nasal cannula)... skin warm and dry. [MEDICATION NAME] 5/325 given... will continue to observe... 2:45 p.m. - VS 135/91, 105, 44, 99.6, 94%... Send to (hospital) due to change of condition..." d. Hospital Emergency Department documentation dated 1/20/13 documented, "...presented to the Emergency Department at 1535 (3:35 p.m.)... The patient was triaged at 1540 (3:40 p.m) with the following vital signs: T: 99.4 AX (axillary), P: 105 regular, R: 62 labored, BP: 124/85, SPO2: 97. Amt: 4L N.C. (nasal cannula)... BUN (blood urea nitrogen) 74, Creatinine 1.4, Sodium 151... Clinical Impression: Severe Dehydration, Respiratory Distress, Nursing Home Neglect, Pneumonia..." e. A hospital Laboratory Report dated 1/20/13 upon admission to the hospital documented, "BUN (Blood Urea Nitrogen) 74 (reference units: 7-18), Creatinine 1.4 (reference units: 0.6-1.3), BUN/CR ratio 52.9 (reference units: 10-17), Sodium 151 (reference units: 136-145), Potassium 5.2 (3.5-5.1), Chloride 116 (reference units: 98-107)." k. The hospital History and Physical dated 1/20/13 documented, "...He was brought to the emergency room for worsening shortness of breath. Apparently patient was diagnosed with [REDACTED]. Today he was found to be severely dyspneic with a worsening cough and was unresponsive...There is also reported history of fever... Physical Examination... mucous membranes are dry... Assessment/Plan: ...nursing home resident who came with severe dehydration... At this point we will perform aggressive IV (intravenous) hydration with consideration of patient's [MEDICAL CONDITION] status..." l. The hospital Discharge Summary dated 1/25/13 documented, "The patient came with acute hypoxemic [MEDICAL CONDITION] and diagnosed with [REDACTED]. The patient was treated with IV antibiotics, IV fluid, free water... The patient had mild improvement of his chemistries. However, his kidney status overall did not improve despite maximum medical treatment. The patient's condition deteriorated. On 1/25/13, the patient became unresponsive and the patient is pronounced dead at 3:15 p.m... Final Diagnosis: [REDACTED]. m. On 2/6/13 at 1:51 p.m., the hospital Social Worker was asked about the [DIAGNOSES REDACTED]. She stated, "I was told by QA (Quality Assurance) that it was because the patient was a tube feeder and that he never should have gotten to that point... that they should have been monitoring him. The lab work showed severe dehydration." n. On 2/6/13 at 2:41 p.m., Licensed Practical Nurse (LPN) #1, who provided care to Resident #1 on 1/17/13, 1/19/13 and 1/20/13, was asked why Resident #1 would be diagnosed with [REDACTED]. He stated, "He was running a fever and that caused him to sweat. And he sweated a lot even before the fever." He was asked if, based on that, a resident's fluid needs would increase if they were sick and have a fever. He stated, "Yes." He was asked who would be responsible for assessing the resident for the additional hydration needs. He stated, "I guess, me." He was asked where that information would be documented if it was done. He stated, "In the Nurse's Notes." o. On 2/6/13 at 3:14 p.m., a hospital QA representative was asked about the [DIAGNOSES REDACTED]. He stated, "It's not that there was a gross neglect situation. The physician felt that there was no need in having a really high sodium and being dehydrated when the patient had a PEG tube." p. On 2/6/13 at 3:56 p.m., LPN # 2, who provided care to Resident #1 on 1/17/13 and 1/20/13, was asked during a telephone interview if she felt Resident #1's fluid needs would increase since he was sick and running a fever. She stated, "Yes." She was asked who would be responsible for assessing the resident for the hydration needs. She stated, "I would say the nurses, but honestly I didn't even think about that until you said it. I have taken care of tube feeders and I can't remember even one time checking with the doctor for extra fluid needs because they get their fluid from the tube feeding and flushes. But it's so obvious. I will think of it from now on." LPN #2 was asked where hydration assessments such as skin turgor and mucous membranes would be documented. She stated, "The Nurse's Notes. But he didn't appear to be dehydrated." She was asked why a resident who receives all of their hydration through a PEG tube would be severely dehydrated. She stated, "I don't know. That should never happen." q. On 2/6/13 at 4:25 p.m., the Director of Nursing (DON) was asked during an interview if she felt a resident's fluid needs would increase if they were sick and running a fever. She stated, "Yes." She was asked who would be responsible for assessing the resident for the hydration needs. She stated, "The nurses on the floor should be assessing that and contacting the doctor for an order." She was asked where hydration assessments, such as skin turgor and mucous membranes, would be documented. She stated, "In the Nurse's Notes." The DON was asked if she knew the resident was diagnosed with [REDACTED]. She stated, "No." r. As of 2/6/13 at 4:30 p.m., there was no documentation in the Nurse Notes to indicate hydration assessments had been conducted on the resident from 1/17/13-1/20/13 when he was sent to the hospital.

Complaint # , substantiated , all or part, in these findings. Based on observation, record review and interview, the facility failed to ensure all staff were trained and competent in the proper and safe use of a mechanical lift to prevent the potential for injury for 1 (Resident #2) of 2 (Resident #1 and #2) case mix residents who required the use of a mechanical lift for transfers. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death for Resident #2 and had the potential to cause more than minimal harm to 8 residents who were transferred using a mechanical lift according to a list provided by the Certified Nursing Assistant (CNA) Supervisor on 11/16/12. The facility was informed of the Immediate Jeopardy on 11/16/12 at 4:00 p.m. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/13/12 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), was totally dependent on 2 staff members for transfers, had functional limitation on range of motion on one side of upper and lower extremities. a. The Resident Overall Plan of Care last reviewed on 8/16/12 documented, "At Risk For Falls R/T (related to) S/P (status [REDACTED]. Up in Reclining Geri Chair as tolerated, ...1. Assist of two staff and specified mechanical lift with all transfers... 8/31/12 at 1620 (4:20 p.m.) 1:1 inservice with 2 CNA's done immediately on proper use of lift..." b. The Closet Care Plan, not dated, documented, "Transfers: Mechanical Lift with 2 staff (checked)..." c. The Incident/Accident Report dated 8/31/12 at 4:20 p.m. documented, "...Witnesses: (CNA #1 and CNA #2) ...Description of Incident: Mechanical Lift fell over while transferring resident from bed to Geri Chair. (No) injury. Resident landed in chair. Will continue to observe for injury... Steps to Prevent Reoccurrence: Immediate I/S (Inservice) done (with) staff involved." The Resident Overall Plan of Care updated on 8/31/12 documented, "...8/31/12 at 1620 (4:20 p.m.) 1:1 inservice with 2 CNA's done immediately on proper use of lift..." d. On 11/15/12 at 3:50 p.m. CNA #1 stated, "(CNA #2) and I were transferring the resident with the new lift that was just delivered before the incident. We had the lift pad positioned correctly and the legs of the lift were spread open during the entire transfer. As we were positioning her over the Geri Chair the lift flipped over causing the resident to fall approximately 3 - 4 inches down onto the arm of the chair. She did not sustain any injuries. We did not get any inservice on the use of the new lift before using it and we definitely did not receive any inservice (1:1 or otherwise) on the proper and safe use of it nor were we asked or offered to perform a return demonstration on the use of the new one or any of the other lifts. Some of the other CNAs told me that it was just like the other ones, no different. The new one is different; it squeezes the the resident together in the lift." e. On 11/15/12 and 11/16/12 during interviews with 10 other CNAs they all confirmed that they did not receive any inservice (1:1 or group) on the new lift before or after the incident (8/31/12) with this resident and none of them had been asked to perform a return demonstration on the proper/safe use of the new or any other lift. f. On 11/16/12 at 3:40 p.m., CNA #1 and CNA #3 transferred Resident #2 from the bed to a ger-chair. The lift pad was up above the resident's head approximately 3 - 4 inches causing the resident to bend forward toward her knees when up in the air. After the resident was in the air she stated, "Your squishing me!" The CNAs did not lock the wheels of the Geri Chair and the chair was moving while the CNAs were chasing the chair with the resident suspended in the air. CNA #3 was pushing the lift and CNA #1 was grabbing the resident's legs trying to hold steady over the moving chair before lowering her down onto the chair. After being lowered to the chair and the lift pad removed from the lift bar the resident shouted, "You got me cock-sided!" After repositioning the resident in the chair with the lift pad the resident stated, "Glad that's over you were hurting me!" 2. The Manual/Electric Portable Patient Lift Owner's Operator and Maintenance Manual received from the Administrator on 11/16/12 at 3:00 p.m. documented, "...WARNING: DO NOT OPERATE THIS EQUIPMENT WITHOUT FIRST READING AND UNDERSTANDING THIS MANUAL. IF YOU ARE UNABLE TO UNDERSTAND THE WARNINGS, CAUTIONS AND INSTRUCTIONS CONTACT A QUALIFIED DEALER OR INVACARE TECHNICAL SUPPORT BEFORE ATTEMPTING TO USE THIS EQUIPMENT - OTHERWISE INJURY OR DAMAGE MAY RESULT.... Transferring the Patient... Wheelchair wheel locks MUST be in a locked position before lowering the patient into the wheelchair for transport...WARNING: DO NOT attempt any transfer without approval of the patient's physician, nurse or medical assistant. Thoroughly read the instructions in this Owner's Manual, observe a trained team of experts performing the lifting procedures and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient...." 3. The Immediate Jeopardy was removed and the scope and severity lowered to a E on 11/16/12 at 7:00 p.m. when the following the Plan Plan of Removal was implemented: a. Beginning immediately, 11/16/12, all residents requiring the use of the mechanical lift for transfer will be identified by the DON (Director of Nursing) Designee. This will be completed by 11/16/12 at 7:00 p.m. This list will be updated weekly x (times) 4 weeks, and every two x four weeks and then monthly thereafter as needed. b. Each resident identified by the DON/Designee requiring the use of the mechanical lift for transfers will have their closet care plans updated. We will document "m" mechanical lift for transfers, number of staff and type/size of lift sheet to be used. This will be updated weekly x 4 weeks and every two weeks x four weeks and then monthly thereafter or more often as needed. This will be on-going. c. Effective immediately, 11/16/12, all licensed staff and CNAs currently working will be in-serviced by the DON/Designee and perform a return demonstration on the proper and safe transfer of resident with mechanical lift. Any negative findings will be corrected immediately. All other licensed staff and CNAs will be in-serviced by the DON/Designee and required to perform a return demonstration on the proper and safe use of the mechanical lift prior to the next scheduled shift. Any negative findings will be corrected immediately. Each new hire, licensed staff or CNA will be in-serviced by the DON/Designee. They will be required to perform return demonstration on the proper/safe use of transferring residents with the mechanical lift prior to work. Any negative findings will be corrected immediately. After initial inservicing and return demonstration is completed, all licensed staff and CNAs will be required to perform return demonstrations on the proper and safe use of transferring residents with the mechanical lift, five times a week x one week, three times a week for two weeks, then two times a week for one week, one time a week x four weeks, then monthly until substantial compliance is obtained. Any negative findings will be corrected immediately. After substantial compliance is obtained, all licensed staff and CNAs will be required to perform a return demonstration of the proper and safe use of transferring residents with the mechanical lift at least quarterly. Any negative findings will be corrected immediately. This will be on-going. d. All negative findings will be reported to the QAA (Quality Assurance and Assessment) Committee and corrected immediately through in-services, one-on-one training, return demonstration, etc. All in-services and return demonstrations regarding proper and safe use of transfers with residents and mechanical lift will be conducted by the DON/Designee and documented on In-Service records, QAA/Stand-Up Meetings Minutes and signed by the DON/Designee and staff. This will be on-going.