Every finding on record at Avir at Monahans

Based on interview and record review the facility failed to ensure residents had the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed for 1 (Resident #1) of 7 residents reviewed for medical records. The facility failed to ensure Resident #1 was provided an explanation regarding the reason for her room change, which occurred without her agreement, on 06/23/2026 at 11:41 a.m. This failure could place residents at risk for emotional distress and loss of autonomy related to room chnages without adequate notice of explanation. Findings included:Record review of Resident #1's face sheet, dated 08/11/2026, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #1's history and physical, dated 02/13/2026, revealed the resident had diagnoses of hypertension (high blood pressure) and depression (a mood disorder that may cause persistent sadness, loss of interest, and changes in mood or daily functioning), anemia (a condition in which the blood does not carry enough oxygen because of too few healthy red blood cells or insufficient hemoglobin), cerebrovascular accident/CVA or stroke (an interruption of blood flow to part of the brain that can cause brain damage and loss of function), hemiplegia or hemiparesis (paralysis or significant weakness affecting one side of the body), seizure disorder/epilepsy (a condition that causes recurrent seizures due to abnormal electrical activity in the brain), depression other than bipolar disorder (a mood disorder associated with persistent sadness, loss of interest, or related symptoms), cerebral infarction due to unspecified occlusion or stenosis of the right middle cerebral artery (a stroke caused by blockage or narrowing of a major artery supplying the right side of the brain), generalized muscle weakness (overall decreased muscle strength), lack of coordination (difficulty controlling or coordinating body movements), chronic pain syndrome (long-lasting pain that affects daily functioning or quality of life), legal blindness (vision loss severe enough to meet the legal definition of blindness), and altered mental status (a change in normal thinking, awareness, behavior, or alertness). Record review of Resident #1's quarterly MDS assessment, dated 06/09/2026, revealed the resident had a BIMS score of 15, which indicated intact cognition. Section GG, Functional Abilities, revealed the resident required setup or clean-up assistance with eating. Resident #1 was dependent for toileting hygiene, showering/bathing, upper-body dressing, lower-body dressing, putting on or taking off footwear, and personal hygiene, meaning the helper or staff performed all the effort, the resident performed none of the effort. For mobility, Resident #1 required supervision or touching assistance to roll left and right and was dependent for sit-to-lying, lying-to-sitting on the side of the bed, and tub/shower transfers, sit-to-stand, chair/bed-to-chair transfer, and toilet transfer. Record review of Resident #1's care plan, with the latest documented revisions dated 06/30/2026, revealed the resident had an ADL self-care performance deficit related to activity intolerance, confusion, hemiplegia, and impaired balance. The care plan documented that Resident #1 was bedfast all or most of the time and required extensive staff assistance with daily care. CNA interventions included encouraging the resident to participate to the fullest extent possible during each interaction and encouraging her to use the call bell for assistance. The care plan directed staff to monitor and document the residents' abilities with ADLs, assist her as needed, and encourage her to perform the portions of care she remained capable of completing. CNAs were also to assist Resident #1 with turning and repositioning at least every two hours and as needed while maintaining proper body alignment and tell the resident where items were placed and remain consistent with item placement because of her impaired vision. The care plan revealed that Resident #1 was totally dependent on staff for bathing/showering, bed mobility, dressing, personal hygiene/oral care, transfers, and locomotion. Record review on 08/11/2026 at 11:55 a.m. of the room-change progress note, dated 06/23/2026, revealed Resident #1 was moved to a different room because her roommate had been interfering with resident care. The available documentation did not establish the complete room-change process, the explanation provided to Resident #1, or documentation of Resident #1's consent. During an interview on 08/11/2026 at 11:17 a.m., RN A stated Resident #1 previously wanted to move because the roommate could be controlling and would make decisions for her without her consent by telling staff when she needed to be assisted off the bed, when to be taken for a shower and when to request food. RN A stated that Resident #1 as first moved within the same hallway and was later moved to another hallway after concerns continued with the former roommate. During an interview on 08/11/2026 at 11:40 a.m., Resident #1 stated that facility staff moved her room without giving her an explanation. Resident #1 stated t she was doing okay and adjusting to the new room and new roommate, and that she felt safe; however, she stated the room change occurred without her agreement. During an interview on 08/11/2026 at 11:56 a.m., CNA B stated she had not known why Resident #1 was moved to a different room and a different hallway and that Resident #1 did not look distressed after the move. CNA B stated when a resident was moved, it was expected that the facility to follow the proper process by notifying the resident and explaining the move. CNA B stated that moving a resident without consent could have negatively affected the resident by making her feel her opinion did not matter and like the facility was not her house. During an interview on 08/11/2026 at 12:11 p.m., CNA C stated she did not know why Resident #1 was moved and the resident had not complained to her about the move. CNA C stated the facility should have determined the reason for a room change and explained the reason to the resident because an unexplained move could have caused confusion or negatively affected the resident's mood. During an interview on 08/11/2026 at 12:34 p.m., the Administrator stated Resident #1 verbally agreed to the room change and that the reason for the move was explained to her. The Administrator stated Resident #1's verbal agreement to the room change had not been documented and that the available record did not contain documentation showing the complete room-change process or the resident's consent. The Administrator stated that significant or unusual circumstances involving residents should have been documented to establish an accurate record and stated that she had not consistently documented the repeated concerns involving Resident #1 and the former roommate. The Administrator stated complete and accurate documentation was necessary so staff could identify concerns and determine what had occurred and verify whether appropriate follow-up was completed. The Administrator stated the documentation regarding Resident #1's room change was not completed and that the facility should have maintained documentation reflecting the circumstances of the move, the explanation provided to the resident, and the resident's agreement. During an interview on 08/12/2026 at 10:18 a.m., CNA D stated Resident #1 had not look angry, sad, or distressed at the time of the room change and later indicated that she was fine in the new room. CNA D stated that whenever a resident was moved from one room to another, the change needed to be documented in the resident's record and the resident needed to be informed and explained the reason for the change or if the resident had a representative, the change needed to be discussed and approved by them. CNA D stated if the facility had not followed proper procedures, it could potentially impact the residents negatively by making them feel their opinion did not matter and making the residents feel they could not make decisions on their own.During an interview on 08/12/2026 at 10:33 a.m., CNA E stated that if two residents were having issues between them, it was expected for the facility staff to intervene and then report it to the charge nurse so they could document it in the electronic medical record. CNA E stated it was important to document every interaction before deciding to move a resident from one room to another and stated the facility needed to discuss the change with the resident or their representative and have the necessary paperwork signed before making the room change. CNA E stated that if the facility did not explain to the resident the reason they were being moved and just moved them, it could potentially make a negative impact on the resident's well being by making them feel their opinion did not matter, which could make them feel sad.During an interview on 08/12/2026 at 10:46 a.m., ADON F stated when a CNA observed significant information or a change involving a resident, the CNA was expected to report it to the charge nurse. ADON F stated the charge nurse was expected to document the information in the electronic medical record and that, as the information progressed through the nursing chain of command, each staff member involved was expected to document the information. ADON F stated that Resident #1's room change should have been documented, including the reason for the move and the circumstances surrounding the change. ADON F explained that without documentation, there was no record showing why Resident #1 was moved, what was discussed with Resident #1, or what actions staff had taken. ADON F stated failure to document the room change could have prevented subsequent staff from knowing what occurred and completing appropriate follow-up. ADON F further stated that proper documentation was necessary to maintain an accurate resident record and that missing documentation could have resulted in regulatory consequences.During an interview on 08/12/2026 at 11:01 a.m., the DON stated that significant or reportable resident information was expected to be communicated to the charge nurse and documented in the resident's medical record. The DON stated that Resident #1's move from one hallway to another should have been documented and that completing the room change without documentation was not acceptable. The DON explained documentation should have reflected the room change and provided information regarding the circumstances surrounding the move. The DON stated proper documentation was necessary to maintain an accurate resident record and ensure staff were informed of Resident #1's condition and care.During an interview on 08/12/2026 at 11:26 a.m., LVN G stated she had not known what process was followed when Resident #1 was moved and could not confirm whether subsequent concerns involving Resident #1 were documented in the electronic medical record. LVN G stated documentation was necessary to create a history or paper trail, communicate information between shifts, permit follow-up, and identify recurring patterns. LVN G stated without documentation, subsequent staff might not have known that a concern had previously occurred. Record review of the facility's policy and procedure titled, Room Change/Roommate Assignment. revised March 2021, stated in part: Policy Statement: Changes in room or roommate assignment are made when the facility deems it necessary or when the resident requests the change. Policy Interpretation and Implementation 4. Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g, residents and their representatives) are given at least a __ hour/day advance written notice of such change.a. Advance written notice of a roommate change includes why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate.5. Residents have the right to refuse to move to another room in the facility if the purpose of the move is:a. to relocate the resident from a skilled nursing unit within the facility to one that is not a skilled nursing unit;b. to relocate the resident from a nursing unit within the facility to one that is a skilled nursing unit; orc. solely for the convenience of the staff.6. If a resident exercises his or her right to refuse a room change, this will not affect the resident's eligibility or entitlement to Medicare or Medicaid benefits.7. Documentation of a room change is recorded in the resident's medical record.8. Inquiries concerning room changes should be referred to the administrator. Record review of the facility's policy and procedure titled, Charting and Documentation, revised on July 2017, stated in part: Policy StatementAll services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation1. Documentation in the medical record may be electronic, manual or a combination.2. The following information is to be documented in the resident medical record:a. Objective observations;b. Medications administered;c. Treatments or services performed;d. Changes in the resident's condition;e. Events, incidents or accidents involving the resident; andf. Progress toward or changes in the care plan goals and objectives.3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.4. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy. Certified nursing assistants may only make entries in the resident's medical chart as permitted by facility policy.5. Information documented in the resident's clinical record is confidential and may only be released in accordance with state law, the Health Insurance Portability and Accountability Act (HIPAA) and facility policy. Refer all requests for information to the director of nursing services, nurse supervisor/charge nurse or to the business office.6. To ensure consistency in charting and documentation of the resident's clinical record, only facility approved abbreviations and symbols may be used when recording entries in the resident's clinical records.7. Documentation of procedures and treatments will include care-specific details, including:a. the date and time the procedure/treatment was provided;b. the name and title of the individual(s) who provided the care;c. the assessment data and/or any unusual findings obtained during the procedure/treatment;d. how the resident tolerated the procedure/treatment;e. whether the resident refused the procedure/treatment;f. notification of family, physician or other staff, if indicated; andg. the signature and title of the individual documenting.

Based on interviews and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 4 of 12 residents (Resident #2, Resident #4, Resident #5, Resident #10) reviewed for pharmacy services.The facility failed to ensure the hypertensive medication orders included adequate indications for its use to include parameters to administer or hold medications for Resident #2, Resident #4, Resident #5, and Resident #10. This failure could place the residents at risk of inadequate care and services. Findings included :Record review of Resident #2's Face Sheet reviewed on 5/10/2026 reflected a [AGE] year-old female, with an admission date of 01/21/2026. Resident #1 had diagnoses which included: acute respiratory failure (not enough oxygen or too much carbon dioxide in your body), major depressive disorder (consistent sadness), history of leukemia (cancer of the body's blood forming tissues), lack of coordination, and essential hypertension (high blood pressure). Record review of Resident #2's MAR dated 5/11/2026 reflected her Carvedilol Oral Tablet was to be given two times a day for hypertension. The MAR did not have parameters on when to hold or administer this antihypertensive medication. In an interview on 5/9/2026 at 11:05 A.M., Resident #2 said she received her medications timely and correctly with no concerns. Record review of Resident #4's Face sheet reviewed on 5/11/2026 reflected an [AGE] year-old female, with an admission date of 11/15/2024. Resident #4 had diagnoses which included: essential hypertension (high blood pressure), anxiety disorder (persistent worry or fear), lack of coordination, excoriation disorder (skin picking), pain disorder with related psychological factors, acute respiratory failure (not enough oxygen or too much carbon dioxide in your body).Record review of Resident #4's MAR dated 5/11/2026 reflected her Diovan Oral Tablet was given in the morning for hypertension. The MAR lacked parameters on when to hold or administer this antihypertensive medication. In an interview on 5/9/2026 at 10:02 A.M., Resident #4 said she received her medications timely and correctly with no issue. Record review of Resident #5's Face sheet reviewed on 5/11/2026 reflected a [AGE] year-old female, with an admission date of 01/21/2026. Resident #5 had diagnoses which included: essential hypertension (high blood pressure), atherosclerotic heart disease (hardening of the arteries), cardiomegaly (enlarged heart), osteoarthritis (degenerative joint disease-causing cartilage cap at the end of bones to wear away).Record review of Resident #5's MAR dated 5/11/2026 reflected her Losartan Potassium Oral Tablet was given two times a day for hypertension. The MAR lacked parameters on when to hold or administer this antihypertensive medication. In an interview on 5/9/2026 at 10:26 A.M., Resident #5 said she received her medications timely and correctly with no issue. Record review of Resident #10's Face sheet reviewed on 5/11/2026 reflected a [AGE] year-old male, with an admission date of 10/23/2025. Resident #10 had diagnoses which included: Alzheimer's Disease (appearance of buildup of proteins that affects the memory, thinking, and behavior), chronic kidney disease, stage 4 (moderately to severely damaged and not filtering waste from your blood), combined systolic (congestive) and diastolic (congestive) heart failure (heart muscle loses the ability to pump leading to significant blood backpressure), atherosclerosis heart disease of native coronary artery without angina pectoris (build up of plaque in the arteries without chest pain), heart failure. Record review of Resident #10's MAR dated 5/11/2026 reflected his Lotrel Oral Tablet was to be given by mouth one time a day for hypertension related to combined systolic (congestive) and diastolic (congestive) heart failure. The MAR lacked parameters on when to hold or administer this antihypertensive medication. In an interview on 5/9/2026 at 11:52 A.M., Resident #10 said he had no issues with any care concerns. In an interview on 5/9/2026 at 6:00 P.M., ADM A stated she was not aware of any medication concerns with any residents.In an interview on 5/10/2026 at 4:13 P.M., LVN D stated that she was not aware of any adverse effects to residents related to medications. In an interview on 5/10/2026 at 6:00 P.M., DON B stated that she was not aware of any issues with medications.In an interview on 5/11/2026 at 2:11 P.M., CR C stated the parameters of antihypertensive medications should be on the MAR. She stated she would get it fixed and educate staff to always ask that of the doctor. CR C stated the facility used their nursing judgement and monitored the residents for any medication effects. CR C stated she contacted the doctor and started fixing the orders to include the parameters. In a follow up interview on 5/11/2026 at 2:18 P.M., DON B did not comment on the need for parameters on antihypertensive medication orders. Record review of Administering Medications policy dated 2001 reflected, Medications are administered in a safe and timely manner, and as prescribed.2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions.8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 12 residents (Resident #1 and Resident #2) reviewed for care plans.The facility failed to ensure the staff developed the comprehensive care plan goals and interventions from the comprehensive assessment for Resident #1. The facility failed to ensure the comprehensive care plans for Resident #1 and Resident #2 described the resident's goals for admission and desired outcomes.The facility failed to ensure the comprehensive care plan for Resident #2 described the resident's preference and potential for future discharge. The facility failed to ensure the comprehensive care plan for Resident #2 documented a desire to return to the community was assessed. This failure could place the residents at risk of inadequate care and services. Findings included:Record review of Resident #1's Face Sheet reviewed on 5/10/2026 reflected a [AGE] year-old female, with an admission date of 5/8/2025. Resident #1 had diagnoses which included: schizoaffective disorder (both schizophrenia and mood disorders that affect the perception of reality with hallucinations, delusions, disorganized thoughts or speech), Osteoporosis (loss of bone), Osteoarthritis (degenerative joint disease causing cartilage cap at the end of bones to wear away), lack of coordination, depression (persistent feelings of sadness), hereditary motor and sensory neuropathy (A group of genetic disorders affecting the peripheral nervous system characterized by progressive degeneration of motor and sensory nerves), unsteadiness on feet. Record review of Resident #1's MDS dated [DATE] reflected occasional urinary incontinence. Record review of Resident #1's CAA dated 3/23/2026 reflected urinary incontinence, dehydration/fluid maintenance, and falls was triggered and indicated a new care plan, revision, or continuation of care plan is necessary to address the identified area. It further reflected the care planning decision must be completed within 7 days.Record review of Resident #1's CAA dated 3/23/2026 reflected that she utilized a walker for mobility. Record review of Resident #1's Care plan undated lacked documentation/goals for urinary incontinence, dehydration/fluid maintenance, or falls. In an interview on 5/10/26 at 11:48 P.M., Resident #1 stated her medical needs are met by the facility. She stated she had not fallen and she had therapy. Record review of Resident #2's Face Sheet reviewed on 5/10/2026 reflected a [AGE] year-old female, with an admission date of 01/21/2026. Resident #2 had diagnoses which included: acute respiratory failure (not enough oxygen or too much carbon dioxide in your body), major depressive disorder (consistent sadness), history of leukemia (cancer of the body's blood forming tissues), and lack of coordination. Record review of Resident #2's care plan undated lacked documentation on her preference and potential for future discharge. In an interview on 5/10/2026 at 4:13 P.M., LVN D stated Resident #1 had a urinary incontinence decline, and poor fluid intake but the facility staff were addressing those needs. LVN D stated she had access to the care plans but did not use that for information but used reports from other staff. In an interview on 5/11/2026 at 2:11 P.M., CR C stated DON B and herself were responsible for care plans and she was not aware that urinary incontinence, dehydration/fluid maintenance, and falls were not documented in the care plan. CR C did not comment about what adverse effects could occur with this not being in the care plan. In an interview on 5/11/2026 at 2:18 P.M., DON B stated the facility did not have an MDS nurse until recently and she had done care plans, but CR C helped. She stated she was not aware Resident #1's care plan did not address urinary incontinence, dehydration/fluid maintenance, or falls. DON B stated Resident #1 had declined in urinary incontinence but had not had any falls and staff address hydration needs. DON B stated there have been no negative effects from not being in the care plan and she would do a complete audit to get it back on track. In an interview on 5/11/2026 at 2:58 P.M., ADM A stated DON B was responsible for care plans because the MDS nurse was new. ADM A stated bad things like not having their needs met or not receiving services they need if the services were not in the care plan could occur. She stated Resident #1 had a decline in urinary incontinence, but her needs were being addressed, but it should be in the care plan. ADM A stated Resident #2 had no plans to discharge from the facility and that information should be in the care plan. Record review of Care Plans, Comprehensive Person-Centered dated 2001 reflected, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review the facility failed to ensure that all services, as outlined by the comprehensive care plan, being provided meet professional standards for 1 of 12 residents (Resident #1) reviewed for care plans.The facility failed to ensure Resident #1 was diagnosed by a practitioner using evidence-based criteria that meet professional standards of quality and lacked supporting documentation (comprehensive assessment) in the resident's medical record for a schizoaffective disorder diagnosis. This failure could place the residents at risk of not meeting their mental health needs. Findings included:Record review of Resident #1's Face Sheet reviewed on 5/10/2026 reflected a [AGE] year-old female, with an admission date of 5/8/2025. Resident #1 had diagnoses which included: schizoaffective disorder (both schizophrenia and mood disorders that affect the perception of reality with hallucinations, delusions, disorganized thoughts or speech), Osteoporosis (loss of bone), Osteoarthritis (degenerative joint disease causing cartilage cap at the end of bones to wear away), lack of coordination, depression (persistent feelings of sadness), hereditary motor and sensory neuropathy (A group of genetic disorders affecting the peripheral nervous system characterized by progressive degeneration of motor and sensory nerves), unsteadiness on feet. Record review of Resident #1's Medical Diagnosis reviewed on 5/10/2026, reflected schizoaffective disorder dated 5/16/25. Record review of Resident #1's Care Plan undated reflected interventions provided for hallucinations, delusions and behaviors related to diagnosis of schizophrenia/psychosis/mental illness. Record review of Resident #1's electronic health records for the period of 05/08/25 to 05/11/26 lacked documentation of a comprehensive assessment diagnosing Resident #1 with schizoaffective disorder.In an interview on 5/11/2026 at 2:11 P.M., CR C stated the psychiatry physician had been told three times prior that the facility needed a comprehensive evaluation to diagnose a resident with schizoaffective disorder. She stated she spoke with the diagnosing physician on the phone a moment ago, and he told her to discontinue and delete the diagnosis because he did not have a comprehensive evaluation. CR C stated that Resident #1 was not receiving any psychotropic medications for the disorder. In an interview on 5/11/2026 at 2:18 P.M., DON B stated she could not locate a comprehensive evaluation for schizoaffective disorder for Resident #1. She stated she spoke to the psychiatric physician, and he stated not to discontinue the diagnosis because Resident #1 did have a history of the diagnosis and he would see the resident on the next visit. DON B stated the psychiatric physician told her he did not have a comprehensive evaluation to provide. In an interview on 5/11/2026 at 2:58 P.M., ADM A stated she was not aware Resident #1 did not have a comprehensive evaluation in her file supporting her diagnosis. ADM A stated the facility's clinical was to do a complete an audit of files after the last violation for the same thing. Interview attempted with psychiatric physician but was unable to speak to him as of 05/11/26 at 6:00 PM . Interview attempted with Medical Director but was unable to speak to him as of 05/11/26 at 6:00 PM . Record review of the facility's Care Plans, Comprehensive Person-Centered policy dated 2001, reflected The comprehensive, person-centered care plan: .e. reflects currently reorganized standards of practice from problem areas and conditions.

Based on observation, interview, and record review, the facility failed to assure that all services, as outlined by the comprehensive care plan, being provided or arranged by the facility met professional standards for 1 of 8 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1 was diagnosed by a practitioner using evidence-based criteria that met professional standards of quality and lacked supporting documentation in the resident's medical record for schizoaffective disorder diagnosis. This failure could place residents at risk of physical and psychosocial harm by not following the clinical standards of practice.Findings included:Record review of Resident #1's face sheet undated, accessed on 02/8/2026 reflected a [AGE] year-old male, admitted [DATE]. Resident #1 had diagnoses which included: hemiparesis following cerebral infarction affecting right dominant side (paralysis on right side after a stroke), Schizoaffective Disorder (condition combining schizophrenia such as hallucinations and disorganized thinking, and mood disorder like bipolar or depression), Unspecified Dementia, mild, with psychotic disturbance (early-stage cognitive decline with symptoms such as hallucinations, delusions or paranoia), Other psychotic disorder not due to substance or known physiological condition (hallucinations, or delusions that do not meet schizophrenia, bipolar, or other specific disorders), Other speech and language deficits following cerebral infarction (wide range of speech deficits beyond aphasia), Cerebral Infarction (type of stroke caused by blockage in a brain artery resulting in oxygen deprivation and tissue death), Anxiety disorder (persistent, excessive, irrational fear or worry that interferes with daily life), Functional Quadriplegia (permanent immobility and inability to care for oneself resulting from advanced frailty or end-stage chronic illness), Depression (persistent sadness, loss of interest in activities, fatigue, and physical pain lasting two weeks), other symbolic dysfunctions (Have impairments that affect the person's ability to use and understand symbols, language, and perform related tasks). Record review of Resident #1's Care Plan, dated 01/20/2026, revealed interventions were to administer psychotropic medications as ordered by the physician. The care plan further revealed GDR was dated 12/17/25. Record review of Resident #1's clinical physician's orders, dated 12/17/25, revealed Olanzapine 2.5 MG tablet ordered by the PHY directed to give 1.25 mg by mouth two times a day related to schizoaffective disorder. Record review of Resident #1's Consent for Antipsychotic or Neuroleptic Medication Treatment, dated 11/27/25, revealed the PHY was treating Resident #1's psychiatric condition: F25.9 (schizoaffective disorder). Olanzapine 2.5 MG PO BID was proposed for the course of therapy. Record review of Resident #1's Medical Diagnosis undated, accessed on 02/08/2026 revealed code F25.9 Schizoaffective Disorder, Unspecified dated 5/16/25. Record review of Resident #1's electronic health records accessed on 02/08/2026 reflecting no documentation diagnosing Resident #1 with Schizoaffective Disorder, Unspecified (F25.9). During an interview on 2/07/2026 at 3:44 p.m., LVN A stated when she first started working with Resident #1 in July of 2025, he would not come out of his room at all. LVN A stated Resident #1 gradually would come out for meals but wanted to go back to his room right after. LVN A stated now Resident #1 comes out for meals and sits out in the lobby with the other residents during activities for a little while. LVN A stated Resident #1 would not interact but was better than before. During an attempted interview on 02/07/2026 at 3:39 p.m., Resident #1 stated everything is fine and refused to answer any questions. During an attempted interview on 02/07/2026 at 5:13 p.m., Resident #1 stated to leave him alone. During an attempted interview on 02/08/2026 at 10:20 a.m., Resident #1 would not speak or answer any questions. During an observation on 2/08/2026 at 4:40 p.m., Resident #1 was sitting in his wheelchair with other residents in the common area watching TV with no behavior or concerns noted. During an interview on 2/08/2026 at 7:54 p.m., ADON stated Resident #1 was doing better and being a little more active and coming out of his room. ADON stated Resident #1 had less aggression regarding his care. In an interview on 2/09/2026 at 1:10 p.m., DON stated the facility does not have a comprehensive assessment diagnosing Resident #1 with schizoaffective disorder. DON stated the failure had no negative resident effects. She stated they had completed a GDR, and he had done well with that and felt his course of treatment was effective and appropriate. During an interview on 2/09/2026 at 2:35 p.m., PHY stated Resident #1 had sleep and depression issues and last year Resident #1 was having more issues on a psychosis phase. PHY stated he had staff document information about the resident and Resident #1 had paranoid behaviors and episodes of hallucinations and agitation for several weeks. PHY stated he did not use a comprehensive assessment and just went by symptoms. PHY stated he knew Resident #1, and he definitely had schizoaffective disorder, and he stands by his diagnosis. PHY stated he would get the documentation and send it to the facility. In an interview on 2/09/2026 at 4:00 p.m., ADM stated she had known Resident #1 since approximately 2020. ADM stated Resident #1 used to holler and scream. She stated he would yell if he was removed from his chair. ADM stated the facility did not have a comprehensive assessment diagnosing Resident #1 with schizoaffective disorder. ADM stated she believed his treatment helped him and was appropriate care because he was more active, would come out of his room, and did not scream anymore. ADM did not state how not having the comprehensive assessment could affect a resident.Record review of the facility's Care Plans, Comprehensive Person-Centered policy, dated 2001, reflected, The comprehensive, person-centered care plan: .e. reflects currently reorganized standards of practice from problem areas and conditions.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. The facility failed to ensure foods were properly stored, labeled and dated.The facility failed to dispose of spoiled food items properly.The facility failed to prevent possible cross contamination.The facility failed to ensure dietary staff used hair restraints properly. These failures could place residents at risk for food borne illnesses.Findings included:Observation on 7/27/2025 at approximately 9:42 AM revealed [NAME] E touching the lid of a trash can to place paper towels in it after washing hands.Observation on 7/27/2025 at approximately 9:45 AM revealed a box with 5 bags of corn tortillas received 8/13/2024 did not have a use by date (UBD). The tortillas at the bottom of each bag were hard. Observation on 7/27/2025 at approximately 9:45 AM revealed 2 bags of crispy rice cereal removed from the original packaging, without a UBD.Observation on 7/27/2025 at approximately 9:45 AM revealed breadcrumbs in a sealed bin received 12/17/24, without a UBD.Observation on 7/27/2025 at approximately 9:55 AM revealed a bin of apples and oranges. Three of the oranges had fuzzy, green and white growth on them. Observation on 7/28/2025 at approximately 11:56 AM revealed the spoiled oranges were no longer in the bin.Observation on 7/28/2025 at approximately 11:59 AM revealed [NAME] E and Dietary Aide (DA) F were not wearing hair restraints correctly. Their hair was not restrained above the ears, at the nape of neck, and forehead. Observation on 7/28/2025 at approximately 12:15 PM revealed [NAME] E touched the food surface area of 3 serving utensils when she reached up to retrieve the utensils from an open-air hanging rack. Observation on 7/28/2025 at approximately 12:17 PM revealed [NAME] E touched the corn bread with a bare finger when dishing it from the pan to the first 6 plates.Observation on 7/28/2025 at approximately 12:17 PM - 12:43 PM revealed [NAME] E touched the rim and the food surface of plates with her bare hands while dishing food items.Observation on 7/28/2025 at approximately 12:43 PM revealed [NAME] E picked up a divided plate, used her thumb nail to flick something off the food surface of the plate then placed food items on the plate. During an interview on 7/29/2025 at 3:40 PM [NAME] E said she would not have used the corn tortillas. She said she used the bread/buns unless molded. Said she is not sure who should remove old products from dry storage. [NAME] E said the bags of cereal did not have a UBD because they were removed from the original box. [NAME] E said the staff did not use the step-open trash can at the hand sink because they never knew if it would have a bag in it. [NAME] E said they use the big rolling one next to it and must touch the lid to open it. [NAME] E said she was aware that hair nets must cover all hair. Said only one size is available at the facility. [NAME] E said she knows she is not supposed to touch the food surface of utensils, plates, or food with bare hands. [NAME] E said the divided plate she flicked something off was the last clean one. [NAME] E said she thinks it was something from the dishwasher. [NAME] E said she was not aware of touching the food surface of the plates while dishing food onto them. [NAME] E said all those things can cause residents to get sick. During an interview on 7/29/2025 at 4:10 PM the Administrator said the dietary staff knew all the rules/requirements. The Administrator said if the DM had been here, she feels like none of the findings would have been present. The Administrator said all dry storage items should have a received date and a UBD. The Administrator said the corn tortillas should not still be in the dry storage. Record review of the facility policy Food Receiving and Storage revised November 2022 revealed in part:- Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use.- Dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date). Such foods are rotated using a first in-first out system.Record review of the facility policy Food Preparation and Service revised November 2022 revealed in part:- Cross-contamination can occur when harmful substances. i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. Cross-contamination can also occur when raw food touches or drips onto cooked or ready-to-eat foods.- Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.- Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays.- Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks.- Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 7 residents (Residents #5, #6, and #33) reviewed for care plans in that: The facility failed to ensure Resident #5 had a care plan for Activities of Daily Living, Incontinence, Insulin, Psychotropic Medication, or Hospitalization. The facility failed to ensure Resident #6 had a care plan for Activities of Daily Living, Psychotropic Medications, Opiate Medications, and Hospice Care. The facility failed to ensure Resident #33 had a care plan for Activities, Psychotropic Medications, and Diuretic Use. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.The findings included the following: Resident #5 1. Review of Resident #5's admission Record, dated 7/29/25, revealed he was a [AGE] year-old male readmitted to the facility 7/1/25 from the hospital with diagnosis that included cardiomyopathy (heart does not pump blood effectively), diabetes, depression, and contractures (the muscles begin to stiffen causing reduced mobility). Review of Resident #5's admission MDS, dated [DATE], revealed:He had a Brief Interview for Mental Status score of 8 of 15 (indicating moderate cognitive impairment).He was dependent on staff for Activities of Daily Living.He used a wheelchair.He had range of motion impairment of both legs.He was incontinent of bowel.He received insulin injections for 7 of 7 days prior to the assessment.He was on an anticoagulant(medication to prevent blood from clotting). Review of Resident #5's Order Summary, dated 7/29/25, revealed orders:The diuretic Bumetanide 1mg every 24 hours for fluid overload, dated 7/1/25.The anticoagulant Apixaban 5mg twice a day related to heart disease.Insulin Lispro (short-acting insulin) per sliding scale dated 4/10/25.Insulin Glargine (long-acting insulin) 13 units in the morning dated 7/1/25.Melatonin 3 mg at bedtime for insomnia dated 4/10/25. Review of the electronic care plan, updated 6/19/25, revealed No care plan for Resident #5's activities of daily living status.No care plan for Resident #5's incontinence of bowel.No care plan for Resident #5's medication use including Bumetanide, Apixaban, insulin, or Melatonin. No care plan for Resident #5's hospitalization. 2. Review of Resident #6's admission Record, dated 7/29/25, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including contractures. Resident #6 was on hospice services. Review of Resident #6's quarterly MDS assessment, dated 7/9/25, revealed:His Brief Interview for Mental Status indicated he scored a 15 of 15 (indicating he was cognitively intact).He was totally dependent on staff for ADL assistance.He was on an opioid medication.He was on hospice care. Review of Resident #6's Order Summary, reviewed 7/29/25, revealed orders:Admit to hospice services dated 7/22/24.The antidepressant Duloxetine dated 4/1/25 and Trazadone dated 4/1/25.The opioid pain medication Hydrocodone-Acetaminophen 10-235mg dated 4/22/25.The opioid pain medication Morphine Sulfate 20 mg/ 5 ml by mouth at bedtime and three times a day, dated 4/1/25. Review of Resident #6's care plan revealed:No care plan for Resident #6's ADL's including eating, dressing, bathing, hygiene, and bed mobility.No care plan for the use of anti-depressants.No care plan for the use of opioid medication.No care plan for hospice services. 3. Review of Resident #33's admission Record, dated 7/29/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including aftercare for surgery. Review of Resident #33's Initial MDS Assessment, dated 4/23/25, revealedShe scored a 12 of 15 on her Brief Interview for Mental Status (indicating she was moderately cognitively impaired).She had constipation.She took an anti-depressant and a diuretic. Review of Resident #33's Order Summary, dated 7/29/25, revealed orders:Docusate Sodium 100 mg twice a day dated 4/17/25.Trazadone 50 mg for insomnia at bedtime dated 4/17/25. Review of Resident #33's care plan, dated 5/14/25 revealed:Focus: Resident #33 enjoys the following solitary activities: word search, coloring, talking. The identified goal was Resident #33 would be provided opportunities to enjoy solitary activities of choice. There were no interventions identified.There was no care plan for the Docusate Sodium 100 mg.There was no care plan for the Trazadone 50 mg or insomnia. Interview on 07/28/2025 at 3:32 PM the Business Office Manager said the Social Worker was responsible for care plans. Interview on 07/28/2025 3:32 PM the MDS Coordinator stated the transition from the previous electronic documentation program to the current documentation occurred in March 2025. The MDS Coordinator stated she did not do a care plan in the current documentation program because the RN or DON had to approve or open the care plan. The MDS Coordinator stated the Corporate RN went over care plans. The MDS Coordinator said there were a lot of care plans that were not updated or not in the current electronic program. The MDS Coordinator stated the old care plans were printed and at the nurse's station. The MDS Coordinator said she did not know why it took over 4 months long to get the care plans transferred into the new program. The MDS Coordinator stated the DON did immediate care plans with antibiotics or behaviors. Interview on 07/28/2025 at 3:47 PM the DON said there was an issue with care plans because the care plans were not entered into the current electronic documentation program. The DON stated they talked to the MDS Coordinator to get them updated and into the system. The DON said the Corporate RN stepped down but offered to help the MDS Coordinator because she was responsible for MDS assessments in two buildings so the facility could catch up. The DON agreed it took over three months get the care plans into the electronic documentation system. The DON said she did some of the care plans to help get them updated. The DON said she in-serviced the nurses on getting care plans updated once it was opened. The DON stated the facility did have interdisciplinary care plan meetings with the Social Services Designee, the Activity Director, and Dietary were responsible for putting in their own care plans. The DON stated she did an audit on resident records two weeks ago and the care plans did not appear complete. The DON stated she identified issues with dietary orders, code status, resident preferences, and interventions for falls and wound care. The DON said there were a lot of issues that were not care planned and the facility needed to follow up. The DON said she did not have an answer for why emergent issues were not care planned. Interview on 7/29/25 at 1:52 PM the Administrator and DON stated there were care issues not care planned. The Administrator said the MDS Coordinator was supposed to be helping enter in the care plans. The Administrator said she never did a chart audit because she was never trained on how to do one, but she knew how to access the information. The surveyor asked for the policy on care plans and a policy was not provided. Interview on 07/29/2025 at 4:19 PM the Social Service Designee stated his responsibility for care plans was to hold the care plan meetings. He stated he mainly did code status care plans. The Social Service Designee stated the RN could open the care plan and he would enter in his part. The Social Service Designee stated he did not know why he was getting blamed for incomplete or not entered care plans.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for and 1 of 3 medication carts (Hall 100 and 200 nurse medication cart) and 1 out of 1 med room reviewed for medication storage. The facility failed to ensure the nurses cart #1 for 100 and 200 halls did not contain insulin, that were opened and not labeled with the open date. The medication room had an open vial of tuberculosis (a bacterial infection that affects the lungs and can spread to other organs) solution that was not labeled with an open date. Findings included:Observation on 07/28/25 at 4:30 PM revealed the nurse's medication cart #1 for 100 and 200 halls had the following opened medications with no open date labeled:1. Humalog insulin vials (Insulin is an essential hormone that helps the body turn food into energy and manage the blood sugar levels)2. Novolog insulin Kwik pensObservation on 7/29/2025 at 10:30 AM revealed the refrigerator in Medication room [ROOM NUMBER] had the following opened medications with no open date labeled:1. Aplisol Tuberculin solutionInterview on 07/28/25 at 4:31 PM with LVN D, she said once insulin, and tuberculosis solution were opened they needed to be dated with open dates. She said it was the responsibility for all nurses to check carts for labelling and dating every shift, but she did not check the whole cart that morning. She stated insulins and tuberculosis solutions were good for 28 days. She stated the risk of not having an open date was they would not be able to know when they expire, and they will not be effective. Interview on 07/29/25 at 12:36 PM the DON said insulin, and tuberculosis solution when opened should be dated. She stated it was the responsibility of nursing management to check and audit the carts after the nurses. The DON said the nurses were responsible for dating the medication when opened. She stated insulin and tuberculosis solution was good for 28 days and should be dated once the box or pen was opened. Interview on 07/29/25 at 3:02 PM the Administrator said the expectations were for nursing staff to date any medications with an open date after they were put into use. The Administrator said that was supposed to be done so that the staff would know when to discard the medication. Record review of the Recommended Medication Storage policy, dated 2/2023, reflected the following:Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 1 of 5 staff (Medication Aide C) reviewed for infection control in that: -Medication Aide C did not sanitize or wash her hands before handling medication or in between administering medications to different residents. This failure could place residents at risk for infectious diseases. Findings Included: During an observation on 07/28/25 at 12:06 PM revealed Medication Aide C came out of a resident's room and proceeded to pour more medications without washing or sanitizing hands. Medication Aide C continued to not sanitize her hands in between the 12 residents she administered the med pass. During an interview on 07/28/25 at 12:07 PM, with Medication Aide C, she said she knew she was forgetting something. Medication Aide C said the facility policy and procedure was that all staff were required to conduct hand hygiene prior to handling and administering medication. During an observation on 07/28/25 at 12:15 PM revealed Medication Aide C administered medication to Resident #37, then prepared Resident #20's medications with no hand hygiene. Medication Aide C gave Resident #20's medications, left the room with no hand hygiene. Medication Aide C prepared Resident #46's medications with no hand hygiene, administered medications and left room with no hand hygiene. During an interview on 07/28/25 at 12:30 PM, the DON said based on the facility policy and procedure for infection control/hand hygiene, medication aides were required to conduct hand hygiene prior to handling medication, and she would expect medication aides to either wash their hands with soap and water before leaving a resident's room or use the hand sanitizer in the hallway. During an interview on 07/29/25 at 3:04 PM the Administrator said the expectations were for nursing staff to wash or sanitize their hands in between resident medication administration to prevent the spread of infections. Record review of the facility policy on Hand Hygiene revised October 2023, [NAME] Handwashing/Hand Hygiene reflected All Personnel shall follow the handwashing/Hand hygiene procedures to help prevent the spread of infection to other personnel, residents and visitors .Before preparing or Handling Medications .Perform hand hygiene before applying non-sterile gloves.

Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for physical environment. The facility failed to ensure the refrigerator door adequately closed and sealed in the kitchen on 07/27/2025. This failure could place residents at risk of foodborne illnesses and potential for injury to residents and staff. Findings included:During an observation and interview on 07/27/2025 at 9:42 AM, 1 of 3 refrigerators observed in the kitchen revealed the door did not latch or seal. The refrigerator door stayed slightly open. [NAME] G said the door must be lifted and closed at the same time. [NAME] G demonstrated closing the door. [NAME] G said dietary staff were aware of the broken door and how to close it. During an interview with [NAME] E on 07/29/2025 at 3:40 PM, [NAME] E said the refrigerator door had been broken more than one year. [NAME] E said she thought the Dietary Manager (DM) reported it to the Administrator. [NAME] E said if the refrigerator was not sealed correctly the residents could get sick. During an interview on 07/29/2025 at 4:10 PM, the Administrator was made aware of the broken refrigerator door. The Administrator said the broken door was not reported to her by staff.Review of facility policy Sanitization, revised November 2022, revealed: All utensils, counters, shelves and equipment are kept cleaned, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair

Based on observation, interview, and record review the facility failed to ensure adequate supervision and assistance devices was provided for 2 of 3 residents reviewed for transfers (Resident #26 and #52).The facility failed to ensure staff locked the breaks of the mechanical lift (device used to assist in lifting a resident) during transfer for Resident #26.The facility failed to ensure staff completed gait belt transfer correctly for Resident #52. This deficient practice has the potential to affect residents in the building who required extensive assistance with proper transfers. The findings included: Resident #26Review of Resident #26's Quarterly MDS assessment dated [DATE] revealed Resident #26 was a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses including arthritis, osteoporosis (bone thinning due to loss of calcium) without fracture, and contractures.Resident #26's Brief Mental Status was scored at 13 of 15 (indicating she was cognitively intact).Resident #26 had range of motion impairment on both sides of her lower extremities.Resident #26 was totally dependent on staff for transfers.Observation at [DATE] at 10:13 AM revealed CNA A and CNA H entered the room and donned(put on) gloves. The aides put the sling(material used to hold resident) under Resident #26, then hooked the sling to the electrical mechanical lift. CNA A told CNA H to make sure the sling was positioned high enough on Resident #26's head. CNA A operated the lift while CNA H steadied the resident. CNA A did not lock the lift while raising or lowering Resident #26. While lowering the Resident #26, the lift was noted to rock back and forth not allowing Resident #26 to be positioned in her wheelchair correctly. Interview on [DATE] at 1:27 p.m. the DOR stated the mechanical lift should be locked when moving a resident up and down because the weight was unsteady and it could cause the lift to roll away. The DOR said if the lift moved away while the resident was still up in air they could not be controlled during the lowering of the resident. The DOR stated especially the electrical lifts needed to be locked. The DOR stated they had not done any checkoffs regarding resident Hoyer lift transfers for the nursing staff. Resident #52Review of Resident #52's admission Record, dated [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including unspecified dementia. Resident #52's admission care plan, dated [DATE], did not have transfer status checked. Resident #52 did not have an admission MDS as she was still in her assessment period. Observation on [DATE] at 3:11 PM revealed CNA I and CNA A putting a gait belt on Resident #52 loosely. CNA A locked both sides of the wheelchair. Both aides were observed hooking their arms under Resident #52. CNA I grabbed the gait belt that slid up Resident #52's torso. CNA A grabbed the back of Resident #52's pants. Interview on [DATE] at 3:19 PM CNA A said Resident #52 could be spicy and she (CNA A) got bit by Resident #52 on [DATE]. CNA A said she grabbed the back of Resident #52's pants because she felt like the like the belt was slipping. Interview on [DATE] at 1:27 p.m. PTA J stated a two-person gait belt transfer should be completed by putting the gait belt on the resident and one staff stand on each side of the resident. PTA J stated at the count of three both aides should lift the resident by the front and back of the gait belt. PTA J said in her opinion it was not ok to hold a resident by the back of their pants. The Director of Rehab who was present stated it was not acceptable to hook their arms under a resident. The DOR stated grabbing the back of the pants was not comfortable for the resident and there was no point if the gait belt was present. PTA J stated the last time the therapy department in-serviced the facility on transfers was 1.5 years ago. Interview on [DATE] at 1:52 the Administrator and DON were informed of the transfers. The DON stated a two-person transfer was supposed to look like the aides putting on the gait belt at the waist or right above the hips tight enough to slide two fingers under the belt. The DON stated the aides were supposed to grab the gait belt on each side and help the resident stand up on the count of three. The DON stated hooking under the arms was not ok because the arms were more prone to fractures. The DON said if the resident had weight bearing issues the resident should be a mechanical lift. The Administrator stated picking up a resident by the waist of the pants would not be comfortable. The DON said she did not have a chance to do checkoffs for transfers because she had only been in the facility three months. The DON stated the expectation for the mechanical lift was for the aide controlling the lift to lock the lift when the resident was going up or down. The DON said if the lift was not locked the staff could lose control of the resident. The DON stated if the resident was being placed in the wheelchair, the lift unlocked could cause the resident to not be aligned properly. The Administrator and DON stated they understood the issue with transfers. Review of the Facility's policy and procedure for Safe Lifting and Movement of Residents, revised 7/2017, revealed: In order to protect the safety and well being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needed in the care plans. Such assistance shall include: Resident's mobility (degree of dependency); weight bearing status; cognitive status; whether the resident is usually cooperative with staff; and the resident's goals for rehabilitation, including restorative or maintaining functional abilities. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Review of the facility's policy and procedure on Using a Mechanical Lifting Machine, dated 7/2017, revealed: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for the manufacture's training or instructions. Mechanical lifts may be used for tasks that require: Transferring a resident from bed to chair. Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. Make sure the lift is stable and locked.

Based on interview and record review the facility failed to develop a comprehensive person-centered care plan for each resident , consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment which were to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 4 of 4 residents (Resident #3, Resident #4, Resident #5, Resident #6) reviewed for care plans. 1. The facility failed to implement a comprehensive person-centered care plan for Resident #3's physical altercation with Resident #4 on 07/10/24. 2. The facility failed to implement a comprehensive person-centered care plan for Resident #4's incident on 07/10/24 with Resident #3 in which Resident #3 physical hit Resident #4. 3. The facility failed to implement a comprehensive person-centered care plan for Resident #5's physical altercation with Resident #6 on 07/21/24. 4. The facility failed to implement a comprehensive person-centered care plan for Resident #6's incident on 07/21/24 with Resident #5 in which Resident #5 physical hit Resident #6. These deficient practices could place residents at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings include: 1. Record review of Resident #3's face sheet, dated 02/25/25, revealed an admission to the facility on [DATE] and re-admission on 07/19/24. Record review of Resident #3's hospital history and physical, dated 07/05/24, revealed a [AGE] year-old male with diagnoses which included [NAME]-Korsakoff disorder (a life-threatening brain disorder caused by a severe deficiency of thiamine, or vitamin B1), Dementia, and anxiety disorder. Record review of Resident #3's MDS dated ,d+[DATE], revealed a moderate cognitive impairment BIMS score of 12 to recall and or make daily decisions. Record review of Resident #3's Care Plan, dated 03/30/23, revealed Problem: Resident has verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others). Resident will verbalize understanding of need to control verbal abusive behaviors. Maintain a calm, slow, understandable approach. Remove resident from group activities when behavior was unacceptable. During an interview on 02/25/25 at 9:46 AM with the DON, she stated Resident #3 had an incident on 07/10/24 in which he hit another resident. The DON stated she did not see Resident #3 had a focus area care planned for the incident in which he had a physical behavior. The DON stated the purpose of the care plan was to direct staff as far as the resident had a problem or condition and to provide to care. The DON stated the negative outcome of not having it care planned would be staff not monitoring for and where and how to intervene. The DON stated for Resident #3 the staff would not know to intervene if he had a physical behavior placing the other residents at risk. The DON stated the MDS department, and the nurses were responsible ensuring the comprehensive care plans were accurate. During an interview on 02/25/25 at 3:00 PM with the Administrator, she stated Resident #3 had an incident on 07/10/24, were he hit another resident. The Administrator stated she would have to check to see if it was care planned and should have been care planned. The Administrator stated if it was not documented in the care plan it did not happen. The Administrator stated the purpose of the care plan was to inform the resident or representative party of a complete picture of the care the resident was being provided. The Administrator stated the negative outcome would be the resident or the representative party would be they would not make informed decisions that were mindful. The Administrator stated the DON, and the Social Worker were responsible for ensuring the care plans were accurate. 2. Record review of Resident #4's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on 09/15/24. Resident #4 was a [AGE] year-old male with diagnoses which included Diabetes Mellitus, chronic pain due to trauma, major depressive disorder. Record review of Resident #4's Care Plan, reviewed on 02/25/25, revealed there was no focus area nor interventions in place for the resident-to-resident altercation on 07/10/24. During an interview on 02/25/25 at 9:46 AM with the DON, she stated she did not see the interventions care planned for Resident #4 any focus area or interventions for the incident he had with Resident #3 on 07/10/24 in which they got into a physical altercation. 3. Record review of Resident #5's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on 01/29/25. Resident #5 was a [AGE] year-old female which diagnoses which included Cerebral Palsy and intellectual disabilities. Record review of Resident #5's annual MDS, dated [DATE], revealed there was no BIMS score taken to measure the cognition of impairment of the resident. Record review of Resident #5's care plan, reviewed on 02/25/25, revealed there was not a focus area or interventions documented for the altercation on 07/21/24 with Resident #6. Record review of Resident #5's progress notes, dated 07/21/24, revealed Another resident in wheelchair refuse to give a different resident the cordless phone state, 'This was her phone. She was not giving it up.' This resident struck another resident in the face with a closed fist and began crying, both residents were separated and taken to their rooms. During an interview on 02/26/25 at 10:54 AM with MDS Coordinator, she stated there were not interventions or focus areas in the care plan for Resident #5's altercation with Resident #6 on 07/21/24. During an interview on 02/27/25 at 10:28 AM with the DON, she stated Resident #5 had a physical altercation with Resident #6 in which she hit her while trying to get the phone. The DON stated it was not care planned for both Resident #5 and Resident #6. 4. Record review of Resident #6's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on 09/30/24. Resident #6 was an [AGE] year-old female with a diagnosis which included anxiety disorder. Record review of Resident #6's quarterly MDS, dated [DATE], revealed a severely impaired cognition BIMS score of 7. Resident #6 was able to recall or make daily decisions. Resident #6 had diagnoses which included dementia, anxiety and depression. Record review of Resident #6's care plan, reviewed on 02/25/25, revealed there was no focus area or interventions documented for the incident with the physical altercation incident on 07/21/24. During an interview on 02/26/25 at 10:54 AM, with the MDS Coordinator, revealed the MDS department and the DON were responsible for the care plans and ensuring they were accurate. The MDS Coordinator stated the purpose of a care plan was to provide the best service for the resident and if the resident had a problem, then the care plan would address the steps to help provide the best care for the resident. The MDS Coordinator stated Resident #3 and Resident #4 did not have focus areas with interventions addressed to each resident with their specific incident. The MDS Coordinator stated the risk would be the facility staff not knowing how to care for the resident(s). Record review of the facility's Comprehensive Assessments Policy, dated 10/2023, revealed Comprehensive MDS assessments are conducted to assist in developing person-centered care plans. The facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity using the Resident Assessment Instrument specified by CMS.

Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 washing machine and 1 of 4 resident wheelchair brakes reviewed for essential equipment. 1. The facility did not provide necessary repairs for 1 industrial washing machines. 2. The facility failed to ensure Resident #1's wheelchair brakes were not broken These failures could place residents at risk of not having clean clothes to wear and place residents at risk of function mobility and injuries. Findings include: Observation and interview on 02/24/25 at 8:40 AM with Resident #1 revealed the right wheelchair brake would not disengage, and the handle was observed loose. Resident #1 was observed trying to move his wheelchair with his right arm/hand and moving slowly and veins in his arm could be seen popping out of his right arm/hand. Resident #1 did not have any legs as they were amputated. During an interview on 02/24/25 at 2:31 PM Resident #1 stated he told RN on 02/23/25 in the evening that his wheelchair brake was broken. Resident #1 stated she told him okay and walked away. During an interview on 02/25/25 at 10:44 AM with CNA C, she stated the maintenance department had a maintenance logbook by their office to put in work orders for broken items. CNA C stated it was expected for everyone to put work orders in the maintenance logbook for broken items. CNA C stated not doing so could be a hazard to the residents. Observation and interview on 02/25/25 at 2:41 PM with the DON revealed, the DON looked at Resident #1's wheelchair brake. Resident #1 was observed giving the DON the screw and another metal piece in the DON's hand. The DON stated she was not notified of the broken wheelchair brake and was generally notified of issues. The DON stated it was expected of the nursing staff to report any broken equipment to the charge nurse, physician and the DON. The DON stated the equipment should be pulled and not used and looked at. The DON stated by looking at Resident #1's broken right wheelchair brake, it was not reported as it should have been done. The DON stated the risk was mobility and injury. Observation and interview on 02/25/25 at 2:49 PM with the Maintenance Director revealed the Maintenance Director observed Resident #1's right wheelchair brake. The Maintenance Director stated he verbally gave an in-service to the facility on how to report broken items. The Maintenance Director stated there was a maintenance logbook in which they were to write down the name, date, time of the broken item (work orders). The Maintenance Director stated sometimes the staff told him of the broken items (work orders), but it was expected for the facility staff to document it in the maintenance logbook because he did have a lot of work and might forget to fix it. The Maintenance Director stated the risk for Resident #1 would be him rolling off the wheelchair and affect his mobility. During an interview on 02/25/25 at 4:50 PM with the Administrator, she stated if something was broken then it needed to be removed until it was fixed. The Administrator stated if it was reported to them about the broken wheelchair brake then they could have removed it and got a rental wheelchair for Resident #1. The Administrator stated it was expected and the responsibility of the staff and everyone to report broken items. The Administrator stated the risk for Resident #1 could be him hurting himself . During an interview on 02/26/25 at 4:56 PM with RN, she stated she was notified of the broken right wheelchair brake from Resident #1. The RN stated she asked Resident #1 how long the wheelchair brake had been broken and Resident #1 had told her he had already reported it. The RN stated she did not confirm it had been reported nor did she log it in the maintenance logbook. The RN stated it was expected to be place work orders in the maintenance logbook for broken items. The RN stated the facility staff was trained on how to place work orders. The RN stated the risk would be Resident #1 having a fall. During an interview on 02/27/25 at 12:03 PM with the DON, she stated the facility staff were trained and in-serviced on placing work orders. The DON stated it was expected for staff to be placing it in the work order logbook. The DON stated she saw the broken blinds and had reported it in the morning meeting and during stand down meeting but failed to place it in the work order logbook . Record review of the facility's Maintenance Service Policy, dated 12/2009, revealed Maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are not limited to: maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. Maintain the building in good repair and free from hazards. Maintain the heat/cooling system, plumbing fixtures, wiring etc., in good working order. The Maintenance Director was responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Records shall be maintained in the maintenance director's office. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. Record review of the facility's Work orders, Maintenance Policy, dated 04/2010, revealed, Maintenance work orders shall be completed in order to establish a priority of maintenance service. In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director.

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 2 of 2 (Broken blinds), 2 warped tiles, 3 holes in the walls, 1 exit door missing sweep of 4 exit doors, and 1 of 1 maintenance log reviewed for environment. 1. The facility failed to ensure the blinds were not broken. 2. The facility failed to ensure floor tiles were not warped. 3. The facility failed to ensure there were not holes in hallway 3 and a hole in the hall leading to the back smoking patio/laundry room. 4. The facility failed to ensure the hallway 1 Exit door was not missing a sweep and created a seal on the mid-top side of the door to not expose the outside elements. 5. The facility staff failed to input broken items into the maintenance work order log. These failures could residents at risk of living, working and visiting in an unsafe, unsanitary, and uncomfortable environment. Findings include: Observation on 02/24/25 at 8:04 AM revealed in hallway 1 in room [ROOM NUMBER] the blinds were broken. Observation on 02/24/25 at 8:21 AM revealed in room [ROOM NUMBER] had broken blinds. Observation on 02/24/25 at 8:37 AM revealed in hallway 3 there was a large scrap hole on the bottom wall just above the border near room [ROOM NUMBER] around a foot or more in length. On the opposite side of the wall towards the back smoking/patio hall was another hole just above the border around 4-5 inches in lengths and around 2-3 inches wide. On the floor was two long warped floorboards with 2 wheelchairs next to them. During an interview on 02/2/525 at 4:30 PM with the Administrator, she stated the washer and drier had broken down. The Administrator stated the facility fixed the drier and was sending resident clothes to the laundry mat until the washer got fixed. The Administrator stated the residents had their clothes washed and cleaned. During an interview on 02/25/25 at 4:50 PM with the Administrator, she stated if something was broken then it needed to be removed until it was fixed. The Administrator stated the staff were to report it and the department heads would remove the broken item. The Administrator stated it was expected and the responsibility of the staff and everyone was to report broken items. The Administrator stated not reporting broken items could be a risk of residents hurting themselves. During an interview on 02/26/25 at 9:12 AM with the Maintenance Director, he stated the residents were always breaking the blinds and the facility staff placed work orders in the maintenance logbook. The Maintenance Director stated the exit door in hallway 1 was not reported and was missing the seep on the bottom of the door as there was a black blanket placed. The Maintenance Director stated the risk of having the blanket on the floor could be impeding the resident's movement to go outside. The Maintenance Director stated he could see the light coming from outside on the side of the exit door as it was not creating a seal preventing the outside weather and pest from coming into the facility. The Maintenance Director stated the broken walls in hallway 3 were not reported to him and it was not in the maintenance logbook. The Maintenance Director stated the floorboards in hallways 3 had been reported to him a couple of weeks ago but was waiting on corporate to see how they were going to fix it. The Maintenance Director stated it was a fall hazard. The Maintenance Director stated the washer had been broken for about 2-3 weeks and was fixed but the water came out to fast that it overflowed and leaked back onto the laundry room. The Maintenance Director stated the risk would be structural damage and could be creating an environment suitable for mold and pests. Observation and interview on 02/26/25 at 2:54 PM with the DON, revealed she observed the hallway 1 exit door with the black blanket on the floor. The DON was observed looking through the opening of the exit door that was not creating a seal. The DON was observed going to hallway 3 and looking at the holes in the wall and the hole near the smoking back patio area. The DON was observed looking at the floorboards in hallway 3 that were warped. The DON was observed looking at the towel on the floor in the laundry room placed around the washers. The DON stated the blanket on the floor of the exit door in hallway 1 created a trip hazard. The DON stated the holes on the wall were reported two weeks ago and should have been fixed. The DON stated the floorboards were a trip and fall risk. The DON stated the water leaking over into the laundry room could be a trip hazard. During an interview on 02/26/25 at 4:37 PM with RN, she stated the washer was broken for about two weeks and the facility was washing the residents' clothes at the laundry mat. The RN stated she noticed there were towels on the floor around the washers in the laundry room to prevent the water from overflowing into the laundry room. The RN stated the risk would be slippery of the ground for someone walking by creating a hazard for the residents. The RN stated it could also create mold due to the humidity in the laundry room with the drier and water and possibly invite pests. During an interview on 02/27/25 at 9:05 AM with LVN B, she stated the facility had a binder in which facility staff could place the work orders. LVN B stated it was expected to put the room number, date, and time it was reported to maintenance. LVN B stated an in-service was provided about placing work orders. LVN B stated it was expected for the facility staff to be placing work orders for broken items in the facility. LVN B stated the negative outcome would be for safety. During an interview on 02/27/25 at 12:03 PM with the DON, she stated the facility staff were trained and in-serviced on placing work orders. The DON stated it was expected for staff to be placing it in the work order logbook. The DON stated she saw the broken blinds and reported it in the morning meeting and during stand down meeting but failed to place it in the work order logbook. Record review of the facility's maintenance work order log, dated 02/26/25, revealed there was no documentation of work orders for walls being broken, broken blinds, washer/dryer break downs, hallway 1 exit door sweep missing and a gap with the exit door and building mid door. Record review of the facility's Maintenance Service Policy, dated 12/2009, revealed Maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are not limited to: maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. Maintain the building in good repair and free from hazards. Maintain the heat/cooling system, plumbing fixtures, wiring etc., in good working order. The Maintenance Director was responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Records shall be maintained in the maintenance director's office. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. Record review of the facility's Work orders, Maintenance Policy dated 04/2010, revealed Maintenance work orders shall be completed in order to establish a priority of maintenance service. In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director.

Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible and includes ensuring that the resident could receive care and services safely and that the physical layout of the facility maximized resident independence and did not pose a safety risk for 1 of 4 hallways (hall 100) and 1(Resident #2) of 3 residents reviewed for clean homelike environment. 1. The facility failed to ensure Hallway 1 did not smell of urine. 2. The facility failed to ensure Resident #2 did not have a dirty bed linens. These failures could place residents at risk of residing in an unsafe, unsanitary, and uncomfortable environment. Findings include: 1. Observation on 02/24/25 at 8:14 AM, with the Administrator, revealed her coming down hallway 1 to get state agency. Walking down the hallway smelled of urine. During an interview on 02/25/25 at 4:50 PM, with the Administrator, she stated the day the state survey agency was in hallway 1 and went to get him she could smell the odor of urine in the hallway. The Administrator stated the urine smell was strong and was inappropriate and she would not like being in a place where it smelled like urine. The Administrator stated that housekeeping was responsible for cleaning and should have cleaned the urine smell. 2. Observation on 02/24/25 at 8:21 AM, revealed, Resident #2's white bed sheets had a large brown unknown substance on it. During an interview on 02/24/25 at 2:09 PM with Resident #2, she stated the facility staff went to change out her bed sheets. Resident #2 did not respond and turned her head away, when asked about the brown unknown substance on the bed sheets. The interview was terminated. During an interview on 02/25/25 at 10:24 AM with the DON, she stated the CNAs were to be checking the resident beds to ensure they were clean and made. The DON stated it was not okay to have dirty or stained sheets. The DON stated it was a dignity issue. During an interview on 02/25/25 at 10:44 AM with CNA C, she stated when residents got up for the day the bed sheets, if they were dirty were picked up and changed for new ones. CNA C stated the residents deserved clean sheets and it was unsanitary to leave them on the bed. CNA C stated it was everyone's responsibility for ensuring the bed sheets were clean and changed. During an interview on 02/25/25 at 4:50 PM with the Administrator, she stated it was the responsibility of the CNAs to change the bed sheets for the residents. The Administrator stated it was inappropriate for the resident to have dirty and or stained sheets. The Administrator stated it was a dignity issues for the residents. During an interview on 02/27/25 at 8:27 AM with CNA A, she stated staff were expected to change the bed sheets of the residents. CNA A stated this was to keep it clean and sanitized which was the responsibility of the CNAs. CNA A stated any dirty or stained sheets would not be appropriate and she would not like it if she had dirty or stained sheets. Record review of the facility's Homelike Environment Policy, dated 02/2021, revealed Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Clean, sanitary, and orderly environment, inviting colors and decor, clean bed and bath linens that are in good condition.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 5 (Resident #3) reviewed for pharmacy services. The facility failed to record Tramadol-50 mg Schedule IV tablet was given to Resident #3 at 7:30 AM per physician orders in the narcotic logbook. This failure could place residents at risk for being over mediated which could result in medical complications and drug diversion. Findings include: Record review of Resident #3's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on 07/19/24. Record review of Resident #3's hospital history and physical, dated 07/05/24, revealed a [AGE] year-old male with diagnoses which included [NAME]-Korsakoff disorder (a life-threatening brain disorder caused by a severe deficiency of thiamine, or vitamin B1), Dementia and anxiety disorder. Record review of Resident #3's MDS, dated ,d+[DATE] revealed, a moderate cognitive impairment BIMS score of 12. Resident #12 was able to recall and or make daily decisions. Record review of Resident #3's Orders, dated 09/18/23, revealed Tramadol - Schedule IV tablet- 50 mg oral four times a day. at 7:30AM, 1:00PM, 7:30PM, 1:00AM. Observation and interview on 02/26/25 at 12:49 PM with the MA, she stated observed logging on the bingo card (medication card) and then looked at the narcotic logbook. The MA was seen writing down that tramadol was given in the morning and then writing med error next to it. The MA stated she forgot to log down the tramadol -50 mg which was given in the morning to Resident #3 at 7:30 AM. MA stated it was expected to log it in the narcotic logbook and not doing it would be considered a medication error. During an interview on 02/26/25 at 1:19 PM with the Physician, he stated narcotic medications were given had to be documented on the narcotic logbook as it was being taken out to be given. The Physician stated logging the narcotic that was taken out was for counting purposes and had to be documented in the narcotic logbook. The Physician stated a negative outcome would be the count would be wrong and would not know if the resident received the medication. During an interview on 02/26/25 at 4:37 PM with the RN , she stated the medication aides gave the narcotics to the residents. The RN stated they were to fill out the narcotic logbook as it was given. The RN stated this was to prevent another nursing staff member from coming by and giving the resident more medication causing the resident to be overly medicated. The RN stated it would also be a med error . During an interview on 02/27/25 at 11:40 AM, with the DON, he stated Resident #3 had an order for Tramadol-50 mg. The DON stated when giving the medication since it was a narcotic, it had to be logged in the narcotic logbook at the same time it was going to be given. The DON stated not logging it in the narcotic logbook would throw off the bingo card (the medication card) and show that it was off by one medication pill. The DON stated the risk would be the resident could be over mediated or the medication could be stolen by facility staff. Record review of the facility's Administering Medications Policy, dated 04/2019, revealed Medications are administer in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. Medications errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training .

Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 4 residents (Resident #3) reviewed for accuracy of MDS assessment. The facility failed to ensure Resident #3's quarterly MDS, dated ,d+[DATE], accurately reflected the residents' behaviors. This deficient practice could place residents at risk of not receiving adequate care. Findings include: Record review of Resident #3's face sheet, dated 02/25/25, revealed an admission to the facility on [DATE] and re-admission on 07/19/24 to the facility. Record review of Resident #3's hospital history and physical, dated 07/05/24, revealed a [AGE] year-old male with diagnoses which included [NAME]-Korsakoff disorder (a life-threatening brain disorder caused by a severe deficiency of thiamine, or vitamin B1), Dementia, and anxiety disorder. Record review of Resident #3's MDS, dated ,d+[DATE], revealed a moderate cognitive impairment BIMS score of 12 to recall and or make daily decisions. Behaviors were not coded for any behaviors. Record review of Resident #3's Care Plan, dated 03/30/23, revealed Problem: Resident has verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others). Resident will verbalize understanding of need to control verbal abusive behaviors. Maintain a calm, slow, understandable approach. Remove resident from group activities when behavior was unacceptable. During an interview on 02/26/25 at 10:54 AM with the MDS Coordinator, she stated Resident #3 had behaviors in 01/25 and the MDS did not reflect this in the Behavioral Section (E) of the MDS. The MDS Coordinator stated the MDS was incorrect for Resident #3's 01/2025 MDS assessment. The MDS Coordinator stated the negative outcome could be the inaccurate MDS would create an inaccurate care plan and billing would not be accurate. The MDS Coordinator stated it was her responsibility for ensuing the MDS assessment was accurate and correct.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for three of eight residents (Resident #1, #2, and #3) reviewed for infection control. 1. MA A touched Resident #3's pills with her bare hands during medication administration. 2. LVN B failed to prevent cross contamination between Residents #1 and #2 by brining in uncleaned diabetic supplies from one room to another. These failures could place resident's risk for cross contamination and the spread of infection. Finding included: Review of Resident #3's CCD dated 11/01/23, revealed a 90- year- old female admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation (heart does not beat with a regular beat all the time) and acute respiratory failure (person cannot get enough oxygen). Review of Resident #3's MDS assessment dated [DATE] revealed Resident #3 had a BIMS score of 11 indicating moderately impaired cognition. Review of Resident #3's Care Plan dated 12/10/24 revealed Resident #3 was at risk for frequent infections. Review of Resident #3's Continuity of Care Document, dated 1/24/25 revealed Resident #3 had orders for Aspirin 81 mg dated 11/2/23 for Atrial Fibrillation Carvedilol 12.5 mg dated 4/16/24 for Atrial Fibrillation Digoxin 125 mcg dated 11/1/23 for Atrial Fibrillation Apixaban 2.5 mg dated 11/1/23 fore Atrial Fibrillation Furosemide 20 mg 1/2 tablet for 20 mg dated 1/24/25 stop date 2/6/25 for Heart failure Gabapentin 400 mg dated 11/1/23 for Chronic Pain Guaifenesin 400 mg dated 3/30/24 for Cough Multivitamin dated 11/22/23 Olmesartan 40 mg 1/16/25 for Hypertension Spironolactone 50 mg to five with Furosemide 40mg dated 11/1/23 for Congestive Heart Failure Observation of medication administration for Resident #3 on 01/24/25 at 11:25 a.m. revealed MA A did not wash her hands or use hand sanitizer after administering the previous resident's medication or before preparing Resident #3's medications. MA A added all of Resident #3's currently due medications to a medication cup: Aspirin 81 mg, Carvedilol 12.5 mg, Digoxin 125 mcg, Apixaban 2.5 mg, gabapentin 400 mg, guaifenesin 400 mg, multivitamin, Olmesartan 40mg and spironolactone 50mg. Before entering Resident #3's room, MA A verified medication orders on the electronic medical record (EMR). MA A said the spironolactone had instructions to be given with furosemide, which was being held. MA A stated she would hold the spironolactone and ask the ADON for verification. Using her bare (not gloved, not cleaned) index finger, MA A placed the spironolactone into another medication cup. MA A proceeded to give the remaining medications to Resident #3. In an interview on 1/24/25 at 1:44 p.m., the DON stated she monitored medication administration by watching the staff because she did not have a lot of staff who had been at the facility a long time. The DON said she did annual competencies with the staff at the first part of February and any new hires had an initial check off. IIn an interview at 1/25/25 at 2:55 a.m., the DON stated the facility's policy about handling medications in general was medications should be popped into cup and skin should not touch a pill at all because then there was a contamination factor. The DON said her expectation with over-the-counter medications were to be tapped into lids and the lid used to dump the pill into the medication cup. Review of Resident #1's Continuity of Care Document, dated 1/24/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including Diabetes Mellitus (body does not produce enough insulin causing the body to have abnormally high blood sugar levels). Resident #1 had orders for have blood glucose checks three times a day and insulin administer by a sliding scale beginning 5/26/23. Review of Resident #1's Quarterly MDS Assessment, dated 1/4/25, revealed: She had a BIMS score of 4 of 15 (indicating she was severely cognitively impaired). She had a diagnosis of diabetes. She received injections 6 of 7 days prior to the assessment. Review of Resident #1's Care Plan, beginning 3/15/25, revealed the goal was her Diabetic status would remain stable as evidenced by resident blood sugar staying within the resident's normal limits through the next quarter. Resident #1's Care Plan, beginning 3/15/25, revealed: Enhanced Barrier Precautions will reduce risk of the spread of organisms. Observation on 1/24/24 at 10:15 a.m. during initial rounds revealed Resident #1 was in her room lying in bed. She had a catheter. Review of Resident #2's Quarterly MDS Assessment, dated 11/18/24 revealed: He had a 13 of 15 on his BIMS score (indicating he was cognitively intact) He had a diagnosis of diabetes. He had injections for 7 of 7 days prior to the assessment. His care plan, start date 2/22/24 read he was at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/hypoglycemia, renal failure, cognitive/ physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. Identified interventions were to Administer medications as ordered and monitor for side effects and effectiveness. Observation on 1/24/25 at 11:17 a.m. revealed LVN B put on gloves and set up the glucometer (machine for measuring blood sugar levels) and went into Resident #1's room. LVN B was not wearing a gown even though Resident #1 was identified as an EBP resident. LVN B took the blood level reading of Resident #1. LVN B came out with gloves on, looked at surveyor and said, she should probably not be in the hall with gloves on. LVN B kept the gloves on. LVN B put the lancet she used to poke Resident #1's finger into the sharps container. With the same gloved hands, LVN B grabbed the top drawer of the medication cart, realized it was locked, put her hands in her pocket pulled out the keys, unlocked the cart, put the keys back into her pocket. LVN B kept the same dirty gloves on, found a container of strips for the glucometer and another lancet, shut the medication cart drawer, and locked it. LVN B, with the same contaminated gloves, returned to Resident #1's room. LVN B with the same dirty gloves opened the container of glucometer strips, stuck her finger into the container and pulled out a glucometer strip, then laid the container of glucometer strips on Resident #1's bed. With the same gloves, LVN B used a new lancet and stuck Resident #1's finger and took the glucometer reading. With the same gloves, LVN B took all the supplies to the medication cart, placed the container of glucometer strips onto the top of the medication cart, disposed of the used lancet, then disposed of the gloves. LVN B cleaned her hands with ABHG and cleaned the glucometer. LVN B did not clean the bottle of glucometer strips. LVN B put on new gloves, took the glucometer, and the (uncleaned) bottle of glucometer strips. LVN B went into Resident #2's room which also had an EBP posting on the door frame, placed everything on the dresser. LVN B put her finger down the container of glucometer strips, and performed the blood glucose reading. LVN B took her supplies, left the room, took off her gloves, cleaned her hands with ABHG and cleaned the glucometer. In an interview and observation on 1/24/25 at 11:36 a.m., LVN B stated she was an agency nurse, but had worked at the facility before. LVN B said if she could do anything different, she would have changed gloves more often and used disinfecting wipes on the glucometer instead of alcohol wipes, but she used what she had. LVN B said she would have changed gloves more often to prevent cross contamination, and she was not aware of everything she touched with the one pair of gloves. State surveyor reviewed the list with her, and her response was wow. LVN B said EBP meant she was supposed to wear a gown and gloves. LVN B said this applied to anyone who had a catheter, indwelling device or wound. LVN B stated most facilities had it posted on the door and most facilities had supplies outside the door. LVN B said she did not notice supplies outside the door. LVN B and state surveyor went to Resident #1's room. There was a sign posted but no PPE outside of the room in any fashion or visually available in the room. LVN B said there was a sign, and she was aware Resident #1 had a catheter, and could see the catheter. LVN B admitted she was aware she needed to wear a gown and did not wear one because there were none outside of the room. LVN B said the point of EBP was to protect the resident from other infections. Interview on 1/24/25 at 11:58 a.m., the DON stated she had a container of gowns behind the nurse's station because the other containers the facility had went missing. The DON said there were a couple on order. The DON said the facility did have the type of gown container that could be hung over the door. The DON said having the gowns at the nurse's station was not an effective process because the staff had to go all over the building. The DON stated she had four residents on EBP. Interview on 1/24/25 at 2:55 p.m., the DON explained the mechanics of cross contamination. She stated cross contamination happened when anyone did not use gloves or held linens too close to the body and the contaminate goop gets on you and you go into the next room. She said the same thing would happen when a person had gloves on. The DON stated gloves would cause cross contamination if it had germs on the surface and the staff go across hall with gloves on the staff had the risk of bringing contamination across the hall. The DON stated the Medication Cart could be contaminated because if the gloves touched the resident, they were dirty, and the gloves should have been removed and the nurse's hands should have been sanitized. The DON stated the keys to the medication cart were contaminated. The DON said the glucometer strips were now contaminated all the others and the nurse impaired the integrity. The DON said she trained nurses to tap the bottle like you would a pill until a strip comes out. The DON stated the outside of tube was contaminated when it touched the resident's bed. The DON said Resident #2 currently did not qualify for EBP, She stated he had pseudomonas UTI but it had resolved. Review of in-services reveal the facility trained staff on EBP policy on 1/17/25: The facility's policy and procedure on Enhanced Barrier Precautions, undated, revealed: Enhanced barrier precautions are utilized to reduce transmission of multi-drug resistant organisms to residents. Policy Interpretation: Enhanced barrier precautions are used as an infection prevention and control intervention to reduce to transmission of multi-drug resistant organisms to residents. Enhanced barrier precautions employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Enhanced barrier precautions are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. B indwelling devices include urinary catheters. Review of in-services revealed the facility in-served staff on the 6/21/24 on Glove use: Review of the facility's policy and procedure on Personal Protective Equipment - Using Gloves, revised October 2010, revealed: Purpose: To guide the use of Gloves Objective: To prevent the spread of infection. Review of the facility's policy and procedure on Handwashing/Hand Hygiene, revised April 2012, revealed: The facility considered hand hygiene the primary means to prevent the spread of infection. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, used an alcohol-based hand rub containing 60 - 90% ethanol or isopropanol for all the following situations: before preparing or handling medications. Review of the facility's policy and procedure on Administering Medications, revised December 2012, revealed: Medications shall be administered in a safe and timely manner. Staff shall follow established infection control practices (e.g. handwashing, antiseptic technique, gloves, isolation precautions etc.) for the administration of medications, as applicable.

Based on observation, interview, and record review, the facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment for the residents on the 300 Hall reviewed for resident rights in that: The facility failed to ensure resident's room hand sinks maintained functioning hot water. This failure could place residents at risk for living in an uncomfortable, and unhomelike environment which could cause a diminished quality of life. The findings included: Observations on 06/11/2024 through 06/13/2024revealed the hand sinks in the rooms on hall 300 had no hot water. The hot water did not turn on at all. Interview on 06/12/24 at 01:33 PM with the Administrator revealed that Hall 300 did not have hot water for approximately 2 months due to a broken pipe. The Administrator stated the residents in hall 300 used the showers on Hall 200 and 400 which had hot water. The Administrator stated she had gotten several quotes and was waiting for approval from corporate. The Administrator stated she had received approval that morning, 06/12/24, to have the hot water fixed. The Administrator stated she did not have any residents complain about not having hot water. The Administrator did not think there was a negative outcome for them not having hot water since the residents were able to shower on the other halls. The Administrator stated they do not have maintenance in the facility and have to share a maintenance man with a facility in Pecos.

Based on interview and record review, the facility failed to use the services of a RN for at least 8 consecutive hours a day, 7 days a week for 16 days in Quarter 2 2024 reviewed for Licensed Nursing coverage from January 2024, February 2024 reviewed for nursing services. The facility did not have the required 8 consecutive hours of RN coverage during the month of January 2024 (11 days) and February 2024 (5 days). This failure could place residents at risk for not having their nursing care and medical needs met. Findings included: Review of PBJ [Payroll Based Journal] Staffing Data Report, with a run date of 06/06/2024 revealed Failed to have Licensed Nursing Coverage 24 Hours/Day was triggered for the fiscal year Quarter 2 2024 (January 1 - March 31). The infraction dates were 01/01 (MO); 01/02 (TU); 01/03 (WE); 01/04 (TH); 01/05 (FR); 01/08 (MO); 01/16 (TU); 01/17 (WE); 01/18 (TH); 01/24 (WE); 01/25 (TH); 02/02 (FR); 02/08 (TH); 02/16 (FR); 02/21 (WE); 02/22 (TH). Record review of the January 2024 schedule/time sheets indicated no 24-hour licensed nursing coverage for any of the dates. Record review of the February 2024 schedule/time sheets indicated no 24-hour licensed nursing coverage for any of the dates. In an interview on 6/12/24 at 4:12 pm, ADON stated that facility only had one RN employed full time and no DON during the Quarter 2. The ADON stated that on the days in question they had no RN coverage. In an interview on 6/12/24 at 4:30 pm, Regional Compliance Nurse stated that the facility only had 2 PRN RNs and agency RNs. Regional Compliance Nurse stated that she checked clock in logs and was unable to find any proof of RN coverage for any of the days in question. The Regional Compliance Nurse stated that she has been covering for the DON since October 2023. Stated she did not work any of the days in question. In an interview on 6/13/24 at 11:30 am, Administrator stated that the facility lost staff when the company changed to new owners. Administrator stated that they had no DON and were unsuccessful in getting RN coverage during that time. Stated she attempted to provide coverage with agency RNs and Regional Compliance Nurse but was unsuccessful. A new DON was hired and started that week. Review of undated facility policy titled Departmental Supervision, revised August 2006 revealed, in part: Policy Statement: The nursing services department shall be under the direct supervision of a Registered Nurse at all times. A Registered Nurse (RN) will be employed as the Director of Nursing (DON). The DON will be on duty during the day shift Monday through Friday. During the absence of the DON, a Registered Nurse/ Nurse Supervisor will be responsible for supervision of all direct care staff.

Based on observation, interview, and record review the facility failed to ensure adequate supervision and assistance devices was provided 1 of 3 resident reviewed for transfers (Resident # 1) The facility did not completely and accurately assess Resident #1 for use of a lift device even though she was non weight-bearing. The facility failed to ensure CNA and nurses were transferring Resident #1 in a manner to prevent injuries. The staff were performing one-person lifts by hugging the resident or hooking their arms under her shoulders. If doing a two-person transfers the staff would hook their arms under a resident's arms. Resident #1 had bruising to chest area and 2 possibly fractured ribs. This failure could place residents who required assistance during transfers at risk for pain and injury. Findings included: Review of Resident #1's Admission Record dated 9/16/2020 documented she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's 8/12/2020 quarterly MDS assessment documented she had long and short-term memory impairment with severely impaired decision-making abilities. She was totally dependent on one person for transfers. She did not receive any anticoagulant medications in the 7 days prior to the assessment. Review of Resident #1's Mobility assessment dated [DATE] (completed by the ADON) documented Resident #1 had bilateral contractures of the ankles. She was unable to maintain an upright posture and kept head leaning to the right side. Resident #1 was rigid and she had poor range of motion. Resident #1 was unable to bear weight and did not participate in transfers. The assessment documented Resident #1 could not bear weight through one leg to be moved from one surface to another, was not consistent and reliable in bearing weight, could not communicate with staff, and could not follow commands. The assessment documented if any of those criteria were met, the resident needed to be assessed for the appropriate type of lift. There was no type of lift identified. Review of Resident #1's Incident/Accident Report dated 9/9/2020 documented: Nurse Aide reported to this nurse of bruising, nurse followed nurse aide to resident's room, resident sitting in wheelchair. Nurse assessed resident. Resident with bruising to chest, left arm and left ribs. This nurse notified DON, who also assessed resident's bruising. There were no predisposing factors to explain the bruise identified. Resident unable to give description. Review of Resident #1's Incident/Accident Report dated 9/14/2020 documented: Nurse aide called this nurse to resident's room and showed me excessive bruising to resident's chest, extending over to breast. There is a history of bruising from last week, this appears worse. Called doctor. Received order for labs. Resident unable to give description. There were no predisposing factors identified. Review of the statements taken by the facility documented: On 9/16/2020 CNA A documented she transferred Resident #1 with one person by hugging her. On 9/16/2020 CNA B documented she transferred Resident #1 under her arms with a one-person transfer. Review of the Incident/Accident log 7/1/2020 through 9/15/2020 documented no other incidents of bruising for Resident #1. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Care Plan updated 8/3/2020 documented Resident #1 had a history of [REDACTED]. The goal was she would be free from falls through the next review date. Identified approaches included use geri-chair for comfort and positioning. There was nothing about the appropriate type of transfer. Review of Resident #1's Care Plan updated 8/3/2020 documented Resident had an ADL self-performance deficit related to advanced dementia and impaired mobility. The identified goal was she would maintain ability to participate with self-care at current level. Identified approaches included she required extensive assistance with transfers. Review of Resident #1's Care Plan updated 8/3/2020 documented Resident had alteration in mobility related to poor balance, pain, inability to ambulate, generalized weakness, and no weight bearing. The identified goal was she would maintain her current mobility status. Identified approaches included provide appropriate level of assistance to promote safety of resident; and provide assistive devices as required. Review of Resident #1's CNA ADL spread sheet/care plan, undated, documented she needed assistance of one staff for transfers and used the geri-chair. Review of Resident #1's ADL transfer status for 8/18/2020 through 9/14/2020 documented staff documented she was total dependence except for 9/3/2020. 9/4/2020, and 9/7/2020 when they documented she was extensive assistance with transfers. Review of Resident #1's Skin assessment dated [DATE] documented she had bruising to the left chest, shoulder and upper arm. Review of Resident #1's Incident Note dated 9/9/2020 documented Nurse Aide reported to this nurse of bruising to chest, left arm and left ribs. This nurse notified DON, who also assessed residents bruising. No signs of pain noted. Review of Resident #1's Skilled Charting Note dated 9/9/2020 documented she did not bear weight, had weakness, and needed assistance with transfers. Review of Resident #1's Nurse's Note dated 9/10/2020 at 10:20 p.m. documented: Resident with continued bruising to chest, left arm, and left ribs. Review of Resident #1's Nurse's Note dated 9/11/2020 at 12:47 p.m. documented: Resident up to geri-chair for meals. She continues with bruise to her left side of body. Review of Resident #1's Nurse's Note dated 9/12/2020 at 10:10 p.m. documented Resident continues with bruising to left side of ribs. Review of Resident #1's Nurse's Note dated 9/13/2020 at 10:00 p.m. documented no mention of the bruising. Review of Resident #1's SBAR note dated 9/14/2020 documented she had excessive bruising and critical lab results which began on 9/10/2020. Review of Resident #1's Nurse's Notes dated 9/14/2020 at 8:02 a.m. documented Nurse aide called nurse (DON) to resident's room to show excessive bruising to resident's chest and left breast. Review of Resident #1's Radiology Results from the local hospital dated 9/14/2020 documented she had a CT scan due to a large hematoma on the anterior left chest. Conclusion: Anterior left chest wall hematoma measuring 6.1 x 12.3 x 13.1 cm. There are potential left lateral sixth and seventh rib fractures. Review of Resident #1's CBC dated 9/14/2020 report documented she had critically low levels for her RBC (1.97) (average range is 3.92-5.13), HGB (6.3) (average range is 12.0 - 15.5), and HCT (18.0) (normal range 35.5 - 44.9). Review of Resident #1's Nurse's Notes dated 9/15/2020 at 10:24 p.m. documented: spoke with doctor and he told this nurse that resident has two rib fractures and a hematoma to the left shoulder/rib area that needs to be evacuated (removed). Review of Resident #1's Nurse's Notes dated 9/16/2020 at 4:04 p.m. documented: received call from a hospitalist at a nearby city's hospital. Per the hospitalists the hematoma does not require surgical intervention and the CT scan does not show active bleeding. Vitals are stable, is on [MEDICATION NAME] and awaiting blood cultures. No [MEDICAL CONDITION] present. CBC good. Mild [MEDICAL CONDITION]. During an interview on 9/16/2020 at 9:51 a.m. the DON said Resident #1 came up with bruising on 9/9/2020. The DON said Resident #1 had a history of [REDACTED]. She said prior to going to the hospital, the facility got orders for labs and Resident #1 had some critical results. She said they transferred Resident #1 to the hospital and the CT scan showed two fractured ribs and the hematoma on her upper chest. The DON said the hospital transferred Resident #1 to a larger hospital to evacuate the blood clot. The DON clarified Resident #1 had bruising on the 9th and when it appeared worse on the 14th the facility got labs. The DON said Resident #1 was a one or two-person transfer. She said the staff did not have to use a gait belt with her. The DON said she was unsure the facility's policy and procedure regarding gait belts were. During an interview on 9/16/2020 at 11:13 a.m. the Corporate RN said residents were supposed to be assessed for transfers. She said if the resident had multiple falls, skin tears related to transfers or was fragile a Hoyer lift should be used. During an interview and observation on 9/16/2020 at 1:45 p.m. CNA C described Resident #1 as very fragile. She said before the bruising she would transfer Resident #1 under her arms. CNA C described and pantomimed the transfer as hook the CNA's arm under the arm of the Resident and grab their pants. She said no one ever asked her to help them with an arm-in-arm transfer. CNA C said she saw Resident #1's bruising. She said the bruising went from Resident #1's armpit to below Resident #1's breast. CNA C said she did not remember if there was bruising on Resident #1's arm or not and the bruising was purplish in color. CNA C she routinely transferred Resident #1 by herself and Resident #1 might grunt when transferred but did not act like she was in pain. During an interview on 9/16/2020 at 1:52 p.m. CNA A said Resident #1 was usually a one-person transfer. CNA A described how she would transfer Resident #1 as a hug transfer. CNA A said Resident #1 was not able to bear weight but was not very heavy. She said her Charge Nurse told them to use a Hoyer lift on Resident #1 after the bruising on 9/9/2020 and they officially got orders for the Hoyer lift later. She said she saw Resident #1's bruise and it was terrible. CNA A said she saw the first bruise was just on Resident #1's shoulder area. CNA A said Resident #1 would get bruises occasionally, but not like that. CNA A said she was unsure what would cause the bruising. She said Resident #1 had been the same type of transfer since she started over a year ago and Resident #1 never had bruising like that before. During an interview on 9/16/2020 at 2:05 p.m. CNA D said Resident #1 was a grab and go transfer. CNA D explained Resident #1 would stand with you in a hug transfer and if she did not the aides would have to get a second person to come help transfer her. She said sometimes Resident #1 could bear weight but not in the last 2 or 3 months. CNA D said Resident #1 quit trying to stand up with you. CNA D said Resident #1 used a geri-chair. CNA D said Resident #1 was light so the aides could just grab under her arms to transfer her and if she would not stand, then the aides would get a second person to help Resident #1 would stand with the aides and they would arm-in-arm her. CNA D acknowledged it meant Resident #1's arms were hanging out (over the CNA's arms unsupported). CNA D said when she saw Resident #1's bruise on Tuesday (9/8/2020) the bruise was greyish-black. CNA D said the bruise wasn't bad and she made sure she reported it to the charge nurse. CNA D said when the Charge Nurse saw it she gave the order for Resident #1 to be a Hoyer lift. CNA D said she had her days off and when she came back Friday (9/11/2020) the bruise went from Resident #1's shoulder, covered her entire breast and was all the way across the front of her body. CNA D said Resident #1 did not act like it hurt her. CNA D said Resident #1 had a history of [REDACTED]. During an interview on 9/16/2020 at 2:21 p.m. LVN E said Resident #1 was a total assist with all ADL's. She said she had instructed her aides to use a Hoyer lift on Resident #1 because she always bruised easily. LVN E said when she returned from her days off, the nurse told her in report that Resident #1 had a big bruise on her side but there had been no falls. LVN E said her response was to tell the aides to use a Hoyer lift and not transfer Resident #1 by her arms. LVN E said she came back to work yesterday (9/15) and she was told Resident #1 not only had the bruise she had a big hematoma on her chest right above her breast. LVN E said the original bruise started around the mid shoulder, around her breast and to her side. She said the bruise was a weird brownish color. LVN E said she never saw Resident #1's 9/14/2020 bruising but the nurse described it as dark blue and that was where the hematoma was. LVN E said the hematoma worried everyone so they sent her out. LVN E said she thought this was a bruise on top of another bruise. LVN E said she thought the bruises were from being picked up wrong. LVN E said Resident #1 needed to be a Hoyer lift because she could not bear weight and has not been able to bear weight for two years, was in a geri-chair, and was too delicate to move a whole lot. LVN E said she did not like one-person assistance with transfers in geri-chairs; LVN E explained people in geri-chairs could not help very much or they would not be in the geri-chair so she did not like one person transferring them. LVN E said Resident #1 would be gotten up taken to the dining room, fed wait a little bit and then put back to bed because she could not reposition on her own. LVN E said the aides knew Resident #1 at least should have been a two-person transfer. LVN E said the undated CNA care plan spreadsheet was at least 6 months old. During an interview on 9/16/2020 at 3:23 p.m. the Corporate RN, DON, and ADON said to do a one-person transfer the staff were expected to bend at the knees with their back straight, slide their arms under the resident's arm and help them pivot to the other surface. They said Resident #1 was appropriate because she was small and able to stand and bear weight. They said to do a two-person transfer they staff were to put their arms under the resident's arms, turn, and lift. They said a gait belt may be beneficial to use. The Corporate RN said it was recommended but they would have to check the policy to see if gait belts were mandatory. The ADON said Resident #1 was a safe one-person transfer, that was how she was always transferred. The Corporate RN acknowledged Resident #1 had declined a lot but at the time it seemed appropriate because she was on therapy. The ADON said it was safe to move her because they could ease the chair to an upright position and the foot rest was down. They acknowledged the bruises could possibly happen during a transfer but since the bruising was only on one side they thought it was liver issues due to aspirin use and [MEDICATION NAME] Acid. The DON said the hematoma did not occur with the original bruising, the staff noticed it the morning of 9/14 and they thought it was a tumor or some kind of bleeding in that spot. She said the x-ray report documented some kind of fracture. The DON said the charge nurse came and had the DON assess the bruise. The DON said on 9/9/2020 the bruise was on Resident #1's left upper chest to the top of the breast, to the shoulder and bicep. The DON said on 9/14 the bruising had faded but the nipple area had a dark purple bruise and she did not know what would cause that. She said maybe Resident #1's bruising was spreading. The ADON said Resident #1 had liver issues and always bruised easily so the bruising had to happen during a transfer from picking her up and doing a hug-type of transfer. The ADON said I can transfer her that way, she was small and non-weight bearing so the ADON did not think a gait belt was appropriate. During an interview on 9/17/2020 at 12:30 p.m. PTA F said he had been at the facility for two weeks. He said therapy was working with Resident #1, mostly stretching to prevent further contractures. PTA F said Resident #1 did not bear weight and her feet were contracted forward so she was unable to put her feet flat on the ground. He said typically with a ger-chair people would use a Hoyer lift, if a Hoyer lift was unavailable than a two-person transfer using a draw sheet. He said he would not recommend a one-person transfer. He said a hug-transfer could cause fractured ribs. He said a heave-ho transfer when arms were hooked under a resident's shoulders could also cause rib fractures. He said he was always told to never hook arms under the shoulders due to the risk of dislocating a shoulder. During an interview on 9/17/2020 at 1:03 p.m. the ADON said the facility's policy on transfers was pretty non-specific. She said there was no policy on gait belt use, just the nurse aide competency checklist. During an interview on 9/17/2020 at 1:19 p.m. the ADON said she could not find a recent in-service on transfers and she did not know when the last in-service on transfers was. During an interview on 9/17/2020 at 1:39 p.m. the DON and ADON said a resident's transfer ability was assessed on admission and was based on weight, presence of contractures and weight bearing status. They said a quarterly mobility assessment was done to help the facility decide how to transfer the resident. The ADON said that information was communicated between the MDS department and therapy. The ADON said at the time of the last mobility assessment Resident #1 was still able to transfer one person and she had never had a problem transferring her. The ADON reviewed the 4/28/2020 assessment and acknowledged that the lift assessment was not evaluated. The DON and ADON acknowledged the care plan was very non-specific to the resident's needs. The DON said she continued her investigation on the rib fracture and the overnight staff said they saw the bruising over the weakened. She said they became aware of the initial bruising on 9/9/2020 and on 9/14/2020 the bruising was reassessed due to [MEDICAL CONDITION] to the chest. The DON said when she looked at the bruising it was worse. She said Resident #1 did not normally have bruising to the chest and the shoulder could be a suspicious area because it raised questions about if something else happened. The DON said the doctor told her it was a [MEDICAL CONDITION] hematoma but that was not documented. Review of the facility's policy and Procedure on Safe Lifting and Movement of Residents updated 7/2017 documented: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devises to lift and move residents. Policy Interpretation and Implementation: Manual lifting of residents shall be eliminated when feasible. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: Resident's mobility (degree of dependency); resident's size; weight bearing ability; and cognitive status. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary.

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to prevent the development and promote the healing of pressure sores for 5 of 6 residents reviewed for pressure ulcers. (Residents #1, #2, #3, #4, and #5) 1. Resident #2 developed an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, black) in the wound bed) on 8/20/15 to her heel. The facility did not have care planned interventions in place to promote wound healing. The facility did not monitor the pressure ulcer for healing or deterioration. 2. Resident #3 was readmitted to the facility on [DATE] with a scab to her left heel heel. She developed a facility acquired Stage II to the coccyx on 7/07/15 . On 7/28/15 the pressure ulcer deteriorated. The facility did not have care planned interventions in place to promote wound healing. The facility did not monitor the pressure ulcer for healing or deterioration. 3. Resident #1 developed a Stage II pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed without slough. May also present as an intact or open/ruptured serum-filled blister) on approximately 8/03/15. The facility did not notify the doctor and get wound care orders. The facility did not document what (if any) treatments were being done. The facility did not monitor the pressure ulcer weekly for healing or deterioration 4. Resident #5 developed an unstageable pressure ulcer to her Left heel that reopened on 6/12/15. The facility did not have care planned interventions in place to promote wound healing. The facility did not monitor the pressure ulcer for healing or deterioration from 8/10/15 through 9/02/15. 5. Resident #4 was admitted to the facility on [DATE], Resident #4 was placed on Hospice services on 7/25/15. Resident #4 developed a Stage II pressure ulcer to his coccyx on 7/30/15. The facility did not have care planned interventions in place to to promote wound healing. 6. The facility failed to ensure staff had weekly skin meetings to assure an interdisciplinary approach to wound healing and tracking of wound development/ improvement/ decline. This failure could place 7 residents with pressure ulcers at risk for developing new pressure sores or worsening of existing pressure ulcers. Findings included: RESIDENT #2 Review of Resident #2's undated Record of Admission documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's 8/18/15 30 day Minimum Data Set (MDS) Assessment documented she scored a 9 of 15 on her mental status (indicating moderate cognitive impairment) and was dependent on staff for transfers, getting around the facility, dressing, hygiene, and bathing. She had no impairments to her range of motion an used a wheelchair. She was incontinent of bowel and bladder. She was at risk for developing a pressure ulcer but had none. Review of Resident #2's 8/20/15 Care Plan documented the problem was potential or actual pressure ulcer or altered skin integrity related to: ___(this was left blank) as evidenced by: unstageable to right heel. Identified approaches included use pressure reduction/ pressure relieving mattress or overlay as ordered to promote wound healing, maintain skin integrity, and body audits at least weekly by licensed staff. Review of Resident #2's Admission Nursing assessment dated [DATE] documented she had a stage II pressure ulcer on the coccyx but no ulcers to her feet. Resident #2's Braden Scale for Predicting Pressure Sore Risk dated 7/21/15 documented she scored a 10 (indicating high risk to develop a pressure ulcer). Review of the Nurses Notes documented: 7/21/15 (admission) at 1645 (4:45 p.m.) Stage II decubitus to coccyx. (Review of the nurse's notes from 7/22/15 through 7/26/15 showed no other documentation that any treatment and/or monitoring was done for the stage II.) Review of Resident #2's 7/23/15 Comprehensive Metabolic Panel (CMP) Lab documented her [MEDICATION NAME] level was a 2.9 (low). Resident #2's Weekly Skin Assessments documented (undated) buttocks excoriated pink. Review of the nurse's notes 8/10/15 through 8/20/15 showed no use of a pillow to reduce the pressure to Resident #2's heel. Review of the nurse's notes documented on 8/20/15 at 1300 (1 p.m.) up in geri chair for meals, alert, confused able to state needs. Stage II (crossed out) found to right heel. New Order to clean with normal saline, pat dry, apply Santyl ointment ([MEDICATION NAME] ointment), to wound bed, mediseptic periwound cover with 2 x 2 gauze, and [MEDICATION NAME] tape daily until healed. Unstageable pink around wound. MD (medical doctor) notified. Will continue to monitor. Review of the nurse's notes documented on 8/20/15 2 p.m. - 10 p.m. Brace adjusted right leg, unstageable decubitus present right heel - dressing intact, heel protectors in place. Review of the Nurse's Notes 8/22/15 through 8/31/15 did not mention the use of heel protectors at any other time. Review of the nurse's notes documented on 8/21/15 0130 (1:30 a.m.) awake, in bed, heel protectors on. Dressing clean, dry and in place to right heel. Review of Resident #2's Telephone Orders dated 8/20/15 documented unstageable to the right heel cleanse with normal saline, pat dry, apply Santyl, cover with 2 x 2 every day until healed. Review of the 24 - hour report book (communication book between shifts) for August 2015 documented: 8/20/15 Unstageable right heel. Review of Resident #2's Telephone Orders dated 8/26/15 documented Protein Powder (used to increase the [MEDICATION NAME]/ protein level in the blood to increase wound healing). There were no documented skin assessments completed between 8/20/15 and 9/01/15. Resident #2's Weekly Skin Assessments documented on 9/01/15 unstageable decubitus right heel 25% eschar (dead tissue) present - moderate red and yellow drainage. (no measurements documented) Resident #2's Treatment Flow Sheet for August 2015 documented 8/20/15 clean unstageable decubitus right heel with normal saline, dry and apply Santyl ointment to wound-bed and mediseptic to periwound - cover with gauze and [MEDICATION NAME] every day and as needed. The following days were blank (not initialed indicating the treatment may or may not have been done) 8/23/15, 8/24/15, 8/29/15 and 8/30/15. During an interview on 8/31/15 at 4:40 p.m. Resident #2 said her foot hurt. She said the nurses hadn't gotten to the wound care today. She said she did not remember if it was done over the weekend or not. Resident #2 was observed at that time in her room in bed. She had socks on and her feet were covered with a thin blanket. Her foot was not on a pillow and there was not a heel protector within visible sight. During an interview on 9/01/15 at 11:45 p.m. the Director of Nurses (DON) said Resident #2 came from the hospital with a fractured tibia and fibia and pretty much stayed in bed. During an interview on 9/01/15 at 2:25 p.m. with the Corporate Nurse Resident #2's risk factors were discussed. The Corporate Nurse was informed of the 7/23/15 lab results where Resident #2's [MEDICATION NAME] level was low and her Braden Score was a 10. She was shown the 8/20/15 wound care orders and the 8/26/15 order for protein powder. The Corporate Nurse was shown the documentation in the nurse's notes where the facility documented heel protectors in place on 8/20/15 and 8/21/15 only. RESIDENT #3 Review of Resident #3's undated Resident Admission Record documented she was a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's 8/10/15 quarterly MDS Assessment documented she was severely cognitively impaired and was fully dependent on the staff for all ADL's (Activities of Daily Living). She had range of motion limitations on one side for both upper and lower extremities. She was incontinent of bowel and bladder. She had 2 stage II pressure ulcers present with slough (necrotic tissue in the process of seperating from the viable tissue). Review of Resident #3's care plan dated 2/26/15 documented Problem: Ischemic Ulcer to right foot. identified approaches included body audits at least weekly by licensed staff. The care plan had no been updated since Resident #3's 6/15/15 readmission. Review of Resident #3's most recent Braden Scale to Predict Pressure Ulcers dated 1/23/15 documented she scored a 19 (indicating she was mildly at risk for developing a pressure ulcer.) There was no updated Braden Scale upon her return from the 6/15/15 surgery. Review of Resident #3's Admission Nursing assessment dated [DATE] documented she was a right above the knee amputation and she had a scab to her left foot. (There was no pressure ulcer to her coccyx documented). Review of Resident #3's CMP Lab dated 6/18/15 documented she had an [MEDICATION NAME] level of 2.7 (low). Review of Resident #3's Monthly Physician Report for 8/2015 documented: - 6/15/15 protein powder supplement, 1 scoop with meals three times a day; - 6/15/15 daily multivitamin; - 6/15/15 vitamin C 500 mg twice a day. - 7/20/15 clean decubitus to right heel with normal saline, pat dry, apply Mupirocin ointment (antibiotic ointment) to wound bed, cover with gauze and secure with medifix tape daily until healed. - 7/28/15 irrigate sacral decubitus with normal saline, pat dry, loosely pack with hydrogel moistened packing, apply mediseptic to periwound bed and cover with gauze and [MEDICATION NAME] tape daily until healed. Review of Resident #3's Telephone orders documented on 7/07/15 Clean stage II decubitus to coccyx every day with normal saline, apply collagen (connective tissue protein) gauze to wound bed, skin protectant to periwound cover with foam dressing. Review of Resident #3's Dietary Notes dated 7/09/15 documented: open wound, stage II to coccyx. Review of Resident #3's Telephone orders documented on 7/20/15 Decubitus noted on right heel area 1 cm x 1.5 cm clean with normal saline, pat dry, apply Mupirocin ointment to wound bed, cover with gauze and secure with medifix tape daily until healed. Review of Resident #3's Telephone orders documented on 7/20/15 Irrigate wound bed with normal saline, pat dry, pack with moistened gauze packing strip and Santyl (a [MEDICATION NAME] ointment), cover with gauze 2 x 2 or 4 x 4, secure with medfix tape. Coccyx wound 5 cm x 2.5 cm x 1.5 cm. Change dressing daily until healed. Review of Resident #3's Nurse's Notes documented on 8/01/15 (no time) wound care done to decubitus to coccyx area - no signs of infection noted, no foul smells. Review of Resident #3's Nurse's Notes documented on 8/03/15 (no time) changed dressing to left heel area and coccyx area per MD orders. Resident tolerated procedure. Facial grimacing/ crying noted throughout procedure. Review of Resident #3's Nurse's Notes documented on 8/03/15 1425 (2:25 p.m.) dressing to coccyx area and foot clean and dry. Review of Resident #3's Nurse's Notes documented on 8/05/15 0730 (7:30 a.m.) dressings to coccyx area and left heel area dry and intact. Review of Resident #3's Nurse's Notes documented on 8/06/15 0100 (1:00 a.m.) dressing to sacrum soiled changed at this time. Review of Resident #3's Nurse's Notes documented on 8/06/15 0715 (7:15 a.m.) dressing clean, dry to coccyx area. Review of Resident #3's Nurse's Notes documented on 8/06/15 1420 (2:20 p.m.) Dressing to coccyx area intact. Review of Resident #3's Nurse's Notes documented on 8/07/15 0030 (12:30 a.m.) Dressing to coccyx clean, dry and intact. Review of Resident #3's Nurse's Notes documented on 8/07/15 (no time indicated) complains of pain when changed decubitus dressing to coccyx and to left back of heel. Review of Resident #3's Nurse's Notes documented on 8/09/15 0100 (1:00 a.m.) dressing to wound on coccyx off. wound care given. Review of Resident #3's Nurse's Notes documented on 8/09/15 1100 decubitus care done to coccyx. Review of Resident #3's Nurse's Notes documented on 8/10/15 0000 (midnight) dressing to coccyx clean dry and intact. Review of Resident #3's Nurse's Notes documented on 8/10/15 1000 Dressing to ankle area changed per MD order . Coccyx dressing soiled. Removed old dressing, cleaned with normal saline and dressed per MD orders. Review of Resident #3's Nurse's Notes documented on 8/11/15 0815 (8:15 a.m.) Dressing to left heel area intact, dry. Coccyx dressing dry and intact. Review of Resident #3's Nurse's Notes documented on 8/12/15 1000 (10:00 a.m.) Skilled nurse cleaned decubitus on coccyx, and right heel with normal saline. Heel wound 2.5 cm in diameter. Stage II. Mupirocin ointment applied to open area covered with gauze and secured with tape. Coccyx area cleaned with normal saline, packed with gauze 1/4 inch dressing impregnated with hydrogel covered with 4 x 4s, secured with tape. Review of Resident #3's Nurse's Notes documented on 8/13/15 Resident Transfer Form [DIAGNOSES REDACTED]. Slough or eschar may be present on some parts of the wound bed.) Review of Resident #3's Nurse's Notes documented on 8/14/15 1130 (11:30 a.m.) admitted back to (facility) in stable condition, oriented to person, color pink. Continue to do decubitus care to coccyx. Review of Resident #3's Nurse's Notes documented on 8/15/15 1030 (10:30 a.m.) Treatment to coccyx done per order. Review of Resident #3's Nurse's Notes documented on 8/16/15 0100 (1 a.m.) continue treatment to coccyx. Review of Resident #3's Nurse's Notes documented on 8/16/15 (next entry, no time) continue to do treatment to coccyx - healing well. Review of Resident #3's Nurse's Notes documented on 8/25/15 0930 (9:30 a.m.) Decubitus to coccyx area changed per protocol and dressing to right heel area changed per protocol. Review of Resident #3's Nurse's Notes documented on 8/26/15 0730 (7:30 a.m.) Dressing to right heel and coccyx area intact this morning. Review of Resident #3's Nurse's Notes documented on 8/27/15 0615 (6:15 a.m.) Dressing to right heel and coccyx area changed per MD orders. Review of Resident #3's Dietary Notes documented on 8/16/15 no open areas identified. Review of Resident #3's August 2015 Treatment Flowsheets documented: -7/20/15 Clean Decubitus to right heel with normal saline, pat dry, apply Mupirocin ointment to wound bed, cover with gauze, and secure with Medi tape daily until healed. -7/28/15 Irrigate sacral decubitus with normal saline , pat dry, loosely pack with hydrogel moistened packing, apply mediseptic to periwound bed and cover with gauze and [MEDICATION NAME] tape daily until healed. The following days were blank (indicating treatment may not have been completed): 8/08/15, 8/21/15, 8/22/15, 8/28/15, 8/29/15, 8/30/15 and 8/31/15. Review of Resident #3's Weekly Skin Assessments documented: on 7/07/15 (1) 2.5 cm (centimeter) x 1 cm stage II decubitus ulcer coccyx, no slough red and pink wound bed. (2) right above the knee amputation edges approximate with some scabs. 7/09/15 slough 0.5 x 0.5 cm noted to wound bed. There were no documented skin assessments done between 7/07/15 through 9/01/15. Review of Resident #3's Weekly Skin Assessments documented: on 9/01/15 (1) Stage III sacral decubitus size 1.4 x 1 cm x 3 cm deep with undermining moderate yellow drainage. (2) 1.5 x 1.5 cm callous with < (less than) 0.5 cm opening superficial skin prep. During an interview and observation on 9/01/15 at 10:35 a.m. the Assistant Director of Nurses (ADON) performed the wound care on Resident #3's coccyx. There was no dressing on Resident #3's coccyx. The ADON pushed on the wound and drainage came out. The ADON said it might be an abscess under the wound because of the drainage and it was not cool to have an abscess. The ADON pulled two strips of packing out of the wound. Drainage was noted when the ADON applied pressure to the wound. Once the packing was removed there was no drainage. There was a very slight odor noted. There was white/yellow slough present on the wound bed. The wound measured 1.4 cm in length, 1 cm wide, and had undermining (wound is bigger under than skin than the opening) at less than 3 cm deep. During an observation and interview on 9/01/15 at 11:10 a.m. Liscensed Vocational Nurse (LVN) I performed the wound care on Resident #3's heel. The dressing on the wound was dated 8/30/15 (indicating the wound care was not done on 8/31/15). The dressing was dried to the wound. LVN I applied normal saline to the dried gauze and then peeled it off the wound. The ADON who was present said she had never seen Resident #3's pressure ulcer to the foot and had not measured it. As LVN I applied Mupirocin ointment. The ADON said she did not know if the Mupirocin ointment was the right treatment for [REDACTED]. During an interview on 9/01/15 at 2:25 p.m. the Corporate Nurse and surveyors reviewed Resident #3's clinical record together. The Corporate Nurse said Resident #3 had bilateral venous problems. At 2:35 p.m. the ADON joined the conversation and said Resident #3 did not come back from the amputation surgery with a pressure ulcer. The ADON pointed out where Resident #3 was readmitted with a left heel scab. The ADON said Resident #3 developed a stage II pressure ulcer on her sacrum that had increased in stage from there. The Corporate Nurse said the nurses should documented the assessment in the nurse's notes. The Corporate Nurse said she did not want them on the skin assessment. RESIDENT #1 Review of the list of Residents with Pressure Sores provided by the Director of Nurses (DON) on 8/31/15 documented Residents #2, #3, #4, and #5 were the only pressure ulcers in the building with wound care. (Indicating the DON was unaware of Resident #1's pressure ulcer.) Review of Resident #1's undated Record of Admission documented he was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change MDS assessment dated [DATE] documented Resident #1 was severely cognitively impaired, rejected care 1 - 3 days of the last 7, was dependent on staff for all ADL Care, he had no limitations to his range of motion and used a walker or a wheelchair. Resident #1 had a catheter but was incontinent of bowel. He was on Hospice. There were no pressure ulcers documented on the MDS Assessment Review of Resident #1's 6/23/15 Care Plan documented: Potential for pressure ulcer or altered skin integrity related to: impaired mobility. The identified goals were risk of skin breakdown will be minimized and will have intact skin, with minimal redness, blisters, or discoloration through review date. Identified Approaches included body audits at least weekly by licensed staff. There was no care plan for the actual pressure ulcer developed on 8/03/15. Review of Resident #1's Braden Scale - for Predicting Pressure Sore Risk was completed on 6/12/15 and he had a score of 14 (indicating moderate risk to develop pressure ulcers). Review of Resident #1's CMP Lab documented his [MEDICATION NAME] level was 2.4 (low) on 8/11/15. Review of Resident #1's 8/01/15 - 8/31/15 Physician order [REDACTED]. Review of Resident #1's Telephone Orders documented 7/01/15 Admit to Hospice Review of Resident #1's Telephone Orders documented 7/09/15 Heel protectors on at all times bilateral heels. Review of Resident #1's 7/09/15 Nutritional Assessment documented no open areas. Review of Resident #1's Weekly Skin Assessment documented 7/09/15 2 x 2 cm (centimeter) blanching pink area left heel. There were no skin assessments documented between 7/09/15 and 8/03/15. Review of Resident #1's Weekly Skin Assessment documented 8/03/15 (next skin assessment on record) Decubitus ulcer to right side buttocks. 0.5/0.3 (units of measurement not documented, or stage unknown). Review of Resident #1's Weekly Skin Assessment documented on 8/10/15 Right side decubitus ulcer to buttocks (no documented measurements or stage). There were no skin assessments documented between 8/10/15 and 9/01/15. Review of Resident #1's Weekly Skin Assessment documented on 9/01/15 Measurements were 0.6 x 0.1 x 0.1 cm to the coccyx. There were no telephone orders for wound care in the 8/2015 indicating the physician had been notified of the 8/03/15 pressure ulcer. Review of the August 2015 24 hour report documented no pressure areas noted for Resident #1. Review of Resident #1's 8/2015 Treatment Flow sheet showed no orders for wound care and no wound care provided/ documented. Review of Resident #1's Nurse's Notes 7/01/15 through 8/20/15 showed no documentation on the pressure ulcer and nothing at all on 8/03/15. Review of Resident #1's nurse's notes 9/01/15 at 9:30 a.m. the Nurse documented a new order to irrigate sacral (triangular-shaped bone at the bottom of the spine) decubitus with normal saline, pat dry, apply hydrogel ([MEDICATION NAME] gel) and apply mediseptic (skin protectant cream) to periwound bed and cover with gauze and [MEDICATION NAME] (medical tape) daily until healed. During an interview on 8/31/15 at 1:30 p.m. Licensed Vocational Nurse (LVN) A said she still had to do wound care on Resident #5 and #1 (Resident #1 was not on the list of residents with pressure ulcers). LVN A said Resident #1's pressure ulcer was to the coccyx. She was asked what stage the pressure ulcer was and she looked at surveyor but did not answer the question. LVN A said she put Calazine cream (moisture barrier cream) on it. She said she was not really sure how long Resident #1 has had the pressure ulcer. During an interview on 8/31/15 at 1:40 p.m. the DON said Resident #1 had a Foley catheter and heel protectors on his feet. The DON said she was not aware of Resident #1 having a pressure ulcer to his coccyx. She said if they told me it slipped my mind. The DON said she got the list of pressure ulcers from the treatment book. During an interview on 8/31/15 at 3:40 p.m. the Minimum Data Set (MDS) Coordinator said she was unaware of Resident #1 having a pressure ulcer. During an interview on 9/01/15 at 9:30 a.m. the MDS Coordinator said she was trying to update Resident #1's care plan to reflect the pressure ulcer, but she could not find any information on it. She said there were no measurements, no characteristics or anything. During an interview on 9/01/15 at 11:11 a.m. the DON said she could not find a word about Resident #1's stage II pressure ulcer anywhere in the nurse's notes. She said she could not find where the doctor had been notified. During an observation and interview on 9/01/15 at 11:45 a.m. LVN A performed the wound care on Resident #1's coccyx. There was no dressing on the wound. The wound was approximately quarter sized with white slough present. At that time LVN A said skin assessments should be done every week. LVN A said the prior treatment nurse left about a month ago and the Charge Nurses were a little behind on getting the skin assessments done. LVN A said at first I was overwhelmed because I didn't know what to do but after a while it was ok. LVN A did not date the dressing until it was asked about. During an interview on 9/01/15 at 2:10 p.m. the Corporate Nurse said they could not find documentation the doctor was notified about Resident #1's pressure ulcer. The DON who was also present said she asked the nurse who told her she did not know why the nurse did not notify the doctor. The Corporate Nurse said she did not think the pressure ulcer was avoidable. During an interview on 9/02/15 at 2:05 p.m. LVN F said she became aware of Resident #1's pressure sore a couple of weeks ago. She said she was just putting hydrogel and a dressing on him and making sure the staff turned him. She acknowledged she did not document it. She said the aides were very good about letting her know when there was a change. She said she usually found out about pressure ulcers from the 24 hour report. LVN F said the aides told her about Resident #1's pressure ulcer. LVN F said she did not call the doctor because the facility was already aware of the pressure ulcer. She said she did not remember who discovered the pressure ulcer. Resident #5 Review of Resident #5's undated Resident Admission Record documented she was an [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Care Plan dated 11/12/14 documented: Resident #5 had a pressure ulcer to the left heel, has frail/thin skin. Identified approaches included: Body audits at least weekly by licensed staff. Review of Resident #5's annual MDS assessment dated [DATE] documented she was severely cognitively impaired, and was completely dependent on staff for all ADL Care. Resident #5 was incontinent of bowel and bladder. Resident #5 had one unstageable pressure ulcer measuring Length - 0.2 cm by Width - 0.4 cm with granulation tissue present. She received insulin injections, an antidepressant, and an anti-coagulant. Review of Resident #5's Dietary Assessments documented on 2/12/15 Stage II decubitus (no location identified). Review of Resident #5's Dietary Assessments documented on 3/06/15 Open Wound on great left toe. Review of Resident #5's Dietary Assessments documented on 4/15/15 No longer on wound report. Review of Resident #5's 8/13/15 Braden Scale for Prediction of Pressure Sore Risk (Acuity) documented a score of 14 indicating she was moderate risk. The form documented she had orders to float heels, vitamin C 500 mg twice a day and zinc 50 mg twice a day. Review of Resident #5's 8/01/15 through 8/31/15 Physician order [REDACTED].> - 6/16/15 Protein Powder 1 scoop with Healthshakes with meals. - 6/15/15 Vitamin C 500 mg twice a day; - 6/15/15 Zinc 50 mg twice a day. Review of Resident #5's CMP Lab dated 8/07/15 documented her [MEDICATION NAME] level was 3.4 (low). Review of Resident #5's Nurse's Notes documented on 5/26/15 (no time) stage II left heel has healed, callous formed. Review of Resident #5's Nurse's Notes documented on 5/26/15 1500 ( 3 p.m.) sore to left heel looks dry and intact. Replaced her heel protectors. Review of Resident #5's Dietary Assessments documented on 5/31/15 Open wound, stage II left heel. Review of Resident #5's Weekly Skin Assessment Sheets documented on 6/02/15 Skin warm and dry, turgor poor, callous left heel. Review of Resident #5's Nurse's Notes documented on 6/12/15 Blood noted and reported by CNA before shower - noted size 2 x 3 cm and 0.5 cm deep. Received orders to use Santyl ointment daily. Review of Resident #5's Telephone Orders documented on 6/12/15 Clean unstageable to left heel with normal saline, dry and apply Santyl ointment to wound bed; skin protectant to periwound, cover with foam and secure. Review of Resident #5's Nurse's Notes documented on 6/15/15 1430 (2:30 p.m.) Resident back from hospital vial ambulance. New order for [MEDICATION NAME] (an antibiotic) 1 gm (gram) daily for next 7 days. Starting 6/16 Diet no added salt, no concentrated sweets, Prevealon boot to bilateral heels with wound care to left heel. No pain or discomfort voiced. Review of Resident #5's nurse's notes documented the nurse's monitored Resident #5's dressing and/or boots/pillows in place on 6/25/15, 6/30/15, 7/01/15 and 7/05/15. Review of Resident #5's Weekly Skin Assessment Sheets documented on 6/15/15 5 x 2.5 cm decubitus ulcer. No drainage. Review of Resident #5's Telephone Orders documented on 6/16/15 Clean ulcer to left heal with normal saline, pat dry, hydrogel to wound bed; skin protectant to periwound, cover with tefla cling wrap every day until healed. Review of Resident #5's Weekly Skin Assessment Sheets documented on 6/23/15 Left heel Stage III 2.5 x 1.5 cm [MEDICATION NAME] tissue, healing. Review of Resident #5's Weekly Skin Assessment Sheets documented on 7/08/15 0.2 x 0.4 cm decubitus ulcer left heel. Granulated tissue with (illegible) bloody drainage. Review of Resident #5's Weekly Skin Assessment Sheets documented on 8/03/15 0.2 x 0.4 cm left heel, granulated. Review of Resident #5's Weekly Skin Assessment Sheets documented on 8/10/15 0.2 x 0.4 cm left heel, granulated. Review of Resident #5's Weekly Skin Assessment Sheets documented on 9/02/15 No sore documented. (no indication of when the pressure ulcer healed) Review of Resident #5's Dietary Assessments documented on 7/09/15 Has open wound (no location identified); Review of Resident #5's Dietary Assessments documented on 8/16/15 Open Wound - Chronic. (No location identified.) Review of Resident #5's Treatment Flowsheet for 8/2015 documented: Order dated 6/16/15 Clean decubitus ulcer to left heel with NS, pat dry, and apply hydrogel to wound bed and skin protectant to periwound area, cover with tefla and secure with cling until healed once a morning. The treatment sheet was blank (indicating the treatments may not have been done) on 8/01/15, 8/02/15, 8/08/15, 8/09/15, 8/15/15, 8/16/15, 8/22/15, 8/23/15, 8/29/15, and 8/30/15. Order dated 6/29/15 (after the pressure ulcer developed) Keep knees supported with pillows behind them when resident in supine position. Every Shift. and an order dated 6/15/15 Prevealon Boot on Left Foot. Every Shift. The treatment sheet was blank (indicating the shift did not monitor the placement). - Day Shift: 8/01/15, 8/02/15, 8/08/15, 8/09/15, 8/15/15, 8/16/15, 8/29/15, and 8/30/15 - Evening Shift: 8/01/15, 8/03/15, 8/04/15, 8/05/15, 8/06/15, 8/08/15, 8/09/15, 8/10/15, 8/11/15, 8/12/15, 8/13/15, 8/14/15, 8/15/15, 8/16/16, 8/17/15, 8/18/15, 8/19/15, 8/24/15, 8/25/15, 8/26/15, 8/27/15, 8/28/15, 8/29/15, 8/30/15, and 8/31/15. - Night Shift: 8/12/15, 8/16/15, 8/17/15, 8/26/15, 8/30/15, and 8/31/15. Resident #4 Review of Resident #4's undated Resident Admission Record documented he was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Significant Change MDS assessment dated [DATE] documented he was severely cognitively impaired and was dependent on staff for ADL care. He had no limitations to his range of motion and used a wheelchair. He was incontinent of bowel and bladder. He experienced pain and did not have any pressure ulcers. Review of Resident #4's Care Plan dated 7/25/15 documented: Problem: Actual pressure ulcer or altered skin integrity related to impaired mobility due to [MEDICAL CONDITION] as evidenced by: Stage II to Coccyx, Unstageable to right heel. Identified approaches included: body audits at least weekly by licensed staff. Review of Resident #4's 7/25/15 Braden

Based on observation, interview and record review, the facility failed to immediately inform the physician of a significant change in condition for 1 of 7 residents (Resident #1). The facility failed to notify Resident #1's primary care physician or responsible party when Resident #1 developed a Stage II Pressure Ulcer on his coccyx on 8/03/15. As a result, no orders were received for treatment or prevention of further skin breakdown. This deficient practice resulted in Resident #1 having an untreated Stage II pressure ulcer and could place the other 6 residents with pressure ulcers at risk for skin breakdown which could lead to pain and infection. The findings include: RESIDENT #1 Review of Resident #1's undated Record of Admission documented he was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 was severely cognitively impaired, rejected care 1 - 3 days of the last 7, was dependent on staff for all ADL Care (transfers, movement, dressing, eating, hygiene, and bathing), he had no limitations to his range of motion and used a walker or a wheelchair. Resident #1 had a catheter but was incontinent of bowel. He was on Hospice. There were no pressure ulcers documented on the MDS Assessment. Review of Resident #1's 6/23/15 Care Plan documented: Potential for pressure ulcer or altered skin integrity related to impaired mobility. The identified goals were risk of skin breakdown will be minimized and will have intact skin, with minimal redness, blisters, or discoloration through review date. Identified Approaches included body audits at least weekly by licensed staff. There was no care plan for the actual pressure sore identified on 8/03/15. Review of Resident #1's Weekly Skin Assessment documented 7/09/15 2 x 2 cm (centimeter) blanching pink area left heel 8/03/15 (next skin assessment on record); Decubitus ulcer to right side buttocks- 0.5/0.3 (units of measurement not documented, stage of the pressure ulcer unknown). 8/10/15 Right side decubitus ulcer to buttocks (measurements unknown, stage unknown. 9/01/15 Measurements were 0.6 x 0.1 x 0.1 cm to the coccyx. Review of the August 2015, 24 hour report (communication book between shifts) documented no pressure areas noted for Resident #1. Review of Resident #1's Nurse's Notes 7/01/15 through 8/20/15 showed no documentation on the pressure ulcer and no documentation at all on 8/03/15 or that the physician/ responsible party had been notified of the pressure ulcer. Review of Resident #1's August 2015 Treatment Administration Record showed no mention of the pressure ulcer or that any treatment of [REDACTED]. Review of Resident #1's Physician Telephone Orders for August 2015 showed no wound care orders. Nurse's notes dated 9/01/15 at 9:30 a.m. showed the Nurse documented a new order to irrigate sacral decubitus with normal saline, pat dry, apply hydrogel and apply mediseptic to periwound bed and cover with gauze and [MEDICATION NAME] daily until healed. During an interview on 8/31/15 at 1:30 p.m. Licensed Vocational Nurse (LVN) A said she still had to do wound care on Resident #5 and #1 (Resident #1 was not on the list of residents with pressure sores). LVN A said Resident #1's pressure ulcer was to the coccyx. LVN A was asked what stage the pressure ulcer was and she looked at surveyor but did not answer the question. LVN A then said she put Calazine cream (moisture barrier cream)on it. She said she was not really sure how long Resident #1 has had the pressure ulcer. During an interview on 8/31/15 at 1:40 p.m. the Director of Nurses (DON) said when an aide discovers a pressure ulcer the CNA (Certified Nurse Aide)is supposed to report it to the Charge Nurse. The DON said the Charge Nurse would then assess the wound, call the doctor and get wound care orders, and notify the family. The DON said she would tell the Charge Nurses to call the dietician for Resident #1 now. She said the orders should be on a doctor's order, the treatment sheet, and in the nurse's notes. She said Resident #1 had a Foley catheter and heel protectors on his feet. The DON said she was not aware of Resident #1 having a pressure ulcer to his coccyx. She said if they told me it slipped my mind. The DON said she got the list of pressure ulcers from the treatment book (notebook of residents who need some form of nursing skin care). During an interview on 9/01/15 at 11:11 a.m. the DON said she could not find a word about Resident #1's stage II pressure ulcer anywhere in the nurse's notes. She said she could not find where the doctor had been notified. Observation on 9/01/15 at 11:45 a.m. LVN A performed the wound care on Resident #1's coccyx. There was no dressing on the wound. The wound was approximately quarter sized with white slough present. At that time LVN A said skin assessments should be done every week. During a follow up interview on 9/01/15 at 2:10 p.m. the Corporate Nurse said they could not find documentation the doctor was notified about Resident #1's pressure ulcer. The DON who was also present said she asked LVN A who told her she did not know why LVN A did not notify the doctor. During an interview on 9/02/15 at 2:05 p.m. LVN F said she became aware of Resident #1's pressure ulcer a couple of weeks ago. She said she was just putting hydrogel and a dressing on him and making sure the staff turned him. She acknowledged she did not document it. She said the aides were very good about letting her know when there was a change. She said she usually found out about pressure ulcers from the 24 hour report. LVN F said the aides told her about Resident #1's pressure sore. LVN F said she did not call the doctor because the facility was already aware of the pressure ulcer. She said she did not remember who discovered the pressure ulcer. Review of the facility's Revised 2013 Policy and Procedure on Change in a Resident's Condition or Status documented, in part: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care). The Nurse Supervisor/ Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: A need to alter the resident's medical treatment significantly. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self limiting) b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan The Nurse Supervisor/ Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Of a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required. Review of Revised April 2013 Policy and Procedure on Physician Services documented, in part: The resident's attending physician participates in the resident's assessment and care planning, monitoring changes in resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for a resident. Review of the facility's 2014 Policy and Procedure on Pressure Ulcer Risk Assessment documented, in part: Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care is indicated. Documentation in medical record addressing family, guardian or resident notification if new skin alteration noted with change of plan of care if indicated. Reporting: Notification of attending MD if new skin alteration noted. Notification of family, guardian or resident update if new skin alteration noted. Review of the facility's 2014 Policy and Procedure on Prevention of Pressure Ulcers documented, in part: General Guidelines: The facility should have a system/procedure to assure assessments are timely and appropriate and charges in condition are recognized, evaluated, reported to the practitioner, physician, and family and addressed. Interventions and Preventative Measures: Report any signs and symptoms of a developing pressure ulcer to the physician. Review of the facility's 9/01/15 Weekly Wound Tracking Worksheet documented there were 7 residents in the facility who had pressure ulcers.

Based on observation, interview and record review, the facility failed to maintain essential patient care equipment in safe operating condition for one (Resident #1) of four residents reviewed for needing (mechanical) Hoyer lift assistance. Resident #1 was transferred from her bed to her wheelchair by way of a Hoyer lift and the worn sling snapped (broke). The resident fell to the floor and hit her head. This caused the resident to need emergency medical attention and was discovered she had sustained a brain bleed (sub-arachnoid hemorrhage). The failure to ensure slings used with Hoyer lift transfers were in safe operating condition resulted in Resident #1 falling to the floor and suffering a head injury, and placed the other three residents at risk for falling, resulting in similar injuries and the need for hospital treatment. Findings included: Review of the facility's Investigation Report, completed on 6/13/14, reflected Resident #1's fall while in her room on 6/08/14 at 4:45 p.m. The report documented: "Certified Nurse Aide (CNA) A and Nurse Aide (NA) B transferred Resident #1 from her bed to her wheelchair with the Hoyer lift. CNA A and NA B said as they were turning the Hoyer lift to put the resident in her chair, one of the straps on the sling broke and the resident fell to the floor. The resident hit the base of her head on the Hoyer lift. This resulted in a large knot to the base of Resident #1's head. The resident was immediately taken to the local emergency room and transported to a larger city with a [DIAGNOSES REDACTED]. Review of Resident #1's face sheet showed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was an [AGE] year old female. Review of Resident #1's most recent care plan conference summary dated 4/12/14 noted the resident used a Hoyer lift for transfers. Review of Resident #1's care plan for transfers dated 2/28/14 and most recently updated on 5/09/14 noted the resident used a Hoyer lift for transfers. Review of the most recent Minimum Data Set (MDS) assessment 5/02/14 indicated Resident #1 was usually understood, usually understands, and required total assistance with ADLs (Activities of Daily Living) including transfers. Interview with Resident #1 on 6/24/14 at 3:15 p.m. (while she rested in her bed) confirmed she fell to the floor on 6/08/14 because a strap on the Hoyer snapped. She said she was "scared to death and still was and she knew the two aides were as well." Resident #1 also said the back of her head "still hurt bad and was very tender." She added she was evaluated by therapy to see if the aides could physically transfer her themselves but she felt better to continue using the Hoyer lift for her transfers. Record review of a physician consultation report dated 6/09/14 noted, Resident #1 suffered [MEDICAL CONDITION]. The report noted, "the patient was lifted using a mechanical device. The device malfunctioned in some way leading to her fall to the floor." Record review of a Computed Tomography (CT) of the head on 6/09/14 confirmed Resident #1 suffered a subarachnoid hemorrhage. subarachnoid hemorrhage is bleeding into the subarachnoid space-the area between the and the surrounding the brain. This may occur spontaneously, usually from a ruptured cerebral aneurysm, or may result from head injury. http://en.wikipedia.org/wiki/Subarachnoid_hemorrhage Observation on 6/24/14 at 10:15 a.m., of the full-body sling used for Resident #1's Hoyer lift transfer on 6/08/14 revealed one of the four material type hooks was torn in two. The other three hooks were worn and beginning to fray/ ravel. Interview was conducted on 6/24/14 at 2:20 p.m. with NA B, NA B said she had been "doing aide work since she was about 18 and she was 34 now." She added she knew Resident #1's care needs "well and had transferred her many times with the lift." NA B said she did not feel the sling was "too worn to not be able to use it, but that one of the straps was frayed." NA B added she did not think the sling was unsafe. Interview was conducted on 6/24/14 at 2:40 p.m. with CNA A, CNA A said she felt the sling was worn but "felt it was still maybe ok to use a little longer." CNA A added it was the only clean sling in the building at the time and she needed to get the resident up for the meal. CNA A acknowledged the "yellow hook" (the one that snapped) was frayed and the other side had a red and a green hook that were "kinda worn out also." CNA A also said she "believed the Director of Nurses (DON) and/or the administrator were responsible for taking the worn slings out of use. CNA A said all the slings were washed every shift every day so they wore out quickly. Observation on 6/24/14 at 3:30 p.m. of Resident #1's sling that was currently used for her revealed a sewn in tag that read, "Inspect patient slings for wear prior to each use. If signs of tearing, fraying or wear are found discard the sling immediately- worn out slings are not safe for use and may result in injury or death. Useful life of this product is 6 months from date of purchase under normal use; however heavy use or excessive washing may decrease the useful life of the product." In an interview on 6/26/14 at 9:30 a.m., the Administrator said the nursing department was responsible for monitoring the condition of the slings and removing all worn ones immediately. She said the instructions on the sling were the same as for all brands she orders. Interview on 6/26/14 at 11:45 a.m. with CNA C, CNA C verified all slings were washed every shift every day. A list provided by the facility on 6/26/14 indicated 4 residents were transferred with the Hoyer lift.

Based on observation, interview and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections by boodborne pathogens for 16 of 16 diabetic residents (Resident #2, #6, #12, #16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28 and #29). The facility failed to ensure single-use lancets (used to obtain drops of blood for testing blood sugar for diabetic residents) were available and a reusable pen-like lancing device was not used on multiple residents for 7 days in April 2014 (04/18/14 through 04/24/14). These failures resulted in the identification of an IJ (Immediate Jeopardy) on 5/22/14. While the IJ was removed prior to exit on 5/23/14, the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "Pattern". These failures involved 16 diabetic residents requiring use of a lancing device to obtain blood by fingerstick for blood glucose testing. These failures placed these 16 residents at risk of blood borne infections. Non-IJ Failure: The facility failed to ensure staff practiced infection control measures to help prevent the transmission of diseases and infection. This affected 2 of 5 residents observed for incontinent care (Resident #2 and #6), 2 of 3 residents observed for wound care (Resident #5 and #12) and 9 of 23 employees reviewed for [DIAGNOSES REDACTED] (TB) screening. a) Certified Nursing Assistant (CNA) I washed her hands before she donned gloves to provide incontinent care for Resident #2 and she did not change her gloves before she applied the new brief and assist resident in bed. b) CNA B washed her hands before she donned gloves to provide incontinent care for Resident #6 and she did not change her gloves before she applied barrier cream. c) Licensed Vocational Nurse (LVN) A provided a clean field for treatment supplies, disinfected the scissors used for Resident #12's wound care and feeding tube site. d) LVN A properly disposed of soiled dressing and used supplies after Resident #5's feeding tube site care. e) LVN A used a clean field when gathering wound care supplies and cleaned scissors used on dressings for Resident #12. f) Nine employees were screened for TB within 14 days of hire or annually. Failure to reduce the spread of infections, prevent cross-contamination during incontinent care, wound care and screen employees for TB could place residents at risk for transmission of diseases and organisms to compromised individuals living together in an institutional environment. This failure could affect 24 residents that were occasionally or frequently incontinent of bladder, 23 residents occasionally or frequently incontinent of bowel, 2 residents with wound care and 4 residents with feeding tubes. The IJ findings included: BLOOD SUGAR MONITORING During observation of the medication room on 5/14/14 at 10:37 a.m. with LVN F revealed a drawer that contained supplies to draw blood for laboratory testing. In the drawer was a reusable fingerstick device (pen-like device) inside a box of lancets (used inside the reusable fingerstick device to make a puncture, to obtain small blood specimens). During an interview on 5/14/14 at 11:00 a.m. LVN F was asked if the reusable fingerstick device was used. LVN F said she "heard they (facility nurses) had to use it when they ran out of single use lancets, it was after I left, I left the end of March 2014, I did not see them use it and I have not used it." During observation on 5/14/14 at 11:22 a.m. of the insulin medication cart with LVN D there was a reusable fingerstick device in one of the trays. LVN D pulled off the top part of the device. There was dried blood in the cap and around the lower part of the pen-like device. During an interview on 05/14/14 at 11:25 a.m. LVN D said all the nurses had to use the reusable fingerstick device because they ran out of the single-use lancets. LVN D said it was the Thursday before Easter (4/17/14) and did not get any single-use lancets until the Friday after Easter (4/25/14). LVN D said the Administrator was out of town. LVN D said she tried to clean down inside the device with a bacterial wipe. LVN D said they called the pharmacy and they did not have the single-use lancet type. LVN D said when she came in to work she was told by the night nurse "this is what we had to use." LVN D said she "didn't like to use it, we should have had one for each resident with their name." LVN D said she was told by the Assistant Director of Nurses (ADON) "that is what we've got to use." LVN D said the ADON worked in home health before she started here. LVN D said "the ADON had the pen (reusable lancet device) from home health, it was new." During an interview on 5/14/14 at 12:07 p.m. LVN H said she did not use the reusable pen-like device. LVN H said "I just know it was used about a month ago (April 2014), cause we ran out of those stick thingies (single-use lancets)." During an interview on 5/14/14 at 12:15 p.m. LVN A said she had used the pen-like device on Resident #12 last month (April 2014). LVN A said they ran out of the single-use lancets. LVN A said she cleaned the top of the pen-like device with an alcohol pad. LVN A said "I think they are gross, can't get them clean, not safe, could poke yourself taking the lancet out of the device." LVN A said she would not want the reusable pen-like device used to check her blood sugar. During an interview on 5/14/14 at 12:30 p.m. the ADON said "we have always had the pen (reusable pen-like device) in the drawer." The ADON said LVN D mentioned to her they were low on the single use lancets and she told LVN D to use the pen device. The ADON said she notified the Administrator, that was out of town the Friday (04/18/14) before Easter. The ADON said the Administrator told her the single use lancets had been ordered. The ADON said she went out of town for the Easter weekend. The ADON said she was "pretty sure" she told LVN D to clean the pen device before and after use. The ADON said she was a home health nurse and they used the pen device. During an interview on 5/14/14 at 12:45 p.m. the ADON said "Oh, I see what the issue is". She said that the person was "blindly putting the needle in there so you don't know what it's hitting." She acknowledged the concern about the use of the device. She said "I guess we need to pull these from the cart." During an interview on 5/14/14 at 5:00 p.m. Registered Nurse (RN) Q acknowledged the facility had run out of the single use lancets last month. RN Q said "they gave us some funky looking pen that we had to use to check blood sugars." She said she did not remember when it was but they did not use the pen "very long". She said she came in to relieve LVN D (04/18/14) and it (reusable lancet device) was there. RN Q said she used the pen-like device on several residents. RN Q said she had used that kind of device before, a long time ago. RN Q said "now that I think about it, after you stick the finger, it (puncture needle) goes up inside, then you put another one on it (the device) and no telling what's inside." RN Q said she would not want one used to check her blood sugar. During an interview on 5/14/14 at 5:45 p.m. the Administrator said the pens were behind double locked doors and could not be used again. The Director of Nurses (DON) said she was going to contact the pharmacist consultant and ask her how to properly dispose of the pens. Record review of Blood Sampling - Capillary (Finger Sticks) revised April 2012 indicated the following: Purpose - the purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees. Equipment - 1. Alcohol [MEDICATION NAME]; 2. Disinfected blood glucose meter (glucometer) with sterile lancet; or single-resident use spring-loaded device (penlet) or automatic or safety type lancet; 3. Disposable lancet; 4. Personal protective equipment (gloves); and 5. Sharps container. 6. Approved EPA registered disinfectant for cleaning of sampling device. General Guidelines - 1. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. Single-resident use fingerstick devices (pen-like devices) should never be used by more than one resident. 2. The lancets and platforms must always be changed after use on each resident. 3. Handle the lancet as a used needle. RESIDENT #2 Record review of Resident #2's record of admitted d 01/23/12 documented that he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #2 was [AGE] years old. Record review of Resident #21's physician orders [REDACTED]. ? Accucheck (blood sugar check) via FS (fingerstick) every week every Sunday. Record review of Resident #2's Diabetic Meds/Accuchecks (DMA) dated 04/01/14 through 04/30/14 indicated Resident #2 had his CBG checked 1 time between 04/18/14 and 04/24/14. RESIDENT #6 Record review of Resident #6's Physician order [REDACTED]. Resident #6 was [AGE] years old. Physician orders [REDACTED]. Record review of Resident #21's DMA dated 04/01/14 through 04/30/14 indicated Resident #6 had her CBG checked 28 times between 04/18/14 and 04/24/14. During an interview on 5/22/14 at 3:22 p.m. Resident #6 said she remembered the nurses "used something different." Resident #6 said "it was longer than the ones they have now. It didn't hurt real bad, it hurt but not real bad." Resident #6 said she gets her blood sugar checked four times a day. RESIDENT #12 Record review of Resident #12's record of admitted d 5/06/13 indicated she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #12 was [AGE] years old. Record review of Resident #12's physician orders [REDACTED]. Record review of Resident #12's DMA dated 04/01/14 through 04/30/14 indicated Resident #12 had her CBG checked 26 times between 04/18/14 and 04/24/14. RESIDENT #16 Record review of Resident #16's Physician order [REDACTED]. Resident #16 was [AGE] years old. physician's orders [REDACTED]. Record review of Resident #16's DMA dated 04/01/14 through 04/30/14 indicated Resident #16 had her CBG checked 3 times between 04/18/14 and 04/24/14. RESIDENT #18 Record review of Resident #18's Physician order [REDACTED]. Resident #18 was [AGE] years old. Physician orders [REDACTED].M. and Q P.M. Record review of Resident #18's DMA dated 04/01/14 through 04/30/14 indicated Resident #18 had her CBG checked 14 times between 04/18/14 and 04/24/14. RESIDENT #19 Record review of Resident #19's Physician order [REDACTED]. Resident #19 was [AGE] years old. physician's orders [REDACTED]. Record review of Resident #19's DMA dated 04/01/14 through 04/30/14 indicated Resident #19 had her CBG checked one (1) time between 04/18/14 and 04/24/14. RESIDENT #20 Record review of Resident #20's Physician orders [REDACTED]. Resident #20 was [AGE] years old. physician's orders [REDACTED]. Record review of Resident #20's DMA dated 04/01/14 through 04/30/14 indicated Resident #20 had her CBG checked one (1) time between 04/18/14 and 04/24/14. RESIDENT #21 Record review of Resident #21's record of admitted d 03/02/12 documented that she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #21 was [AGE] years old. Record review of Resident #21's physician orders [REDACTED]. ? CBG before meals and at bedtime. Record review of Resident #21's DMA dated 04/01/14 through 04/30/14 indicated Resident #21 had her CBG checked 28 times between 04/18/14 and 04/24/14. During an interview on 05/22/14 at 3:18 p.m. Resident #21 said she remembered the nurses using the pen like device to check her blood sugar about a month ago. Resident #21 said she remembered because this pen was less painful than the small lancets. RESIDENT #22 Review Resident #22's Physicians Order, dated 05/01/ 10 through 06/31/14, revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review Resident #22's Physicians Order, dated 05/01/14 through 06/30/14 also documented: ? CBG before meals and at bedtime. Record review of Resident #22's DMA dated 04/01/14 through 04/30/14 indicated Resident #22 had her CBG checked 14 times between 04/18/14 and 04/24/14. RESIDENT #23 Record review of Resident #23 record of admitted d 08/27/13 documented she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #23 was [AGE] years old. Review Resident #23's Physicians Order, dated 05/01/14 through 06/30/14 also documented: ? CBG's 3 times a week at 0600. Record review of Resident #23's DMA dated 04/01/14 through 04/30/14 indicated Resident #23 had her CBG checked three (3) times between 04/18/14 and 04/24/14. RESIDENT #24 Record review of Resident #24's record of admitted d 03/13/14 documented that she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #24 was [AGE] years old. Record review of Resident #24's physician orders [REDACTED]. ? Accucheck via FS every morning and as needed. Record review of Resident #24's DMA dated 04/01/14 through 04/30/14 indicated Resident #24 had her CBG checked 5 times between 04/18/14 and 04/24/14. RESIDENT #25 Record review of Resident #25's record of admitted d 12/19/13 documented that he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #25 was [AGE] years old. Record review of Resident #25's physician orders [REDACTED]. ? CBG 3 times a week. Record review of Resident #25's DMA dated 04/01/14 through 04/30/14 indicated Resident #25 had his CBG checked 3 times between 04/18/14 and 04/24/14. RESIDENT #26 Record review of Resident #26 record of admitted d 05/16/14 documented he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #26 was [AGE] years old. Review Resident #26's Physicians Order, dated 05/01/14 through 06/30/14 also documented: ? CBG's Q (every) week Q Monday. Record review of Resident #26's DMA dated 04/01/14 through 04/30/14 indicated Resident #26 had his CBG checked 1 time between 04/18/14 and 04/24/14. RESIDENT #27 Record review of Resident #27 record of admitted d 07/24/13 documented he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #27 was [AGE] years old. Review Resident #27's Physicians Order, dated 05/01/14 through 06/30/14 also documented: ? CBG's before meals and at bedtime. Record review of Resident #27's DMA dated 04/01/14 through 04/30/14 indicated Resident #27 had his CBG checked 17 times between 04/18/14 and 04/24/14. RESIDENT #28 Record review of Resident #28 record of admitted d 05/16/14 documented he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #28 was [AGE] years old. Review Resident #28's Physicians Order, dated 05/01/14 through 06/30/14 also documented: ? CBG's fasting blood sugar Q Sunday and PRN. Record review of Resident #28's DMA dated 04/01/14 through 04/30/14 indicated Resident #28 had his CBG checked 1 time between 04/18/14 and 04/24/14. RESIDENT #29 Record review of Resident #29's record of admitted d 09/28/10 documented that she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #29 was [AGE] years old. Record review of Resident #29's physician orders [REDACTED]. ? Accucheck via FS every morning and at bedtime. Record review of Resident #29's DMA dated 04/01/14 through 04/30/14 indicated Resident #29 had her CBG checked 13 times between 04/18/14 and 04/24/14. Information posted by the Center of Disease Control, updated 02/09/11, at website http://www.cdc.gov/injectionsafety/Fingerstick-DevicesBGM.html contained the following: "The shared use of fingerstick devices is one of the common root causes of exposure and infection in settings such as long-term care (LTC) facilities, where multiple persons require assistance with blood glucose monitoring. Risk for transmission of bloodborne pathogens is not limited to LTC settings but can exist anywhere multiple persons are undergoing fingerstick procedures for blood sampling. For example, at a health fair in New Mexico earlier this year, dozens of attendees were potentially exposed to bloodborne pathogens when fingerstick devices were reused to conduct diabetes screening. Recommendations Anyone performing fingerstick procedures should review the following recommendations to ensure that they are not placing persons in their care at risk for infection. ? Fingerstick devices should never be used for more than one person. ? Auto-disabling single-use fingerstick devices should be used for assisted monitoring of blood glucose. These recommendations apply not only to licensed healthcare facilities but also to any setting where fingerstick procedures are performed, including assisted living or residential care facilities, skilled nursing facilities, clinics, health fairs, shelters, detention facilities, senior centers, schools, and camps. Protection from infections, including bloodborne pathogens, is a basic requirement and expectation anywhere healthcare is provided. " These failures resulted in the identification of an IJ (Immediate Jeopardy) on 5/22/14 at 6:15 p.m. While the IJ was removed prior to exit on 5/23/14 at 11:48 a.m., the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "Pattern". The following plan of removal was submitted and accepted on 05/23/14 at 11:48 a.m. ? The pens (reusable finger stick device) were removed and locked up in the DON's closet where drugs that are to be destroyed are kept under double lock. Date of plan initiation 05/15/14. ? DON and or ADON will check the med room and CBG cart weekly to be sure no multi-use pens are in the facility. The pharmacy consultant on her monthly med room audit will also double check for pens. Date of plan initiation 05/15/14. ? Nurses were instructed that finger stick/pen devices are prohibited in this facility. The DON and ADON checked the med room to be sure there were no other pens in the facility. Date of plan initiation 05/15/14. ? Nurses were in-serviced/instructed if anyone brings in a multi device/pen like device they are not to accept it and send it home or the DON/ADON will notify and lock it up in the dc narcotic closet. They were also given a copy of F-441 which gives an example of how we got the IJ by using the pen on more than one resident. Date of plan initiation 05/23/14. ? Charge nurse will check the CBG cart daily to be sure there are no pen-like devices in the cart. If any are found they will be sent to the DON office to be locked up in the dc drug closet and will be destroyed at the next drug destruction. The DON/ADON will check the cart and med room weekly. Date of plan initiation 05/23/14. ? Lancets are ordered on a weekly basis and a backup box will be kept in the Administrator closet, in the DON office and the med room. If the nurses need to get into one of the offices, they will call the on call phone. She will call the appropriate person to get the key. Both the DON and ADON have keys to their office. The Assistant Administrator has keys to the Administrator office if she should be out of town. On 05/22/14 there were 600 lancets in the facility in boxes that had not been opened and 4 more boxes were ordered which totaled 800 more lancets. Date of plan initiation 05/22/14. ? The med nurse and treatment nurse will check the supplies that need to be ordered and they will give the list to the Administrator who will place the order on Tuesday or Wednesday so supplies will be in the facility by Friday. If the facility runs out of lancets a member of the staff will go to the local pharmacy where they do carry single use lancets or Wal-Mart who also carries lancets. Date of plan initiation 05/22/14. Surveyors verified the facility had completed the above actions prior to removing the IJ through observations and interviews with staff. Interviews were conducted on 05/23/14 with staff to verify in-service participation and the participant's understanding of information discussed regarding multi-use device pen and what to do if they ran out of lancets. During an interview on 5/22/14 at 3:45 p.m. the Administrator said she ordered boxes of lancets from two difference companies so if one does not deliver the other one would. She said she had always done it in the past but had not been consistent but would be from now on after what happened the last time (referring to staff using the multi-use device pen). She said she would always have a spare box of lancets in her office closet and staff was able to go into her office to get them when needed. During an interview on 5/23/14 at 3:30 p.m. the ADON said she was going to put the signs up regarding the lancets and how to get more if they ran out. The IJ was removed 05/23/14 at 11:48 a.m. the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm, pattern, because all staff had not been in-serviced and the facility had not yet monitored their plan of action for effectiveness. A list provided by the DON on 5/14/14 indicated there were 16 diabetic residents that received blood sugar monitoring at the facility. Non-IJ Findings: INCONTINENT CARE RESIDENT #2 Record review of Resident #2's record of admitted d 01/23/12 documented that he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #2 was [AGE] years old. During an observation on 05/13/14 at 2:21 p.m. CNA I performed incontinent care on Resident #2. CNA I entered the room, donned gloves and did not wash her hands. Resident #2 had a bowel movement. CNA I wiped the stools then continued to apply the new brief while still wearing the same gloves. CNA I then adjusted the resident's clothes and helped him reposition in bed while wearing the same gloves. During an interview on 05/15/14 at 1:47 p.m. CNA I stated "I understand what I did was wrong, I was nervous" regarding the incontinent observation. During an interview on 05/16/14 at 3:10 p.m. the DON was made aware of the observation with CNA I. The DON stated "her hands were contaminated then she touched the brief and the other areas and then other staff come and touch those areas". RESIDENT #6 Record review of Resident #6's record of admitted d 7/10/13 indicated she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #6 was [AGE] years old. During an observation on 5/16/14 at 9:35 a.m. CNA B performed incontinent care on Resident #6. CNA B entered the room, donned gloves (did not wash her hands), got a basin in the bathroom and filled it with water. CNA B opened drawers with her gloved hands to get out clothes. CNA C entered the room, washed her hands and gloved. Resident #6 stood up and held onto CNA C while CNA B pulled the resident's pants and disposable brief down. Resident #6 sat back down on the pad. CNA B cleaned Resident #6's groin and peri area while she was sitting. Resident #6 stood again and held onto CNA C. CNA B cleaned the resident's buttocks and rectal area. CNA B removed the lid from a jar of [MEDICATION NAME] ointment, scooped out some ointment and applied it to the resident's buttocks with the same gloved hand she cleaned the resident with. CNA B then removed her gloves and put on another pair of gloves without washing her hands. CNA B put a clean brief on the resident and pulled up her pants. During an interview on 5/16/14 at 10:02 a.m. CNA B acknowledged she did not wash her hands before she put on gloves. CNA B was informed of the cross-contamination touching multiple items/surfaces with her gloved hands then providing incontinent care. CNA B was informed of cross-contamination after she cleaned the resident she dipped the same gloved hand into the jar of [MEDICATION NAME] ointment and applied it to the resident's buttocks. CNA B said she understood the cross-contamination. CNA B said "ok I will change gloves next time, thank you for telling me." During an interview on 5/16/14 at 3:10 p.m. the DON was informed of Resident #6's incontinent care observation. The DON said the CNA should have washed her hands and changed her gloves. The DON acknowledged there was cross-contamination. Record review of the facility's policy and procedure titled "perineal care" and dated 8/2010 indicated in part; ? The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin. ? Wash and dry your hands thoroughly. ? Put on gloves. Record review of the facility's policy and procedure titled "hand washing/hand hygiene" and dated 4/2012 indicated in part; ? This facility considers hand hygiene the primary means to prevent the spread of infections. ? All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. ? Employees must wash their hands for at least 15 seconds using antimicrobial or non-microbial soap and water under the following conditions. Before and after direct resident contact for which hand hygiene is indicated by acceptable professional practice. Before and after assisting a resident with personal care. ? The use of gloves does not replace handwashing/hand hygiene. Record review of the facility's policy and procedure titled "using gloves" and dated 8/2010 indicated in part; ? When gloves are indicated use disposable single use gloves. ? Discard used gloves into the waste basket. ? Wash hands after removing gloves (Note. Gloves do not replace hand washing). ? When to use gloves. When touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin and whenever in doubt. Review of the form CMS 672 Resident Census and Conditions of Residents completed by the DON on 5/16/14 documented there were 24 residents occasionally or frequently incontinent of bladder and 23 residents occasionally or frequently incontinent of bowel. WOUND CARE RESIDENT #5 Review of Resident #5's Record of admitted d 5/07/14 documented he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's consolidated Physician order [REDACTED]." During an observation on 5/12/14 at 2:20 p.m., LVN A said she was going to do a dressing change on Resident #5's peg tube. LVN A put her wound care supplies on a paper towel (a porous barrier) and put the supplies on Resident #5's night stand. She washed her hands and donned gloves. LVN A took off Resident #5's dressing. LVN A sprayed normal saline on the wound, patted it dry with gauze and put the new bandage on Resident #5's peg site. She did not wash her hands or change gloves. LVN A took off her gloves and washed her hands. LVN A wrapped all the dirty (used) supplies in the paper towel and stuffed them in her scrubs pocket. She left the room and threw her used supplies in the regular trash on the treatment cart with her bare hands. She began to set up for the next treatment. During an interview on 5/14/14 at 3:20 p.m. LVN A said she did not take a bio-hazard bag into the room when she was doing wound care. She said that was because unless the dressing was saturated you did not need to. She said the paper towel was a clean field and she thought it was an effective barrier because it was not wet. She acknowledged she did not change gloves. She acknowledged she put the contaminated supplies in her pocket. During an interview on 5/14/14 at 3:25 p.m. the DON described her expectation for Peg Dressing change as the staff to wash their hands, get everything on a clean field, wash their hands again, remove the old dressing, wrap the soiled dressing in a glove before putting it in a biohazard bag, wash hands again, clean the area, put on the new dressing, date/time/initial the dressing and assess and respond to pain if necessary. She said a clean field would be wax paper or some other non-porous surface. She acknowledged a paper towel could be leaked through. The DON said LVN A contaminated her pocket when she put the dirty supplies in her pocket and it all needed to go into a biohazard bag. She was informed of the observation. She said "it'll be addressed." During an interview on 5/14/14 at 3:50 p.m. the Administrator was informed of the observation with Resident #5. She acknowledged LVN A contaminated her pocket by putting the soiled dressing/gloves in her pocket. RESIDENT #12 Record review of Resident #12's record of admitted d 5/06/13 indicated she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #12 was [AGE] years old. Record review of Resident #12's Physician order [REDACTED]. ? "Clean decub (decubitus - pressure ulcer) L (left) buttock with NS (normal saline) dry and apply hydrogel, cover with gauze & [MEDICATION NAME] q (every) daily prn (as needed)." ? "Clean decub R (right) buttock with NS (normal saline) dry, and apply hydrogel, cover with gauze & [MEDICATION NAME] q (every) daily prn". During an observation on 5/13/14 at 10:40 a.m. Resident #12 was in her room in her bed. LVN A gathered supplies from the treatment cart in preparation to do a wound treatment on Resident #12's buttocks. LVN A squeezed some Hydrogel (wound gel to maintain a moist wound bed to promote healing) into a medication cup and placed two cotton tipped a

Based on observation, interview and record review the facility failed to follow their infection control policy and procedures and to ensure isolation procedures were instituted to prevent the spread of infection for 1 of 8 residents reviewed for infection. (Resident #1) in that: ? Resident #1 had a [DIAGNOSES REDACTED]. ? Licensed Vocational Nurse (LVN) C did not use isolation precautions while providing care for Resident #1. This failure could place 51 residents at risk for exposure to infection and disease. Findings include: Record review of Resident #1's record of admitted d 04/01/14 documented that she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #1 was [AGE] years old. Review of Resident #1's hospital discharge report dated 03/27/14 indicated in part: ? Patient has advanced dementia and confused, she also has a problem with diarrhea from Clostridium Difficile and [DIAGNOSES REDACTED]. ? [MEDICATION NAME] (antibiotic) 250 milligrams by mouth three times a day for 2 weeks. Started on 03/28/14. ? Diagnosis: [REDACTED]. Review of the facility's undated policy and procedure titled contact isolation indicated in part: ? Contact isolation when caring for resident must wear gown and gloves. ? Use contact precautions or the equivalent for specified residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items. ? Place the resident in a private room. (NOTE: Resident #1 was in private room) ? Wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the resident, environmental surfaces or items in the resident's room of if the resident is incontinent or had diarrhea. ? If the resident is transported out of the room, ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other residents and contamination of environmental surfaces or equipment. Review of the facility's undated policy and procedure titled learning how to control the spread of Clostridium Difficile indicated in part: ? During the time the patient is on special precautions activities outside the room may be restricted. ? Healthcare staff needs to wash hands and put on gowns before entering room. ? Before leaving room staff must remove gowns, gloves and wash their hands with soap and water. ? If someone is diagnosed with [REDACTED]. ? People can be colonized with Clostridium Difficile in their bowel without it causing an infection. ? Person with Clostridium Difficile may be asked to shower and/or change to fresh, clean gown before leaving their room to go into other areas of the hospital. ? People without diarrhea are much less likely to spread germs into the environment. Observation on 04/03/14 at 9:39 a.m. LVN C was seen assisting Resident #1 in her room. LVN C was wearing gloves but no gown. Outside of the room was a plastic dresser that contained gloves and disposable gowns. LVN C was seen wiping Resident #1's legs with wipes because resident had stool on them. During an interview on 04/03/14 at 9:40 a.m. LVN C said she would wear a gown only if she came in contact with stools. During an interview on 04/03/14 at 10:25 a.m. LVN C said Resident #1 was supposedly in isolation and according to her doctor and the Administrator if the resident's stool was formed she no longer needed to be in isolation. LVN C said the stool was on Resident #1's legs only from her removing her brief. LVN C the stool in the residents brief was not loose but somewhat formed. Observation on 04/03/14 at 10:30 a.m. LVN C and the surveyor went to observe the stool in Resident #1's brief. The stool was formed and not loose and nor did it have the foul smell that usually accompanies[DIAGNOSES REDACTED] bacteria. During an interview on 04/03/14 at 11:21 a.m. the Administrator said Resident #1 probably needs to be back in isolation. The Administrator said when she spoke with the doctor he said if the stools were not runny there was no need for isolation. The Administrator said Resident #1 was going to be here for respite care only while her husband was out of town and once he returned on Monday 04/07/14 he would take her home. The Administrator said they would wash the resident's hands before she came out of her room. The Administrator said they would have one on one from now on to keep her in her room till Monday. The Administrator said if staff had to clean up any stools they were supposed to gown up. The Administrator acknowledged that LVN C should have gowned up when she assisted Resident #1. Observation on 04/03/14 at 3:28 p.m. CNA D was seen in Resident #1's room gowned up and wearing gloves. CNA D was monitoring the resident and making sure she did not leave her room. Resident #1 was walking around her room and appeared to be confused. Observation on 04/04/14 at 10:15 a.m. Resident #1 was seen in her room being monitored to prevent her from exiting her room. During a telephone interview on 04/03/14 at 2:53 p.m. the doctor said he had looked at the CDC website regarding[DIAGNOSES REDACTED] guidelines. The doctor said the guidelines were "not very clear." The doctor said when a resident is still having diarrhea then they should be in isolation. The doctor said there was no specific length of time for a resident to be in isolation. When asked by the surveyor if a stool specimen would be required to indicate if a resident was cleared from isolation the doctor responded, "isolation would be based on the clinical symptoms like loose stools if no more loose stools then they can be released from isolation". Review of the facility's census report dated 04/02/14 indicated there were 51 resident's residing at the facility.

Based on observation, interview and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections by boodborne pathogens for 16 of 16 diabetic residents (Resident #2, #6, #12, #16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28 and #29). The facility failed to ensure single-use lancets (used to obtain drops of blood for testing blood sugar for diabetic residents) were available and a reusable pen-like lancing device was not used on multiple residents for 7 days in April 2014 (04/18/14 through 04/24/14). These failures resulted in the identification of an IJ (Immediate Jeopardy) on 5/22/14. While the IJ was removed prior to exit on 5/23/14, the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "Pattern". These failures involved 16 diabetic residents requiring use of a lancing device to obtain blood by fingerstick for blood glucose testing. These failures placed these 16 residents at risk of blood borne infections. Non-IJ Failure: The facility failed to ensure staff practiced infection control measures to help prevent the transmission of diseases and infection. This affected 2 of 5 residents observed for incontinent care (Resident #2 and #6), 2 of 3 residents observed for wound care (Resident #5 and #12) and 9 of 23 employees reviewed for [DIAGNOSES REDACTED] (TB) screening. a) Certified Nursing Assistant (CNA) I washed her hands before she donned gloves to provide incontinent care for Resident #2 and she did not change her gloves before she applied the new brief and assist resident in bed. b) CNA B washed her hands before she donned gloves to provide incontinent care for Resident #6 and she did not change her gloves before she applied barrier cream. c) Licensed Vocational Nurse (LVN) A provided a clean field for treatment supplies, disinfected the scissors used for Resident #12's wound care and feeding tube site. d) LVN A properly disposed of soiled dressing and used supplies after Resident #5's feeding tube site care. e) LVN A used a clean field when gathering wound care supplies and cleaned scissors used on dressings for Resident #12. f) Nine employees were screened for TB within 14 days of hire or annually. Failure to reduce the spread of infections, prevent cross-contamination during incontinent care, wound care and screen employees for TB could place residents at risk for transmission of diseases and organisms to compromised individuals living together in an institutional environment. This failure could affect 24 residents that were occasionally or frequently incontinent of bladder, 23 residents occasionally or frequently incontinent of bowel, 2 residents with wound care and 4 residents with feeding tubes. The IJ findings included: BLOOD SUGAR MONITORING During observation of the medication room on 5/14/14 at 10:37 a.m. with LVN F revealed a drawer that contained supplies to draw blood for laboratory testing. In the drawer was a reusable fingerstick device (pen-like device) inside a box of lancets (used inside the reusable fingerstick device to make a puncture, to obtain small blood specimens). During an interview on 5/14/14 at 11:00 a.m. LVN F was asked if the reusable fingerstick device was used. LVN F said she "heard they (facility nurses) had to use it when they ran out of single use lancets, it was after I left, I left the end of March 2014, I did not see them use it and I have not used it." During observation on 5/14/14 at 11:22 a.m. of the insulin medication cart with LVN D there was a reusable fingerstick device in one of the trays. LVN D pulled off the top part of the device. There was dried blood in the cap and around the lower part of the pen-like device. During an interview on 05/14/14 at 11:25 a.m. LVN D said all the nurses had to use the reusable fingerstick device because they ran out of the single-use lancets. LVN D said it was the Thursday before Easter (4/17/14) and did not get any single-use lancets until the Friday after Easter (4/25/14). LVN D said the Administrator was out of town. LVN D said she tried to clean down inside the device with a bacterial wipe. LVN D said they called the pharmacy and they did not have the single-use lancet type. LVN D said when she came in to work she was told by the night nurse "this is what we had to use." LVN D said she "didn't like to use it, we should have had one for each resident with their name." LVN D said she was told by the Assistant Director of Nurses (ADON) "that is what we've got to use." LVN D said the ADON worked in home health before she started here. LVN D said "the ADON had the pen (reusable lancet device) from home health, it was new." During an interview on 5/14/14 at 12:07 p.m. LVN H said she did not use the reusable pen-like device. LVN H said "I just know it was used about a month ago (April 2014), cause we ran out of those stick thingies (single-use lancets)." During an interview on 5/14/14 at 12:15 p.m. LVN A said she had used the pen-like device on Resident #12 last month (April 2014). LVN A said they ran out of the single-use lancets. LVN A said she cleaned the top of the pen-like device with an alcohol pad. LVN A said "I think they are gross, can't get them clean, not safe, could poke yourself taking the lancet out of the device." LVN A said she would not want the reusable pen-like device used to check her blood sugar. During an interview on 5/14/14 at 12:30 p.m. the ADON said "we have always had the pen (reusable pen-like device) in the drawer." The ADON said LVN D mentioned to her they were low on the single use lancets and she told LVN D to use the pen device. The ADON said she notified the Administrator, that was out of town the Friday (04/18/14) before Easter. The ADON said the Administrator told her the single use lancets had been ordered. The ADON said she went out of town for the Easter weekend. The ADON said she was "pretty sure" she told LVN D to clean the pen device before and after use. The ADON said she was a home health nurse and they used the pen device. During an interview on 5/14/14 at 12:45 p.m. the ADON said "Oh, I see what the issue is". She said that the person was "blindly putting the needle in there so you don't know what it's hitting." She acknowledged the concern about the use of the device. She said "I guess we need to pull these from the cart." During an interview on 5/14/14 at 5:00 p.m. Registered Nurse (RN) Q acknowledged the facility had run out of the single use lancets last month. RN Q said "they gave us some funky looking pen that we had to use to check blood sugars." She said she did not remember when it was but they did not use the pen "very long". She said she came in to relieve LVN D (04/18/14) and it (reusable lancet device) was there. RN Q said she used the pen-like device on several residents. RN Q said she had used that kind of device before, a long time ago. RN Q said "now that I think about it, after you stick the finger, it (puncture needle) goes up inside, then you put another one on it (the device) and no telling what's inside." RN Q said she would not want one used to check her blood sugar. During an interview on 5/14/14 at 5:45 p.m. the Administrator said the pens were behind double locked doors and could not be used again. The Director of Nurses (DON) said she was going to contact the pharmacist consultant and ask her how to properly dispose of the pens. Record review of Blood Sampling - Capillary (Finger Sticks) revised April 2012 indicated the following: Purpose - the purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees. Equipment - 1. Alcohol [MEDICATION NAME]; 2. Disinfected blood glucose meter (glucometer) with sterile lancet; or single-resident use spring-loaded device (penlet) or automatic or safety type lancet; 3. Disposable lancet; 4. Personal protective equipment (gloves); and 5. Sharps container. 6. Approved EPA registered disinfectant for cleaning of sampling device. General Guidelines - 1. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. Single-resident use fingerstick devices (pen-like devices) should never be used by more than one resident. 2. The lancets and platforms must always be changed after use on each resident. 3. Handle the lancet as a used needle. RESIDENT #2 Record review of Resident #2's record of admitted d 01/23/12 documented that he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #2 was [AGE] years old. Record review of Resident #21's physician orders [REDACTED]. ? Accucheck (blood sugar check) via FS (fingerstick) every week every Sunday. Record review of Resident #2's Diabetic Meds/Accuchecks (DMA) dated 04/01/14 through 04/30/14 indicated Resident #2 had his CBG checked 1 time between 04/18/14 and 04/24/14. RESIDENT #6 Record review of Resident #6's Physician order [REDACTED]. Resident #6 was [AGE] years old. Physician orders [REDACTED]. Record review of Resident #21's DMA dated 04/01/14 through 04/30/14 indicated Resident #6 had her CBG checked 28 times between 04/18/14 and 04/24/14. During an interview on 5/22/14 at 3:22 p.m. Resident #6 said she remembered the nurses "used something different." Resident #6 said "it was longer than the ones they have now. It didn't hurt real bad, it hurt but not real bad." Resident #6 said she gets her blood sugar checked four times a day. RESIDENT #12 Record review of Resident #12's record of admitted d 5/06/13 indicated she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #12 was [AGE] years old. Record review of Resident #12's physician orders [REDACTED]. Record review of Resident #12's DMA dated 04/01/14 through 04/30/14 indicated Resident #12 had her CBG checked 26 times between 04/18/14 and 04/24/14. RESIDENT #16 Record review of Resident #16's Physician order [REDACTED]. Resident #16 was [AGE] years old. physician's orders [REDACTED]. Record review of Resident #16's DMA dated 04/01/14 through 04/30/14 indicated Resident #16 had her CBG checked 3 times between 04/18/14 and 04/24/14. RESIDENT #18 Record review of Resident #18's Physician order [REDACTED]. Resident #18 was [AGE] years old. Physician orders [REDACTED].M. and Q P.M. Record review of Resident #18's DMA dated 04/01/14 through 04/30/14 indicated Resident #18 had her CBG checked 14 times between 04/18/14 and 04/24/14. RESIDENT #19 Record review of Resident #19's Physician order [REDACTED]. Resident #19 was [AGE] years old. physician's orders [REDACTED]. Record review of Resident #19's DMA dated 04/01/14 through 04/30/14 indicated Resident #19 had her CBG checked one (1) time between 04/18/14 and 04/24/14. RESIDENT #20 Record review of Resident #20's Physician orders [REDACTED]. Resident #20 was [AGE] years old. physician's orders [REDACTED]. Record review of Resident #20's DMA dated 04/01/14 through 04/30/14 indicated Resident #20 had her CBG checked one (1) time between 04/18/14 and 04/24/14. RESIDENT #21 Record review of Resident #21's record of admitted d 03/02/12 documented that she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #21 was [AGE] years old. Record review of Resident #21's physician orders [REDACTED]. ? CBG before meals and at bedtime. Record review of Resident #21's DMA dated 04/01/14 through 04/30/14 indicated Resident #21 had her CBG checked 28 times between 04/18/14 and 04/24/14. During an interview on 05/22/14 at 3:18 p.m. Resident #21 said she remembered the nurses using the pen like device to check her blood sugar about a month ago. Resident #21 said she remembered because this pen was less painful than the small lancets. RESIDENT #22 Review Resident #22's Physicians Order, dated 05/01/ 10 through 06/31/14, revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review Resident #22's Physicians Order, dated 05/01/14 through 06/30/14 also documented: ? CBG before meals and at bedtime. Record review of Resident #22's DMA dated 04/01/14 through 04/30/14 indicated Resident #22 had her CBG checked 14 times between 04/18/14 and 04/24/14. RESIDENT #23 Record review of Resident #23 record of admitted d 08/27/13 documented she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #23 was [AGE] years old. Review Resident #23's Physicians Order, dated 05/01/14 through 06/30/14 also documented: ? CBG's 3 times a week at 0600. Record review of Resident #23's DMA dated 04/01/14 through 04/30/14 indicated Resident #23 had her CBG checked three (3) times between 04/18/14 and 04/24/14. RESIDENT #24 Record review of Resident #24's record of admitted d 03/13/14 documented that she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #24 was [AGE] years old. Record review of Resident #24's physician orders [REDACTED]. ? Accucheck via FS every morning and as needed. Record review of Resident #24's DMA dated 04/01/14 through 04/30/14 indicated Resident #24 had her CBG checked 5 times between 04/18/14 and 04/24/14. RESIDENT #25 Record review of Resident #25's record of admitted d 12/19/13 documented that he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #25 was [AGE] years old. Record review of Resident #25's physician orders [REDACTED]. ? CBG 3 times a week. Record review of Resident #25's DMA dated 04/01/14 through 04/30/14 indicated Resident #25 had his CBG checked 3 times between 04/18/14 and 04/24/14. RESIDENT #26 Record review of Resident #26 record of admitted d 05/16/14 documented he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #26 was [AGE] years old. Review Resident #26's Physicians Order, dated 05/01/14 through 06/30/14 also documented: ? CBG's Q (every) week Q Monday. Record review of Resident #26's DMA dated 04/01/14 through 04/30/14 indicated Resident #26 had his CBG checked 1 time between 04/18/14 and 04/24/14. RESIDENT #27 Record review of Resident #27 record of admitted d 07/24/13 documented he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #27 was [AGE] years old. Review Resident #27's Physicians Order, dated 05/01/14 through 06/30/14 also documented: ? CBG's before meals and at bedtime. Record review of Resident #27's DMA dated 04/01/14 through 04/30/14 indicated Resident #27 had his CBG checked 17 times between 04/18/14 and 04/24/14. RESIDENT #28 Record review of Resident #28 record of admitted d 05/16/14 documented he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #28 was [AGE] years old. Review Resident #28's Physicians Order, dated 05/01/14 through 06/30/14 also documented: ? CBG's fasting blood sugar Q Sunday and PRN. Record review of Resident #28's DMA dated 04/01/14 through 04/30/14 indicated Resident #28 had his CBG checked 1 time between 04/18/14 and 04/24/14. RESIDENT #29 Record review of Resident #29's record of admitted d 09/28/10 documented that she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #29 was [AGE] years old. Record review of Resident #29's physician orders [REDACTED]. ? Accucheck via FS every morning and at bedtime. Record review of Resident #29's DMA dated 04/01/14 through 04/30/14 indicated Resident #29 had her CBG checked 13 times between 04/18/14 and 04/24/14. Information posted by the Center of Disease Control, updated 02/09/11, at website http://www.cdc.gov/injectionsafety/Fingerstick-DevicesBGM.html contained the following: "The shared use of fingerstick devices is one of the common root causes of exposure and infection in settings such as long-term care (LTC) facilities, where multiple persons require assistance with blood glucose monitoring. Risk for transmission of bloodborne pathogens is not limited to LTC settings but can exist anywhere multiple persons are undergoing fingerstick procedures for blood sampling. For example, at a health fair in New Mexico earlier this year, dozens of attendees were potentially exposed to bloodborne pathogens when fingerstick devices were reused to conduct diabetes screening. Recommendations Anyone performing fingerstick procedures should review the following recommendations to ensure that they are not placing persons in their care at risk for infection. ? Fingerstick devices should never be used for more than one person. ? Auto-disabling single-use fingerstick devices should be used for assisted monitoring of blood glucose. These recommendations apply not only to licensed healthcare facilities but also to any setting where fingerstick procedures are performed, including assisted living or residential care facilities, skilled nursing facilities, clinics, health fairs, shelters, detention facilities, senior centers, schools, and camps. Protection from infections, including bloodborne pathogens, is a basic requirement and expectation anywhere healthcare is provided. " These failures resulted in the identification of an IJ (Immediate Jeopardy) on 5/22/14 at 6:15 p.m. While the IJ was removed prior to exit on 5/23/14 at 11:48 a.m., the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "Pattern". The following plan of removal was submitted and accepted on 05/23/14 at 11:48 a.m. ? The pens (reusable finger stick device) were removed and locked up in the DON's closet where drugs that are to be destroyed are kept under double lock. Date of plan initiation 05/15/14. ? DON and or ADON will check the med room and CBG cart weekly to be sure no multi-use pens are in the facility. The pharmacy consultant on her monthly med room audit will also double check for pens. Date of plan initiation 05/15/14. ? Nurses were instructed that finger stick/pen devices are prohibited in this facility. The DON and ADON checked the med room to be sure there were no other pens in the facility. Date of plan initiation 05/15/14. ? Nurses were in-serviced/instructed if anyone brings in a multi device/pen like device they are not to accept it and send it home or the DON/ADON will notify and lock it up in the dc narcotic closet. They were also given a copy of F-441 which gives an example of how we got the IJ by using the pen on more than one resident. Date of plan initiation 05/23/14. ? Charge nurse will check the CBG cart daily to be sure there are no pen-like devices in the cart. If any are found they will be sent to the DON office to be locked up in the dc drug closet and will be destroyed at the next drug destruction. The DON/ADON will check the cart and med room weekly. Date of plan initiation 05/23/14. ? Lancets are ordered on a weekly basis and a backup box will be kept in the Administrator closet, in the DON office and the med room. If the nurses need to get into one of the offices, they will call the on call phone. She will call the appropriate person to get the key. Both the DON and ADON have keys to their office. The Assistant Administrator has keys to the Administrator office if she should be out of town. On 05/22/14 there were 600 lancets in the facility in boxes that had not been opened and 4 more boxes were ordered which totaled 800 more lancets. Date of plan initiation 05/22/14. ? The med nurse and treatment nurse will check the supplies that need to be ordered and they will give the list to the Administrator who will place the order on Tuesday or Wednesday so supplies will be in the facility by Friday. If the facility runs out of lancets a member of the staff will go to the local pharmacy where they do carry single use lancets or Wal-Mart who also carries lancets. Date of plan initiation 05/22/14. Surveyors verified the facility had completed the above actions prior to removing the IJ through observations and interviews with staff. Interviews were conducted on 05/23/14 with staff to verify in-service participation and the participant's understanding of information discussed regarding multi-use device pen and what to do if they ran out of lancets. During an interview on 5/22/14 at 3:45 p.m. the Administrator said she ordered boxes of lancets from two difference companies so if one does not deliver the other one would. She said she had always done it in the past but had not been consistent but would be from now on after what happened the last time (referring to staff using the multi-use device pen). She said she would always have a spare box of lancets in her office closet and staff was able to go into her office to get them when needed. During an interview on 5/23/14 at 3:30 p.m. the ADON said she was going to put the signs up regarding the lancets and how to get more if they ran out. The IJ was removed 05/23/14 at 11:48 a.m. the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm, pattern, because all staff had not been in-serviced and the facility had not yet monitored their plan of action for effectiveness. A list provided by the DON on 5/14/14 indicated there were 16 diabetic residents that received blood sugar monitoring at the facility. Non-IJ Findings: INCONTINENT CARE RESIDENT #2 Record review of Resident #2's record of admitted d 01/23/12 documented that he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #2 was [AGE] years old. During an observation on 05/13/14 at 2:21 p.m. CNA I performed incontinent care on Resident #2. CNA I entered the room, donned gloves and did not wash her hands. Resident #2 had a bowel movement. CNA I wiped the stools then continued to apply the new brief while still wearing the same gloves. CNA I then adjusted the resident's clothes and helped him reposition in bed while wearing the same gloves. During an interview on 05/15/14 at 1:47 p.m. CNA I stated "I understand what I did was wrong, I was nervous" regarding the incontinent observation. During an interview on 05/16/14 at 3:10 p.m. the DON was made aware of the observation with CNA I. The DON stated "her hands were contaminated then she touched the brief and the other areas and then other staff come and touch those areas". RESIDENT #6 Record review of Resident #6's record of admitted d 7/10/13 indicated she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #6 was [AGE] years old. During an observation on 5/16/14 at 9:35 a.m. CNA B performed incontinent care on Resident #6. CNA B entered the room, donned gloves (did not wash her hands), got a basin in the bathroom and filled it with water. CNA B opened drawers with her gloved hands to get out clothes. CNA C entered the room, washed her hands and gloved. Resident #6 stood up and held onto CNA C while CNA B pulled the resident's pants and disposable brief down. Resident #6 sat back down on the pad. CNA B cleaned Resident #6's groin and peri area while she was sitting. Resident #6 stood again and held onto CNA C. CNA B cleaned the resident's buttocks and rectal area. CNA B removed the lid from a jar of [MEDICATION NAME] ointment, scooped out some ointment and applied it to the resident's buttocks with the same gloved hand she cleaned the resident with. CNA B then removed her gloves and put on another pair of gloves without washing her hands. CNA B put a clean brief on the resident and pulled up her pants. During an interview on 5/16/14 at 10:02 a.m. CNA B acknowledged she did not wash her hands before she put on gloves. CNA B was informed of the cross-contamination touching multiple items/surfaces with her gloved hands then providing incontinent care. CNA B was informed of cross-contamination after she cleaned the resident she dipped the same gloved hand into the jar of [MEDICATION NAME] ointment and applied it to the resident's buttocks. CNA B said she understood the cross-contamination. CNA B said "ok I will change gloves next time, thank you for telling me." During an interview on 5/16/14 at 3:10 p.m. the DON was informed of Resident #6's incontinent care observation. The DON said the CNA should have washed her hands and changed her gloves. The DON acknowledged there was cross-contamination. Record review of the facility's policy and procedure titled "perineal care" and dated 8/2010 indicated in part; ? The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin. ? Wash and dry your hands thoroughly. ? Put on gloves. Record review of the facility's policy and procedure titled "hand washing/hand hygiene" and dated 4/2012 indicated in part; ? This facility considers hand hygiene the primary means to prevent the spread of infections. ? All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. ? Employees must wash their hands for at least 15 seconds using antimicrobial or non-microbial soap and water under the following conditions. Before and after direct resident contact for which hand hygiene is indicated by acceptable professional practice. Before and after assisting a resident with personal care. ? The use of gloves does not replace handwashing/hand hygiene. Record review of the facility's policy and procedure titled "using gloves" and dated 8/2010 indicated in part; ? When gloves are indicated use disposable single use gloves. ? Discard used gloves into the waste basket. ? Wash hands after removing gloves (Note. Gloves do not replace hand washing). ? When to use gloves. When touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin and whenever in doubt. Review of the form CMS 672 Resident Census and Conditions of Residents completed by the DON on 5/16/14 documented there were 24 residents occasionally or frequently incontinent of bladder and 23 residents occasionally or frequently incontinent of bowel. WOUND CARE RESIDENT #5 Review of Resident #5's Record of admitted d 5/07/14 documented he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's consolidated Physician order [REDACTED]." During an observation on 5/12/14 at 2:20 p.m., LVN A said she was going to do a dressing change on Resident #5's peg tube. LVN A put her wound care supplies on a paper towel (a porous barrier) and put the supplies on Resident #5's night stand. She washed her hands and donned gloves. LVN A took off Resident #5's dressing. LVN A sprayed normal saline on the wound, patted it dry with gauze and put the new bandage on Resident #5's peg site. She did not wash her hands or change gloves. LVN A took off her gloves and washed her hands. LVN A wrapped all the dirty (used) supplies in the paper towel and stuffed them in her scrubs pocket. She left the room and threw her used supplies in the regular trash on the treatment cart with her bare hands. She began to set up for the next treatment. During an interview on 5/14/14 at 3:20 p.m. LVN A said she did not take a bio-hazard bag into the room when she was doing wound care. She said that was because unless the dressing was saturated you did not need to. She said the paper towel was a clean field and she thought it was an effective barrier because it was not wet. She acknowledged she did not change gloves. She acknowledged she put the contaminated supplies in her pocket. During an interview on 5/14/14 at 3:25 p.m. the DON described her expectation for Peg Dressing change as the staff to wash their hands, get everything on a clean field, wash their hands again, remove the old dressing, wrap the soiled dressing in a glove before putting it in a biohazard bag, wash hands again, clean the area, put on the new dressing, date/time/initial the dressing and assess and respond to pain if necessary. She said a clean field would be wax paper or some other non-porous surface. She acknowledged a paper towel could be leaked through. The DON said LVN A contaminated her pocket when she put the dirty supplies in her pocket and it all needed to go into a biohazard bag. She was informed of the observation. She said "it'll be addressed." During an interview on 5/14/14 at 3:50 p.m. the Administrator was informed of the observation with Resident #5. She acknowledged LVN A contaminated her pocket by putting the soiled dressing/gloves in her pocket. RESIDENT #12 Record review of Resident #12's record of admitted d 5/06/13 indicated she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #12 was [AGE] years old. Record review of Resident #12's Physician order [REDACTED]. ? "Clean decub (decubitus - pressure ulcer) L (left) buttock with NS (normal saline) dry and apply hydrogel, cover with gauze & [MEDICATION NAME] q (every) daily prn (as needed)." ? "Clean decub R (right) buttock with NS (normal saline) dry, and apply hydrogel, cover with gauze & [MEDICATION NAME] q (every) daily prn". During an observation on 5/13/14 at 10:40 a.m. Resident #12 was in her room in her bed. LVN A gathered supplies from the treatment cart in preparation to do a wound treatment on Resident #12's buttocks. LVN A squeezed some Hydrogel (wound gel to maintain a moist wound bed to promote healing) into a medication cup and placed two cotton tipped

The facility failed to ensure that the resident environment remained as free from accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 5 of 11 residents reviewed for incidents and accidents (Residents #1, 2, 3, 4, and 5) as evidenced by: -failure to determine risks and hazards and implement interventions to prevent accidents and injuries to Resident #1 following injuries including bruises and a puncture wound to her head during accidents on 9/30/13, 10/2/13, 12/17/13, 1/17/14, 2/6/14, and 2/7/14; -failure to determine risks and hazards and implement interventions when Resident #2 sustained multiple bruises and was required to wear a right wrist splint and right arm sling when she was thrown out of her wheelchair in the facility ' s van when she was not restrained properly with a seat belt on 1/24/14; -failure to determine risks and hazards and implement interventions when Resident #3 sustained multiple injuries on 1/10/14, 1/11/14, 1/17/14, and 1/23/14 that included large bruises and a swollen hand. Resident #3 complained that staff were grabbing her tightly. -failure to determine risks and hazards and implement interventions for Resident #4 following an incident on 1/19/14 when he sustained a fractured humerus (the bone that extends from the shoulder to the elbow) while being assisted in the shower; and -failure to determine risks and hazards and implement interventions for Resident #5 (now discharged ) following multiple injuries sustained on 12/19/13, 12/30/13, and 1/2/14 including multiple bruises on her legs, arms, and face. On 2/5/14 at 12:15 p.m., an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to actual harm at a pattern on 2/7/14 at 2:00 p.m. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. These failures resulted in actual harm to Residents #2 (bruising, pain, decreased mobility) and 4 (fracture). These failures could result in future accidents and injuries for residents that are in wheelchairs and/or who are dependent on staff for assistance with transferring and activities of daily living. The facility had 20 residents dependent on staff for transfers and 31 that were in a chair most of the time. Findings included: 1. a) The Record of Admission Sheet for Resident #1 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. b) A Minimum Data Set (MDS) Assessment for Resident #1 dated 1/19/14 documented the resident had clear speech, was easily understood and could understand others. The interview for mental status was not completed. The Resident Mood Interview was not completed. The MDS documented Resident #1 was totally dependent on the assistance of one person to transfer between surfaces, for toileting, dressing, and personal hygiene. She had range of motion limitations/impairment on both lower extremities. She was not steady during surface-to-surface transfer. She was frequently incontinent of bladder and bowel. She used a wheelchair for mobility. c) A Nursing Summary dated 2/9/14 documented Resident #1 ' s cognitive skills were modified independence. d) Incident/Accident reports, physician notification forms and change of condition forms for Resident #1 revealed the following injuries: -2/7/14 at 1600 (4:00 p.m.): " Found bruise right elbow size .5 x 1 cm (centimeter) purple. Resident said both elbows have been bumped on hand rail in B/R (bathroom) today. CNA (certified nurse ' s aide) reports L (left) elbow hit rail this p.m. Also resident said the back of the R (right) arm got squished during transfer to bed, 0 injuries. The section of the incident report with the heading, " Additional comments and/or steps taken to prevent recurrence " was blank. The incident report was signed by the Director of Nurses but was not dated " . -1/17/14 0930-1200 (between 9:30 am and 12:00 noon) in the resident ' s room (Resident #1 stated in interview (below) that this occurred in her restroom): " Resident states CNA was transferring resident. States CNA slipped her hold and resident hit her head. She has a 1 cm. puncture mark on scalp " . The section of the incident report with the heading, " Additional comments and/or steps taken to prevent recurrence " was blank. The incident report was signed by the Director of Nurses and Administrator. (Signatures were not dated). -12/17/13 1:30 a.m. - " CNA A removed resident from bedpan at approximately 0545 (5:45 a.m.). Resident has red marks from bedpan. Resident states she was put on it at 1:30 a.m. " . (Redness was drawn in a circle on the diagram of the person ' s bottom with measurements of 13 x .5 cm, 7 x 2 cm, 15.5 x 13 cm, and 7 x 3.5 cm. The section of the incident report with the heading, " Additional comments and/or steps taken to prevent recurrence " revealed, " Remind CNAs to check resident as she fell asleep on bedpan. " The incident report was signed by the DON previously employed by the facility. The Administrator did not sign the report in the section labeled for her signature. -10/2/13 9:30 a.m.: " Res. hit arm on something? Arm of w/c (wheelchair) and received a skin tear to upper L (left) forearm " . -9/30/13: (Physician ' s note). Call from facility 9/26/13. Resident states as she was assisted into bed at bedtime she hit her forearm on side rail. She did not know she injured it at the time. Resident has hematoma to R (right) forearm. e) A care plan dated dated 4/19/13 and updated 2/5/14 (two days after the beginning of this investigation/visit) included a problem of impaired mobility related to disease process from Parkinson ' s and spinal stenosis. Interventions included to exercise caution during transfers and handling due to fragile skin and to provide protective coverings to arms and legs. A problem identified as dressing and grooming deficit had interventions including teaching the resident to use the call light for assistance. Under the problem of toileting deficit, interventions included perineal care after each episode of incontinence, and reduce stress as much as possible to decrease incontinence. Under a problem of depression, interventions included assessing for symptoms of depression (sadness, hopelessness, anxiety, tearfulness, etc.). Under a problem of risk for falls, the interventions included keeping the environment free from obstructions. The care plan did not include any specific interventions to address the multiple injuries sustained during CNA assistance with transfers, such as any change in the amount of support provided the resident or addressing the hazards that resulted in multiple injuries occurring in the resident ' s bathroom when hitting her on the hand rails when transferring her to the toilet. The care plan did not include any past interventions for use of a bed pan. f) During observations of Resident #1on 2/4/14 at 11:50 a.m., 2/6/14 at 6:30 a.m., 2/6/14 at 7:15 a.m., 2/11/14 at 11:00 a.m., 2/11/14 at 11:30 a.m., and 2/12/14 at 4:00 p.m., Resident #1 was not observed to be wearing any protective garments on her arms and legs. g) During an interview on 2/4/14 at 11:50 a.m., Resident #1and her daughter were present. Resident #1 was a soft spoken female who was oriented to person and place. Resident #1 ' s daughter said that she was the one who found and identified the head wound. They stated that the CNA who was caring for Resident #1 the night this injury occurred (CNA B) was now gone. Resident #1 said that CNA B was very mean to her. She said that when CNA B helped her to transfer, the CNA would tell the resident she was not allowed to touch the CNA to hold on. Resident #1 said that some of the young CNAs that worked there were rough and rude to her. Resident #1 said many injuries occurred in her restroom because she often hit herself on the hand rails. She said the restroom was small and when a staff member was in there assisting her, there really was not room for them to both move around safely. Resident #1 said the head injury occurred in the restroom. She said the CNA assisting her lost control of her and she hit her head on the hand rails. When discussing that she was left on the bedpan, Resident #1 said she was told to use a bedpan by the staff because they told her it was better and would keep her from falling. She said she did not like using a bedpan because she had a harder time urinating on the bedpan. She said that the CNA placed her on the bedpan and left her there all night, and she fell asleep on it. Resident #1 said she was in a lot of pain when she woke up. Resident #1 said that the staff, especially at night, did not answer her call light and often left her call light out of her reach so she could not call for help. Resident #1 said she had not complained for fear of retaliation from the nurse ' s aides. Resident #1 ' s daughter stated that Resident #1 ' s bottom looked awful after being left on the bedpan. She said she was so concerned that she took pictures. She said she also talked to the administrator about her concerns. h) During an interview on 2/4/13 at 2:35 p.m., CNA A said that Resident #1 was correct in that it did not appear that CNA B liked Resident #1. CNA A said that when she came on duty early in the mornings, she would find Resident #1 " soaked " after CNA B ' s shift. CNA A said that she found Resident #1 on the bedpan, and her call light was lying on the floor. She said Resident #1 had a large red ring where the bedpan was, and she complained of pain. CNA A said she reported it to the nurse on duty, but no one else had really asked her about it. i) During an interview on 2/4/14 at 10:15 a.m., LVN (licensed vocational nurse) A said that she was the nurse on duty when CNA A reported to her that Resident # 1 was found on the bedpan. She said that Resident #1 ' s bottom was very red and that it would have blistered if she had stayed on it much longer. LVN A said she documented everything in a nurse ' s note, change of condition report, and incident report and gave the incident report to the DON. LVN A said she thought the multiple injuries occurred with Resident #1 because the staff were not trained to transfer residents. j) During an interview on 2/4/13 at 3:30 p.m., the Administrator said that if any of the incident reports were investigated by the nurses, the investigations would be attached to the incident reports. She had no comment when discussing that none of the incident reports for Resident #1 had anything attached to them. She said that she fired CNA B for the incident when Resident #1 received the head injury during a transfer. When discussing with her that the incident report stated NA A was working with Resident #1 that day and not CNA B, the Administrator said she guessed she had not looked at the incident report. She said she had not spoken to NA A about it. In order to clarify the information, LVN A was asked to join the interview, since she wrote the incident report. LVN A came to the interview and reported that CNA B could not have been the one responsible for the injury as she was not on duty. LVN A said that the resident had reported that day that NA A was taking her to the restroom when the head injury occurred. When discussing the bedpan incident, the Administrator said she had not determined which CNA left Resident #1 on the bedpan. The Administrator said the aide that was working that night must have just gotten busy, and the resident should have used her call light. The Administrator acknowledged she had taken no actions in response to the incident reports named above, other than to terminate CNA B. k) During interview with the DON (Director of Nurses) and ADON (Assistant Director of Nurses) on 2/4/14 at 4:30 p.m., they said they did not look at Resident #1 when the incident with the bedpan occurred. The ADON said she was on vacation at the time, and the DON said she did not look at the resident until several days later. When discussing why the resident was on a bedpan, they said that Resident #1 had asked for a bedpan. When discussing whether they had asked the resident what happened, they said that she complained, but appeared to be afraid to give details. They said one of the staff was terminated (CNA B) and another was moved to a different shift. When discussing actions taken following the incident, the DON said, " I think we discussed no more bedpan use. " The ADON and DON said they had no evidence of any determinations regarding the cause of accidents or any actions taken on the incidents for Resident #1 to prevent re-occurrence of injuries during care and transfers. When discussing Resident #1 ' s multiple complaints about staff not responding to her call light and being rough with her, the DON and ADON said they knew nothing about it. l) During interview with Resident #1 on 2/6/14 at 6:20 a.m., she said that the staff had been hitting her leg when they transferred her. m) During an observation on 2/6/14 at 7:15 a.m., CNA A came into the room and raised Resident #1 ' s bed covers to show her legs. Resident #1 had what appeared to be a fresh blue bruise to her right shin. She had a fading light blue bruise to the back of her calf of her right leg. n) Nurse ' s notes revealed no entries for Resident #1 between 12/23/13 and 2/7/14. o) During an interview on 2/12/14 at 3:00 p.m., the DON was asked for nursing notes for Resident #1 that appeared to be missing from the resident ' s record. The DON said there were no nursing notes and directed the investigator to read the weekly nursing summaries because that was probably the only documentation during that time period. Nursing notes had been reviewed and observed to be in the record (by the investigator) the previous week. p) During interview on 2/11/14 at 11:10 a.m. Resident #1 said that the staff hurt her bottom this weekend when they were transferring her from the toilet back to her wheelchair. LVN A assessed Resident #1 and found no evidence of trauma. Her skin was clear and intact. q) During an interview on 2/12/14 at 10:55 a.m., the Administrator, DON, and ADON said they should " probably consider " changing Resident #1 from a one-person transfer to a two-person transfer and moving her into a room with a bigger bathroom. 2. a) A Record of admitted d 7/3/13 documented Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. b) An MDS dated [DATE] documented Resident #2 scored 15 of 15 in the Brief Interview for Mental Status indicating she had no cognitive impairment - mild/borderline impairment. She had no symptoms indicating a mood disorder. She had range of motion limitations in both lower extremities and used a wheelchair for mobility. She had no history of falls. c) An Incident/Accident report dated 1/24/14 at 1:15 p.m. documented, " During transport from Dr. appt. (appointment), driver hit his brakes and resident went forward out of her chair, landing on right leg/arm. W/C (wheelchair was locked into van and resident ' s leg was on unlock button. This writer and CNA (sentence not finished.) Type of injury was 2.1 cm skin tear to right forearm. The incident report documented the resident was sent to the hospital by ambulance. Under, " Additional comments and/or steps taken to prevent recurrence " staff documented, " Driver will make sure seat belt restraint is secure. " d) Nurse ' s notes revealed the following: -1/24/14 at 1745 (5:45 p.m.) documented Resident #2 returned from the hospital with a splint to her right wrist, sling to her right arm to be worn 4-5 days. She had no broken bones. She was prescribed medication for pain. Resident #2 was reporting soreness all over that increased with movement. -1/25/14 at 0745 (7:45 a.m.) documented Resident #2 would not get up in her wheelchair as she was sore and hurting. -1/27/14 at 0920 (9:20 a.m.) documented [DIAGNOSES REDACTED], edema and hot to touch to left shin at bruise area. X-ray ordered and Resident #2 was medicated for pain. -1/27/14 at 1151 (11:51 a.m.) documented the X-ray of the tibia and fibula were negative for fracture or dislocation. Moderate upper calf swelling noted by radiologist ... -1/27/14 at 1545 (3:45 p.m.) documented the resident was sent to the hospital for evaluation for possible DVT (deep vein thrombosis) or cellulitis (bacterial skin infection). -1/28/14 0930 and 11:30 (9:30 a.m. and 11:30 a.m.) documented Resident #2 complained of pain. -1/29/14 at 0900, 1200 (9:00 a.m. and 12:00 noon) documented Resident #2 complained of pain with movement. At 1300 (1:00 p.m.) a new bruise noted on left mid inside of arm, 3 cm x 1.5 cm. -1/31/14 at 1100 (11:00 a.m.) documented Resident #2 complained of right wrist soreness, both lower extremities were hot to touch and had 3+ edema (swelling) and were sore when moved. -2/5/14 at 0845 (8:45 a.m.) documented pain was still present in bilateral (both) lower legs. Both calves were still warm to the touch and bruises were still present. -2/7/14 no time: ...Resident complained of right upper shoulder joint pain ... e) physician's order [REDACTED]. 1/24/14: Dx (diagnosis): Contusions from ER; Splint L wrist for 4-5 days; Sling to R arm for 4-5 days; Follow up with doctor 3-5 days or next visit 1/24/14: Norco 5 mg. po (by mouth) Q (every) 6 hours as needed for pain not relieved by Ultram. 1/24/14: Keflex 500 mg TID (three times daily) for 10 days f) Weekly Skin Assessments for Resident #2 revealed the following: -1/16/14: No skin issues identified -1/25/14: 23 x 12 cm red and purple bruise to the back of the upper right arm; 15 x 11 cm bruise with 2- 5 cm skin tears to the back, lower portion of the right arm; 3 x 1 cm purple bruise to the front lower portion of the left leg; 1 x 5 cm blue/green bruise to the left knee; 2 x 1 cm and 1.5 x 1 cm blue/purple bruises to right foot toes; 5.5 x 0.5 cm purple bruise to the right shin; 4 x 3 cm bruise to the right knee; and a 2 x 0.8 bruise to the right knee area. g) A care plan for Resident #2 dated 1/22/14 revealed it included the following: Problem: Needs assistance with the following ADLs (activities of daily living): (none identified). Interventions for this problem included to encourage independence and praise when attempts were made, assist with transfers as needed, assist with repositioning as appropriate, assist with shower, and assist with ADLs as needed. Under a problem identified as do not resuscitate, the care plan identified an intervention for pain medication as ordered by the physician. Under restorative care, the care plan indicated the resident would receive active range of motion. The care plan did not address Resident #2 ' s weakness, risk of falls, or any care related to Resident #2 ' s injuries, pain, or mental anguish resulting from the van accident. h) During a telephone interview on 2/3/14 at 12:05 p.m., the Ombudsman said that she had expressed concern to the Administrator about Resident #2 ' s accident on the van, and had asked the Administrator about her response. The Ombudsman said she told the Administrator that Resident #2 said that the van driver did not secure her seat belt. She said the Administrator acknowledged that the van driver admitted he may not have buckled the resident in correctly, but did not identify any actions she would take. i) During interview on 2/4/14 at 3:30 p.m., the Administrator said that she was not sure what occurred that had caused Resident #2 to come unbuckled and fall from her wheelchair in the van. When discussing whom she had talked to about the incident, she said she talked to the van driver and to the nurse that was called out to the accident and who had completed the incident report. The Administrator did not state that she talked to Resident #2 about what happened. She said that Van Driver A had said that she was buckled in the van and some children walked in front of him and he had to throw on the brakes. She said there was no action taken following the incident except to tell the van driver to be sure residents were buckled in the van. The Administrator acknowledged that the van driver was her brother. The Administrator acknowledged that the incident report and nurse ' s note was the only documentation related to the incident. She had not documented any interviews or other actions related to the incident. j) During interview on 2/6/14 at 1:10 p.m., Van Driver A said that he thought he had Resident #2 buckled into the van appropriately. He was taking her to a physician appointment. He said some school children stepped out in front of him and he hit the brakes. He said Resident #2 fell out of her wheelchair and her seat belt was completely unbuckled. Van Driver A said, " You know some residents remove the seat belt themselves. " When asked to elaborate, he could not describe any time that this had occurred. k) During interview on 2/6/14 at 1:35 p.m., Resident #2 said that she remembered the incident very clearly. Resident #2 said that, although she was losing her physical health, her memory was as sharp as it ever was. She said that Van Driver A did not buckle her seat belt at all. She said he just laid it across her lap. She said she was very nervous when she realized that he was not going to buckle her in, but figured the trip was a short one, so she would be alright. She said he threw on the brakes and she fell forward, onto the metal bottom of the van. She said her knees hit the metal that was the floor, and her hands hit the back of the front seats when she tried to protect herself from hitting the metal that was also on the back of the seats, and this was when she hurt her wrist. She said he also had not anchored one side of the wheelchair to the van and one side of the wheelchair fell forward on top of her. She said she lay there in pain for what seemed like a long time while he called someone from the nursing home to come help him get her up. She said she did not understand why he just did not call paramedics. She said she did not think she needed to go to the hospital but after her family was informed, they wanted her to go. l) During an interview on 2/12/14 at 4:00 p.m., Resident #2 ' s daughter said she was very upset about the incident in the van. She said that her mother told everyone what happened and yet did not receive any acknowledgement or apology from the van driver about his error that had caused Resident #2 so much pain and mental anguish. Resident #2 ' s daughter said that the day of the accident, the facility expected Resident #2 to get back in the van and ride home from the hospital after treatment. Resident #2 ' s daughter said they had no choice, but she rode in the van with her mother to ensure she was safe. Resident #2 ' s daughter said that Resident #2 had been deteriorating physically for a while and she thought the deterioration was avoidable, and this accident would only add to the resident ' s continued deterioration due to her extreme fear of falling now. She said Resident #2 did not receive restorative care as identified in the care plan. She said Resident #2 had come in to the facility using a walker and getting around pretty well, but now she was in a wheelchair, spent more time in bed, and required a Hoyer lift for transfers. m) During observation and interview on 2/6/14 at 6:53 a.m., CNAs A and C were transferring Resident #2 from bed to wheelchair with the Hoyer (mechanical) lift. NA A was operating the Hoyer lift and CNA A was behind the resident ' s wheelchair to guide her into the chair. As NA A began to lower Resident #2 into the chair, she released the Hoyer ' s mechanism for lowering and lowered the resident quickly, which did not give time for CNA A to guide the resident into the middle of the seat of the chair. Resident #2 was not centered and hit the back of the wheelchair, causing the wheelchair to go up on the two back wheels temporarily until CNA A shifted the resident ' s weight forward. When discussing whether they could control the speed of the Hoyer when lowering the resident, CNA A said that it could be released slower. 3. a) Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. b) An MDS assessment for Resident #3 dated 12/20/13 documented the brief interview for mental status was not completed. The mood interview was not completed. There were no indicators of psychosis and no behavioral symptoms. The MDS documented that Resident #3 was totally dependent on the assistance of one staff for dressing, toilet use, personal hygiene, and toilet use. She was always incontinent of bowel and bladder. The MDS documented Resident #3 was 91 inches tall (which was an error) and weighed 86 pounds. c) Incident reports, nurse ' s notes, and a physician ' s note revealed the following information regarding injuries to Resident #3: -1/28/14 at 1500 (3:00 p.m.): During entry to room, R hand hit door jam (sic) causing 3 x 1 cm purple bruise to R 4th finger. The incident report did not name the staff member involved. Under the section heading, " Additional comments and/or steps taken to prevent recurrence " the form was blank. The incident report was signed by the DON and Administrator. -1/23/14 at 2200 (10:00 p.m.): Res c/o (complaining of) pain to R arm from wrist to shoulder. Grimaces upon touching arm. 9 cm x 7 cm purple bruise noted to R FA (right forearm). There was no incident report for the injury described in this nurse ' s note. -1/17/14 at 12:00 p.m.: Resident told daughters that CNA caught her finger between the wall and chair when placing her at the table for lunch. Bruising noted in-between fingers on resident ' s right hand. Under, " Additional comments and/or steps taken to prevent recurrence " the DON documented, " Counseled Aide on transferring carefully. " -A physician ' s note dated 1/11/14 included the following: " Patient ' s son noticed that her left hand was swollen 7 days ago. The swelling continues through the hand. Patient denies any decrease in range of motion and pain. There is no history of trauma. " -1/10/14 at unknown time: Resident was being transferred from bed to chair. Bruises found on L lower extremity 6 x 1 cm, and R lower extremity 17 x 8 cm. (Picture diagram showed the bruises on the back, outer calf. Resident states girls are grabbing her tightly when moving. No CNA witnesses were named on the incident report. Under, " Additional comments and/or steps taken to prevent recurrence " the form was blank. The incident report was signed by the previous DON. The Administrator did not sign the incident report in the space designated for her signature. -Nurse ' s note on 1/10/14 at 0720 (7:20 a.m.) documented the CNA (not identified) called LVN A to the resident ' s room and bruises were reported to both shins and a small bruise was on her L buttocks. -Nurse ' s note on 1/10/14 documented at 11:00 a.m. that bruises were observed to Resident #3 ' s lower extremities and the resident stated staff were rough when moving her. d) During an interview on 2/10/14 at 11:00 a.m., the DON said there was a care plan meeting on 1/29/14. The MDS Coordinator stated the care plan was held but had not been written or entered in the record. e) Resident #3 ' s care plan included a cover page with signatures of the care team dated 1/29/14, but the only care plan in the record was the Admission care plan dated 12/13/13. The Admission Care Plan documented that Resident #3 required " full assistance " with dressing, grooming, and transferring. The care plan did not address the multiple injuries Resident #3 had sustained between 1/10/14 and 1/28/14. f) During an interview on 2/4/14 at 10:00 a.m., LVN A said that she was the charge nurse for all halls and residents. She said the CNAs/nurse aides were transferring Resident #3 in ways that were injuring Resident #3, including " cradling " her and hitting her legs on the side rails of the bed. LVN A said she told the aides to start using two people to transfer her, but she did not know if they changed to two persons or not. She said she never had time to check. LVN A said the nurse ' s aides were not trained in transferring skills and no one was monitoring what the aides were doing in the resident rooms. g) During an interview on 2/4/14 at 11:15 a.m., Resident #3 was interviewed with an interpreter, since she spoke Spanish only. Resident #3 denied memories of any specific details about how she received the injuries identified above except to say she did not want to talk bad about the workers, but they grab her too hard. h) During an interview on 2/4/14 at 2:10 p.m., NA (Nurse Aide) A said she worked with Resident #3 but did not know how Resident #3 was getting injured. When discussing how they transfer Resident #3, she said, " We arm and leg her. " She explained that meant that two of them support the resident under the arms while placing their arms under her upper legs as in a sitting position. NA A said she had not received any training on transferring residents other than another CNA. She said the facility had never checked her skill. i) During an interview on 2/4/14 at 2:20 p.m. NA B said she worked with Resident #3 and could be partially responsible for the injuries to Resident #3. She said Resident #3 was hard to transfer because her legs were very limp and would hit objects like the side rails. NA B said they were using two people to transfer the resident now. NA B said she did not have any training to transfer residents, other than from other nurse aides, and her skills had never been evaluated by the facility. j) During an interview on 2/4/14 at 3:30 p.m., the Administrator said that she could not locate an incident report for the injury identified in the nurse ' s note dated 1/23/14. When discussing the incident reports and injuries, the Administrator said she thought the staff were told to be more careful when transferring Resident #3, but stated, " I ' d be lying if I told you we talked to each aide, I don ' t know. " The Administrator said she did not know how the staff were transferring Resident #3. She said she had not investigated to determine the potential causes of the injuries and referred the investigator to the ADON. k) During interview on 2/4/14 at 4:30 p.m., the DON and ADON said that they were aware Resident #3 had alleged that staff were being rough with her. The DON and ADON said that they had not addressed the injuries (multiple bruises) to prevent re-occurrence. 4. a) A Record of Admission sheet for Resident #4 dated 7/13/12 documented he was a [AGE] year-old male admitted to the facility 10/14/05 with [DIAGNOSES REDACTED]. b) An MDS assessment for Resident #4, dated 1/25/14 documented that he used a wheelchair for mobility. c) A Care Plan for Resident #4 dated 11/20/13 documented that Resident #4 could not ambulate without extensive assistance. The Care Plan documented that Resident #4 required the assistance of one staff for transfers and other ADL activities. d) An incident report dated 1/19/14 at 7:30 a.m. documented the resident stood up to be transferred from a shower chair to a wheelchair and started to sit down before the chair was placed correctly. He slid down to the floor and no injuries were noted. There were no witnesses identified on the incident report. Under the section, " Additional comments and/or steps taken to prevent recurrence " there was no entry. The Director of Nurses and the Administrator signed the incident report. They did not date their signature. An attached statement by CNA C with no date documented that she was giving the resident a shower and a student CNA was with her. She

Based on observation, interview and record review the facility Administrator, DON and ADON failed to manage the facility in a manner that utilized its resources effectively and efficiently to attain the highest practicable physical, mental and psychosocial well-being for 5 of 11 sampled residents reviewed for accidents and injuries as evidenced by: A) Failure of the Administrator, who was the Abuse and Neglect Coordinator for the facility, to implement the facility ' s Abuse and Neglect Policies and Procedures to thoroughly investigate and report allegations of abuse and neglect for Residents 1, 2, 3, 4, and 5 and to ensure residents and staff were free to report allegations without fear of retaliation; B) Failure of the Administrator, DON, and ADON to follow-up on incidents and accidents to identify risks and hazards for Residents #1, 2, 3, 4, and 5 and to implement measures to prevent future accidents; C) Failure of the Administrator, DON, and ADON to train and monitor/supervise all certified nurse ' s aides and non-certified nurse ' s aides to ensure competency of skills, attention to resident care tasks such as call lights, and adherence to abuse and neglect polices for the safety of the residents. Failure of the Administrator, DON and ADON to show respect for residents and ensure all other staff also respected residents. On [DATE] at 12:15 p.m., an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to actual harm at a pattern on [DATE] at 2:00 p.m. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The failure of Administrative Staff to effectively manage the resources of the facility resulted in actual harm to Residents #2 and 4 and could lead to abuse, neglect, accidents, and injuries to residents. The facility reported 41 residents that required assistance with dressing, 32 residents that required assistance with transferring, 36 residents that required assistance with toilet use, and 31 residents that were in the chair most of the time. Findings included: A and B: Resident #1 1) The Record of Admission Sheet for Resident #1 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 2) Incident/Accident reports, physician notification forms and change of condition forms for Resident #1 revealed Resident #1 sustained a hematoma to the right forearm on [DATE]; a skin tear to the left upper forearm on [DATE]; redness and irritation around her buttocks from being left on a bedpan for approximately four hours on [DATE]; a 1 cm puncture to her scalp during a transfer on [DATE]; and sustained a bruise to her right elbow during a transfer on [DATE]. 3) During an interview on [DATE] at 3:30 p.m., the Administrator said that she was the Abuse and Neglect Coordinator for the facility and had not initiated investigations into Resident #1 ' s injuries. She also was not aware of any interventions the facility had implemented to address the risks and hazards that were contributing to Resident #1 ' s injuries. 4) During interview with the DON (Director of Nurses) and ADON (Assistant Director of Nurses) on [DATE] at 4:30 p.m., they said they did not look at Resident #1 when the incident with the bedpan occurred. When discussing actions taken following the incident, the DON said, " I think we discussed no more bedpan use. " The ADON and DON said they had no evidence of any determinations regarding the cause of accidents or any actions taken on the incidents for Resident #1 to prevent re-occurrence of injuries during care and transfers. When discussing Resident #1 ' s multiple complaints about staff not responding to her call light and being rough with her, the DON and ADON said they knew nothing about it, but acknowledged they knew that Resident #1 seemed afraid to talk to them about the incidents. Resident #2 5) A Record of admitted d [DATE] documented Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 6) An MDS dated [DATE] documented Resident #2 scored 15 of 15 in the Brief Interview for Mental Status indicating she had no cognitive impairment - mild/borderline impairment. She had no symptoms indicating a mood disorder. She had range of motion limitations in both lower extremities and used a wheelchair for mobility. She had no history of falls. 7) An Incident/Accident report dated [DATE] at 1:15 p.m. documented, " During transport from Dr. appt. (appointment), driver hit his brakes and resident went forward out of her chair, landing on right leg/arm. W/C (wheelchair was locked into van and resident ' s leg was on unlock button. This writer and CNA (sentence not finished.) Type of injury was 2.1 cm skin tear to right forearm. The incident report documented the resident was sent to the hospital by ambulance. Under, " Additional comments and/or steps taken to prevent recurrence " staff documented, " Driver will make sure seat belt restraint is secure. " 8) Weekly Skin Assessments for Resident #2 revealed the following: [DATE]: No skin issues identified [DATE]: 23 x 12 cm red and purple bruise to the back of the upper right arm; 15 x 11 cm bruise with 2- 5 cm skin tears to the back, lower portion of the right arm; 3 x 1 cm purple bruise to the front lower portion of the left leg; 1 x 5 cm blue/green bruise to the left knee; 2 x 1 cm and 1.5 x 1 cm blue/purple bruises to right foot toes; 5.5 x 0.5 cm purple bruise to the right shin; 4 x 3 cm bruise to the right knee; and a 2 x 0.8 bruise to the right knee area. 9) During interview on [DATE] at 3:30 p.m., the Administrator said that she was not sure what occurred that had caused Resident #2 to come unbuckled and fall from her wheelchair in the van. She said she did not talk to the resident and she did not report the incident to the State. 10) During interview on [DATE] at 1:35 p.m., Resident #2 said that she remembered the incident very clearly. Resident #2 said the van driver did not buckle her seat belt and he did not attach the wheelchair to the van on one side, which caused her to fall forward with great force when he slammed on the brakes. Resident #3 11) Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 12) An MDS assessment for Resident #3 dated [DATE] documented that Resident #3 was totally dependent on the assistance of one staff for dressing, toilet use, personal hygiene, and toilet use. 13) Incident reports, nurse ' s notes, and a physician ' s note revealed Resident #3 sustained injuries (bruises) on both calves, both shins, and her buttock that were identified on [DATE], and the resident complained that the staff were grabbing her too tightly; swelling of her left hand identified [DATE]; bruising between the fingers of her right hand when the CNA hit her hand between the wall and the chair on [DATE]; a large bruise to her right forearm on [DATE] that was of unknown origin; and a bruise to her right 4th finger on [DATE] sustained when her right hand it the door jamb. 14) During an interview on [DATE] at 3:30 p.m., the Administrator said that she could not locate an incident report for the injury identified in the nurse ' s note dated [DATE]. When discussing the incident reports and injuries, the Administrator said she thought the staff were told to be more careful when transferring Resident #3, but stated, " I ' d be lying if I told you we talked to each aide, I don ' t know. " The Administrator said she did not know how the staff were transferring Resident #3. She said she had not investigated to determine the potential causes of the injuries and referred the investigator to the ADON. 15) During interview on [DATE] at 4:30 p.m., the DON and ADON said that they were aware Resident #3 had alleged that staff were being rough with her. The DON and ADON said that they had not addressed the injuries (multiple bruises) to prevent re-occurrence. Resident #4 16) A Record of Admission sheet for Resident #4 dated [DATE] documented he was a [AGE] year-old male admitted to the facility [DATE] with [DIAGNOSES REDACTED]. 17) An MDS assessment for Resident #4, dated [DATE] documented that he used a wheelchair for mobility. 18) A Care Plan for Resident #4 dated [DATE] documented that Resident #4 could not ambulate without extensive assistance. The Care Plan documented that Resident #4 required the assistance of one staff for transfers and other ADL activities. 19) An incident report dated [DATE] at 7:30 a.m. documented the resident stood up to be transferred from a shower chair to a wheelchair and started to sit down before the chair was placed correctly. He slid down to the floor and no injuries were noted. An attached statement by CNA C with no date documented that she was giving the resident a shower and a student CNA was with her. She documented she was getting the resident ' s chair and the student was helping the resident stand up. The resident slipped and hit his arm on the rail on the way down. 20) During an interview on [DATE] at 3:30 p.m., LVN B said that she noticed Resident #4 ' s arm was very obviously swollen and had a large bruise on the day following his fall in the shower. She said that she initiated physician notification to get an X-ray. 21) A nurse ' s fax to the physician on [DATE] at 1600 (4:00 p.m.) documented that dark bruising was noted to the underside and armpit of the right arm, and there was a dip at the bicep. At 2245 (10:45 p.m.) the nurses documented that X-ray results showed an acute humerus neck fracture with modest displacement. Resident #4 was sent to the hospital. 22) During an interview on [DATE] at 2:05 p.m., CNA C said there were students in the building on the day of the incident. A student was helping her with Resident #4 in the shower. CNA C said she did not remember who the student was. She said she turned around to get the chair and while her back was turned, the student attempted to help Resident #4 and he slid. She said she did not really know how the resident hurt his arm, but assumed he must have hit it on the rail. 23) During an interview on [DATE] at 1:05 p.m., the Administrator said she did not report Resident #4 ' s fracture to the State as an allegation. She said she never called accidents in to the State if there was a witness stating, " I thought I didn ' t have to. " 24) During an interview on [DATE] at 3:30 p.m., the Administrator said she reviewed the incident and determined that it was just an accident and there was no need to take any actions other than to talk to CNA C. She did not thoroughly investigate the incident or report the incident to the State. Resident #5 25) A Record of Admission sheet dated [DATE] documented Resident #5 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 26) A discharge summary documented Resident #5 was discharged home with her spouse on [DATE]. 27) An MDS dated [DATE] documented Resident #5 had hallucinations, no behavioral symptoms, transferred herself independently, was ambulatory, and required only supervision for dressing, eating, and toilet use. She was frequently incontinent of urine and occasionally incontinent of bowel. 28) Incident reports, nurse ' s notes, a physician ' s note, and skin assessments revealed Resident #5 sustained an abrasion and a bruise after getting stuck in a door on [DATE]; a bruise and a knot on her forehead of unknown origin on [DATE]; multiple bruises to her leg when her leg got stuck in the side rail of her bed on [DATE]; and multiple bruises to her face and body described on a weekly skin assessment [DATE] that were not accounted for in incident reports and nurse ' s notes. 29) During an interview on [DATE] at 2:30 p.m., the Administrator said that she talked to the resident ' s roommate and the resident ' s husband to try and find out what happened to Resident #5 ' s forehead. She said they did not know anything and she did not make any other attempts to find out what happened. She said she did not know if there were any actions taken to prevent accidents for Resident #5. REFER TO F225 and F323 FOR ADDITIONAL INFORMATION C: 32) During a confidential interview on [DATE], Staff member #2 said that the aides were not trained and they were causing residents to get injured. Staff member #2 said that non-certified aides have halls of residents to care for by themselves. Staff member #2 said that nobody (licensed or administrative staff) were watching what was going on in resident rooms. Staff member #2 said the facility ' s administration had been told of the problems related to the un-trained staff and just did not do anything about it. Staff member #2 said the nurse aides were not monitored or supervised and often, " sat around and talked and smoked " when on duty. Staff member #2 said that when the residents made any complaints, the Administrator dismissed the complaints and told the residents that the staff were just doing the best they could. Staff member #2 said if complaints and/or allegations got to the Administrator, that was where they stopped. 33) During an interview on [DATE] at 11:50 a.m., Resident #1 said the some of the young aides were rough with her, but she was scared to report them because she was afraid they would retaliate against her. She said they were, " downright hateful at times. " She said they staff were a " clique " and would gang up against the resident. 34) During interview on [DATE] at 3:30 p.m., when discussing that Resident #1 had been left on a bedpan for most of the night on [DATE], the Administrator did not voice concern, stating, " The aide must have got busy. " The Administrator also stated the resident should have used her call light. When informing her that Resident #1 ' s call light was found on the floor that morning so she could not have called for help, the Administrator said she was unaware of that. 35) During interview on [DATE] at 4:30 p.m., the ADON and DON acknowledged that when Resident #1 was left on the bedpan [DATE] and sustained a reddened area on her buttocks, neither of them assessed the resident. The DON said she looked at her a couple of days later. 36) During a confidential interview on [DATE], Staff #1 said the aides were not trained. Staff #1 said, " We have a lot of warm bodies but not caring hearts. " Staff #1 said the aides were insubordinate and did what they wanted with no consequences for doing poor jobs or not doing their jobs. Staff #1 said that incidents were reported by residents and that was how they came to light, but were not reported by the staff that had knowledge. Staff #1 said that things were " swept under the rug. " Staff #1 said that residents and staff did not report or complain because there was retaliation from reporting. 37) During an interview on [DATE] at 3:00 p.m., Resident #7, she said that sometimes when she turned on her call light and did not get an answer, she could hear the staff at the nurse ' s station " giggling and going on " while she waited long periods of time. Resident #7 ' s room was located near the nurse ' s station. Resident #7 said that when she made complaints, the staff (licensed nursing staff) treated her like she was " senile " and told her that she could just call the State. 38) During an interview with Resident #2 and her daughter on [DATE], Resident #2 ' s daughter said that she had seen call lights going off on all the halls while staff were at the nurse ' s station talking and giggling. She said that at times she had been so concerned about the residents that she would go around and peek in the rooms just to make sure that the residents whose lights were on were not hurt or lying on the floor. Resident #2 ' s daughter said that Resident #2 was also afraid of making complaints for fear of retaliation from direct care staff. 39) During interview on [DATE] at 2:10 p.m., NA A said she had been working at the facility a year and was trained for her job by another CNA. She said she had not been in a CNA class but performed the same care for residents that CNAs did, such as turning, transferring, and feeding residents. 40) During interview on [DATE] at 2:20 p.m., NA B said she had not received any formal training for her job. She said she was taught by CNAs. When discussing whether Administrative staff monitored her while caring for residents, she said that a previous employee had, but not now so much. 41) During interview on [DATE] at 2:50, CNA G said that she did not think abuse and neglect was occurring in the facility, but added that she did not think the residents got the attention they deserved. When discussing whether licensed or administrative staff monitored resident care by direct care workers, she said there were two nurses that popped in occasionally. When discussing whether the administrative staff addressed problems when staff were not doing their jobs, CNA G said, " No, not really. " 42) The Personnel files for NAs A, B, C, D, and E documented they had each been working in their positions over four months and there was no record that these staff had completed a training and competency evaluation approved by the State (except NA D whose certification expired in 2010). 43) During an interview on [DATE] at 9:00 a.m., the Administrator said she was aware that she was in violation of regulations by employing non-certified staff. She said the facility had just had " barriers " to providing certification classes. She said the ADON was going to start providing orientation " this week. " She said she knew she had been losing staff because they were not properly trained. SEE F225, F323, F494, and F498 FOR ADDITIONAL INFORMATION. 44) On [DATE] at 12:15 p.m. the Administrator, DON, and ADON were notified of the Immediate Jeopardy that had been identified with regard to Residents #1, 2, 3, and 4. 45) The facility submitted the following corrective action plan of removal: -A full head to toe skin assessment was completed on all residents to assess for skin issues, including bruises or any other injury. Completed [DATE] -In-Service on Abuse/Neglect for all staff. Completed [DATE] -In-Service on answering call lights for all staff. Completed [DATE] -In-Service on Transfers of all types for direct care staff, with return demonstration included. Completed [DATE]. -In-Service on Incident Reports for Licensed nurses. Completed [DATE] -In-Service on dignity and respect when caring for and communicating with residents. Completed [DATE] -Interview of 100% of residents who have been transported in the van for the last 4 months to evaluate their experience/safety. Completed [DATE]. -Interview of 100% of residents in the facility regarding staff treatment. Completed [DATE] -Office Manager will go to the van and check that belts are buckled and chair secured properly by the van driver x 3 months. A log will be kept. Initiated [DATE]/Ongoing. -In-Service the Van Drivers on the importance of securing seatbelts prior to transporting. Completed [DATE]. -DON will record all incident/accident reports on a worksheet and bring to the morning meeting daily. Department heads will determine what interventions need to be done to prevent future accidents. Initiated [DATE] and ongoing. -Tracking and Trending of incident/accidents implemented. [DATE] -Department heads in-serviced on abuse policy, what to report, how to investigate unexplained injuries, how to do a thorough investigation. New forms provided. Completed [DATE]. -Federal requirement F323 was reviewed with the Department Heads in the morning meeting on [DATE]. Completed [DATE] 46) Plan of removal verification: -Interviews were conducted with staff to verify in-service participation and the participant's understanding of information discussed. -Interview with the Administrator to discuss and review results of 100% interviews of residents -Review of documentation of skin assessments for all residents -Review of incidents recorded and facility ' s actions between identification of Immediate Jeopardy and lifting of Immediate Jeopardy -Interviews with sampled residents and random residents regarding safety during care by nurse aides 47) During a conference on [DATE] at 2:00 p.m., the facility was notified that the Immediate Jeopardy was lowered to actual harm at the scope of a pattern as when the action plan was fully implemented. 48) The CMS 672 form (undated), provided by the facility on [DATE] documented 41 residents that required assistance with dressing, 32 residents that required assistance with transferring, 36 residents that required assistance with toilet use, and 31 residents that were in the chair most of the time.

Based on observation, interview, and record review, the facility failed to implement Abuse and Neglect Prevention policies and procedures to ensure that all alleged violations involving neglect and injuries of unknown source were thoroughly investigated and immediately reported to the Administrator of the facility and to other officials in accordance with state laws for 5 of 11 residents reviewed for accidents and injuries as evidenced by: -failure to thoroughly investigate and report when Resident #1 sustained red, irritated skin around her buttocks from laying on a bed pan for most of the night on 12/17/13 and when she received a puncture wound to her head on 1/17/14; -failure to thoroughly investigate and report when Resident #2 was not restrained by a seat belt in the facility ' s van on 1/24/14 and sustained multiple bruises. She was required to wear a splint on her right wrist and a sling to her right arm. Resident #2 had decreased mobility, soreness, and pain; -failure to thoroughly investigate and report when Resident #3 made an allegation on 1/10/14 that staff were rough with her and was observed to have bruises on both calves, both shins and her buttocks; when observed by family and the physician to have a swollen hand on 1/11/14; and when a bruise to her forearm was observed on 1/23/14; d) failure to thoroughly investigate and report when Resident #4 sustained a fracture to his right humerus (upper arm); and -failure to thoroughly investigate and report injuries when Resident #5 got stuck in a door on 12/19/13; when she sustained an injury of unknown origin (bruise and knot on her forehead) on 12/30/13; and when she sustained multiple bruises from getting stuck in a bed rail on 1/2/14. On 2/5/14 at 12:15 p.m., an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to actual harm at a pattern on 2/7/14 at 2:00 p.m. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The failure to implement policies and procedures to thoroughly investigate accidents, injuries, and allegations of abuse and neglect involving caregivers could result in residents being abused and neglected in the facility. The facility reported 41 residents required assistance with dressing, 32 required assistance with transferring, 36 required assistance with toilet use, and 31 were in the chair most of the time. Findings included: 1. The Administrator provided a copy of the facility ' s undated Abuse Prevention Program Policies and Procedures on 2/4/14. This policy included the following: Under, " Policy Interpretation and Implementation " : " Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the administrator, or his/her designees, will appoint a member of management to investigate the alleged incident. The administrator will provide to the person in charge of the investigation a completed copy of the Resident Abuse Report Form and any supporting documents relative to the alleged incident. The individual conducting the investigation will, at a minimum: -Review the completed Resident Abuse Report Form -Review the resident ' s medical record to determine events leading up to the incident -Interview the persons reporting incident -Interview any witnesses to the incident -Interview the resident (as medically appropriate) -Interview the resident ' s attending physician to determine the resident ' s current mental status -Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident -Interview the resident ' s roommate, family members and visitors -Interview other residents to whom the accused employee provides care or services -Review all events leading up to the alleged incident " . Under, " Reporting Abuse to Facility Management " : " When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse is reported, the facility administrator, or his/her designees will notify the following persons or agencies of such incident: a. The Department of Human Services in Austin ... " " All personnel, residents, family members, visitors, etc., are encouraged to report incident of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff. " Under, " Accidents and Incidents " : " All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. -The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident " . Under, " Investigating Unexplained Injuries " : - " Should a resident be observed with unexplained injuries (including bruises, abrasions, and injuries of an unknown source), the nurse supervisor on duty must complete an accident/injuries form and record such information in the resident ' s clinical record. -A listing of all personnel, including consultants, contract employees, visitors, family member, etc., who have had contact with the resident during the past 48 hours will be compiled and provided to the person conducting the investigation. -The investigation will follow the protocols set forth in our facility ' s established abuse investigation guidelines ... " Under, " Recognizing Signs and Symptoms of Abuse/Neglect " : " Signs of Actual Physical Abuse: *Welts or bruises *Abrasions or lacerations; *Fractures, dislocations or sprains of questionable origin ... Signs of Actual Physical Neglect: ... *Inadequate provision of care; Caregiver indifferent to resident ' s personal care and needs ... " 2. a) The Record of Admission Sheet for Resident #1 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. b) A Minimum Data Set (MDS) Assessment for Resident #1 dated 1/19/14 documented the resident had clear speech, was easily understood and could understand others. The interview for mental status was not completed. The Resident Mood Interview was not completed. The MDS documented Resident #1 was totally dependent on the assistance of one person to transfer between surfaces, for toileting, dressing, and personal hygiene. She had range of motion limitations/impairment on both lower extremities. She was not steady during surface-to-surface transfer. She was frequently incontinent of bladder and bowel. She used a wheelchair for mobility. c) A Nursing Summary dated 2/9/14 documented Resident #1 ' s cognitive skills were modified independence. d) Incident reports for Resident #1 included the following incidents: -1/17/14 0930-1200: Resident states CNA (certified nurse ' s aide) was transferring resident. States CNA slipped her hold and resident hit her head. She has a 1 cm (centimeter) puncture mark on scalp. The section of the incident report with the heading, " Additional comments and/or steps taken to prevent recurrence " was blank. The incident report was signed by the Director of Nurses (DON) and Administrator. (Signatures were not dated). -12/17/13 1:30 a.m. - CNA A removed resident from bedpan at approximately 0545 (5:45 a.m.). Resident has red marks from bedpan. Resident states she was put on it at 1:30 a.m. (Redness was drawn in a circle on the diagram of the person ' s bottom with measurements of 13 x .5 cm, 7 x 2 cm, 15.5 x 13 cm, and 7 x 3.5 cm. The section of the incident report with the heading, " Additional comments and/or steps taken to prevent recurrence " revealed, " Remind CNAs to check resident as she fell asleep on bedpan. " The incident report was signed by the DON previously employed by the facility. The Administrator did not sign the report in the section labeled for her signature. e) A care plan dated 4/19/13 and updated 2/5/14 (two days following the initiation of this investigation) included a problem of impaired mobility related to disease process from Parkinson ' s and spinal stenosis. Interventions included to exercise caution during transfers and handling due to fragile skin and to provide protective coverings to arms and legs. A problem identified as dressing and grooming deficit had interventions including teaching the resident to use the call light for assistance. Under the problem of toileting deficit, interventions included perineal care after each episode of incontinence, and reduce stress as much as possible to decrease incontinence. Under a problem of depression, interventions included assessing for symptoms of depression (sadness, hopelessness, anxiety, tearfulness, etc.). Under a problem of risk for falls, the interventions included keeping the environment free from obstructions. The care plan did not include any specific interventions to address the multiple injuries (bruises and head wound) sustained during CNA assistance with transfers, such as any change in the amount of support provided the resident or addressing the issues that resulted in multiple injuries occurring in the resident ' s bathroom when hitting her on the hand rails while transferring her to the toilet. The care plan did not include any past interventions for use of a bed pan. f) During an interview on 2/4/14 at 11:50 a.m., Resident #1and her daughter were present. Resident #1 was a soft spoken female who was oriented to person and place. Resident #1 ' s daughter said that she was the one who found and identified the head wound. They stated that the CNA who was caring for Resident #1 the night this injury occurred (CNA B) was now gone. Resident #1 said that CNA B was very mean to her. She said that when CNA B helped her to transfer, the CNA would tell the resident she was not allowed to touch the CNA to hold on. Resident #1 said that some of the young CNAs that worked there were rough and rude to her. She said they were, " downright hateful at times. " Resident #1 said she was afraid these same staff would retaliate against her if she complained about them. She stated, " You ' re at their mercy. " Resident #1 said the nurse aides were a " clique " and, " would gang up against you. " Resident #1 said there were only a few staff members that she trusted. Resident #1 said many injuries occurred in her restroom because she often hit herself on the hand rails. She said the restroom was small and when a staff member was in there assisting her, there really was not room for them to both move around safely. Resident #1 said the head injury occurred in the restroom. She said the CNA assisting her lost control of her and she hit her head on the hand rails. When discussing that she was left on the bedpan, Resident #1 said she was told to use a bedpan by the staff because they told her it was better and would keep her from falling. She said she did not like using a bedpan because she had a harder time urinating on the bedpan. She said that the CNA placed her on the bedpan and left her there all night, and she fell asleep on it. Resident #1 said she was in a lot of pain when she woke up. Resident #1 said that the staff, especially at night, did not answer her call light and often left her call light out of her reach so she could not call for help. Resident #1 said she had not complained for fear of retaliation from the nurse ' s aides. Resident #1 ' s daughter stated that Resident #1 ' s bottom looked awful after being left on the bedpan. She said she was so concerned that she took pictures. She said she also talked to the administrator about her concerns. g) During an interview on 2/4/13 at 2:35 p.m., CNA A said that Resident #1 was correct in that it did not appear that CNA B liked Resident #1. CNA A said that when she came on duty early in the mornings, she would find Resident #1 " soaked " after CNA B ' s shift. She said there were times when she came to work early and would see Resident #1 ' s call light on. A half hour later when she clocked in to work, she would notice Resident #1 ' s call light was still on and had never been answered by the previous shift. CNA A said that she found Resident #1 on the bedpan, and her call light was lying on the floor. She said Resident #1 had a large red ring where the bedpan was, and she complained of pain. CNA A said she reported it to the nurse on duty, but no one else had really asked her about it. h) During an interview on 2/4/14 at 10:15 a.m., LVN (licensed vocational nurse) A said that she was the nurse on duty when CNA A reported to her that Resident # 1 was found on the bedpan. She said that Resident #1 ' s bottom was very red and that it would have blistered if she had stayed on it much longer. LVN A said she documented everything in a nurse ' s note, change of condition report, and incident report and gave the incident report to the DON. She did not recall an investigation by facility administration or being interviewed regarding her knowledge of the incident. i) During an interview on 2/4/13 at 3:30 p.m., the Administrator said that she was the Abuse and Neglect Coordinator for the facility. She said that if any of the incident reports were investigated by the nurses, the investigations would be attached to the incident reports. The Administrator said that she did not investigate the above incidents as allegations of neglect. She said she fired CNA B (who she thought was responsible for the resident ' s head injury), not because of neglect, but because of multiple problems with the CNA. She said she was not aware that CNA B was not the CNA named as being on duty the day that Resident #1 ' s head injury was identified. She said she guessed she had never looked at the incident report to see that NA A was on duty that day. She said she never spoke with NA A about it. She said that she also did not investigate the incident when Resident #1 was left on a bedpan for most of the night. The Administrator said she did not know what staff was on duty or who was responsible. She said she did not talk to the staff to find out. She said she just figured the staff got busy and forgot to go back and check on the resident. She said the resident should have used her call light. When discussing that the resident ' s call light was found on the floor that morning, the Administrator said she was not aware of that. The Administrator acknowledged she should have investigated the incidents as neglect and reported the incidents to the State. j) During interview with the DON and ADON (Assistant Director of Nurses) on 2/4/14 at 4:30 p.m., they said they did not look at Resident #1 when the incident with the bedpan occurred. The ADON said she was on vacation at the time, and the DON said she did not look at the resident until several days later. When discussing why the resident was on a bedpan, they said that Resident #1 had asked for a bedpan. When discussing whether they had asked the resident what happened, they said that she complained, but appeared to be afraid to give details. They said one of the staff was terminated (CNA B) and another was moved to a different shift. When discussing actions taken following the incident, the DON said, " I think we discussed no more bedpan use. " When discussing Resident #1 ' s multiple complaints about staff not responding to her call light and being rough with her, the DON and ADON said they knew nothing about it. k) Nurse ' s notes revealed no entries for Resident #1 between 12/23/13 and 2/7/14. l) During an interview on 2/12/14 at 3:00 p.m., the DON was asked for nursing notes that appeared to be missing from the resident ' s record. The DON said there were no nursing notes and directed the investigator to read the weekly nursing summaries because that was probably the only documentation during that time period. Nursing notes had been reviewed and observed to be in the record the previous week. 3. a) A Record of admitted d 7/3/13 documented Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. b) An MDS dated [DATE] documented Resident #2 scored 15 of 15 in the Brief Interview for Mental Status indicating she had no cognitive impairment - mild/borderline impairment. She had no symptoms indicating a mood disorder. She had range of motion limitations in both lower extremities and used a wheelchair for mobility. She had no history of falls. c) An Incident/Accident report dated 1/24/14 at 1:15 p.m. documented, " During transport from Dr. appt. (appointment), driver hit his brakes and resident went forward out of her chair, landing on right leg/arm. W/C (wheelchair was locked into van and resident ' s leg was on unlock button. This writer and CNA (sentence not finished.) Type of injury was 2.1 cm skin tear to right forearm. The incident report documented the resident was sent to the hospital by ambulance. Under, " Additional comments and/or steps taken to prevent recurrence " staff documented, " Driver will make sure seat belt restraint is secure. " d) Nurse ' s notes revealed the following outcomes for Resident #2 as a result of the injuries suffered from falling in the van: -1/24/14 at 1745 (5:45 p.m.) documented Resident #2 returned from the hospital with a splint to her right wrist, sling to her right arm to be worn 4-5 days. She had no broken bones. She was prescribed medication for pain. Resident #2 was reporting soreness all over that increased with movement. -1/25/14 at 0745 (7:45 a.m.) documented Resident #2 would not get up in her wheelchair as she was sore and hurting. -1/27/14 at 0920 (9:20 a.m.) documented [DIAGNOSES REDACTED], [MEDICAL CONDITION] and hot to touch to left shin at bruise area. X-ray ordered and Resident #2 was medicated for pain. -1/27/14 at 1151 (11:51 a.m.) documented the X-ray of the tibia and fibula were negative for fracture or dislocation. Moderate upper calf swelling noted by radiologist ... -1/27/14 at 1545 (3:45 p.m.) documented the resident was sent to the hospital for evaluation for possible [MEDICAL CONDITION] ([MEDICAL CONDITION] or [MEDICAL CONDITION] (bacterial skin infection). -1/28/14 0930 and 11:30 (9:30 a.m. and 11:30 a.m.) documented Resident #2 complained of pain. -1/29/14 at 0900, 1200 (9:00 a.m. and 12:00 noon) documented Resident #2 complained of pain with movement. At 1300 (1:00 p.m.) a new bruise noted on left mid inside of arm, 3 cm x 1.5 cm. -1/31/14 at 1100 (11:00 a.m.) documented Resident #2 complained of right wrist soreness, both lower extremities were hot to touch and had 3+ [MEDICAL CONDITION] (swelling) and were sore when moved. -2/5/14 at 0845 (8:45 a.m.) documented pain was still present in bilateral (both) lower legs. Both calves were still warm to the touch and bruises were still present. -2/7/14 no time: ...Resident complained of right upper shoulder joint pain ... e) physician's order [REDACTED]. -1/24/14: Dx (diagnosis): Contusions from ER; Splint L wrist for 4-5 days; Sling to R arm for 4-5 days; Follow up with doctor 3-5 days or next visit -1/24/14: [MEDICATION NAME] 5 mg. po (by mouth) Q (every) 6 hours as needed for pain not relieved by [MEDICATION NAME]. -1/24/14: Keflex 500 mg TID (three times daily) for 10 days f) Weekly Skin Assessments for Resident #2 revealed the following: -1/16/14: No skin issues identified -1/25/14: 23 x 12 cm red and purple bruise to the back of the upper right arm; 15 x 11 cm bruise with 2- 5 cm skin tears to the back, lower portion of the right arm; 3 x 1 cm purple bruise to the front lower portion of the left leg; 1 x 5 cm blue/green bruise to the left knee; 2 x 1 cm and 1.5 x 1 cm blue/purple bruises to right foot toes; 5.5 x 0.5 cm purple bruise to the right shin; 4 x 3 cm bruise to the right knee; and a 2 x 0.8 bruise to the right knee area. g) A care plan for Resident #2 dated 1/22/14 revealed it included the following: Problem: Needs assistance with the following ADLs (activities of daily living): (none identified). Interventions for this problem included to encourage independence and praise when attempts were made, assist with transfers as needed, assist with repositioning as appropriate, assist with shower, and assist with ADLs as needed. Under a problem identified as do not resuscitate, the care plan identified an intervention for pain medication as ordered by the physician. The care plan did not address Resident #2 ' s weakness, risk of falls, or any care related to Resident #2 ' s injuries, pain, or mental anguish resulting from the van accident. h) During a telephone interview on 2/3/14 at 12:05 p.m., the Ombudsman said that she had expressed concern to the Administrator about Resident #2 ' s accident on the van, and had asked the Administrator about her response. The Ombudsman said she told the Administrator that Resident #2 said that the van driver did not secure her seat belt. She said the Administrator acknowledged that the van driver admitted he may not have buckled the resident in correctly, but did not identify any actions she would take to prevent reoccurrence. The Ombudsman said that she suggested to the Administrator that the incident should be reported to the State as an allegation, and the Administrator told her that since the incident did not occur at the facility it was not a reportable incident. i) During interview on 2/4/14 at 3:30 p.m., the Administrator said that she was not sure what occurred that had caused Resident #2 to come unbuckled and fall from her wheelchair in the van. When discussing whom she had talked to about the incident, she said she talked to the van driver and to the nurse that was called out to the accident and who had completed the incident report. The Administrator did not state that she talked to Resident #2 about what happened. She said that Van Driver A had said that she was buckled in the van and some children walked in front of him and he had to throw on the brakes. She said there was no action taken following the incident except to tell the van driver to be sure residents were buckled in the van. The Administrator acknowledged that the van driver was her brother. The Administrator acknowledged that the incident report and nurse ' s note were the only documentation related to the incident. She had not documented any interviews or other actions related to the incident. When discussing whether DADS (Department of Aging and Disability Services) should have been notified of the incident, the Administrator said, " I probably should have called it in. " j) During interview on 2/6/14 at 1:10 p.m., Van Driver A said that he thought he had Resident #2 buckled into the van appropriately. He was taking her to a physician appointment. He said some school children stepped out in front of him and he hit the brakes. He said Resident #2 fell out of her wheelchair and her seat belt was completely unbuckled. Van Driver A said, " You know some residents remove the seat belt themselves. " When asked to elaborate, he could not describe any time that this had occurred. k) During interview on 2/6/14 at 1:35 p.m., Resident #2 said that she remembered the incident very clearly. Resident #2 said that, although she was losing her physical health, her memory was as sharp as it ever was. She said that Van Driver A did not buckle her seat belt at all. She said he just laid it across her lap. She said she was very nervous when she realized that he was not going to buckle her in, but figured the trip was a short one, so she would be alright. She said he threw on the brakes and she fell forward, onto the metal bottom of the van. She said her knees hit the metal that was the floor, and her hands hit the back of the front seats when she tried to protect herself from hitting the metal that was also on the back of the seats, and this was when she hurt her wrist. She said he also had not anchored one side of the wheelchair to the van and one side of the wheelchair fell forward on top of her. She said she lay there in pain for what seemed like a long time while he called someone from the nursing home to come help him get her up. She said she did not understand why he just did not call paramedics. She said she did not think she needed to go to the hospital but after her family was informed, they wanted her to go. 4. a) Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. b) An MDS assessment for Resident #3 dated 12/20/13 documented the brief interview for mental status was not completed. The mood interview was not completed. There were no indicators of [MEDICAL CONDITION] and no behavioral symptoms. The MDS documented that Resident #3 was totally dependent on the assistance of one staff for dressing, toilet use, personal hygiene, and toilet use. She was always incontinent of bowel and bladder. The MDS documented Resident #3 was 91 inches tall (which was an error) and weighed 86 pounds. c) Incident reports, nurse ' s notes, and a physician ' s note revealed the following information regarding injuries to Resident #3: -1/23/14 at 2200 (10:00 p.m.): Res c/o (complaining of) pain to R arm from wrist to shoulder. Grimaces upon touching arm. 9 cm x 7 cm purple bruise noted to R FA (right forearm). There was no incident report for the injury described in this nurse ' s note. -A physician ' s note dated 1/11/14 included the following: " Patient ' s son noticed that her left hand was swollen 7 days ago. The swelling continues through the hand. Patient denies any decrease in range of motion and pain. There is no history of trauma. " -1/10/14 at unknown time: Resident was being transferred from bed to chair. Bruises found on L lower extremity 6 x 1 cm, and R lower extremity 17 x 8 cm. (Picture diagram showed the bruises on the back, outer calf). Resident states girls are grabbing her tightly when moving. No CNA witnesses were named on the incident report. Under, " Additional comments and/or steps taken to prevent recurrence " the form was blank. The incident report was signed by the previous DON. The Administrator did not sign the incident report in the space designated for her signature. -Nurse ' s note on 1/10/14 at 0720 (7:20 a.m.) documented the CNA called LVN A to the resident ' s room and bruises were reported to both shins and a small bruise was on her L buttocks. -Nurse ' s note on 1/10/14 documented at 11:00 a.m. that bruises were observed to Resident #3 ' s lower extremities and the resident stated staff were rough when moving her. d) During an interview on 2/10/14 at 11:00 a.m., the DON said there was a care plan meeting on 1/29/14. The MDS Coordinator stated the care plan was held but had not been written or entered in the record. e) Resident #3 ' s care plan included a cover page with signatures of the care team dated 1/29/14, but the only care plan in the record was the Admission care plan dated 12/13/13. The Admission Care Plan documented that Resident #3 required " full assistance " with dressing, grooming, and transferring. The care plan did not address the multiple injuries Resident #3 had sustained between 1/10/14 and 1/28/14. f) During an interview on 2/4/14/ at 10:00 a.m., LVN A said the CNAs/nurse aides were transferring Resident #3 in ways that were injuring Resident #3, including " cradling " her and hitting her legs on the side rails of the bed. LVN A said she told the aides to start using two people to transfer her, but she did not know if they changed to two persons or not. She said she never had time to check. LVN A said the nurse ' s aides were not trained in transferring skills and no one was monitoring what the aides were doing in the resident rooms. g) During an interview on 2/4/14 at 11:15 a.m., Resident #3 was interviewed with an interpreter, since she spoke Spanish only. Resident #3 denied remembering any specific details about how she received the injuries identified above except to say she did not want to talk bad about the workers, but they grab her too hard. h) During an interview on 2/4/14 at 2:10 p.m., NA A said she worked with Resident #3 but did not know how Resident #3 was getting injured. When discussing how they transfer Resident Alvarado, she said, " We arm and leg her. " She explained that meant that two of them support the resident under the arms while placing their arms under her upper legs as in a sitting position. NA A said she had not received any training on transferring residents other than another CNA. She said the facility had never checked her skill. i) During an interview on 2/4/14 at 2:20 p.m. NA B said she worked with Resident #3 and could be partially responsible for the injuries to Resident #3. She said Resident #3 was hard to transfer because her legs were very limp and would hit objects like the side rails. NA B said they were using two people to transfer the resident now. NA B said she did not have any training to transfer residents, other than from other nurse aides, and her skills had never been evaluated by the facility. j) During an interview on 2/4/14 at 3:30 p.m., the Administrator said that she could not locate an incident report for the injury identified in the nurse ' s note dated 1/23/14. She said she was not aware of the injury until the investigator asked. When discussing the incident reports and injuries, the Administrator said she thought the staff were told to be more careful when transferring Resident #3, but stated, " I ' d be lying if I told you we talked to each aide, I don ' t know. " The Administrator said she did not know how the staff were transferring Resident #3. She said she had not investigated to determine the potential causes of the injuries and referred the investigator to the ADON. The Administrator stated she should have called in the bruises and injuries of unknown origin to DADS and should have investigated them. k) During interview on 2/4/14 at 4:30 p.m., the DON and ADON said that they were aware Resident #3 had alleged that staff were being rough with her. The DON and ADON said that they had not addressed the injuries in any way. 5. a) A Record of Admission sheet for Resident #4 dated 7/13/12 documented he was a [AGE] year-old male admitted to the facility 10/14/05 with [DIAGNOSES REDACTED]. b) An MDS assessment for Resident #4, dated 1/25/14 documented that he used a wheelchair for mobility. c) A Care Plan for Resident #4 dated 11/20/13 documented that Resident #4 could not ambulate without extensive assistance. The Care Plan documented that Resident #4 required the assistance of one staff for transfers and other ADL activities. d) An incident report dated 1/19/14 at 7:30 a.m. documented the resident stood up to be transferred from a shower chair to a wheelchair and started to sit down before the chair was placed correctly. He slid down to the floor and no injuries were noted. There were no witnesses identified on the incident report. Under the section, " Additional comments and/or steps taken to prevent recurrence " there was no entry. The Director of Nurses and the Administrator signed the incident report. They did not date their signature. An attached statement by CNA C with no date documented that she was giving the resident a shower and a student CNA was with her. She documented she was getting the resident ' s chair and the student was helping the resident stand up. The resident slipped and hit his arm on the rail on the way down. e) During an interview on 2/10/14 at 3:30 p.m., LVN B said that she noticed Resident #4 ' s arm was very obviously swollen and had a large bruise on the day following his fall in the shower. She said that she initiated physician notification to get an X-ray. f) A nurse ' s fax to the physician on 1/20/14 at 1600 (4:00 p.m.) documented that dark bruising was noted to the underside and armpit of the right arm, and there was a dip at the bicep. At

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving neglect and injuries of unknown source were thoroughly investigated and immediately reported to the Administrator of the facility and to other officials in accordance with state laws for 5 of 11 residents reviewed for accidents and injuries (Residents #1, 2, 3, 4, and 5) as evidenced by: -failure to thoroughly investigate and report when Resident #1 sustained red, irritated skin around her buttocks from laying on a bed pan for most of the night on 12/17/13 and when she received a puncture to her head on 1/17/14; -failure to thoroughly investigate and report when Resident #2 was not restrained by a seat belt and was thrown from her wheelchair while riding in the facility van 1/24/14 and sustained multiple bruises and was required to wear a splint on her wrist and a sling on her right arm; -failure to thoroughly investigate and report when Resident #3 made an allegation on 1/10/14 that staff were rough with her and was observed to have bruises on both calves, both shins and her buttocks; when observed by family and the physician to have a swollen hand on 1/11/14; and when a bruise to her forearm was observed on 1/23/14; -failure to thoroughly investigate and report when Resident #4 sustained a fracture to his right humerus (upper arm); and -failure to thoroughly investigate and report injuries when Resident #5 got stuck in a door on 12/19/13; when she sustained an injury of unknown origin (bruise and knot on her forehead) on 12/30/13; and when she sustained multiple bruises from getting stuck in a bed rail on 1/2/14. On 2/5/14 at 12:15 p.m., an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to actual harm at a pattern on 2/7/14 at 2:00 p.m. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. The failure to thoroughly investigate accidents, injuries, and allegations of abuse and neglect involving caregivers could result in residents being abused and neglected in the facility. The facility reported 41 residents that required assistance with dressing, 32 residents that required assistance with transferring, 36 residents that required assistance with toilet use, and 31 residents that were in the chair most of the time. Findings included: 1. a) The Record of Admission Sheet for Resident #1 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. b) A Minimum Data Set (MDS) Assessment for Resident #1 dated 1/19/14 documented the resident had clear speech, was easily understood and could understand others. The interview for mental status was not completed. The Resident Mood Interview was not completed. The MDS documented Resident #1 was totally dependent on the assistance of one person to transfer between surfaces, for toileting, dressing, and personal hygiene. She had range of motion limitations/impairment on both lower extremities. She was not steady during surface-to-surface transfer. She was frequently incontinent of bladder and bowel. She used a wheelchair for mobility. c) A Nursing Summary dated 2/9/14 documented Resident #1 ' s cognitive skills were modified independence. d) Incident reports for Resident #1 included the following incidents: -1/17/14 0930-1200: Resident states CNA (certified nurse ' s aide) was transferring resident. States CNA slipped her hold and resident hit her head. She has a 1 cm (centimeter) puncture mark on scalp. The section of the incident report with the heading, " Additional comments and/or steps taken to prevent recurrence " was blank. The incident report was signed by the Director of Nurses (DON) and Administrator. (Signatures were not dated). -12/17/13 1:30 a.m. - CNA A removed resident from bedpan at approximately 0545 (5:45 a.m.). Resident has red marks from bedpan. Resident states she was put on it at 1:30 a.m. (Redness was drawn in a circle on the diagram of the person ' s bottom with measurements of 13 x .5 cm, 7 x 2 cm, 15.5 x 13 cm, and 7 x 3.5 cm. The section of the incident report with the heading, " Additional comments and/or steps taken to prevent recurrence " revealed, " Remind CNAs to check resident as she fell asleep on bedpan. " The incident report was signed by the DON previously employed by the facility. The Administrator did not sign the report in the section labeled for her signature. e) A care plan dated 4/19/3 and updated 2/5/14 included a problem of impaired mobility related to disease process from Parkinson ' s and spinal stenosis. Interventions included to exercise caution during transfers and handling due to fragile skin and to provide protective coverings to arms and legs. A problem identified as dressing and grooming deficit had interventions including teaching the resident to use the call light for assistance. Under the problem of toileting deficit, interventions included perineal care after each episode of incontinence, and reduce stress as much as possible to decrease incontinence. Under a problem of depression, interventions included assessing for symptoms of depression (sadness, hopelessness, anxiety, tearfulness, etc.). Under a problem of risk for falls, the interventions included keeping the environment free from obstructions. The care plan did not include any specific interventions to address the multiple injuries sustained during CNA assistance with transfers, such as any change in the amount of support provided the resident or addressing the hazards that resulted in multiple injuries occurring in the resident ' s bathroom when hitting her on the hand rails when transferring her to the toilet. The care plan did not include any past interventions for use of a bed pan. f) During an interview on 2/4/14 at 11:50 a.m., Resident #1and her daughter were present. Resident #1 was a soft spoken female who was oriented to person and place. Resident #1 ' s daughter said that she was the one who found and identified the head wound. They stated that the CNA who was caring for Resident #1 the night this injury occurred (CNA B) was now gone. Resident #1 said that CNA B was very mean to her. She said that when CNA B helped her to transfer, the CNA would tell the resident she was not allowed to touch the CNA to hold on. Resident #1 said that some of the young CNAs that worked there were rough and rude to her. She said they were, " downright hateful at times. " Resident #1 said she was afraid these same staff would retaliate against her if she complained about them. She stated, " You ' re at their mercy. " Resident #1 said the nurse aides were a " clique " and, " would gang up against you. " Resident #1 said there were only a few staff members that she trusted. Resident #1 said many injuries occurred in her restroom because she often hit herself on the hand rails. She said the restroom was small and when a staff member was in there assisting her, there really was not room for them to both move around safely. Resident #1 said the head injury occurred in the restroom. She said the CNA assisting her lost control of her and she hit her head on the hand rails. When discussing that she was left on the bedpan, Resident #1 said she was told to use a bedpan by the staff because they told her it was better and would keep her from falling. She said she did not like using a bedpan because she had a harder time urinating on the bedpan. She said that the CNA placed her on the bedpan and left her there all night, and she fell asleep on it. Resident #1 said she was in a lot of pain when she woke up. Resident #1 said that the staff, especially at night, did not answer her call light and often left her call light out of her reach so she could not call for help. Resident #1 said she had not complained for fear of retaliation from the nurse ' s aides. Resident #1 ' s daughter stated that Resident #1 ' s bottom looked awful after being left on the bedpan. She said she was so concerned that she took pictures. She said she also talked to the administrator about her concerns. g) During an interview on 2/4/13 at 2:35 p.m., CNA A said that Resident #1 was correct in that it did not appear that CNA B liked Resident #1. CNA A said that when she came on duty early in the mornings, she would find Resident #1 " soaked " after CNA B ' s shift. She said there were times when she came to work early and would see Resident #1 ' s call light on. A half hour later when she clocked in to work, she would notice Resident #1 ' s call light was still on and had never been answered by the previous shift. CNA A said that she found Resident #1 on the bedpan, and her call light was lying on the floor. She said Resident #1 had a large red ring where the bedpan was, and she complained of pain. CNA A said she reported it to the nurse on duty, but no one else had really asked her about it. h) During an interview on 2/4/14 at 10:15 a.m., LVN (licensed vocational nurse) A said that she was the nurse on duty when CNA A reported to her that Resident # 1 was found on the bedpan. She said that Resident #1 ' s bottom was very red and that it would have blistered if she had stayed on it much longer. LVN A said she documented everything in a nurse ' s note, change of condition report, and incident report and gave the incident report to the DON. She did not recall an investigation by facility administration or being interviewed regarding her knowledge of the incident. i) During an interview on 2/4/13 at 3:30 p.m., the Administrator said that she was the Abuse and Neglect Coordinator for the facility. She said that if any of the incident reports were investigated by the nurses, the investigations would be attached to the incident reports. The Administrator said that she did not investigate the above incidents as allegations of neglect. She said she fired CNA B (who she thought was responsible for the resident ' s head injury), not because of neglect, but because of multiple problems with the CNA. She said she was not aware that CNA B was not the CNA named as being on duty the day that Resident #1 ' s head injury was identified. She said she guessed she had never looked at the incident report to see that NA A was on duty that day. She said she never spoke with NA A about it. She said that she also did not investigate the incident when Resident #1 was left on a bedpan for most of the night. The Administrator said she did not know what staff was on duty or who was responsible. She said she did not talk to the staff to find out. She said she just figured the staff got busy and forgot to go back and check on the resident. She said the resident should have used her call light. When discussing that the resident ' s call light was found on the floor that morning, the Administrator said she was not aware of that. The Administrator acknowledged she should have investigated the incidents as neglect and reported the incidents to the State. j) During interview with the DON and ADON (Assistant Director of Nurses) on 2/4/14 at 4:30 p.m., they said they did not look at Resident #1 when the incident with the bedpan occurred. The ADON said she was on vacation at the time, and the DON said she did not look at the resident until several days later. When discussing why the resident was on a bedpan, they said that Resident #1 had asked for a bedpan. When discussing whether they had asked the resident what happened, they said that she complained, but appeared to be afraid to give details. They said one of the staff was terminated (CNA B) and another was moved to a different shift. When discussing actions taken following the incident, the DON said, " I think we discussed no more bedpan use. " When discussing Resident #1 ' s multiple complaints about staff not responding to her call light and being rough with her, the DON and ADON said they knew nothing about it. k) Nurse ' s notes revealed no entries for Resident #1 between 12/23/13 and 2/7/14. l) During an interview on 2/12/14 at 3:00 p.m., the DON was asked for nursing notes that appeared to be missing from the resident ' s record. The DON said there were no nursing notes and directed the investigator to read the weekly nursing summaries because that was probably the only documentation during that time period. Nursing notes had been reviewed and observed to be in the record the previous week. 2. a) A Record of admitted d 7/3/13 documented Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. b) An MDS dated [DATE] documented Resident #2 scored 15 of 15 in the Brief Interview for Mental Status indicating she had no cognitive impairment - mild/borderline impairment. She had no symptoms indicating a mood disorder. She had range of motion limitations in both lower extremities and used a wheelchair for mobility. She had no history of falls. c) An Incident/Accident report dated 1/24/14 at 1:15 p.m. documented, " During transport from Dr. appt. (appointment), driver hit his brakes and resident went forward out of her chair, landing on right leg/arm. W/C (wheelchair was locked into van and resident ' s leg was on unlock button. This writer and CNA (sentence not finished.) Type of injury was 2.1 cm skin tear to right forearm. The incident report documented the resident was sent to the hospital by ambulance. Under, " Additional comments and/or steps taken to prevent recurrence " staff documented, " Driver will make sure seat belt restraint is secure. " d) Nurse ' s notes revealed the following outcomes for Resident #2 as a result of the injuries suffered from falling in the van: -1/24/14 at 1745 (5:45 p.m.) documented Resident #2 returned from the hospital with a splint to her right wrist, sling to her right arm to be worn 4-5 days. She had no broken bones. She was prescribed medication for pain. Resident #2 was reporting soreness all over that increased with movement. -1/25/14 at 0745 (7:45 a.m.) documented Resident #2 would not get up in her wheelchair as she was sore and hurting. -1/27/14 at 0920 (9:20 a.m.) documented [DIAGNOSES REDACTED], [MEDICAL CONDITION] and hot to touch to left shin at bruise area. X-ray ordered and Resident #2 was medicated for pain. -1/27/14 at 1151 (11:51 a.m.) documented the X-ray of the tibia and fibula were negative for fracture or dislocation. Moderate upper calf swelling noted by radiologist ... -1/27/14 at 1545 (3:45 p.m.) documented the resident was sent to the hospital for evaluation for possible [MEDICAL CONDITION] ([MEDICAL CONDITION] or [MEDICAL CONDITION] (bacterial skin infection). -1/28/14 0930 and 11:30 (9:30 a.m. and 11:30 a.m.) documented Resident #2 complained of pain. -1/29/14 at 0900, 1200 (9:00 a.m. and 12:00 noon) documented Resident #2 complained of pain with movement. At 1300 (1:00 p.m.) a new bruise noted on left mid inside of arm, 3 cm x 1.5 cm. -1/31/14 at 1100 (11:00 a.m.) documented Resident #2 complained of right wrist soreness, both lower extremities were hot to touch and had 3+ [MEDICAL CONDITION] (swelling) and were sore when moved. -2/5/14 at 0845 (8:45 a.m.) documented pain was still present in bilateral (both) lower legs. Both calves were still warm to the touch and bruises were still present. -2/7/14 no time: ...Resident complained of right upper shoulder joint pain ... e) physician's order [REDACTED]. -1/24/14: Dx (diagnosis): Contusions from ER; Splint L wrist for 4-5 days; Sling to R arm for 4-5 days; Follow up with doctor 3-5 days or next visit -1/24/14: [MEDICATION NAME] 5 mg. po (by mouth) Q (every) 6 hours as needed for pain not relieved by [MEDICATION NAME]. -1/24/14: Keflex 500 mg TID (three times daily) for 10 days f) Weekly Skin Assessments for Resident #2 revealed the following: -1/16/14: No skin issues identified -1/25/14: 23 x 12 cm red and purple bruise to the back of the upper right arm; 15 x 11 cm bruise with 2- 5 cm skin tears to the back, lower portion of the right arm; 3 x 1 cm purple bruise to the front lower portion of the left leg; 1 x 5 cm blue/green bruise to the left knee; 2 x 1 cm and 1.5 x 1 cm blue/purple bruises to right foot toes; 5.5 x 0.5 cm purple bruise to the right shin; 4 x 3 cm bruise to the right knee; and a 2 x 0.8 bruise to the right knee area. g) A care plan for Resident #2 dated 1/22/14 revealed it included the following: Problem: Needs assistance with the following ADLs (activities of daily living): (none identified). Interventions for this problem included to encourage independence and praise when attempts were made, assist with transfers as needed, assist with repositioning as appropriate, assist with shower, and assist with ADLs as needed. Under a problem identified as do not resuscitate, the care plan identified an intervention for pain medication as ordered by the physician. The care plan did not address Resident #2 ' s weakness, risk of falls, or any care related to Resident #2 ' s injuries, pain, or mental anguish resulting from the van accident. h) During a telephone interview on 2/3/14 at 12:05 p.m., the Ombudsman said that she had expressed concern to the Administrator about Resident #2 ' s accident on the van, and had asked the Administrator about her response. The Ombudsman said she told the Administrator that Resident #2 said that the van driver did not secure her seat belt. She said the Administrator acknowledged that the van driver admitted he may not have buckled the resident in correctly, but did not identify any actions she would take to prevent reoccurrence. The Ombudsman said that she suggested to the Administrator that the incident should be reported to the State as an allegation, and the Administrator told her that since the incident did not occur at the facility it was not a reportable incident. i) During interview on 2/4/14 at 3:30 p.m., the Administrator said that she was not sure what occurred that had caused Resident #2 to come unbuckled and fall from her wheelchair in the van. When discussing whom she had talked to about the incident, she said she talked to the van driver and to the nurse that was called out to the accident and who had completed the incident report. The Administrator did not state that she talked to Resident #2 about what happened. She said that Van Driver A had said that she was buckled in the van and some children walked in front of him and he had to throw on the brakes. She said there was no action taken following the incident except to tell the van driver to be sure residents were buckled in the van. The Administrator acknowledged that the van driver was her brother. The Administrator acknowledged that the incident report and nurse ' s note were the only documentation related to the incident. She had not documented any interviews or other actions related to the incident. When discussing whether DADS should have been notified of the incident, the Administrator said, " I probably should have called it in. " j) During interview on 2/6/14 at 1:10 p.m., Van Driver A said that he thought he had Resident #2 buckled into the van appropriately. He was taking her to a physician appointment. He said some school children stepped out in front of him and he hit the brakes. He said Resident #2 fell out of her wheelchair and her seat belt was completely unbuckled. Van Driver A said, " You know some residents remove the seat belt themselves. " When asked to elaborate, he could not describe any time that this had occurred. k) During interview on 2/6/14 at 1:35 p.m., Resident #2 said that she remembered the incident very clearly. Resident #2 said that, although she was losing her physical health, her memory was as sharp as it ever was. She said that Van Driver A did not buckle her seat belt at all. She said he just laid it across her lap. She said she was very nervous when she realized that he was not going to buckle her in, but figured the trip was a short one, so she would be alright. She said he threw on the brakes and she fell forward, onto the metal bottom of the van. She said her knees hit the metal that was the floor, and her hands hit the back of the front seats when she tried to protect herself from hitting the metal that was also on the back of the seats, and this was when she hurt her wrist. She said he also had not anchored one side of the wheelchair to the van and one side of the wheelchair fell forward on top of her. She said she lay there in pain for what seemed like a long time while he called someone from the nursing home to come help him get her up. She said she did not understand why he just did not call paramedics. She said she did not think she needed to go to the hospital but after her family was informed, they wanted her to go. 3. a) Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. b) An MDS assessment for Resident #3 dated 12/20/13 documented the brief interview for mental status was not completed. The mood interview was not completed. There were no indicators of [MEDICAL CONDITION] and no behavioral symptoms. The MDS documented that Resident #3 was totally dependent on the assistance of one staff for dressing, toilet use, personal hygiene, and toilet use. She was always incontinent of bowel and bladder. The MDS documented Resident #3 was 91 inches tall (which was an error) and weighed 86 pounds. c) Incident reports, nurse ' s notes, and a physician ' s note revealed the following information regarding injuries to Resident #3: -1/23/14 at 2200 (10:00 p.m.): Res c/o (complaining of) pain to R arm from wrist to shoulder. Grimaces upon touching arm. 9 cm x 7 cm purple bruise noted to R FA (right forearm). There was no incident report for the injury described in this nurse ' s note. -A physician ' s note dated 1/11/14 included the following: " Patient ' s son noticed that her left hand was swollen 7 days ago. The swelling continues through the hand. Patient denies any decrease in range of motion and pain. There is no history of trauma. " -1/10/14 at unknown time: Resident was being transferred from bed to chair. Bruises found on L lower extremity 6 x 1 cm, and R lower extremity 17 x 8 cm. (Picture diagram showed the bruises on the back, outer calf). Resident states girls are grabbing her tightly when moving. No CNA witnesses were named on the incident report. Under, " Additional comments and/or steps taken to prevent recurrence " the form was blank. The incident report was signed by the previous DON. The Administrator did not sign the incident report in the space designated for her signature. -Nurse ' s note on 1/10/14 at 0720 (7:20 a.m.) documented the CNA called LVN A to the resident ' s room and bruises were reported to both shins and a small bruise was on her L buttocks. -Nurse ' s note on 1/10/14 documented at 11:00 a.m. that bruises were observed to Resident #3 ' s lower extremities and the resident stated staff were rough when moving her. d) During an interview on 2/10/14 at 11:00 a.m., the DON said there was a care plan meeting on 1/29/14. The MDS Coordinator stated the care plan was held but had not been written or entered in the record. e) Resident #3 ' s care plan included a cover page with signatures of the care team dated 1/29/14, but the only care plan in the record was the Admission care plan dated 12/13/13. The Admission Care Plan documented that Resident #3 required " full assistance " with dressing, grooming, and transferring. The care plan did not address the multiple injuries Resident #3 had sustained between 1/10/14 and 1/28/14. f) During an interview on 2/4/14/ at 10:00 a.m., LVN A said the CNAs/nurse aides were transferring Resident #3 in ways that were injuring Resident #3, including " cradling " her and hitting her legs on the side rails of the bed. LVN A said she told the aides to start using two people to transfer her, but she did not know if they changed to two persons or not. She said she never had time to check. LVN A said the nurse ' s aides were not trained in transferring skills and no one was monitoring what the aides were doing in the resident rooms. g) During an interview on 2/4/14 at 11:15 a.m., Resident #3 was interviewed with an interpreter, since she spoke Spanish only. Resident #3 denied remembering any specific details about how she received the injuries identified above except to say she did not want to talk bad about the workers, but they grab her too hard. h) During an interview on 2/4/14 at 2:10 p.m., NA A said she worked with Resident #3 but did not know how Resident #3 was getting injured. When discussing how they transfer Resident #3, she said, " We arm and leg her. " She explained that meant that two of them support the resident under the arms while placing their arms under her upper legs as in a sitting position. NA A said she had not received any training on transferring residents other than another CNA. She said the facility had never checked her skill. i) During an interview on 2/4/14 at 2:20 p.m. NA B said she worked with Resident #3 and could be partially responsible for the injuries to Resident #3. She said Resident #3 was hard to transfer because her legs were very limp and would hit objects like the side rails. NA B said they were using two people to transfer the resident now. NA B said she did not have any training to transfer residents, other than from other nurse aides, and her skills had never been evaluated by the facility. j) During an interview on 2/4/14 at 3:30 p.m., the Administrator said that she could not locate an incident report for the injury identified in the nurse ' s note dated 1/23/14. She said she was not aware of the injury until the investigator asked. When discussing the incident reports and injuries, the Administrator said she thought the staff were told to be more careful when transferring Resident #3, but stated, " I ' d be lying if I told you we talked to each aide, I don ' t know. " The Administrator said she did not know how the staff were transferring Resident #3. She said she had not investigated to determine the potential causes of the injuries and referred the investigator to the ADON. The Administrator stated she should have called in the bruises and injuries of unknown origin to DADS and should have investigated them. k) During interview on 2/4/14 at 4:30 p.m., the DON and ADON said that they were aware Resident #3 had alleged that staff were being rough with her. The DON and ADON said that they had not addressed the injuries in any way. 4. a) A Record of Admission sheet for Resident #4 dated 7/13/12 documented he was a [AGE] year-old male admitted to the facility 10/14/05 with [DIAGNOSES REDACTED]. b) An MDS assessment for Resident #4, dated 1/25/14 documented that he used a wheelchair for mobility. c) A Care Plan for Resident #4 dated 11/20/13 documented that Resident #4 could not ambulate without extensive assistance. The Care Plan documented that Resident #4 required the assistance of one staff for transfers and other ADL activities. d) An incident report dated 1/19/14 at 7:30 a.m. documented the resident stood up to be transferred from a shower chair to a wheelchair and started to sit down before the chair was placed correctly. He slid down to the floor and no injuries were noted. There were no witnesses identified on the incident report. Under the section, " Additional comments and/or steps taken to prevent recurrence " there was no entry. The Director of Nurses and the Administrator signed the incident report. They did not date their signature. An attached statement by CNA C with no date documented that she was giving the resident a shower and a student CNA was with her. She documented she was getting the resident ' s chair and the student was helping the resident stand up. The resident slipped and hit his arm on the rail on the way down. e) During an interview on 2/10/14 at 3:30 p.m., LVN B said that she noticed Resident #4 ' s arm was very obviously swollen and had a large bruise on the day following his fall in the shower. She said that she initiated physician notification to get an X-ray. f) A nurse ' s fax to the physician on 1/20/14 at 1600 (4:00 p.m.) documented that dark bruising was noted to the underside and armpit of the right arm, and there was a dip at the bicep. At 2245 (10:45 p.m.) the nurses documented that X-ray results showed an acute humerus neck fracture with modest displacement. Resident #4 was sent to the hospital. g) During an interview on 2/3/14 at 2:05 p.m., CNA C said there were students in the building on the day of the incident. A student was helping her with Resident #4 in the shower. CNA C said she did not remember who the student was. She said she turned around to get the chair and while her back was turned, the student attempted to help Resident #4 and he slid. She said she did not really know how the resident hurt his arm, but assumed he must have hit it on the rail. h) During an interview on 2/4/14 at 3:30 p.m., the Administrator said she reviewed the incident and determined that it was just an accident and there was no need to investigate it any further or report it to DADS. i) During an interview on 2/4/14 at 4:30 p.m., the ADON said that she talked to CNA C about what happened. She said CNA C said she turned around and the resident tried to get up on his own and fell . When discussing the student that was helping the resident, the ADON said that was the first she had heard about that. 5. a) A Record of Admission sheet dated 12/20/13 documented Resident #5 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. b) A discharge summary documented Resident #5 was discharged home with her spouse on 2/1/14. c) An MDS dated [DATE] documented Resident #5 had hallucinations, no behavioral symptoms, transferred herself independently, was ambulatory, and required only supervision for dressing, eating, and toilet use. She was frequently incontinent of urine and occasionally incontinent of bowel. c) Incident reports, nurse ' s notes, a physician ' s note, and skin assessments revealed the following documentation regarding Resident #5 ' s injuries: -An incident report dated 1/2/14 with no time documented Resident #5 ' s leg was stuck in her side rail. The resident attempted to get up and stuck R leg through rail. The writer did not document the size of the injuries but wrote " bruising " and circled from the lower calf to the mid-thigh on the front of the right leg, and the same area on the back of the right leg. The witnesses (a CNA and the resident ' s roommate) were named. Under the section of " Additional comments and/or steps taken to prevent recurrence, " the section was blank. The DON signed the incident report, but the Administrator did not sign. -A Weekly Skin Assessment sheet dated 1/2/14 documented a 7 x 5 cm yellow/brown bruise to the back of Resident #5 ' s right leg; an 8 x 5 cm purple yellow faded bruise to the front of the right leg at the knee; a 6 x 6 cm faded brown/yellow bruise on the front of the right arm midway between the elbow and shoulder; a 2.5 x 3 cm purple blue and yellow bruise under the right eye; 2.5 x 2 cm blue bruise under the left eye, a 2 x 1.5 cm yellow bruise across the bridge of her nose; and a 4 x 4 cm purple and yellow bruise on the forehead. -An incident report dated 12/30/13 at 1420 (2:20 p.m.) documented Resident #5 had a bruise and a knot on her forehead. The writer documented that the bruise was not present at lunch and that no one knew how it occurred. There were no witnesses documented. Under the section, " Addition