Every finding on record at Autumn Care of Mechanicsville

Based on observation and staff interview, the facility staff failed to maintain one of two dumpsters in a sanitary manner. Facility staff failed to close one of two lids on the top of a facility's dumpster. The findings include: On 02/24/2025 at approximately 11:35 a.m., an observation of the facility's two dumpsters located behind the facility was conducted with OSM (other staff member) #4, assistant dietary manager. The observation revealed the left lid of the dumpster on the right side (when facing the dumpsters) was resting on a bag(s) of trash in an open position. Further observations revealed the trach bag(s) were exposed. When asked how often the dumpsters were emptied OSM #4 stated they were emptied six days a week. When asked about the open lid on the dumpster she stated the trash should have been pushed down into the dumpster and the lid should have been closed. OSM #4 further stated the dietary department and the facility's maintenance department shared the responsibility of maintaining the dumpsters by alternating the responsibility monthly. On 02/25/2025 at approximately 11:45 a.m., an interview was conducted with OSM #1, director of environmental services regarding maintaining the facility's dumpsters. OSM #1 stated the dietary department, and the maintenance department shared the responsibility of maintaining the dumpsters by alternating the responsibility monthly. When asked how often the dumpsters were emptied OSM #4 stated they were emptied six days a week. When informed of the observation stated above, OSM #4 stated the trach should have been pushed down or removed to a secondary location so the lid would close. When asked why it was important to close the lids on the dumpsters, she stated to keep pests from getting into the trash. On 02/25/2025 at approximately 4:10 p.m., ASM #1, administrator, ASM #2, director of nursing, ASM #3, regional vice president of operations, were made aware of the above findings. No further information was provided prior to exit.

Based on clinical record review staff interview, the facility staff failed to maintain the resident's highest level of well-being for 1 (one) of 35 residents in the survey sample, Resident #31 (R31). The findings include: For R31, the facility staff failed to follow the physician's order for daily weights. R31 was admitted to the facility with a diagnosis that included but was not limited to CHF (congestive heart failure) (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/12/2025, R31 scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating R31 was severely impaired of cognition for making daily decisions. The physician's order for R31 documented in part, Daily weight for CHF Monitoring. Frequency: Once A Day. Repeat: Every Day. Notify MD/NP if Resident has greater than 2.5 lbs. (pounds) weight gain in 3 (three) days or greater than 5 (five) lbs. in a week. Start Date: 1/29/25. The eMAR (electronic medication administration record) for R31 dated February 2025 documented the physician's order as stated above. Further review of the EMAR for 02/07/2025, 02/10/2025, 02/17/2025, 02/22/2025 and 02/24/2025 documented O. Under Information Key it documented in part, O=Oth (Other). Review of the EHR (electronic health record) for R31 revealed a section entitled Vital Signs. Under Vital Signs the subcategory Weights failed to evidence documentation of R31's weights on 02/07/2025, 02/10/2025, 02/17/2025, 02/22/2025 and 02/24/2025. The progress notes for R31 dated 02/01/2025 through 02/25/2025 failed to evidence documentation of R31's weights on 02/07/2025, 02/10/2025, 02/17/2025, 02/22/2025 and 02/24/2025. On 02/26/2025 at approximately 1:03 p.m., an interview was conducted with RN (registered nurse) #4. When asked how it is evidenced that R31's weights were obtained RN #4 stated, The weights are documented in the Matrix (electronic health record) under Vital Signs. When asked about the coding of Other on R31's eMAR for the dates listed above, RN #4 stated,There should be an explanation. After reviewing R31's eMAR, nursing notes and vital sign section of the EHR, she could not say why R31's weights were missing on the above dates. When asked why R31's weight was being obtained daily, she stated, It was due to the diagnosis of CHF (congestive heart failure) to determine if R31 was retaining fluids. RN #4 stated, If R31 was retaining fluids it would put additional pressure on R31's heart . She further stated that if there not a weight(s), it could not be determined if R31 was retaining fluids. On 02/26/2025 at approximately 2:15 p.m., ASM #1, administrator, ASM #2, director of nursing, ASM #3, regional vice president of operations, were made aware of the above findings. No further information was provided prior to exit. References: (1) A condition in which the heart can't pump enough blood to meet the body's needs. This information was obtained from the website: https://medlineplus.gov/heartfailure.html.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to monitor a significant weight loss for one of 35 residents in the survey sample, Resident #120. The findings include: For Resident #120 (R120), the facility staff failed to obtain physician ordered daily weights after the resident experienced a significant weight loss. A review of R120's clinical record revealed the resident's weight was 159 lbs. (pounds) on 1/2/25 and 142 lbs. on 2/1/25 (a 10.69% weight loss in 30 days). A note signed by the RD (registered dietician) on 1/29/25 documented, Tube Feeding reviewed as weekly follow up. #CBW (Current Body Weight): 137 Lbs. BMI (Body Mass Index): 22.86 WNL (Within Normal Limits) but low for age. -14% loss less than a month, significant and concerning. RD requests reweigh for accuracy. Diet: Reg, Puree. Formula: Isosource 1.5 Cal. RD was notified by nurse on floor resident isn't eating well, formula was increased from twice daily to TID (Three Times Daily) for nutrition. If loss is true, frequency of feed will be increased to 4 times daily to combat weight loss .Resident will continue as a feeder; staff assist her with meals .Will be on daily weight to follow up with weight trend closely . A physician's order dated 1/29/25 documented, Obtain weight daily. Further review of R120's clinical record failed to reveal the resident's weight was obtained on 2/5/25, 2/14/25, 2/16/25, 2/17/25, 2/18/25, 2/19/25, and 2/22/25. On 2/26/25 at 10:14 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated, R120's daily weights were not obtained because of time management with CNAs (certified nursing assistants) and staff were trying to figure out whether to use a Hoyer lift or a chair to obtain the resident's weights. On 2/26/25 at 11:15 a.m., an interview was conducted with OSM (other staff member) #7 (the RD). OSM #7 stated, It was important for staff to obtain R120's daily weights because she wants to make sure the resident is not excessively losing weight and getting the nutrition needed. OSM #7 stated daily weights provide a more accurate reading for monitoring R120. On 2/25/25 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Resident Weight Policy documented, Weights will be obtained routinely in order to monitor nutritional health over time. Each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified, or as ordered. No further information was presented prior to exit.

Based on observation, staff interview, and facility document review, facility staff failed to store food in a sanitary manner in one of one facility kitchens and failed to maintain holding temperatures during lunch in one of two dining rooms observed. The findings include: 1. On 02/24/2025 at approximately 11:15 a.m., an observation of the facility's walk-in refrigerator in the facility kitchen was conducted with OSM (other staff member) #4, assistant dietary manager. An observation revealed an open three-pound package of sliced ham with approximate one pound remaining and an open bag of shredded cheddar cheese sitting on the middle shelf in the back of the walk-in refrigerator. Further observations of the packages of ham and cheese failed to evidence an open date. 2. On 02/24/2025 at approximately 11:25 a.m., an observation of the facility's walk-in freezer in the facility kitchen was conducted with OSM (other staff member) #4. An observation revealed two, 2.2 (two point two) pound bags of frozen breaded shrimp laying in an open box on the middle shelf on the left side of the freezer. Further observations revealed one bag containing approximately one pound of frozen breaded shrimp was open to the environment and the second bag of shrimp was resealed without an open date. 3. On 02/24/2025 at approximately 12:15 p.m., holding temperature were observed being obtained by OSM #5, kitchen aide, at the steam table on the facility's Winter unit. The temperature of the baked beans was at 160 degrees ( ) Fahrenheit (F), mash potatoes at 140 F, baked chicken at 160 F, BBQ pork at 120 F, pureed BBQ port at 100 F, pureed vegetables at 100 F, mixed vegetables at 100 F and hamburger at 100 F. Further observation revealed when OSM #5 finished obtaining the temperatures, he immediately began plating the resident's food. On 02/24/2025 at approximately 1:40 p.m., an interview was conducted with OSM #5 and OSM #6, dietary manager, regarding holding temperatures for resident's food. OSM #5 stated the holding temperature should by 65 F. OSM #6 stated holding temperatures for resident's food should be at a minimum of 135 F. She further stated if the holding temperatures are less than 135 F, the food is removed from the steam table, taken back to the kitchen and reheated to 165 F. She further stated the temperature of 165 F needed to be maintained for 15 seconds before being sent out to be served. When asked if the foods listed above below 135 F were sent back to the kitchen, OSM #5 stated no and OSM #6 stated that no food was sent back to the kitchen to be reheated. On 02/26/2025 at approximately 9:10 a.m., an interview was conducted with OSM #6 regarding the storage of opened food items. She stated the food should be wrapped or sealed to protect the food from contamination and dated when it was opened. The facility's policy Freezer and Refrigerator Policy documented in part, 7. All refrigerated and frozen foods must be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use-by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use-by dates indicated once food is opened. On 02/25/2025 at approximately 4:10 p.m., ASM #1, administrator, ASM #2, director of nursing, ASM #3, regional vice president of operations, were made aware of the above findings. No further information was provided prior to exit.

Based on observations, resident / staff interviews, clinical record review and facility document review, it was determined the facility staff failed to evidence bed inspections for four of 35 residents in the survey sample, R20, R59, R409 and R31. The findings include: 1.The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for R20. The facility's bed inspections were reviewed since last survey, they were completed 1/2023 and 2/12/2024. R20 was observed in bed on 2/24/25 at 2:30 PM and 2/25/25 at 8:14 AM in bed with 1/2 rails bilaterally. R20 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CHF (congestive heart failure), prosthetic heart valve, DM (diabetes mellitus) and osteoarthritis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 115/25, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximum assist for bed mobility/transferring/toileting and set up for eating. A review of the comprehensive care plan dated 7/9/24 revealed, PROBLEM: ADLs Functional Status/ Rehabilitation Potential Needs assistance with ADL's (activities of daily living) related to CHF, CKD3, DM, CAD, Dementia, Anemia, history of SBO, Arthritis and impaired mobility. APPROACH: Bilateral 1/4 side rails to bed, for turning and repositioning as tolerated Q shift. On 2/24/25 at 2:00 PM, OSM (other staff member) #2, maintenance, was observed completing bed inspections on the 200s hall. When asked about the bed inspections, OSM #2 stated, they are done every year. We check the bed for safety, to make sure there are no entrapment issues and bed safety. I am from another building helping them out. An interview was conducted on 2/24/25 at 2:30 PM with R20. When asked about the bed rails, R20 stated, they help me sit up and move. On 2/25/25 at approximately 1:30 PM, an interview was conducted with OSM #1. When asked about the bed inspections, OSM #1 stated, we are working on the 2025 inspections. Here are some of them, we are not finished with them. On 2/26/25 10:00 AM An interview was conducted with LPN (licensed practical nurse) #2, when asked side rails, LPN #2 stated, there is a quarterly assessment that needs to be done for the enablers or side rails. We get their consent for the enablers and side rails. When asked if it should be on the care plan, LPN #2 stated, well most of them are enablers so it really depends on the resident. When asked the difference between a side rail and an enabler, LPN #2 stated, it is the length of the rail. On 2/26/25 at 2:40 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services was made aware of the findings. A review of the facility's Bed Identification and Safety Inspection policy, revealed, Inspections will be completed annually and as needed when bed/mattress configuration changes. The inspection Checklist will be kept current by environmental services/maintenance. No further information was provided prior to exit. 2. The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for R59. The facility's bed inspections were reviewed since last survey, they were completed 1/2023 and 2/12/2024. R59 was observed in bed on 2/25/25 at 8:39 AM and 2/26/25 at 8:20 AM in bed with 1/2 rails bilaterally. R59 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident) with hemiplegia and hemiparesis, dementia and DM (diabetes mellitus). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 115/25, coded the resident as scoring a 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximum assist for bed mobility/transferring/toileting and set up for eating. A review of the comprehensive care plan dated 3/15/24 revealed, PROBLEM: ADLs Functional Status/ Rehabilitation Potential Needs assistance with ADL's (activities of daily living) related to CVA, DM, hemiparesis/hemiplegia and impaired mobility. APPROACH: Bilateral 1/2 side rails to bed, for turning and repositioning as tolerated Q shift. On 2/24/25 at 2:00 PM, OSM (other staff member) #2, maintenance, was observed completing bed inspections on the 200s hall. When asked about the bed inspections, OSM #2 stated, they are done every year. We check the bed for safety, to make sure there are no entrapment issues and bed safety. I am from another building helping them out. On 2/25/25 at approximately 1:30 PM, an interview was conducted with OSM #1. When asked about the bed inspections, OSM #1 stated, we are working on the 2025 inspections. Here are some of them, we are not finished with them. On 2/26/25 10:00 AM An interview was conducted with LPN (licensed practical nurse) #2, when asked side rails, LPN #2 stated, there is a quarterly assessment that needs to be done for the enablers or side rails. We get their consent for the enablers and side rails. When asked if it should be on the care plan, LPN #2 stated, well most of them are enablers so it really depends on the resident. When asked the difference between a side rail and an enabler, LPN #2 stated, it is the length of the rail. On 2/26/25 at 2:40 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services was made aware of the findings. A review of the facility's Bed Identification and Safety Inspection policy, revealed, Inspections will be completed annually and as needed when bed/mattress configuration changes. The inspection Checklist will be kept current by environmental services/maintenance. No further information was provided prior to exit. 3. The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for R409. The facility's bed inspections were reviewed since last survey, they were completed 1/2023 and 2/12/2024. R409 was observed in bed on 2/24/25 at 2:09 PM and 2/25/25 at 11:52 AM in bed with 1/2 rails bilaterally. R409 was admitted to the facility on [DATE] with diagnosis that included but were not limited to cellulitis, Afib (atrial fibrillation), embolism and MRSA (methicillin resistant staph aureus). The most recent MDS (minimum data set) assessment, an admission assessment has not been completed. A review of the baseline care plan dated 2/19/24 revealed, PROBLEM: ADLs Functional Status/ Rehabilitation Potential Needs assistance with ADL's (activities of daily living) related to cellulitis and impaired mobility. APPROACH: Bilateral 1/2 side rails to bed, for turning and repositioning as tolerated Q shift. On 2/24/25 at 2:00 PM, OSM (other staff member) #2, maintenance, was observed completing bed inspections on the 200s hall. When asked about the bed inspections, OSM #2 stated, they are done every year. We check the bed for safety, to make sure there are no entrapment issues and bed safety. I am from another building helping them out. An interview was conducted on 2/25/25 at 11:52 AM with R409. When asked about the bed rails, R409 stated, they are used at times to help me turn. On 2/25/25 at approximately 1:30 PM, an interview was conducted with OSM #1. When asked about the bed inspections, OSM #1 stated, we are working on the 2025 inspections. Here are some of them, we are not finished with them. On 2/26/25 10:00 AM An interview was conducted with LPN (licensed practical nurse) #2, when asked side rails, LPN #2 stated, there is a quarterly assessment that needs to be done for the enablers or side rails. We get their consent for the enablers and side rails. When asked if it should be on the care plan, LPN #2 stated, well most of them are enablers so it really depends on the resident. When asked the difference between a side rail and an enabler, LPN #2 stated, it is the length of the rail. On 2/26/25 at 2:40 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services was made aware of the findings. No further information was provided prior to exit. 29843 4. For R31, facility staff failed to conduct a bed and bed rail safety inspection. R31 was admitted to the facility with diagnosis that included but was not limited to: muscle weakness. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/12/2025, R31 scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating R31 was severely impaired of cognition for making daily decisions. On 02/25/25 at approximately 8:36 a.m., an observation revealed R31 in bed with right side quarter bedrail raised. On 02/25/25 at approximately 1:45 p.m., an observation revealed R31 in bed with right side quarter bedrail raised. Review of the facility's Bed and Bed Rail Safety Inspection sheets dated 02/01/2025 through 02/24/2025 failed to evidence documentation of R31's bed inspection. On 2/24/25 at 2:00 p.m., OSM (other staff member) #2, maintenance, was observed completing bed inspections on the 200s hall. When asked about the bed inspections, OSM #2 stated, they are done every year and check the bed for safety, to make sure there are no entrapment issues and bed safety. OSM #1 further stated he from another facility helping out. On 2/25/25 at approximately 1:30 p.m., an interview was conducted with OSM #1. When asked about the bed inspections, OSM #1 stated, he was working on the 2025 inspections, had some of them, but was not finished with them. On 02/26/2025 at approximately 2:15 p.m., ASM #1, administrator, ASM #2, director of nursing, ASM #3, regional vice president of operations, were made aware of the above findings. No further information was provided prior to exit.

Based on observations, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide foot care for one of 35 residents in the sample R20. The findings include: The facility failed to evidence provision of foot care for R20. R20 was observed in bed on 2/24/25 at 2:30 PM with thick toenails on both large toes and toenails approximately one-half inch in length. R20 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CHF (congestive heart failure), prosthetic heart valve, DM (diabetes mellitus) and osteoarthritis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 115/25, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximum assist for bed mobility/transferring/toileting and set up for eating. A review of the comprehensive care plan dated 7/9/24 revealed, PROBLEM: ADLs Functional Status/ Rehabilitation Potential Needs assistance with ADL's (activities of daily living) related to CHF, CKD3, DM, CAD, Dementia, Anemia, history of SBO, Arthritis and impaired mobility. APPROACH: Bilateral 1/4 side rails to bed, for turning and repositioning as tolerated Q shift. A review of the physician's order dated 7/15/24 revealed, Podiatry consult as needed. An interview was conducted on 2/24/25 at 2:30 PM with R20. When asked about toenail care, R20 stated, they do not cut them here, my son has to take me out to get it done. In response to request for evidence of podiatry visits, on 2/25/25 received a podiatry visit note date 11-2-22, and a note son taking her outside center to get nails clipped with no evidence in progress notes or scanned in documents of these appointments. On 2/26/25 10:00 AM An interview was conducted with LPN (licensed practical nurse) #2, when asked about toenail care, LPN #2 stated, The residents' nails are assessed by the nursing assistants on their shower days, and we are informed if the nails need trimmed . We put the resident's name on the podiatry list. If the resident has DM or thick nails, the nurses are not allowed to cut their toenails. On 2/26/25 at 2:40 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services was made aware of the findings. ASM #2 stated, the podiatrist comes next week, we will put him on the list. A review of the facility's ADL (activity of daily living) policy, revealed, Provision of ADL care will be documented each shift by staff providing the care. This shall include, but not be limited to, documentation of food intake, toileting, ambulation, bathing, dressing and transferring. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for three of 35 residents in the survey sample, Residents #120, #2, and #61. The findings include: 1. For Resident #120 (R120), the facility staff failed to implement the resident's comprehensive care plan for obtaining weights. R120's comprehensive care plan dated 10/22/24 documented, Resident requires Enteral tube feeding and is at risk for dehydration, aspiration .Monitor weight per orders. A physician's order dated 1/29/25 documented, Obtain weight daily. Further review of R120's clinical record failed to reveal the resident's weight was obtained on 2/5/25, 2/14/25, 2/16/25, 2/17/25, 2/18/25, 2/19/25, and 2/22/25. On 2/25/25 at 3:46 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated the purpose of the care plan is to follow doctors' orders and nursing staff implement residents' care plans by looking at the care plans. On 2/26/25 at 10:14 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated R120's daily weights were not obtained because of time management with CNAs (certified nursing assistants) and staff were trying to figure out whether to use a Hoyer lift or a chair to obtain the resident's weights. On 2/26/25 at 2:48 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Comprehensive Care Plan Policy documented, Z) All direct care staff must always know, understand, and follow their Resident's Care Plan. No further information was presented prior to exit. 2. For Resident #2 (R2), the facility staff failed to implement the resident's comprehensive care plan for oxygen use. A review of R2's clinical record revealed a physician's order dated 2/20/25 for continuous oxygen via nasal cannula at a rate of four liters per minute for respiratory failure. R2's comprehensive care plan edited on 2/20/25 documented, At risk for altered cardiac/resp (respiratory) status .O2 (Oxygen) and neb (nebulizer) tx (treatment) as ordered. On 2/24/25 at 1:40 p.m. and 2/25/25 at 8:29 a.m., R2 was observed receiving oxygen via nasal cannula at a rate between two and a half and three liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned between the two and a half and three-liter lines. On 2/25/25 at 3:46 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated the purpose of the care plan is to follow doctors' orders and nursing staff implement residents' care plans by looking at the care plans. RN #2 stated nurses administer oxygen per the doctors' orders and the middle of the ball in the oxygen concentrator flowmeter should run through the four-liter line if the physician's order is for four liters. On 2/25/25 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 42106 3. For Resident #61 (R61), the facility staff failed to implement the comprehensive care plan to administer oxygen as ordered. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/22/25, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section O documented R61 receiving oxygen at the facility. On 2/25/25 at 8:22 a.m., an observation was made of R61 in their room. R61 was observed in bed wearing an oxygen cannula attached to an oxygen concentrator. The oxygen was observed to be set at a rate of 3.5 lpm (liters per minute). At that time an interview was conducted with R61 who stated that they wore oxygen all the time and used 3 lpm. R61 stated that the nurses set the oxygen rate, and they had a portable unit that they took with them when they left the building for appointments. An additional observation of the oxygen set at 3.5 lpm was made on 2/25/25 at 2:10 p.m. The comprehensive care plan for R61 documented in part, Problem Start Date: 06/10/2024. Category: Respiratory. Resident requires oxygen therapy. R/T COPD (chronic obstructive pulmonary disease) with shortness of breath. Resident requests longer oxygen tubing so that she can walk to the bathroom, however this allows the tubing to drag on the floor of her room sometimes. Edited: 02/13/2025 . Under Approach it documented in part, Approach Start Date: 06/10/2024, Approach End Date: 07/31/2025, Administer oxygen as ordered. Edited: 02/13/2025 . The physician orders for R61 documented in part, Oxygen: Administer oxygen (O2) via nasal cannula (NC) continuously at: 4 l/min (liters per minute) r/t (related to) respiratory failure. Add humidification if >4 L/min or for comfort, if needed. Special instructions: Check concentrator to ensure functioning and appropriate setting. Check SPO2 (oxygen saturation). Check humidifier if applicable. Every shift Day shift 07:00-15:00, Evening shift 15:00-23:00, Night shift 23:00-07:00. Start Date: 02/13/2025. On 2/25/25 at 2:10 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated that the purpose of the care plan was to know how to work with the resident and how to care for them. She stated that the care plan should be implemented to care for them. She stated that oxygen was checked at least every shift. She stated that the oxygen rate was set at eye level with the flowmeter ball centered on the number line where it ordered. LPN #4 observed R61's oxygen concentrator and stated, That it was set on 3.5 l/min (liters per minute) and not at the prescribed rate of 4 l/min. She spoke with R61 who stated that they thought they were only on 3 l/min and stated that she would clarify the rate with the nurse practitioner. On 2/25/25 at 4:12 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the vice president of operations were made aware of the concern. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of 35 residents in the survey sample, Residents #79, and #75. The findings include: 1.a. For Resident #79 (R79), the facility staff failed to review and revise the resident's comprehensive care plan for adaptive eating equipment. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/10/24, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R79's clinical record revealed a physician's order dated 9/10/24 that documented, Provide 2 handled cup with lid + straw and red foam to knife and fork for all meals as tolerated. R79's comprehensive care plan edited on 2/13/25 failed to revealed documentation regarding a two handled cup with a lid and straw, or red foam to knives and forks. On 2/25/25 at 9:00 a.m., R79 was observed sitting up in bed. A cup containing coffee was observed on the resident's overbed table. The cup had one handle and no lid. Spilled coffee was observed on the overbed table. R79's right hand was observed tremoring. The resident stated she used to feed herself but now staff feed her because of her tremors. R79 stated she cannot pick up the cup, so she uses a straw. R79 stated she used to have a special cup, but it went missing and she used to have red foam handles for utensils but does not have them anymore. On 2/25/25 at 12:50 p.m., R79 was observed sitting up in bed while a CNA (certified nursing assistant) was feeding her. The cup on R79's meal tray contained no handles, and no red foam handles for R79's utensils were observed on the meal tray. R79's meal tray ticket documented, 2 handle cup wit [sic] lid; red foam build [sic] up utensils. On 2/25/25 at 2:56 p.m., an interview was conducted with OSM (other staff member) #3 (an occupational therapist who had previously treated R79). OSM #3 stated that due to an ulnar drift (a hand dysfunction where the fingers bend towards the outer arm bone), R79 has difficulty grasping objects. OSM #3 stated a two handled cup and red foam utensil handles are supposed to aid R79 with grasping objects more easily. On 2/25/25 at 3:38 p.m., an interview was conducted with CNA #1. CNA #1 stated R79 can feed herself finger foods but must be fed other foods because her hands shake. CNA #1 stated she was not aware of R79 requiring any adaptive eating equipment such as a special cup or red foam utensil handles, and she has not seen any adaptive eating equipment for R79 since she began employment in June 2024. On 2/25/25 at 3:46 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated the purpose of the care plan is to follow doctors' orders and nursing staff implement residents' care plans by looking at the care plans. RN #2 stated residents' care plans should be reviewed and revised for the use of special eating equipment for the continuation of patient care. On 2/25/25 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Comprehensive Care Plan Policy documented, F) The Comprehensive Care Plan is reviewed and updated at least every 90 days by the interdisciplinary team. No further information was presented prior to exit. 1.b. For Resident #79 (R79), the facility staff failed to review and revise the comprehensive care plan for the resident's weight loss in October 2024. A review of R79's clinical record revealed the resident weighed 130.4 lbs. (pounds) on 9/10/24 and 120 lbs. on 10/7/24 (a 7.98% weight loss in 30 days). A note signed by the registered dietician on 10/16/24 documented, Resident presents w/ a -7.98% loss x 1 months, significant and undesired .Previously OT (Occupational Therapy) started her on modified cup w/ cover and straw as well as fork and knife to aid with eating. Neuro (Neurology) appointment to find out if she might have Myasthenia gravis (A neuromuscular disorder that leads to weakness of skeletal muscles). Requesting to have resident as weekly weights x 4 weeks to keep close monitoring to wt (weight) . R79's comprehensive care plan initiated on 6/4/24 and edited on 2/13/25 failed to reveal documentation regarding the resident's significant weight loss in October 2024. On 2/25/25 at 3:46 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated the purpose of the care plan is to follow doctors' orders and nursing staff implement residents' care plans by looking at the care plans. RN #2 stated residents' care plans should be reviewed and revised regarding weight loss for the continuation of patient care. On 2/25/25 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 32642 2. For Resident #75 (R75), the facility staff failed to review and revise the resident's care plan to include an orthotic device and assistive devices for eating. On the following dates and times, R75 was observed. At each of these observations, the resident had a visible contracture of her right hand: 2/24/25 at 2:20 p.m., 2/25/24 at 9:05 a.m. and 1:18 p.m. At each of these observations, the resident was feeding herself with her fingers, with no evidence of adaptive eating equipment on her tray. At the 2/24/25 observation at 2:20 p.m., the resident was seated in the facility common area. In the resident's room, a carrot orthotic device was visible on the resident's bedside table. On 2/25/25 at 1:18 p.m., R75 stated she had been seen by the occupational therapy staff, and they had given her a carrot to hold to help the contracture. She stated she did not know where the carrot orthotic device was, and that the staff do not usually offer it to her. She stated she did not mind using it if it would help her right-hand contracture and skin integrity. She also said the occupational therapist had given her adaptive eating devices for her fork and spoon, but she had lost them, and had not been using them. A review of R75's occupational therapy discharge summary dated 2/18/25 revealed, in part: Recommendations .foam built up on utensils for self-feeding .R (right) hand carrot orthosis daily as tolerated. A review of R75's orders revealed the following order, dated 2/18/25: Pt (patient) to wear R (right) hand carrot orthosis daily, as tolerated, to prevent skin breakdown and prevent further contractures. Orthosis can be removed for hygiene and self-feeding. A review of R75's orders revealed the following order, dated 2/23/25: Lightweight spoon and fork when eating. A review of R75's comprehensive care plan, most recently updated on 2/4/25, revealed no information related to the resident's need for a right-hand orthotic device or adaptive eating equipment. On 2/25/25 at 2:53 p.m., OSM (other staff member) #3, an occupational therapist, was interviewed. She stated occupational therapy had recently treated and discharged R75 with a recommendation for a carrot orthosis to go in the resident's right hand. She stated, The resident had been provided the orthotic device, and the resident is able to independently pick it up and drop it as tolerated She also stated, The resident needs adaptive eating utensils, and these had been provided to the staff for the resident's use. On 2/25/25 at 3:46 p.m., RN (registered nurse) #2 was interviewed. RN #2 stated, The purpose of the care plan is to follow doctors' orders and nursing staff implement residents' care plans by looking at the care plans RN #2 stated residents' care plans should be reviewed and revised for the use of special eating equipment for the continuation of patient care. On 2/25/25 at 4:10 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the assistant director of nursing, were informed of these concerns. No additional information was provided prior to exit.

Based on observation, resident interview, clinical record review, staff interview and facility document review, it was determined the facility staff failed to clarify a physician order for one of 35 residents in the survey sample, Resident #16. The findings include: For Resident #16 (R16), the facility staff failed to clarify a physician order regarding tracheostomy (1) change every two months. On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 12/28/2024, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact for making daily decisions. The assessment documented R16 receiving tracheostomy care at the facility. On 2/24/25 at 2:53 p.m., an observation was made of R16 in their room. At that time an interview was conducted with R16 who stated that they had a tracheostomy. R16 was observed with a bandana around their neck and proceeded to remove it to show a tracheostomy tube in place. R16 stated that they had the tracheostomy in place for many years and performed the tracheostomy care themselves. R16 stated that they had been taught how to care for the tracheostomy by the hospital prior to coming to the facility and the staff supplied them with all the supplies needed. R16 stated that the nursing staff offered to do the tracheostomy care for her, but she preferred to do it herself. The physician orders for R16 documented in part, TRACH: Shiley Uncuffed Non disposable 4 mm (millimeter); change Q2mo (every two months) & PRN (as needed). Every shift on the 27th of every 2nd Month. Day shift. Start Date: 10/01/2024 . The eMAR (electronic medication administration record) for R16 dated 12/1/24-12/31/24 documented the tracheostomy tube changed on 12/27/24. The eMAR was signed off by LPN (licensed practical nurse) #4. The progress notes failed to evidence documentation regarding the tracheostomy tube change procedure. On 2/25/25 at 2:10 p.m., an interview was conducted with LPN #4 who stated, That R16 liked to do most of the tracheostomy care themselves. She stated, That the nurses assisted R16 with the tracheostomy care by changing the ties holding the tracheostomy in place and the gauze around the stoma. When asked about the tracheostomy tube change ordered every two months, LPN #4 stated, That she was not sure who did the change and thought that the RN (registered nurse) did it. LPN #4 reviewed the eMAR for R16 with the documented tracheostomy tube change on 12/27/24 and stated that she had not changed the tracheostomy and was not sure what they were supposed to change . She stated that she needed to clarify the order with the nurse practitioner because R16 went to the ENT (ear, nose and throat) physician to follow up on the tracheostomy. The facility policy Physician/Provider Orders failed to evidence guidance on clarifying physician orders. In Fundamentals of Nursing 6th edition, 2005; [NAME] A. [NAME] and [NAME] Perry; Mosby, Inc; Page 419. The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm clients. Therefore, all orders must be assessed if one is found to be erroneous or harmful further clarification from the physician is necessary . On 2/25/25 at 4:12 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, vice president of operations were made aware of the concern. No further information was provided prior to exit. Reference: (1) Tracheostomy A surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is most often placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube. This information was obtained from the website: https://medlineplus.gov/ency/article/002955.htm.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions to prevent worsening of a contracture of 35 residents in the survey sample, Resident #75 (R75). The findings include: For Resident #75 (R75), the facility staff failed to provide an orthotic device to the resident's right hand. On the following dates and times, R75 was observed. At each of these observations, the resident had a visible contracture of her right hand: 2/24/25 at 2:20 p.m., 2/25/24 at 9:05 a.m. and 1:18 p.m. At the 2/24/25 observation at 2:20 p.m., the resident was seated in the facility common area. In the resident's room, a carrot orthotic device was visible on the resident's bedside table. On 2/25/25 at 1:18 p.m., R75 stated she had been seen by the occupational therapy staff, and they had given her a carrot to hold to help the contracture. She stated she did not know where the carrot orthotic device was, and that the staff do not usually offer it to her. She stated she did not mind using it if it would help her right-hand contracture and skin integrity. A review of R75's orders revealed the following order, dated 2/18/25: Pt (patient) to wear R (right) hand carrot orthosis daily, as tolerated, to prevent skin breakdown and prevent further contractures. Orthosis can be removed for hygiene and self-feeding. A review of R75's occupational therapy discharge summary dated 2/18/25 revealed, in part: Recommendations .R (right) hand carrot orthosis daily as tolerated. A review of R75's comprehensive care plan, most recently updated on 2/4/25, revealed no information related to the resident's need for a right-hand orthotic device. On 2/25/25 at 2:53 p.m., OSM (other staff member) #3, an occupational therapist, was interviewed. She stated occupational therapy had recently treated and discharged R75 with a recommendation for a carrot orthosis to go in the resident's right hand. She stated the resident had been provided the orthotic device, and the resident is able to independently pick it up and drop it as tolerated. On 2/25/25 at 3:32 p.m., CNA #2 was interviewed. She stated, She is very familiar with R7 and is regularly assigned to care for her She stated R 75's right hand is contracted, and therapy had given her a carrot device to hold in her hand. She stated this device keeps her contracture from getting worse, and the staff always makes sure she has it to hold. A review of the facility policy, Issuing Adaptive Equipment, revealed, in part: The primary therapist and/or assistant will issue and instruct the patient in adaptive equipment based on patient's need .written instructions will be provided to family members/primary caregivers to increase carry over .The primary therapist will disseminate the type of equipment and its function to other disciplines during team conferences as necessary to increase carry over with proper use. On 2/25/25 at 4:10 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the assistant director of nursing, were informed of these concerns. No additional information was provided prior to exit.

Based on observation, resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice for two of 35 residents, Resident #61 and Resident #2. The findings include: 1. For Resident #61 (R61), the facility staff failed to administer oxygen at the prescribed rate. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/22/25, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section O documented R61 receiving oxygen at the facility. On 2/25/25 at 8:22 a.m., an observation was made of R61 in their room. R61 was observed in bed wearing an oxygen cannula attached to an oxygen concentrator. The oxygen was observed to be set at a rate of 3.5 l/min (liters per minute). At that time an interview was conducted with R61 who stated that they wore oxygen all the time and used 3 l/min . R61 stated that the nurses set the oxygen rate, and they had a portable unit that they took with them when they left the building for appointments. An additional observation of the oxygen set at 3.5 lpm was made on 2/25/25 at 2:10 p.m. The physician orders for R61 documented in part, Oxygen: Administer oxygen (O2) via nasal cannula (NC) continuously at: 4 l/min (liters per minute) r/t (related to) respiratory failure. Add humidification if >4 L/min or for comfort, if needed. Special instructions: Check concentrator to ensure functioning and appropriate setting. Check SPO2 (oxygen saturation). Check humidifier if applicable. Every shift Day shift 07:00-15:00, Evening shift 15:00-23:00, Night shift 23:00-07:00. Start Date: 02/13/2025. The comprehensive care plan for R61 documented in part, Problem Start Date: 06/10/2024. Category: Respiratory. Resident requires oxygen therapy. R/T COPD (chronic obstructive pulmonary disease) with shortness of breath. Resident requests longer oxygen tubing so that she can walk to the bathroom, however this allows the tubing to drag on the floor of her room sometimes. Edited: 02/13/2025 . On 2/25/25 at 2:10 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated that, Oxygen was checked at least every shift. She stated that, The oxygen rate was set at eye level with the flowmeter ball centered on the number line where it ordered. LPN #4 observed R61's oxygen concentrator and stated that it was set on 3.5 l/min and not at the prescribed rate of 4 lpm. She spoke with R61 who stated, That they thought they were only on 3 l/min and stated that . she would clarify the rate with the nurse practitioner. The facility policy, Oxygen Administration (all routes) Policy with a revision date of 7/30/2024 documented in part, .Set flow rate as prescribed or to obtain desired SpO2 . The facility provided manufacturers user's manual for R61's oxygen concentrator documented in part, .Adjust the flow to the prescribed setting by turning the knob on the top of the flow meter until the ball is centered on the line marking the specific flow rate . On 2/25/25 at 4:12 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the vice president of operations were made aware of the concern. No further information was provided prior to exit. 31753 2. For Resident #2 (R2), the facility staff failed to administer oxygen at the physician prescribed rate of four liters per minute. A review of R2's clinical record revealed a physician's order dated 2/20/25 for continuous oxygen via nasal cannula at a rate of four liters per minute for respiratory failure. On 2/24/25 at 1:40 p.m. and 2/25/25 at 8:29 a.m., R2 was observed receiving oxygen via nasal cannula at a rate between two and a half and three liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned between the two and a half and three-liter lines. On 2/25/25 at 3:46 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated, Nurses administer oxygen per the doctors' orders and the middle of the ball in the oxygen concentrator flowmeter should run through the four-liter line if the physician's order is for four liters. On 2/25/25 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

2. For Resident #79 (R79), the facility staff failed to provide physician prescribed adaptive eating equipment. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/10/24, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R79's clinical record revealed a physician's order dated 9/10/24 that documented, Provide 2 handled cup with lid + straw and red foam to knife and fork for all meals as tolerated. On 2/25/25 at 9:00 a.m., R79 was observed sitting up in bed. A cup containing coffee was observed on the resident's overbed table. The cup had one handle and no lid. Spilled coffee was observed on the overbed table. R79's right hand was observed tremoring. The resident stated, I used to feed herself but now staff feed her because of her tremors. R79 stated, She cannot pick up the cup, so she uses a straw R79 stated she used to have a special cup, but it went missing, and she used to have red foam handles for utensils but does not have them anymore. On 2/25/25 at 12:50 p.m., R79 was observed sitting up in bed while a CNA (certified nursing assistant) was feeding her. The cup on R79's meal tray contained no handles and no red foam handles for R79's utensils were observed on the meal tray. R79's lunch meal tray ticket dated 2/25/25 documented, 2 handle cup wit [sic] lid; red foam build [sic] up utensils. On 2/25/25 at 2:56 p.m., an interview was conducted with OSM (other staff member) #3 (an occupational therapist who had previously treated R79). OSM #3 stated,That due to an ulnar drift (a hand dysfunction where the fingers bend towards the outer arm bone), R79 has difficulty grasping objects. OSM #3 stated, A two handled cup and red foam utensil handles are supposed to aid R79 with grasping objects more easily. On 2/25/25 at 3:38 p.m., an interview was conducted with CNA #1. CNA #1 stated, R79 can feed herself finger foods but must be fed other foods because her hands shake. CNA #1 stated, She was not aware of R79 requiring any adaptive eating equipment such as a special cup or red foam utensil handles, and she has not seen any adaptive eating equipment for R79 since she began employment in June 2024. On 2/25/25 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide assistive devices for eating for one of 35 residents in the survey sample, Resident #75 (R75). The findings include: For Resident #75 (R75), the facility staff failed to provide built up eating utensils for the resident to use during meals. On the following dates and times, R75 was observed eating a meal. At each of these observations, the resident was attempting to use regular utensils to feed herself. At all observations, she abandoned using the utensils, and used her fingers to feed herself: 2/24/25 at 2:20 p.m., 2/25/24 at 9:05 a.m. and 1:18 p.m. On 2/25/25 at 1:18 p.m., R75 stated she had been seen by the occupational therapy staff, and they had given her eating utensils that were built up on the ends so she could more easily manipulate them. She stated she had lost the utensils, and it was her fault that she didn't have any adaptive utensils to use. She stated the staff had not attempted to give her additional adaptive eating equipment. A review of R75's tray meal ticket for the lunch meal on 2/25/25 at 1:18 p.m. revealed, in part: Lightweight spoon and fork when eating. A review of R75's occupational therapy Discharge summary dated [DATE] revealed, in part: Recommendations .foam built up on utensils for self-feeding. A review of R75's orders revealed the following order, dated 2/23/25: Lightweight spoon and fork when eating. A review of R75's comprehensive care plan, most recently updated on 2/4/25, revealed no information related to the resident's need for adaptive eating equipment. On 2/25/25 at 2:53 p.m., OSM (other staff member) #3, an occupational therapist, was interviewed. She stated occupational therapy had recently treated and discharged R75 with a recommendation for red, tubular foam build ups on her eating utensils. She stated: She had three of them. They were in her room. The CNAs (certified nursing assistants) are responsible for putting them on her eating utensils. On 2/25/25 at 3:32 p.m., CNA #2 was interviewed. She stated she is very familiar with R7 and is regularly assigned to care for her. She stated: [R75] is not supposed to have any specialized equipment for eating. A review of the facility policy, Adaptive (Assistive) Eating Devices, revealed, in part: Adaptive .eating devices are provided per physicians' order or as needed/requested .Individuals will be referred to the therapy department as needed for evaluation of noted eating difficulty(s) .Adaptive .devices will be provided per order .The dietary department is responsible for ensuring that adaptive devices are cleaned and sanitized after each use and the device is provided for each meal or snack as appropriate. On 2/25/25 at 4:10 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the assistant director of nursing, were informed of these concerns. No additional information was provided prior to exit.

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide the reason for a room change for one of 35 residents in the survey sample, Resident #100. The findings include: For Resident #100 (R100), the facility staff failed to provide the reason for a room change on 1/30/25. On 2/24/25 at 1:52 p.m., R100 was interviewed. She stated she had recently moved to her current room and was still in the process of adjusting to it. She stated she does not like this room as much as she liked her previous room. A review of R100's clinical record revealed she was transferred to different room on 1/30/25. Further review of the resident's clinical record revealed no evidence of why the resident was transferred within the facility, or that the resident was made aware of the reason. On 2/26/25 at 10:56 a.m., OSM (other staff member) #9, the social services assistant, was interviewed. She stated, When a resident is going to change rooms, she is responsible for notifying everyone, including the resident and/or resident representative She stated the resident was having conflict with her roommate, and that is why she was moved to a new room in January 2025. She stated this was not documented anywhere. On 2/26/25 at 2:43 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the assistant director of nursing, were informed of these concerns. A review of the facility policy, Room and Roommate Change Policy, revealed, in part: The facility will notify the resident/resident representative prior to a room or roommate change including the reason for the change .The facility will document that notification was completed with reason for change. No additional information was provided prior to exit.

Based on observation, staff interview, and clinical record review, the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 35 residents in the survey sample, Resident #35. The findings include: For Resident #35 (R35), the facility staff inaccurately coded the resident as having a restraint on the resident's quarterly MDS assessment with an ARD (assessment reference date) of 1/16/25. A review of R35's quarterly MDS assessment with an ARD of 1/16/25 revealed section P, Restraints and Alarms that coded the resident as using a chair that prevents rising less than daily. A review of R35's clinical record failed to reveal documentation regarding the use of a restraint/chair that prevents rising. Observations of R35 during the survey failed to reveal the use of a restraint/chair that prevents rising. On 2/25/25 at 9:13 a.m., RN (registered nurse) #3 (the MDS coordinator) was made aware of the above concern. On 2/25/25 at 9:24 a.m., an interview was conducted with RN #3. RN #3 stated,The coding of the use of a restraint on R35's MDS assessment was a data entry error, and she just corrected the assessment . RN #3 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when coding MDS assessments. On 2/25/25 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The CMS RAI manual documented, After determining whether or not an item listed in (P0100) is a physical restraint and was used during the 7-day look-back period, code the frequency of use: Code 0, not used: if the item was not used during the 7-day look-back period or it was used but did not meet the definition. No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide notification to the physician of a residents refusal of treatment for one of 35 residents in the survey sample, Resident #359. The findings include: For Resident #359 (R359), the facility staff failed to evidence notification of the physician of R359's refusal of lab testing on 11/6/24 and 11/7/24. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/29/24, the resident scored three on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The physician orders for R359 documented in part, - BMP (basic metabolic profile) and CBC (complete blood count); Special Instructions: BMP and CBC Once- One Time 23:00 (11:00 pm)- 07:00 (7:00am). Start Date: 11/06/2024. End Date: 11/06/2024. - BMP and CBC; Special Instructions: BMP and CBC Once- One Time 23:00 - 07:00. Start Date: 11/07/2024. End Date: 11/07/2024. The progress notes for R359 documented in part, 11/05/2024 14:51 (2:51 p.m.) New orders for Pyridium 100 mg (milligram) po (by mouth) BID (twice a day) for 3 days, Keflex 500 mg po every 8 hours for 5 days, and labs for BMP and CBC 11/6/24. RP (responsible party) [Name of RP] aware. The progress notes for R359 failed to evidence the BMP and CBC obtained, results of the BMP or CBC, documentation of refusal of the lab testing or notification of the physician of refusal of the lab testing ordered on 11/6/24 and 11/7/24. On 2/26/25 at 11:52 a.m., a request was made to ASM (administrative staff member) #1, the administrator for the results of the BMP and CBC ordered above. On 2/26/25 at 1:02 p.m., ASM #1 provided laboratory patient log sheets dated 11/6/24 and 11/7/24 which documented R359 refusing the lab testing on both dates. The log sheets failed to evidence notification of the physician of the refusal. On 2/26/25 at 1:04 p.m., an interview was conducted with RN (registered nurse) #3 who stated that when there was an order for a lab test the nurse entered the order into the electronic medical record and into the laboratory system. She stated that the night shift staff printed out the lab orders for that night and gave them to the lab technician who came in six nights a week to draw labs. She stated that when a resident refused to have labs drawn the technician notified the nurse who let the physician, and the responsible party know and documented it in the progress notes. RN #3 stated that this was done because the physician had ordered the lab tests for a reason and needed to know that it had not been obtained. On 2/26/25 at approximately 2:45 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the vice president of operations were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to provide dignity for one of 35 residents in the survey sample, Resident #79. The findings include: For Resident #79 (R79), the facility staff failed to provide a dignified dining experience. A CNA (certified nursing assistant) stood over R79 while feeding the resident. On 2/25/25 at 12:50 p.m. R79 was observed sitting up in bed. CNA #3 was observed standing over R79 while feeding the resident. On 2/25/25 at 3:37 p.m., an interview was conducted with CNA #2. CNA #2 stated the, CNAs should sit in a chair when feeding residents CNA #2 stated standing up while feeding residents does not provide a dignified experience because residents are more comfortable when staff sits down. On 2/25/25 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility document titled, Resident Rights Inservice documented, The Nursing Home Reform Act established the following rights for nursing home residents: The right to be treated with dignity . No further information was presented prior to exit.

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide written notice of a room change for one of 35 residents in the survey sample, Resident #100. The findings include: For Resident #100 (R100), the facility staff failed to provide written notification to the resident of a room change on 9/5/24 and 1/30/25. On 2/24/25 at 1:52 p.m., R100 was interviewed. She stated she had recently moved to her current room and was still in the process of adjusting to it. She stated she does not like this room as much as she liked her previous room. A review of R100's clinical record revealed she was transferred to different room on 9/5/24 and 1/30/25. Further review of the resident's clinical record revealed no evidence that she was provided written notice prior to the room change. On 2/26/25 at 10:56 a.m., OSM (other staff member) #9, the social services assistant, was interviewed. She stated, When a resident is going to change rooms, she is responsible for notifying everyone, including the resident and/or resident representative. She added: Our policy doesn't require a written notice for a room change. On 2/26/25 at 2:43 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the assistant director of nursing, were informed of these concerns. A review of the facility policy, Room and Roommate Change Policy, revealed, in part: The facility will notify the resident/resident representative prior to a room or roommate change including the reason for the change .The facility will document that notification was completed with reason for change. No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide the resident representative and/or the State LTC Ombudsman with written notification of hospital transfers for four of 51 in the survey sample; Residents #68, #147, #61, and #163, The findings include: 1. The facility staff failed to provide the resident representative and the ombudsman with written notice of a hospital transfer when the resident was sent to the hospital on 8/18/22 for Resident #68. On the 10/14/22 quarterly MDS (Minimum Data Set), Resident #68 was coded as being severely cognitively impaired in ability to make daily life decisions. A review of the clinical record revealed a nurse's note dated 8/18/22, that documented, CNA (Certified Nursing Assistant) .found pt (patient) on floor and called nurse. nurse observe pt laying on left hip on floor next to bed, pt was wearing gripper socks. left hip has protrusion and blanchable redness. pt state [they] was trying to get to the hall, pt deny hit head. pt complain of left hip pain. yells it hurts .[Name of responsible party/family member] called and request since this is new pain to send [them] to ER (emergency room ) to eval. Further review of the clinical record revealed a nurse's note dated 8/18/22 that documented, [Name of responsible party/family member] understands reason for transfer. Resident transferred to [name of hospital] via stretcher with [county] EMS (emergency medical services). Resident sent with face sheet, [name of progress note], bed hold policy, copy of mar/tar (medication/treatment administration records), and advance directive and transfer form. There was no documentation or evidence that a written notice of the hospital transfer was provided to the resident's responsible party or to the ombudsman. On 12/1/22 at 9:35 AM, a list given to ASM #1 (Administrative Staff Member) the Administrator, requesting evidence of written notice of the hospital transfer being provided to the resident's responsible party and to the ombudsman; at 10:55 AM, ASM #1 stated that the facility did not have them. On 12/1/22 at 11:24 AM, an interview was conducted with OSM #4 (Other Staff Member) the Director of Social Services. When asked about the written notices to the resident's responsible party and to the ombudsman, she stated, I have not been sending them out for transfers to the ED (emergency department) who are only there for a few hours, but have been sending them out if they are admitted to the hospital. I was just trying to use common sense instead of confusing the RP (responsible party) by sending the bed hold and notification of transfer to them certified, they would have to go to the post office to pick it up and they did not understand, when the resident was back in the facility. I called my corporate person and she said there is not a time frame on how long they are out of the building (i.e. ED visits) before you are required to send these. The facility policy, Resident discharge/transfer letter was reviewed. This policy documented, The facility will complete discharge letters appropriately and according to all federal, state, and local regulations D. Discharge notices must have the following components: 1. The reason for discharge/transfer to include the appropriate verbiage .2. The effective date of transfer/discharge; 3. The location to which the resident is transferred/discharged .4. A statement that the resident has the right to appeal .5. The name, address and telephone number of the local and State long term care ombudsman; 6. The mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals .7. The mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals .E. Social Services or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor if applicable. Copies will be sent to ombudsman office . On 12/1/22 at 1:15 PM, ASM #1, ASM #2 (the Director of Nursing) and ASM #3 (Regional Director of Clinical Services) were made aware of the findings. No further information was provided by the end of the survey. 2. The facility staff failed to provide the resident representative and the ombudsman with written notice of a hospital transfer when the resident was sent to the hospital on 9/23/22 for Resident #147. On the 11/3/22 quarterly MDS (Minimum Data Set), Resident #147 was coded as being severely cognitively impaired in ability to make daily life decisions. Review of the clinical record revealed a nurse practitioner / medical doctor note dated 9/23/22 that documented, .The patient is seen today due to pocketing of food and continued worsening of left-sided weakness involving the left lower extremity. The patient is alert to self. Nursing staff reports no behaviors and the patient is more sleepy . Further review revealed another nurse's note dated 9/23/22 that documented, Resident has been informed and understands reason for transfer. Resident transferred out to [name of hospital] via stretcher with EMT (emergency medical technician) at 1015 (AM). Resident sent with face sheet, [name of progress note], bed hold policy, copy of MAR/Tar (medication/treatment administration record), care plan, advance directives and transfer form. RP (responsible party) and MD (medical doctor) aware. There was no documentation or evidence that a written notice of the hospital transfer was provided to the resident's responsible party or to the ombudsman. On 12/1/22 at 9:35 AM, a list was given to ASM #1 (Administrative Staff Member) the Administrator, requesting evidence of written notice of the hospital transfer being provided to the resident's responsible party and to the ombudsman; at 10:55 AM, ASM #1 stated that the facility did not have them. On 12/1/22 at 11:24 AM, an interview was conducted with OSM #4 (Other Staff Member) the Director of Social Services. When asked about the written notices to the resident's responsible party and to the ombudsman, she stated, I have not been sending them out for transfers to the ED (emergency department) who are only there for a few hours, but have been sending them out if they are admitted to the hospital. I was just trying to use common sense instead of confusing the RP (responsible party) by sending the bed hold and notification of transfer to them certified, they would have to go to the post office to pick it up and they did not understand, when the resident was back in the facility. I called my corporate person and she said there is not a time frame on how long they are out of the building (i.e. ED visits) before you are required to send these. The facility policy, Resident discharge/transfer letter was reviewed. This policy documented, The facility will complete discharge letters appropriately and according to all federal, state, and local regulations D. Discharge notices must have the following components: 1. The reason for discharge/transfer to include the appropriate verbiage .2. The effective date of transfer/discharge; 3. The location to which the resident is transferred/discharged .4. A statement that the resident has the right to appeal .5. The name, address and telephone number of the local and State long term care ombudsman; 6. The mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals .7. The mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals .E. Social Services or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor if applicable. Copies will be sent to ombudsman office . On 12/1/22 at 1:15 PM, ASM #1, ASM #2 (the Director of Nursing) and ASM #3 (Regional Director of Clinical Services) were made aware of the findings. No further information was provided by the end of the survey. 3. The facility staff failed to provide the resident representative and the ombudsman with written notice of a hospital transfer when the resident was sent to the hospital on 9/10/22 for Resident #61. On the 10/7/22 quarterly MDS (Minimum Data Set), Resident #61 was coded as being cognitively moderately impaired in ability to make daily life decisions. A review of the clinical record revealed a nurse's note dated 9/10/22 that documented, Resident laying on floor on left side. Writer assessed resident. Resident was bleeding from the left side of [Resident's] face. Resident C/O (complained of) pain on the left side of face Writer X2 (two times) assisted resident to wheelchair than [sic] to bed Resident RP (responsible party) [name of RP] arrived to facility and was notified. NP (nurse practitioner) wanted to send resident out but RP [name] refused [RP] stated [RP] wanted to wait until Monday when [RP] could be with [Resident]. Writer made [RP] aware that [Resident] needs a head CT, [RP] still refused. PRN (as needed) acetaminophen given. Later RP stated [RP] spoke with family and they decided to send [Resident] out now. Writer call 911 , x2 EMT (emergency medical technician) transferred resident via stretcher to [name of hospital] hospital. A second nurse's note dated 9/10/22 documented, Resident understands reason for transfer. Resident transferred to [name of hospital] via stretcher with EMT. Resident sent with face sheet, [name of progress note], bed hold policy, copy of MAR/TAR (medication/treatment administration record), care plan, advance directive, and transfer form. There was no documentation or evidence that a written notice of the hospital transfer was provided to the resident's responsible party or to the ombudsman. On 12/1/22 at 9:35 AM, a list given to ASM #1 (Administrative Staff Member) the Administrator, requesting evidence of written notice of the hospital transfer being provided to the resident's responsible party and to the ombudsman; at 10:55 AM, ASM #1 stated that the facility did not have them. On 12/1/22 at 11:24 AM, an interview was conducted with OSM #4 (Other Staff Member) the Director of Social Services. When asked about the written notices to the resident's responsible party and to the ombudsman, she stated, I have not been sending them out for transfers to the ED (emergency department) who are only there for a few hours, but have been sending them out if they are admitted to the hospital. I was just trying to use common sense instead of confusing the RP (responsible party) by sending the bed hold and notification of transfer to them certified, they would have to go to the post office to pick it up and they did not understand, when the resident was back in the facility. I called my corporate person and she said there is not a time frame on how long they are out of the building (i.e. ED visits) before you are required to send these. The facility policy, Resident discharge/transfer letter was reviewed. This policy documented, The facility will complete discharge letters appropriately and according to all federal, state, and local regulations D. Discharge notices must have the following components: 1. The reason for discharge/transfer to include the appropriate verbiage .2. The effective date of transfer/discharge; 3. The location to which the resident is transferred/discharged .4. A statement that the resident has the right to appeal .5. The name, address and telephone number of the local and State long term care ombudsman; 6. The mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals .7. The mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals .E. Social Services or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor if applicable. Copies will be sent to ombudsman office . On 12/1/22 at 1:15 PM, ASM #1, ASM #2 (the Director of Nursing) and ASM #3 (Regional Director of Clinical Services) were made aware of the findings. No further information was provided by the end of the survey. 42183 4. The facility staff failed to evidence provision of written RP (responsible party) and/or ombudsman notification at the time of hospital transfer for Resident #163. Resident #163 was transferred to the hospital on 7/4/22. The most recent MDS (minimum data set) assessment, a 5-day Medicare assessment, with an ARD (assessment reference date) of 9/20/22, coded the resident as scoring a 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. There was no evidence of written RP or ombudsman notification for Resident #163 when sent to the hospital on 7/4/22. A review of the nursing progress note written 7/4/22 at 2:45 PM, revealed, Nurse had just walked down hall 25 minutes prior and witnessed patient sleeping in bed. while nurse charting heard man yell out and found patient on the floor to door side of the bed. Patient very agitated and yelling at staff not to help him. Patient was laying on left side. Patient yelling at staff not to touch him, to get on out of here nurse was able to get patient to explain some parts of incident in between patient yelling at staff to leave him alone and that he was not going to answer any questions that we were not asking .Once in wheelchair nurse attempted to ask about details of fall and patient began to yell at nurse that she does not need to ask anything .patient stood up and lunged punching towards nurse. No contact made. informed patient that if harm comes to staff, police will have to be called. patient state 'then call them and my sister'. Patient state self-back in wheelchair and told staff to 'get the hell out of here'. Sister called and notified of details known of fall, patient refusal of help & assessments. notified sister of patient's attempt to punch nurse. Sister asked if she needed to come to building, informed her that patient is calming self while sitting in wheelchair. Patient had left side bed rail down and refused to answer about bed rail preference. A review of the nursing progress note written 7/4/22 at 4:14 PM, revealed, Resident and sister understand reason for transfer. Resident transferred to hospital via stretcher with emergency medical transport. Resident sent with face sheet, SBAR (situation/background/assessment/recommendation), bed hold policy, copy of MAR/TAR (medication administration record/treatment administration record), care plan, advance directives, and transfer form. A request for written RP or ombudsman notification for the resident was made on 11/30/22 at 4:00 PM. On 12/1/22 at 7:30 AM, ASM #1 stated they do not have the ombudsman notice for this resident; and at 10:55 AM, ASM #1 stated they do not have the written RP (responsible party) or ombudsman notification. An interview was conducted on 12/1/22 at 11:24 AM, with OSM (other staff member) #4. When asked what notification is provided when the resident is sent to the hospital, OSM #4 stated, I have not been sending them out for transfers to the ED who are only there for a few hours but have been sending them out if admitted to the hospital. I was just trying to use common sense instead of confusing the RP by sending the bed hold and notification of transfer to them certified, they would have to go to the post office to pick it up and them did not understand, when the resident was back in the facility. I called my corporate person and she said there is not a time frame on how long they are out of the building (i.e., ED visits) before you are required to send these. On 12/1/22 at approximately 1:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services was made aware of the findings. A review of the facilities Resident Transfer/Discharge Letter policy, dated 9/2017, revealed the following: Social Service or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor, if applicable. Copies will be sent to Department of Health, Ombudsman Office and filed in the business file and/or scanned into PCC (point click care) documents tab with administrator/designee signature, with the certified receipt if applicable. For emergency transfers, one list can be sent to the Ombudsman at the end of the month. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review it was determined facility staff failed to prepare food in the facility kitchen in a sanitary manner in one of one facility kitchens. The findings include: On 11/30/2022 at approximately 9:50 a.m., an observation of the facility's dish room revealed OSM (other staff member) #8, dietary staff member, removing clean, wet cups, bowls and plate covers that had just come out of the automatic dishwasher and drying them with a towel and stacking them on drying racks. On 11/30/2022 at approximately 1:45 p.m. an interview was conducted with OSM #6, dietary manager. When asked about hand drying the plate covers OSM # 6 stated that it was their understanding that it was okay to hand dry the dishes as long as staff were wearing gloves. After reviewing the facility's policy Dish Machine Use Policy OSM # 6 stated that they were not aware that the dishes were not to be dried with a towel and needed to air dry. The facility's policy Dish Machine Use Policy documented in part, 11. Allow the dishes to air dry on the dish racks or open shelving. Do not dry with towels. During the unloading process, visually inspect dishes for cleanliness and dryness, and put away if clean. On 12/01/2022 at approximately 1:15 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, staff interview and facility document review, the facility staff failed to maintain one of three dumpsters in a sanitary manner. The dumpster used for cardboard, was observed with debris, including several pieces of cardboard, plastic bags, used face masks and trash lying on the ground on the right and back side of the dumpster. The findings include: On 11/29/2022 at approximately 11:40 a.m., an observation of the facility's dumpsters was conducted with OSM (other staff member) #1, director of maintenance and OSM #2, maintenance helper. The observation revealed that the facility had one dumpster specifically for cardboard surrounded by a wooden fence. Observation of the area around the dumpster revealed several pieces of cardboard, plastic bags, used face masks and trash were found lying on the ground on the right and back side of the dumpster. When asked who was responsible for maintaining the immediate area around the dumpsters in a clean and sanitary manner and how often it was checked and cleaned OSM #1 stated that it was the maintenance department that was responsible for the dumpster area and OSM #2 stated that the dumpster area was checked and cleaned every morning. OSM # 1 further stated that the area described above was unacceptable. On 12/01/2022 at approximately 1:15 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to implement interventions, supervision to ensure resident safety and a safe environment, to prevent a resident from injuring herself after she voiced a threat of self-harm for one of 29 residents in the survey sample, Resident #22. A threat of self-harm was reported to facility staff (4/15/16 at approximately 3:10 p.m.) by the resident and the facility staff did not act on the threat. None of the following were done prior to Resident # 22 stabbing herself with a scissors on the afternoon of 4/15/16 at 4:45 p.m. · Notification of supervisory staff, Administrator, Director of Nurses of Resident # 22's comment of self-harm, · Notification of physician of Resident # 22's comment of self-harm, · No assessment of the resident's environment for potential safety issues and removal of any items that could be a hazard, · Monitoring/ supervision of Resident # 22 related to the self-harm comment The findings include: Resident # 22 was admitted to the facility on [DATE] with a recent readmission on 3/18/16 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a Significant Change Assessment, with an assessment reference date of 3/25/16, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. The resident was coded as requiring extensive assistance of one person for all of her activities of daily living. Review of the three previous MDS assessments for Section D Mood documented the following: an admission assessment with an ARD of 11/27/15 documented a Total Severity Score of 1; a quarterly assessment with an ARD of 2/8/16 documented a Total Severity Score of 4; and a Significant Change Assessment with an ARD of 3/25/16 documented a Total Severity Score* of 6. Review of the previous three MDS assessments for Section E Behavior documented the following: an admission assessment with an ARD of 11/27/15 documented Resident #22 had no behaviors; a quarterly assessment with an ARD of 2/8/16 documented no behaviors; and a Significant Change Assessment with an ARD of 3/25/16 documented no behaviors. *Total Severity Score is a summary of the frequency scores that indicates the extent of potential depression symptoms. The score does not diagnose a mood disorder, but provides a standard of communication with clinicians and mental health specialists. CMS (Centers for Medicare & Medicaid Services) RAI (Resident Assessment Instrument) MDS 3.0 Manual page D-8. Review of Resident # 22's clinical record revealed that she was being treated for [REDACTED]. This is used to treat depression, obsessive-compulsive disorder, bothersome thoughts that won't go away and . including mood swings, irritability, bloating, and breast tenderness. Resident # 22 was under the care of a psychiatrist. Review of the psychiatric notes did reveal that Resident # 22's chief complaints were depression, insomnia, and anxiety. Further review of the psychiatric notes did not reveal any documentation of statements for self injurious behavior or thoughts. *This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 8.html - During an interview on 5/5/16 at 9:40 a.m. with OSM (other staff member) #10, an assistant in the business office, OSM # 10 reported that on 4/15/16 at approximately 3:10 p.m. while he was conducting room rounds Resident # 22 reported to him that she was in a lot of pain. OSM # 10 stated the resident's pain was in both of her legs. OSM # 10 further stated that he told the resident that he would check with the nurse (about pain medication). OSM # 10 stated that resident # 22 threatened to harm herself, She would have to find something to hurt herself if she could not be helped with the pain. OSM # 10 said he told the resident, No, don't do that; let me talk to the nurse and see if they can get you something for the pain. OSM # 10 then stated he went to Resident # 22's nurse (LPN (licensed practical nurse) # 15) and told him that she was in pain. OSM # 10 stated he did not remember telling the nurse about the threat only about the pain but when he returned from rounds to hand in his papers for rounds he definitely told RN (registered nurse) # 3, MDS nurse, and OSM # 12, a social worker, about Resident # 22's pain and her threat to hurt herself. OSM # 10 stated that he told the nurse (LPN # 15) only about the pain; this was confirmed in another interview with OSM # 10 on 5/5/16 at 11:30 a.m. During an interview on 5/5/16 at 10:23 a.m., with RN (registered nurse) # 3, the MDS coordinator, RN #3 related the events of 4/15/16 as she remembered them. RN #3 stated rounds are done at the beginning of the day and at the end of the day. It was about 3:30 p.m. and (Name of OSM # 12, the social worker) was in the room when (name of OSM # 10, staff member that the threat was reported to) was reporting his findings. OSM # 10 stated that (name of Resident # 22) was in a lot of pain in her legs and that she needed something for pain. He further stated the resident stated that if she could not get something she might hurt herself. OSM # 10 told her (RN # 3) that he told the nurse (LPN # 15) about (name of Resident # 22's) pain and the nurse stated the Resident had just had something for pain. He (OSM # 10) could only remember that he told the nurse (LPN# 15) that resident was requesting something for pain but not about the threat to hurt herself. RN # 3 stated OSM # 12 was present for this conversation. During another interview on 5/5/16 at 1:00 p.m. (concerning events of 4/15/16) with RN # 3, RN # 3 repeated that she knew about the threat and that OSM # 12 was in the room when OSM # 10 reported the threat. RN # 3 stated that others in the room, whom she could not identify, stated that the Unit Manager (RN #4) and the physician (ASM # 4) were in the Resident's room. RN # 3 stated OSM # 12, the social worker got up and left the room, although RN # 3 did not know where OSM # 12 was going and did not ask. RN # 3 stated, I thought (name of OSM # 12) was going down to see her (Resident # 22) when she left the room. She (RN # 3) stated she thought everything was being addressed but did not go down there to make sure. When asked if she knew how Resident #22 got the scissors, she stated that she did not. During an interview on 5/5/16 at 10:04 a.m. with OSM # 12, the social worker, OSM # 12 related what she remembered: When she (OSM # 12) got to the stand down meeting at 3:30 p.m. (on 4/15/16) (names of RN # 3 and OSM # 10) were in the room. OSM # 12 reported that she heard OSM # 10 was saying (name of Resident # 22) made a statement she (Resident # 22) wished she was dead because she was in so much pain. OSM # 12 understood OSM # 10 to say he had already notified nursing about the pain and she (OSM # 12) understood that nursing was down there (in the resident's room) assessing the Resident's pain. OSM # 12 also stated there was a distinction between the resident stating I wish I was dead and I am going to find something to hurt myself they are not the same. OSM #12 stated, If the resident had said, 'I'm going to hurt myself, I would have acted immediately. When asked if she (OSM # 12) went down to see the resident OSM # 12 stated, I did not physically go down and see the resident. During an interview on 5/5/16 at 1:25 p.m. with OSM # 12, OSM # 12 again repeated that, I wish I was dead was not a statement of self-harm. Review of the clinical record revealed a Social Services Note dated 4/16/16 at 15:23 (3:23 p.m.) (the day after the incident). This note documented the SW (social worker - OSM # 12) was following up on Resident # 22 and if she (Resident # 22) intended to harm herself. There was no note prior to this note documenting that the social worker was monitoring the Resident for threats of self-harm. During an interview on 5/5/16 at 9:55 a.m. with RN (registered nurse) # 4, the unit manager, on Resident # 22's unit, RN # 4 stated she was not aware of the Resident's threat. RN # 4 stated, she and ASM (administrative staff member) # 4, the physician, were doing rounds (at approximately 3:30 p.m. on 4/15/16) and were in the resident's room. Resident # 22 reported she had pain. RN # 4 stated she notified the charge nurse of the resident's pain. The physician was examining her. RN # 4 stated that Resident # 22 did not report that she (Resident # 22) might hurt herself. An interview on 5/5/16 at 11:15 a.m. with LPN # 15 revealed the following: LPN # 15 only recalled she (Resident # 22) complained of mild pain and LPN # 15 medicated her with Tylenol* for that at about 2:40 p.m. LPN # 15 stated, I do not recall anyone telling me that she had any pain or that she had threatened to hurt herself. I checked on the resident at approximately 3:20 p.m. and she was watching TV and had no complaints of pain at that time. LPN # 15 further stated the resident never mentioned hurting herself and no others told him she had made that threat. LPN # 15 stated if a threat had been made to him or reported to him, he (LPN # 15) I would have been all over it. A request was made for any facility incident report related to this incident. On 5/5/16 at 2:45 p.m. ASM # 3, the assistant director of nursing, stated that she had looked for an incident report and could not locate one. ASM # 3 stated, It was not done. During an interview on 5/5/16 at approximately 2:50 p.m. with ASM # 4, the physician, ASM # 4 stated, No, I was not aware of any threat, she was on hospice and in a lot of pain. She (the resident) never indicated to me that she might hurt herself. No one came to (name of RN # 4) or I (ASM # 4) about a threat. Review of the clinical record revealed the following documentation: Nursing Note, 4/15/16 22:23 (10:23 p.m.) Note Text: @ (at) 1531 (3:30 p.m.) resident called for pain med and oxycodone** 5 mg was given to resident. CNA (certified nurse's assistant) notified writer @ 1645 (4:45 p.m.) that resident had stabbed herself with scissors. Writer noted scissors in residents left abdominal area with blood seeping from area. Writer then covered area with gauze. Writer left the room immediately and called for more help leaving two care givers to assist in monitoring resident while ADON (assistant director of nurses - ASM # 3), MD (Medical doctor - ASM # 4), Unit Manager (RN # 4) were called into the room immediately 911 were immediately notified @ 1647 (4:47 p.m.) resident asked for pain med (medication) and morphine 0.25 mg (milligram) was given. Vitals were obtained (bp - 123/68, p - 73, t - 98.8, r - 18). RP (responsible party) notified @ 1655 (4:55 p.m.), voicemail left and call was returned @ 1725 (5:25 p.m.) and @ 1653 (4:56 p.m.), At home care made aware. 911 arrived, resident was then transported to (name of local hospital). @ 2145 (9:45 p.m.), (name of local hospital) called back that resident was coming back. At this time, resident is not in the building yet. Note: bp - blood pressure, p - pulse, t - temperature, r - respirations. Review of the physician note dated 4/15/16 did not evidence any documentation of self harm statements by the resident or assessment of self injury behaviors for Resident #22. Review of the hospital record revealed the following documentation: 4/15/2016 17:57 (5:57 p.m.) EDT (emergency department trauma) .History of Present Illness: The patient presents with major trauma. The onset was just prior to arrival. The course of symptoms is constant and worsening. Type of injury: puncture wound. The location where the incident occurred was at a nursing home. Location: abdomen. The character of symptoms is pain and bleeding. Associated symptoms: LLQ (lower left quadrant) abdominal pain, BLE (bilateral lower extremities) pain. Medical Decision Making: Trauma team: Trauma criteria met, trauma team assembled, trauma surgeon present. Differential Diagnosis: [REDACTED]. CT (computed tomography): Abd (abdomen)/Pelvis (soft tissue) -- findings: Superficial penetrating wound left lower abdomen with no evidence of intraperitoneal bowel injury. Assessment/Plan: Patient stabbed herself in the abdomen and trauma removed the scissors on arrival . The ED (emergency Department) record further documented the resident was evaluated by a psychiatrist and denied she intended to kill herslef and They cleared the patient to go home. Review of Resident # 22's care plan revealed documentation of a care plan for pain. That was initiated on 3/21/16. Further review revealed no documentation for care plans for behavior, mood, or depression. Review of Resident # 22's clinical record failed to document evidence of the following after Resident # 22 made a threat of self-harm on 4/15/16 at approximately 3:10 p.m.: · Notification of supervisory staff, Administrator, Director of Nurses of Resident # 22 comment of self-harm, · Notification of physician of Resident # 22's comment of self-harm, · No assessment of the resident's environment for potential safety issues and removal of any items that could be a hazard, · Monitoring /supervision of Resident # 22 related to the self-harm comment During an interview on 5/5/16 at 8:20 a.m. with CNA (certified nurse's assistant) # 5, CNA # 5 stated that if a resident expressed a threat of self-harm she (CNA # 5) would let the nurse know immediately, and if the nurse did not respond she would go up the chain of command. An interview was conducted on 5/5/16 at 8:30 a.m. with CNA # 10, CNA # 10 stated that she would report any threats a resident made to the nurse, and if the nurse did not respond she would go to the nursing supervisor, and if she got no response she would go higher to the Director of Nurses. During an interview on 5/5/16 at approximately 8:40 a.m. with CNA # 11, CNA # 11 stated I would make sure that the resident's call bell was in place, lower the bed, and then I would go report the comment to the nurse. If the nurse did not respond I would go to the unit manager then the assistant director of nurses, then the Director of nurses and finally the administrator until there was a response. Review of the facility policy: Suicide Prevention Plan documented the following: POLICY: it is the policy of this facility to provide a guideline, safety measures and treatments to patients who present a suicide risk. Patients who are actively suicidal cannot be cared for at FACILITY. Staff observing potential suicidal statements and behaviors exhibited by patients will report to supervisory staff immediately and take measures to promote safety. Under PROCEDURE: .2. If a patient mentions suicidal ideation at any time, this is reported to the charge nurse, Director of Nursing, Social Worker and Physician to evaluate the threat. 3. All staff members are obligated to report suicidal statements or other indicators of possible ideation to their immediate supervisor. Supervisor to notify physician and psychologist. Assess the patient's environment and remove items or modify conditions to insure safety. Document observations and actions taken in the medical record. 4. If the patient is determined to be actively suicidal with the intent to harm themselves and the ability to do so, they will be transferred to an acute hospital or other appropriate higher level of care. 5. If the patient is actively suicidal, but with limited physical abilities to carry it out, can be persuaded to agree not to kill themselves or who is passively suicidal, a plan of care is developed with interdisciplinary coordination to reduce risk of self-harm and to restore feelings of well-being. 6. At any time a patient is deemed to be at risk of engaging in suicidal or self-injurious behavior, the patient's environment must be examined to remove items or modify conditions that could be used by the patient to harm themselves. This includes, but is not limited to: *Removal of sharp objects (e.g., scissors, knives, nail files). *Visitation may be limited. *Access to windows or other glass items that could be broken to produce a sharp edge may be restricted or require observation. *Removal of belts, power cords, ties, shoelaces. *Removal of plastic bags. * Access to areas where staff cannot see the resident, or that can be locked to prevent entry may be restricted. *Access to chemicals, solvents or medications may be further restricted. *Access to power wheelchair may be restricted. *Leaving the unit while unsupervised may be prohibited (If the patient insists on this while being monitored for SI (suicidal ideation), they should be considered at high risk, and referred to an appropriate acute care setting for evaluation). *The patient may be moved for increased observation and to minimize access to items that may be unknown to staff. Review of the facility policy: Nursing-Notification of Changes documented the following: POLICY: It is the policy of this facility to inform the patient, consult with the patient's physician and notify the patient's legal representative or an interested family member when there is an accident, a significant change in the patient's physical, mental or psychosocial status, a need to alter treatment significantly, a decision to transfer or discharge patient from the facility . Under PROCEDURE: .2. Call the physician to advise and obtain orders . During an interview on 5/5/16 at 3:55 p.m. with ASM # 1, the Administrator, and ASM # 2 the Director of Nurses, in the presence of the survey team, this concern and the possibility of harm was reviewed. ASM # 1 and ASM # 2 were informed that they could have as much time as they needed to respond to this allegation. To which they responded that they did not have anything else. Prior to exit no other information was provided for this concern. After the survey on 5/6/16 at 1:57 p.m., the administrator, ASM #1 emailed the following letter from the physician, ASM # 4, to the state office: To whom it may concern, Regarding the care of (name of Resident # 22): I was with Unit Manager examining the above mentioned patient apparently 10 minutes after this patient indicated an expressed wording of wanting to end her pain/hurt herself. In no way did, ten minutes thereafter, in my evaluation of this patient was there any indication of any desire or expressed thought to believe patient would by any means, harm herself. No statement, no body language, no expression whatsoever. If there would have been any statement in the affirmative, in no way would there have been any alteration in the course of treatment than what was performed; to provide pain relief as a top priority. Sincerely, Name of Physician (ASM # 4) Sent from my iPhone In Basic Nursing, Essential for Practice, 6th edition (Potter and Perry, 2007, pages 56-59), was a reference source for physician's orders and notification. Failure to monitor the patient's condition appropriately and communicate that information to the physician or health care provider are causes of negligent acts. The best way to avoid being liable for negligence is to follow standards of care, to give competent health care, and to communicate with other health care providers. The physician or health care provider is responsible for directing the medical treatment of [REDACTED]. Mood Disorders (especially depression) often are unrecognized or misdiagnosed in older adults. Symptoms of depression include poor cognitive performance, sleep problems, and lack of initiative - symptoms commonly seen in people with dementia .Suicide is the most serious consequence of depression Many factors place an older adult at risk for depression, including recent bereavement, a change in environment, alcohol or substance abuse and chronic pain. Knowledge of these risk factors and careful assessment of older adults at risk allow the nurse to provide support, counseling, and appropriate and timely referral to a health provider for pharmacologic and psychotherapeutic interventions. Fundamentals of Nursing, 5th edition, Lippincott, Williams and Wilkins, page 316 * Tylenol . Acetaminophen is used to relieve mild to moderate pain. https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=tylenol ** Oxycodone is used to relieve moderate to severe pain. <https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=oxycodone> COMPLAINT DEFICIENCY

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care in a manner to prevent accidents with injury over which the facility has control, for one of seven residents in the survey sample, Resident #1. Facility staff, CNA (certified nursing aide) #1 manually transferred Resident #1 from her wheelchair to bed without using a mechanical lift as care planned. In the process of transferring Resident #1, CNA #1 removed the arm of Resident #1's wheelchair, without protecting the resident's flaccid left arm, allowing Resident #1's left arm to fall, causing a skin tear. During this transfer process, Resident #1 also sustained a fractured humerus (bone in the upper arm). The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].*decrease in the amount of calcium and phosphorus in the bone. This can cause bones to be weak and brittle, and increases the risk for broken bones), arthritis, chronic pain, polyneuropathy (#Neuropathy means nerve disease or damage.) Symptoms can range from numbness or tingling, to pricking sensations (paresthesia), or muscle weakness.), and asthma. On the most recent MDS (minimum data set), a 14-day Medicare assessment with assessment reference date 12/2/15, Resident #1 was coded as having no cognitive impairment for making daily decisions. She was coded as having scored 14 out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the extensive assistance of two staff members for bed mobility, and as being completely dependent on two staff members for transfers (moving from bed to chair, chair to bed). She was coded as having impairment on one side of her body for upper extremities, and as having impairment on one side of her body for lower extremities. Resident #1 was discharged from the facility on 12/16/15 and did not return to the facility; her record was reviewed as a closed record. A review of the clinical record for Resident #1 revealed the following nurses' notes: - 12/13/15 at 10:36 p.m. by LPN (licensed practical nurse) #7: Resident remains skilled for right hip replacement and generalized weakness. Resident alert and oriented (sic) X4 (alert to person, place, time and situation). Resident continent of bowel and bladder. Resident needs assistance X1 (of one person) with transfers and ADLs (activities of daily living). Resident c/o (complained of) no pain this shift. Resident resting in bed quietly with call bell within reach. Will continue to monitor. - 12/13/15 at 11:22 p.m. by LPN #7: Resident obtained a skin tear around 1700 (5:00 p.m.) when being tranfered (sic) from wheelchair to bed. Resident stated that her left arm hit the side rail. Resident c/o no pain. Resident has dressing in place to left arm. RP (responsible party) (name of RP) made aware. - 12/14/15 at 3:34 a.m. by LPN #5: Resident alert and oriented X 3 (person, place, time) with no c/o pain. Extensive assist X 1. Continues to be skilled r/t TRHR (total right hip replacement), weakness and rehab (rehabilitation). Skin tear to L (left) arm that has steri strips intact and dry dressing as well. Meds (medications) taken whole without difficulty. Left arm has no feeling. Right leg propped up on pillow. Resident repositioned by charge nurse and aide. Resident sleeping in bed with call bell in reach. Will continue to monitor. - 12/14/15 at 4:15 a.m. by LPN #5: Treatments/Procedures - Skin Tear. Steri strips intact. - 12/14/15 at 5:41 a.m. by LPN #5: Medications - Oxycodone HCl (**Oxycodone Hydrochloride - a narcotic used to treat moderate to severe pain) 40 mg (milligrams) Oral Tablet. Pain scale 5/10 L arm. - 12/14/15 at 10:49 a.m. by LPN #1: Treatments/Procedures Skin Tear. Three steri strips intact. There is no drainage. - 12/14/15 at 1300 (1:00 p.m.) by LPN #3: Resident is alert and oriented and able to make needs known. Remains skilled for right total hip replacement, weakness & (and) rehab. Resident remains weight bearing as tolerated to right leg at this time. Received PT (physical therapy) and OT (occupational therapy) services. Requires limited assistance with ADLs. Resident transfers via total mechanical lift. Resident ambulates via wheelchair and requires staff to propel. Resident is continent of bowel and bladder. No complaints of pain or distress noted at this time. Will continue to monitor. - 12/14/15 at 1345 (1:45 p.m.) by LPN #3: Resident observed with red swollen left upper arm at this time. Resident appears to have a knot at the top of left arm between her shoulder and elbow. Left arm is paralyzed and currently in a sling at this time. MD (physician) notified and asked if we can obtain an X-ray at this time. MD (medical doctor) in agreeance. New order obtained to x-ray left arm. (Name of mobile X-ray company) notified at this time. Son in facility and made aware of new order. Resident denies pain at this time. Will continue to monitor. - 12/14/15 at 1618 (4:18 p.m.) by RN (registered nurse) #1: X-ray left arm, shoulder and elbow ordered r/t (related to) red/swollen left upper arm. Positive humerus fx (fracture). Son and brother at bedside. Aware of x-ray results. Resident sent to (name of local hospital) via rescue squad at 1928 (7:28 p.m.). A review of the imaging report dated 12/14/15 from the local mobile imaging provider revealed, in part, the following: Date of Service: 12/14/2015. Clinical Information: Swelling .Impressions: Osteopenia with acute fracture of the proximal**** third of the humerus with angulation and soft tissue swelling. There is a soft tissue calcification***** present. There is also suggestion of old fracture of the more distal humerus. The report was signed by the imaging company's physician at 6:00 p.m. on 12/14/15. A review of the Occupational Therapy notes revealed the following note written by OSM (other staff member) #3, the occupational therapist (OT), on 12/14/15. The note does not contain a time stamp: Pt (patient) participated in there (therapy) act (activity) to increase functional activity tolerance and independence with self-care tasks .Pt seen in room in AM (morning) with nurse present. Pt presented with increased edema (swelling) and bruising to LUE (left upper extremity) and with multiple skin tears. Pt reported nursing staff transferred her from bed to w/c (wheelchair) with foam arm rest padding removed. Her LUE was caught between the padding of the arm rest and the plate of the arm rest. Pt. presents with flaccidity in LUE due to old injury. This OT noted to nurse present that pt's humerus looked as if it had shifted in position. Nurse agreed and stated she would speak with the Dr. (physician) to see if there could be an x-ray taken to make sure there was no fracture. Pt reported to this OT in PM (afternoon) there had been no x-ray at that time. Will continue to follow. A review of the medication administration record for Resident #1, revealed evidence that she received Oxycodone HCl 40 milligrams every eight hours around the clock as ordered, on 12/13/15 at 9:00 p.m.; and on 12/14/15 at 6:00 a.m. and 2:00 p.m. A review of the physician/provider progress notes revealed the following note, written on 12/14/15 (no time indicated) by the physician: Complaint: Lt (left) arm swelling and pan. History: Asked to see the resident who has atrophic (***relating to or characterized by atrophy) and paralyzed Lt arm (secondary to) MVA (motor vehicle accident) many years ago. She developed swelling of soft tissue and pain after she got transferred from chair to bed. X-ray showed osteopenia and lt. humerus upper third # (fracture) with angulation. A review of the emergency room record for Resident #1 dated 12/14/15 (arrival) and 12/15/15 (discharge at 2:05 a.m.) revealed, in part, the following: Patient is a 79 y.o. (year old) female presenting with arm problem. The history is provided by the patient, the nursing home and medical records. This is a chronic (Acute on chronic) problem. The current episode started yesterday (Per SNF (skilled nursing facility) and Pt (patient), they were moving her in bed and were holding her LUE (left upper extremity) when there was a snap; she was evaluated with xrays and transferred here for evaluation of a left humeral fracture) .Radiology Results: Impression: Acute fracture midshaft of the humerus. Possible subacute fracture or healing fracture of the more distal shaft of the humerus as described. The report also includes a record of splint placement on the resident's left humerus. A review of the facility document entitled Resident Mobility/Transfer Profile dated 11/19/15 revealed, in part, the following: Resident is able to bear weight and perform a Stand-Pivot transfer with Stand-by or minimal assist from staff - No. Can Resident perform ALL of the following: Bear weight on at least 1 lower extremity; Grasp with both hands (2nd caregiver must be present if only able to grasp with one hand); maintain independent sitting position; and follow simple instructions? No. Does the Resident weight less than the Maximum Weight limit as set by the Mfg (manufacturer) and can the resident tolerate a Semi-reclined position? Yes. Candidate for Total Passive Lift. A review of Resident #1's comprehensive care plan, dated 11/19/15 and most recently updated on 12/8/15 revealed, in part the following: Total lift - one person .MECHANICAL LIFT USAGE - Extensive assist needed, Uses Total Lift for transfers .TRANSFER NEEDS - Extensive assist needed, Assist devices as needed; Call light in reach, TML (Total Mechanical Lift). On 1/5/16 at 8:45 a.m., LPN #5 was interviewed about Resident #1's status on the night shift of 12/13/14 into 12/14/15. She stated that the resident was pretty much alert and oriented to person, place and time. She stated that the resident could make her needs known regarding pain and toileting needs. She stated: She always told us that she had no feeling in her left arm. But yet she had significant pain in it. She always had her left arm lying across her belly or on a pillow. She could not move it by herself. She stated that the resident's left hand always appeared pink/purplish, but she was not sure about the baseline color of her upper arm. She denied ever seeing a sling on Resident #1's arm or in her room available for use. She stated she had no memory of what LPN #7 told her about Resident #1 in report when LPN #5 came on duty late on the night of 12/13/14. She stated that she did not assess Resident #1's arm; she stated she looked only at the skin tear. She stated that Resident #1 had a pretty big skin tear on her left forearm, and that she remembered there were steri strips over the skin tear. When shown the above-referenced nurses' notes, she stated that she did not remember anything other than what she had documented regarding Resident #1's left arm pain. On 1/5/16 at 8:25 a.m., LPN #6, a treatment nurse, was interviewed regarding what she remembered about Resident #1's left arm on 12/14/15. She stated that she was called by ASM (administrative staff member) #2, the director of nursing, to go to Resident #1's room on the morning of 12/14/15 to assess the skin tear and to determine if the treatment was appropriate. She stated: I assessed her. She (Resident #1) told me she had real thin skin. She said 'This happens to me all the time.' LPN #6 could not recall exactly what time this assessment occurred. When asked where she had documented this assessment, she stated: In the nurse's notes, I think. When shown the nurses' notes for Resident #1, she stated: I don't see it. I don't guess I put it in the computer. When asked if she assessed Resident #1's upper arm at this time, she stated: No. I was just asked to look at the skin tear on her lower arm. She further stated that Resident #1's arm was in a sling. When asked if she knew why it was in a sling, she stated she did not know. She stated she was able to fold the sling down only from the elbow to the wrist. This was how she was able to assess the skin tear without removing the whole sling. She stated she did not know who had put the sling on Resident #1's left arm. She stated that she asked Resident #1 how she received the skin tear, and that the resident told her that she didn't know. She stated that the resident told her that skin tears happen all the time. When asked if Resident #1 was cognitively intact, LPN #6 stated: Yes. On 1/5/16 at 9:40 a.m., LPN #7 was interviewed regarding what she remembered from the evening shift during which Resident #1 was injured. She stated: I can't remember the CNA's (certified nursing assistant's) name that came to talk to me about the skin tear. I don't really work with her much. She told the surveyor what the CNA's last name might be, but was not certain. She stated: The CNA came to me, and told me the resident had a skin tear. And she told me that it happened when she was transferring the resident. When asked if she inquired of the CNA about how she transferred Resident #1, she stated that she did not ask her and the CNA did not volunteer any information. She stated that she went to the resident's room and asked the resident how the skin tear happened. She stated that Resident #1 told her that she hit it on the rail, and that it happens all the time. When asked which rail to which Resident #1 was referring, LPN #7 stated: I don't know, maybe the bed rail. When asked what she remembered about Resident #1's left arm, she stated: I remember her left arm, but I don't remember about anything else being wrong with it. I noticed she also had bruising, but the resident stated that the bruising was already there. When asked if she was aware of previous bruising on Resident #1's left arm at this time, she stated: No. She stated that she asked Resident #1 if she was in any pain, and the resident denied pain. She stated: Her left arm was paralyzed. This was my first time working with her. I really didn't know her that well. I didn't think anything was wrong, because she could not feel anything in that arm anyway, and she said there was no pain. When asked if she performed an assessment of Resident #1's whole left arm at this time, she stated: No. I only looked at the skin tear. On 1/5/16 at 11:25 a.m., LPN #1 was interviewed regarding what she remembered about taking care of Resident #1 on the day shift on 12/14/15. She stated: I had seen her left arm on that Friday before (12/11/15). We had been working and working on a skin tear on her arm that was almost healed. Then on Monday (12/14/15), I came in and she had a skin tear on her left forearm. She had steri strips. And there was something hard on her upper arm. I want to say it looked like a bone. It was sort of poking up. Her shoulder was swollen. I can't really describe it. But it did not look like when I left it (on Friday). When asked what her next step was, she stated: I put in a new order for the treatment for [REDACTED]. I told (LPN #3) to go look at her arm. When asked if she documented her assessment of the skin tear or of the upper arm, she stated, I was the desk nurse that day. I checked orders, assisted the unit manager. I also try to help with treatments. When shown the nurses' notes for Resident #1, she stated: No, I didn't document. I was the desk nurse that day. I told (LPN #3) to go look at it. She stated that she did not, in fact, follow up with LPN #3 to make sure she had gone in to assess Resident #1's left arm. When asked what time her assessment took place, she stated: I'm not sure. It was definitely before lunch. I also told the unit manager (LPN #2) about it. I also wrote down in the doctor's book for the doctor to see it. I knew he was coming in that day. She stated that she remembered asking Resident #1 if she was having any pain, and she stated that the resident denied pain. She stated that she asked the resident what happened to her arm, and that the resident told her the skin tear happened during a transfer the day before. She stated that Resident #1 did not say anything at that time about her upper arm. LPN #1 later stated (on 1/6/16 at 12:30 p.m.) that when she first looked at Resident #1's arm, the resident told her how she got the skin tear. She stated: At that time, I felt up her arm. I found the knot. Her shoulder looked bumpy, not smooth. I gave her wound care. When asked why she did not document or take any further action regarding the knot in the upper arm, she stated: I didn't do anything because it did not hurt. Yes, I knew that she had very minimum feeling in her arm at baseline. I just didn't think there was anything bad wrong because it did not hurt. On 1/5/16 at 11:37 a.m., LPN #3 was interviewed about caring for Resident #1 on 12/14/15. She stated: (Resident #1) was alert and oriented times four. She could make all her needs known. She stated: I was told in report that morning that she had gotten a skin tear over the weekend. I did not go look at right away. She stated that during the morning at some point, (LPN #1) told me her arm did not look right. She stated that LPN #1 was doing the treatment, and that she thought that LPN #1 had done the assessment. She stated: I knew (LPN #1) had put it in the doctor's book, so I didn't go look at it. She stated: I was the nurse on the floor. She stated that her duties on that shift included passing pills, writing progress notes and assessing residents. When asked why she did not go to assess a resident's arm that 'did not look right' to another nurse, she stated: I was in the middle of med pass when (LPN #1) came to me. I really don't know/remember why I didn't look at it afterwards. When asked what time she would have been passing meds on the morning of 12/14/15, she stated: Somewhere around eight to ten (8:00 a.m. to 10:00 a.m.). When asked if she called the physician when LPN #1 told her about the arm not looking right, she stated: I don't remember. I'm not sure. When asked if she remembered that LPN #1 had specifically asked her to call the physician, she stated: No, I don't remember. She stated that the next thing she remembered happening was that Resident #1's son came to the desk, after lunch, I believe, and asked: What are we going to do? Are we getting an X-ray? She stated that LPN #1 was standing at the desk beside her, and that LPN #1 told the son that doctor would be seeing the resident later on that afternoon when he arrived at the facility. She stated: At that point the son said: 'That's not acceptable. We're going to do something, and we're going to do it now. She stated that at that point, Resident #1 had been taken to the therapy gym. She stated that the son accompanied her to the therapy gym. She pulled down Resident #1's sleeve, and saw that her arm was red. She stated: It looked like a knot in the middle of her upper arm. I don't remember if it was warm or not. I knew that her arm does not usually look like that. I asked her about pain. I don't believe she said she had any pain. She stated that she returned to the unit, called the physician, and requested an order for [REDACTED]. She stated that doctor agreed to the X-ray. She stated that she left the facility at the end of her day (she could not recall the exact time), and that she did not remember the physician arriving prior to her leaving the facility. She stated: Mondays are his later days. He usually doesn't come until the middle of the afternoon. She stated that the mobile X-ray company arrived prior to her departure from the facility, but that the final report had not come in when she left. When asked where she documented her assessment of Resident #1's arm in the therapy gym, the conversation with the son, and the conversation with the physician, she stated: I did not write it down. On 1/5/16 at 10:30 a.m., LPN #2, the unit manager on duty on 12/14/15, was interviewed. She stated that Resident #1 could make all her needs known. She stated: She got scheduled pain medication. She never had constant pain here, but had chronic pain in her left arm from a car accident. She stated: She usually had pain her leg. But she also had it in her left arm a couple of days before she left. She stated that on admission, Resident #1 had a flaccid left arm; she described it as not having much movement. She stated that the resident's son had brought a sling from home, but that the resident did not like to wear the sling. She stated: When I got here (on the morning of 12/14/15), I was told the CNA was getting ready to transfer her, and that the resident's arm fell on the leg of the wheelchair. The CNA was transferring her and her arm hit the wheelchair before she actually transferred her. She stated: I looked at her arm and saw the skin tear. It was a normal skin tear on her forearm. Her upper arm was reddish, warm to touch. I thought she had bumped it or had a cellulitis. I never thought it was fractured because it hung flaccid at baseline. She had no pain. She couldn't move it by herself, but I could move it. She stated she first saw the arm on 12/14/15 between 10:45 a.m. and 11:00 a.m. She stated: I initially looked at the skin tear. (LPN#1) told me that something did not look right. I went back in to look at her arm. (LPN #1), who was the treatment nurse, had told me that she had notified (LPN #3), who was the floor nurse that day. (LPN #3) told me she was going to call the doctor. Somebody told me the doctor would see her when he arrived that evening. She stated that the next thing she remembered was coming out of a meeting around 2:00 p.m. on 12/14/15 and encountering Resident #1's son in the hallway. She stated: The son said, 'I am not happy.' He told me 'the nurse has not even seen it (his mother's left arm).' She stated that the son told her that he and LPN #3 had just gone to the therapy gym to look at Resident #1's arm. She stated: Apparently (LPN #3) had never gone in that morning to assess the resident's arm. She stated she was not sure whether or not LPN #3 had called the physician at any time that day prior to calling to request the X-ray at around 2:00 p.m. that afternoon. When asked who was responsible for resident assessments/documentation/calling the physician, she stated: It would have been (LPN #3). It's my job as the unit manager to manage and oversee everything. My understanding that morning - I think sometime around 11:00 (a.m.) that (LPN #3) was going to go in and assess the arm, look at it, and follow the appropriate steps. She stated that she remembered that the physician (ASM #4) arrived at the facility around 3:00 p.m., that the X-ray happened around 4:30 p.m., and that the report came back around 6:00 p.m. She stated that once the report came back confirming a fracture, ASM #4 wanted her immediately sent to the emergency room . She stated that once Resident #1 returned from the emergency room in the early hours of 12/15/15, she had a big, soft cast applied to her left arm, with orders to follow up with an orthopedist in 48 hours. When asked at 3:00 p.m. on 1/5/16 if she was aware of how Resident #1 was supposed to be transferred, according to the care plan, she stated: By mechanical lift. She was a mechanical lift all the time she was here. On 1/5/16 at 11:20 a.m., CNA #1 was interviewed regarding her transfer of Resident #1 on 12/13/15. She stated: I was transferring (Resident #1) from her wheelchair to the bed. It was before supper. I was doing a manual lift. I did not use the mechanical. She could slightly stand and pivot. I transferred her by myself. I took the side off the wheelchair - the side she was paralyzed on. Her arm fell to the side. It hit on the wheelchair and caused her skin to tear. I told the nurse what happened. She did not hit her upper arm that I remember. But I might not have seen it. When asked if she was aware that Resident #1 had no control of the movement of her left arm, she stated, I knew it was paralyzed. When asked if she did anything to protect Resident #1's arm from falling to the side, she stated: No. Not really. It all happened so fast. The surveyor accompanied CNA #1 to a utility room where CNA #1 demonstrated how she removed the left arm of the wheelchair, and where the chair was positioned. She demonstrated that she had placed the wheelchair adjacent to Resident #1's bed, where the left side of the wheelchair was almost touching the side of the bed. She stated she did not remember whether or not Resident #1's bed rail was up or down when the event occurred. Later on 1/5/16 at 3:02 p.m., CNA #1 was asked if she was aware that Resident #1's care plan called for the use of a total mechanical lift for all transfers. She stated: There was a sign on the door that tells us what we can use for transfers. And when she first came, we were using the mechanical lift. But we just gradually were taking her off the lift. That's what we do with the rehab people. They want them to be able to transfer without the lift. It just depended on the day. I guess about half the time you were with her, she needed the lift. The other times I just transferred her myself. In a later interview on 1/6/15 at 9:35 a.m., CNA #1 was asked specifically about how Resident #1's wheelchair was put together with regards to adaptations. She stated: She fit snug in her wheelchair. And the left arm had a big cushion on it to keep her left arm still. Whether or not I was using the lift, I always had to take the arm off the left side - to either put the sling for the mechanical lift behind her, or to pick her up to transfer her by myself. When asked if she remembered having a hard time pulling the arm off the left side of the wheelchair on 12/13/15, CNA #1 stated: It was a struggle. Because of the cushion. It was hard to get off. Later on 1/6/15, at 2:10 p.m., CNA #1 further stated: Once I got the arm off the wheelchair, I just did a big bear hug. I put my right arm around her whole arm. I was right up against her. My right arm was around her whole left arm, tucked around her arm, not under her armpit, but around her whole upper arm, and went around to her back. My left hand was under her right arm. She stated she lifted the resident up from the wheelchair and moved her to the bed. She stated that she did not use a gait belt. She stated that she saw a lot of blood from the skin tear, and did not even look at her upper arm. She didn't say it hurt. On 1/5/16 at 11:50 a.m., CNA #2, who would have assisted Resident #1 dressed on 12/14/15, was interviewed. She stated that she had no memory of Resident of #1 or of ever taking care of her. On 1/5/16 at 1:00 p.m., LPN #8, a nurse responsible for orientation/in services, was interviewed regarding what she teaches CNAs about determining a resident's transfer needs. She stated: Mobility is on the care plan. It is kept right there beside the assignment book. She stated: It's also above the doors on a sign. It tells what kind of lift is needed. We are a no lift facility. We don't lift anyone manually. We use mechanical lifts. On 1/5/16 at 2:20 p.m., OSM (other staff member) #2, the physical therapist, was interviewed. She stated that Resident #1's status was weight bearing as tolerated. Unless you ask me a specific question, that's all I'm going to say. When asked about the frequency of Resident #1's PT (physical therapy) treatments, she stated: We were treating her five times a week. She stated that she remembered that Resident #1 had chronic pain, but that did not have a memory of her pain interfering with her PT. She stated: I always had her left arm in a sling. I always put the sling on her. I used it as a safety precaution of her left arm due to her past medical history. When asked if Resident #1 had a physician's orders [REDACTED]. When asked if Resident #1 wore the sling when she was not receiving PT, she stated: I'm not sure. I always had to put it on her. She never had it on when I went to get her. In my clinical judgment, she needed the sling to stabilize her left arm. She stated that she treated Resident #1 on 12/11/15. She stated that on that day, her left arm was in a sling, and that they worked on weight-bearing exercises. She stated that the sling always kept the resident's left arm close to her body. She stated that she next saw Resident #1 on 12/14/15. She stated: Everything was done seated in a chair due to an event that occurred that I was not present for. When asked about this event, she stated: Someone told me that she had pain in her arm from a transfer. I was not present when the event occurred. I'm old school. I was being conservative and not having her use her arms to stabilize on the bars in order to practice weight bearing. We only did things with her sitting down that day. When asked about the appearance of Resident #1's arm on 12/14/15, she stated: Her arm appeared flaccid. It was always flaccid. I was advised that there was something with a transfer. I was not going to move her until she was assessed, so I left her in her wheelchair. She stated that Resident #1's son and another nurse arrived in the therapy gym in the midst of the afternoon therapy session to look at the left arm. She stated: I don't recall. This may have been when I found out about the transfer event. When asked if she used a mechanical lift to transfer Resident #1 from bed to wheelchair in preparation for or after PT, she stated: I always stand pivoted her, with the wheelchair parallel to the edge of the bed. When asked if she was aware that the care plan for Resident #1 called for a total mechanical lift at all times, she stated: I don't think we made a transfer recommendation for her. Sometimes we do that, but not all the time. On 1/5/16 at 2:50 p.m., OSM #3, the occupational therapist, was interviewed. She stated: It was hard to judge (Resident #1's) pain. At first she would scream at you if you even went to touch her, then the screaming slowed way down as time went by. She had no pain, no feeling in her left arm. She stated that she worked with Resident #1 on 12/11/15 on upper body tasks, such as fine motor activity and strengthening. She stated that she next saw Resident #1 on 12/14/15 when she went to the resident's room to get her for OT (occupational therapy). She stated: I went in to get her. I noticed her whole left arm was swollen. (LPN #1) was in there with her, putting a dressing on her skin tears. I asked (the resident) what happened. She stated that they caught her arm in the wheelchair armrest. She had her arm propped up on a cushion that was part of the wheelchair. I noticed her arm was bending where the humerus was. I pointed it out to (LPN #1). She had not seen it. I could see it; I just stepped a few feet into her room. We put a sling on it to keep her from moving it. (LPN #3) told me she would talk to the doctor about getting an X-ray. I came back to her room later, and did mostly education with her. I didn't do anything with her left arm. She stated that all of the above happened before lunchtime on 12/14/15. She stated that after lunch, OSM #2 arrived in the therapy gym with Resident #1. She stated that she had already spoken with OSM #2 about whether or not the resident should attempt to stand up with the use of the parallel bars. On 1/5/16 at 5:20 p.m., ASM #1, the administrator, was interviewed regarding Resident #1's transfer on 12/13/14 and the fracture diagnosed on [DATE]. When asked if she was aware of how Resident #1's left humerus fracture occurred, she stated: I believe it happened the way the patient told me - the fracture occurred at the same time that the skin tear occurred. She stated that she first became aware of the skin tear and fracture on 12/14/15 when Resident #1's son went to see her