Every finding on record at Beebe Retirement Center, Inc.

Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to ensure sufficient staffing in accordance with the facility assessment on 24 of 66 shifts reviewed from 08/10/2025 to 09/01/2025, to ensure required care for was provided. The findings include: Review of the Facility Assessment, which was updated on 09/30/2024, indicated the facility's average census was 81 residents with 13 short term residents, 14 residents in the secure memory care unit, with the remainder the census and required staffing at the following ratio to meet the resident's needs: Day Shift (7am to 3 pm): 1 Certified Nursing Assistant (CNA) per 7 residents and 2 licensed nurses and a Medication Assistant Certified. (MA-C) Evening Shift (3 pm to 11 pm):1 CNA per 9 residents, 2 Licensed Practical nurse and a MA-C. Night Shift (11 pm to 7nam) :1 CNA per 13 residents and 2 licensed nurses. With an average daily census of 82 the facility would require 12 CNAs on day shift, 9 CNAs on evening shift and 6 CNAs on night shift. Review of the staffing sheets and assignment sheets for August 10, 2025, to September 1, 2025, indicated the facility did not meet the staffing requirement set forth by the facility assessment for the following:Day shift CNAs on 08/23/24, 08/24/2025, 08/30/2025 and 08/31/2025Evening shift CNAs on 08/17/2025 and 08/30/2025Night shift CNAs on 08/10/2025, 08/11/2025, 08/12/2025, 08/16/2025, 08/17/2025, 08/18/2025, 08/19/2025, 08/20/2025, 08/21/2025, 08/22/2025, 08/24/2025, 08/26/2025, 08/27/2025, 08/28/2025, 08/29/2025, 08/30/2025, 08/31/2025 and 09/01/2025.During initial rounds of the facility on 09/02/2025, Resident #1 (10:44 AM) and Resident #49 (1:27 PM), indicated the facility frequently did not have sufficient staff to complete all care requirements for the residents of the facility. They also reported insufficient staffing occurred across various shifts. On 09/04/2025 at 1:10 PM, during a resident council meeting, Resident #45 indicated it had recently taken an hour and a half for staff to answer their call light. Resident #45 also indicated that sometimes there are only three CNA's working at night and there were not sufficient staff to provide the care they needed. During an interview on 09/05/2025 at 1:20 PM, the Administrator (AD) stated she did not have any concerns about not having enough staff to provide care for the residents. She stated that if the facility had a call-in, every attempt was made to find coverage, and department heads would come in if needed and it was rare to not be able to find coverage, either with someone staying over or coming in. The AD also stated that the facility had a run advertisement on a job website to get applicants for employment, and that there was a local class for CNAs and the facility would recruit from there. During an interview on 09/05/2025 at 2:00 PM, the Director or Nursing (DON) indicated she had no concerns related to insufficient staff to provide required care to the residents. The DON stated if anyone called in, every attempt was made to replace them. If an employee called in often they were counseled on attendance. The DON stated the scheduler had a good rapport with the staff and usually could get the shifts covered. During an interview on 09/05/2025 at 3:13 PM, Housekeeper (HSK) #5 reported insufficient staff in general, with CNAs being short staffed most often and that insufficient staffing was worse on the night shift. HSK #5 stated she knew of CNAs working over their scheduled hours and working extra shifts to help cover for insufficient staffing. During an interview on 09/05/2025 at 3:00 PM, CNA #6 indicated that people call in a lot, which causes the staff to work short. CNA #6 reported being asked to stay late or work extra about every other day to cover for insufficient staffing.Review of a facility policy titled Staffing indicated, The facility would provide sufficient numbers of staff to provide care and services for all residents.

Number of residents sampled: Number of residents cited: Based on observation, interview and policy review, it was determined the facility failed to ensure to ensure no expired medications were given to residents in two of three medication carts observed for expired medications. The findings include: During an observation on 09/04/2025 at 9:15 AM, this surveyor observed four opened multi-use Lantus insulin pens, one opened Basaglar multi-use insulin pen and one opened Degludec insulin pen, were observed in the top drawer of the medication cart used for 400, 500, and 600 halls. There was no indication of an opened date on the insulin pens. During an interview on 09/04/2025 at 9:17 AM, LPN #10 confirmed it was important to write the date opened on insulin to prevent giving expired medication to the residents. Review of a facility policy titled, Medication Labeling and Storage indicated opened medication vials are dated and used or discarded after 28 days unless manufactures indicate a shorter or longer date.

Number of residents sampled: Number of residents cited: Based on observations, interviews, and facility record review, it was determined that the facility failed to ensure residents, family member and legal representatives had access to the facility's most recent survey results. The findings include: During an observation on 09/04/2025 at 2:45 PM, the surveyor was unable to locate the posted results of the most recent survey of the facility. During a concurrent observation and interview on 09/04/2025 at 5:03 PM, the Administrator was asked for the location of the posted survey results and stated, The binder is in the front lobby. The Administrator and Activity Director were unable to locate the binder in the front lobby. After searching, it was found behind the nurse's station, out of sight and out of reach of residents and the public, and unavailable for review without asking.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to accurately complete assessments for 2 (Residents #42 and #59) residents reviewed for accurate completion of the Minimum Data Set (MDS). Findings include: A review of a facility policy titled, Resident Assessment Instrument, revised September 2010, indicated, .1. The Interdisciplinary Assessment Team must use the MDS form currently mandated by Federal and State regulations to conduct the resident assessment. Other assessment forms may be used in addition to the MDS form. 2. The purpose of the assessment is to describe the resident's capability to perform life functions and to identify significant impairments in functional capacity. 3. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning . 1. A review of the Admission Record indicated the facility admitted Resident #42 with a diagnosis of presence of cerebrospinal fluid drainage device. The quarterly MDS with an Assessment Reference Date (ARD) of 06/20/2024 revealed Resident #42 had Section N: O415 - High Risk Drug Classes: Use and Indication were marked indicating Resident #42 was not taking an anticoagulant but was taking an antiplatelet - The admission MDS with an ARD of 09/18/2023 indicated the resident was not taking an anticoagulant. A review of Resident #42's Care Plan, revealed a problem as evidenced by no teeth related to poor oral hygiene initiated 09/25/2023. Intervention was initiated 01/01/2024 to administer medication as ordered and to monitor for side effects. No care plan was noted that addressed cerebrospinal fluid drainage device or the anticoagulant, apixaban. A review of Medication Administration Record for June 2024, revealed Resident #42 had been administered Apixaban, 1 tablet by mouth two times a day related to presence of cerebrospinal fluid drainage device (order date 09/11/2023) from June 1, 2024, to June 30, 2024. A review of the Medication Administration Record for September 2023, revealed Resident #42 had been administered Apixaban 1 tablet by mouth two times a day related to presence of cerebrospinal fluid drainage device (order date 09/11/2023) from September 11, 2023, to September 30, 2023. 2. A review of the Admission Record, indicated the facility admitted Resident #59 with diagnoses that included encephalopathy (inflammation of the brain), acute embolism and thrombosis (blood clot) of deep veins of left upper extremity, dysphagia (difficulty swallowing), and gastrostomy status (feeding tube). The quarterly MDS with an ARD of 06/29/2024 revealed Resident #59 was marked in Section GG0115: functional limitation in range of motion was marked as 0 (no impairment) of upper extremity (shoulder, elbow, wrist, hand). Section N:0415 high-risk drug classes: use and indication were marked anticoagulant (is taking) with indication. The annual MDS with an ARD of 03/29/2024 revealed Resident #59 was marked in Section GG0115: Functional Limitation in Range of Motion as 0 (no impairment). Section N:0415 High-Risk Drug Classes: Use and Indication: antiplatelet was marked (is taking) with indication. A review of Resident #59's Care Plan, revealed the resident was on anticoagulant therapy using apixaban related to deep vein thrombosis to arms initiated 07/01/2022. Interventions: Administer anticoagulant medications as ordered by physician. Monitor side effects and effectiveness every shift. Apixaban tablet black box warning: discontinuation, premature discontinuation of any oral anticoagulant, including apixaban, increases the risk of thrombotic events; daily skin inspection; Labs as ordered, report abnormal lab results to medical doctor; monitor/document/report PRN (as needed) adverse reactions of anticoagulant therapy. A review of Resident #59's Care Plan revealed the resident had an Activities of Daily Living self-care performance deficit related to generalized weakness, decreased mobility secondary to recent hospitalization for encephalopathy. (initiated 08/05/2022). Interventions included: Contractures: the resident has contracture left hand/arm with a deficit to his range of motion. Provide skin care to keep clean and prevent skin breakdown. Hand roll to left hand as tolerated. Resident removes at times. A review of Order Summary Report for Resident #59 revealed there was an order for Apixaban tablet one tablet by mouth two times a day related to acute embolism and thrombosis of deep veins of left upper extremity. Order date of 03/16/2023. A review of the Medication Administration Record, for March 2024 revealed Resident #59 was administered Apixaban 1 tablet by mouth two times a day related to acute embolism and thrombosis of deep veins of left upper extremity (order date 03/16/2023) from 03/01/2024 to 03/31/2024, with the exception of 3/26/2024 (4:00 PM, dose held), 03/27/2024 to 03/28/2024 (was held) and 03/29/2024 8:00 AM dose was held and restarted 03/29/2024 at 4:00 PM. A review of the Restorative Log for the week of 07/15/2024 to 07/21/2024, revealed Resident #59 was provided restorative services of active assistive range of motion to left upper extremity (including elbow, wrist, and all digits) three times a week. Hand roll/wash cloth was to be replaced at that time. Restorative services were to continue indefinitely. During an observation on 07/16/2024 at 8:32 AM, Resident #59 was lying supine in bed with the foot of bed slightly raised. Left hand lying along the side of the resident's body on top of the covers, hand roll noted in Resident #59's left hand. During an observation on 07/16/2024 at 1:17 PM, Resident #59 was being assisted with lunch by a certified nursing assistant and the hand roll was noted to be in the resident's left hand. During an interview on 07/17/2024 at 8:34 AM, Registered Nurse (RN) #2 confirmed that care plans and assessments were in the process of being updated and corrected. During an interview on 07/18/2024 at 11:30 AM, the Director of Nursing (DON) confirmed that the MDS Coordinator and the Medicare Manager are responsible for care planning and the MDS completion. The DON stated that both are new to their positions. When asked by the surveyor what process the nurses use to complete the MDS, the DON responded with, They follow the MDS questions. The DON was asked to review Resident #42's admission MDS with an ARD 09/18/2023, and the quarterly MDS with ARD of 06/20/2024. The DON confirmed Section N on each MDS was marked as an antiplatelet and not an anticoagulant. The DON agreed Apixaban is classified as an anticoagulant not antiplatelet. The DON confirmed Resident #59 had a left-hand contracture. After reviewing Resident #59's quarterly MDS with an ARD of 06/29/2024, the DON agreed that the MDS was marked wrong in Section GG0115 Functional limitation in Range of Motion (ROM) and Section N0415. The DON confirmed it was marked antiplatelet and not anticoagulant.

Based on observations, interviews, record review, facility policy review, it was determined that the facility failed to ensure proper hand hygiene before, during, and after medication pass for 2 (Resident #6 and #132) residents and failed to ensure enhanced barrier precautions were being followed for a resident with a feeding tube for 1 (Resident #59) of 1 resident reviewed for enhanced barrier precautions. The findings are: 1. A review of the Admission Record, indicated the facility admitted Resident #59 with gastrostomy status (placement of a feeding tube). a. The quarterly Minimum Data Set with an Assessment Reference Date of 06/29/2024 revealed Resident #59 had a feeding tube and received a mechanically altered diet and a therapeutic diet. b. A review of the Care Plan revealed Resident #59 requires enhanced barrier precautions related to peg tube status. (Initiated 04/11/2024). Interventions include: 1) Alcohol based hand-rub or wash with soap and water if visibly soiled before and after leaving the room. 2) Follow facility policies and procedures for cleaning and disinfection of medical equipment and devices. All shared equipment must be cleaned between patients. 3) Wear gloves and a gown for high-contact resident care activities. c. A review of Resident #59's Order Summary Report, indicated Resident #59 was on Enhanced Barrier Precautions related to peg tube status. d. During an observation on 07/16/2024 at 8:47 AM, Licensed Practical Nurse (LPN) #1 was gathering supplies to start medication administration for Resident #59. LPN #1 started removing medications from the over-the-counter pill bottles without sanitizing his hands and placing them in a small plastic medicine cup. LPN #1 placed the pill cup containing the medications in the top of the medication cart, locked the cart and left to get syringes and a blood pressure cuff. At 8:51 AM, LPN #1 returned to the medication cart, and without sanitizing his hands he went into Resident #59's room without putting on a gown or gloves. LPN #1 informed the resident that the resident's blood pressure needed to be obtained. LPN #1 removed the covers off the resident to place the blood pressure cuff on the resident. LPN #1 went back to the cart, sanitized his hands and unlocked the medication cart and took out the medication cup. LPN #1 removed medications from Resident 59's pill cards and into the medication cup. LPN #1 placed the medicine cup back into the top drawer of the medication cart, locked the cart, and left to go look for the pill needed for the blood pressure. LPN #1 returned to the medication cart, sanitized his hands, applied gloves and prepared a medication in a syringe. LPN #1 returned the medication bottle to the bottom drawer of the medication cart. LPN #1 crushed the medications, gathered the medications and diabetic formula and a nine ounce drinking cup. LPN #1 walked into Resident #59's room, placed the items on the nightstand, and shut the door to the room. LPN #1 pulled the privacy curtain and went to the bathroom to get tap water, grabbed a towel, and sat down in a chair beside the bed. LPN #1 did not remove his gloves or sanitize his hands. LPN #1 did not wear an isolation gown while providing care to Resident #59. LPN #1 moved Resident #59's gown, exposed the feeding tube, placed the stethoscope on the upper abdomen to check for placement. LPN #1 placed a towel under the feeding tube, flushed the feeding tube with water, and then administered the medications and diabetic formula via the feeding tube. LPN #1 then flushed the feeding tube with water. The syringe was removed from the feeding tube, the towel was removed from under the feeding tube, the resident's gown was pulled back down and then LPN #1 covered the resident. LPN #1 gathered the used supplies and disposed of them in the bathroom trash. With the same gloves on, LPN #1 washed the syringe used for the feeding tube and placed it in the syringe bag, he then removed his gloves and washed his hands. 2. During an observation on 07/17/2024 at 8:12 AM, Registered Nurse (RN) #2 did not sanitize hands prior to preparing to administer medications for Resident #132. After pouring a high calorie supplement into a plastic cup, RN #2 punched medications from medication cards and placed them in a small plastic medicine cup. RN #2 knocked on resident's door and entered the room. Without sanitizing her hands, she administered the medications to Resident #132. 3. During an observation on 07/17/2024 at 8:24 AM, RN #2 did not sanitize her hands prior to preparing medications for Resident #6. Resident #6's medications were placed in a small medication cup. RN #2, placed the medication cup in the top drawer of the medication cart, locked the cart, and stated that there were no lidocaine patches on the medication cart, and she would need to go get them. RN #1 returned to the medication cart, unlocked the cart. Without sanitizing her hands, she opened the cart, put the medications back on top of the cart, grabbed tissues, started looking for gloves, and stated I thought I was prepared. RN #2 poured water into a nine ounce plastic drinking cup, gathered supplies and went into Resident #6's room, and handed the resident an inhaler. Resident #6 self-administered the inhaler then handed RN #2 the inhaler. Without sanitizing her hands, RN #2 put on gloves, and administered eye drops to both of Resident #6 's eyes. RN #2 removed her gloves and handed the resident the plastic medication cup. Resident #6 took the medications without difficulty. RN #2 then put on gloves, without sanitizing hands and administered more eye drops. 4. A review of a facility policy titled, Policies and Practices-Infection Control, revised October 2018, indicated The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections . 5. A review of a facility policy titled, Handwashing/Hand Hygiene, revised October 2023, indicated, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections . 6. During an interview on 07/18/2024 at 12:19 PM, RN #2 confirmed that hands should be washed prior to starting medication preparation, when anything dirty or soiled is touched, upon entering the resident's room, when changing gloves, after removing gloves and before leaving the resident's room. 7. During an interview on 07/18/2024 at 11:30 AM, the Director of Nursing (DON) confirmed that enhanced barrier precautions (EBP) would be treated like other isolation precautions regarding what personal protective equipment is used. The DON confirmed a tube feeder would be on EBP, and that staff would wear gloves when taking care of the resident and the feeding tube. The DON confirmed that hand hygiene should be performed before entering or exiting a resident's room, anytime hands are soiled, before gloves are applied and after removing gloves and anytime something dirty is touched. 8. During an interview on 07/18/2024 at 1:18 PM, Licensed Practical Nurse (LPN) #1 was asked what Enhanced Barrier Precautions meant and LPN #1 replied, I would have to put on a gown and gloves. LPN #1 also confirmed that with a tube feeder, enhanced barriers precautions should be followed. He stated I would have to put on gown and gloves, and I forgot to do that. I am still not used to doing that. LPN #1 confirmed that hands should be sanitized during medication pass or tube feeding and said anytime I have touched something dirty with my hands or my gloved hands, and before and after leaving the resident's room and after removing my gown and gloves.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure residents who want to self-administrate medications were properly assessed and deemed appropriate to do so for 1 (Resident #6) resident reviewed for self-administration of medications. Findings include: A review of a facility policy titled, Self-Administration of Medications, revised December 2016, indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so .2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment . A review of the Admission Record, indicated the facility admitted Resident #6 with a diagnosis of cognitive communication deficit. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/04/2024 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A review of Resident 6's Care Plan with an initiated date of 03/03/2023 revealed Resident #6 has capacity to understand and make decisions regarding healthcare and does not have an Advance Directive/Advance Care Plan (living will)/Healthcare Agent/Healthcare Surrogate/Durable Power of Attorney or other identified healthcare decision-maker. Interventions included follow up with the physician for any needed orders related to resident care decisions. A review of the Order Summary Report, revealed Resident #6 did not have an order to self-administer medications; 1.) Fluticasone Propionate Nasal Suspension, one spray in both nostrils two times a day related to allergic rhinitis, and 2.) Symbicort Inhalation Aerosol, two puffs, inhale orally two times a day for wheezing. Wait one minute between puffs/rinse, spit after administration. A review of the Medication Administration Record, revealed Resident #6 had 1) Fluticasone Propionate nasal solution and 2) Symbicort Inhalation Aerosol signed off by the nurses as being administered by a nurse. A review of Nursing Assessments revealed there was no self-administration of medication assessments completed for Resident #6. During an observation on 07/17/2024 at 8:24 AM, Registered Nurse (RN) #2 was in the process of administering morning medications. RN #2 handed Resident #6 the resident's Symbicort handheld inhaler without instructions given. Resident #6 took the inhaler, brought the inhaler to the resident's mouth, completed one puff then without waiting, (waited approximately five seconds), took a second puff. Resident #6 failed to rinse their mouth and spit after the inhaler was administered. RN #2 administered eye drops, then handed Resident #6 the Fluticasone Propionate spray, without instructions given. Resident #6 took the spray, inserted the tip of the spray bottle into her right nostril, sprayed two squirts, then moved to the left nostril and sprayed two squirts, then handed the spray back to RN #2. During an interview on 07/18/2024 at 12:19 PM, RN #2 was asked if residents were allowed to self-administer medications, RN #2 stated, if the resident has been assessed. During an interview on 07/18/2024 at 11:30 AM, the Director of Nursing (DON) stated for a resident to be able to self-administer medications, an assessment would need to be completed, but stated, We do not let the residents self-administer unless there are extenuating circumstances. The DON confirmed that if an inhaler is self-administered, the resident would need to know the side effects, know and understand the orders for the medications and the nurse to observe the resident who can self-administer, and that the resident waits one minute between puffs if more than one puff is ordered. She also confirmed that the same would be true for nasal sprays. She also confirmed there would need to be an order from the physician and self-administration would need to be care-planned. The DON confirmed that nurses store the medications for any resident who has been assessed and is able to self-administer medications. When asked if there was a policy regarding self-administering medications, the DON replied, It would be in nursing policy book and that the nurses had access to those policies.

Based on observations, interviews, record reviews, facility document reviews, and facility policy review, it was determined the facility failed to revise and update the care plan to reflect current tube feeding status for 1 resident (Resident #59) reviewed for care planning for tube feeding. Findings include: A review of a facility policy titled, Care Plan, Comprehensive Person-Centered revised December 2016, indicated, .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . A review of the Admission Record indicated the facility admitted Resident #59 with diagnoses of dysphagia (difficulty swallowing) and gastrostomy status (feeding tube). The quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 06/29/2024 revealed Resident #59's nutritional approaches while a resident, included a feeding tube, a mechanically altered diet, and a therapeutic diet. A review of Resident #59's Care Plan revealed Resident #59 had an activities of daily living (ADL) self-care performance deficit related to generalized weakness, decreased mobility secondary to recent hospitalization for encephalopathy (inflammation of the brain). Initiated 08/05/2022. Interventions included, eating receives nutrition and medications via peg tube. The diabetic formula at 60 milliliters (ml) per hour via tube feeding pump and the resident is totally dependent on one staff for eating. Resident #59 has a nutritional problem or potential for nutritional problem related to diabetes, gastroesophageal reflux disease, and need for enteral feeding (initiated 01/17/2024), interventions include: explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity and malnutrition risk factors; per resident's preference, meals will be served in room; provide and serve diet as ordered: regular enhanced, mechanical soft, regular consistency; encourage and assist with all meals. A review of the Order Summary Report, revealed Resident #59 had a diet order dated 01/19/2024 for a regular diet, mechanical soft texture, regular consistency, and an enteral feeding order three times a day related to gastrostomy status, give 237 ml of diabetic formula three time a day, dated 06/03/2024. A review of Medication Administration Record, for July 2024, revealed Resident #59 was receiving diabetic formula three times a day by feeding tube. During an observation on 07/15/2024 at 8:31 AM, Resident #59 was being assisted with eating, by a Certified Nursing Assistant (C.N.A.) sitting at the resident's bedside. During an observation on 07/16/2024 at 9:15 AM, Licensed Practical Nurse (LPN) # 1 administered diabetic formula 1.5, 237 ml via the feeding tube to Resident #59. During an observation on 07/16/2024 at 1:17 PM, Resident # 59 was being fed by a C.N.A. sitting in a chair at bedside. During an interview on 07/16/2024 at 9:20 AM, LPN #1 confirmed that Resident #59 received diabetic formula 1.5, one can (237 ml) three times a day and that Resident #59 also gets a regular mechanical soft tray for meals three times a day. During an interview on 07/18/2024 at 11:30 AM, the Director of Nursing (DON) confirmed that changes to the care plan should be made immediately or the next day during start up when orders are discussed. The DON confirmed that the long-term care MDS Coordinator and the Medicare Manager were new to their positions but that both had done MDS' for a while and were working on updating care plans.

Based on record review and interview, the facility failed to complete a comprehensive assessment within 14 days of the facility determining there had been a significant change for 2 Rresidents (Resident #1 and #2) of sampled Residents who received Hospice Care. The findings are: Review of Resident #1's Admission Minimum Data Set (MDS) with an assessment reference date of 6/12/23 showed the Resident received hospice. Review of Resident #1's Order Summary Report showed a physician's order dated 5/31/23 to consult hospice for an evaluation and admit if appropriate. Review of Resident #1's care plan with an initiated date of 5/31/23 showed receiving hospice care related to a terminal diagnosis. Review of the Census list in the Electronic Record showed Resident #1's payor source changed on 6/26/23 from Hospice Private to Private Pay. Review of Resident #2's quarterly MDS with an ARD of 5/19/23 showed no documentation of hospice care while a resident. Review of Resident #2's Significant Change in Status MDS with an ARD of 8/19/23 showed in process. Review of Resident #2's MDS Section of the electronic record showed a ARD: 8/19/2023 25 days overdue. Review of Resident #2's Order Summary Report showed a physician's order dated 7/10/23 to consult hospice for evaluation to admit. Review of Resident #2's care plan with an initiated date of 8/14/23 showed Resident receiving hospice related to terminal diagnosis. The Census section in the Electronic Record showed Resident #2's payor source changed on 7/11/23 from Private Pay to Hospice Private. During interview on 9/27/23 at 1:22 PM, Licensed Practical Nurse (LPN) #2 confirmed Resident #1's last hospice day was 06/20/23, and when she returned from the hospital on 6/26/23 she was private pay. LPN #2 confirmed, Resident #1 should have had a significant change MDS completed at that time. LPN #2 confirmed Resident #2 had been receiving hospice care since 07/11/23, and a significant change was not performed within 14 days.

Based on record review and interview, the facility failed to have sufficient nursing staff available to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each residents' rights, physical, mental, and psychosocial well-being. This failed practice had the potential to affect all 82 residents in the facility. The findings are: Review of the facility's The PBJ (Payroll Based Journal) QuickBase staffing report showed the following: a. July 2023 Did not meet the standard for staffing. Reportable hours were 7679.26 in thirty one calendar days in the month, and the July minimum direct care hours needed based on daily average census was 8282.80. The difference between actual and required minimum for month was -0.24. b. August 2023 Did not meet the standard for staffing. Reportable hours were 7855.77 in thirty-one calendar days in the month, and the August minimum direct care hours needed based on daily average census was 8296.34. The difference between actual and required minimum for the month was -0.18. On 09/26/23 at 2:00PM review of the August 2023 Resident Council Meeting Minutes showed, New Business . call lights not being answered in a timely manner. Review of the facility's [NAME] CARE Report for the 3/11 shift on 9/26/23 showed the following: a. Resident #1's room activated the call light at 3:21 PM with a response time of 2 hours and 52 minutes. b. Resident #1's room activated the call light at 9:21 PM with a response time of 35 minutes 48 seconds. c. Resident #3's room activated the call light at 5:32 PM with a response time of 39 minutes 14 seconds. d. Resident #4's room activated the call light at 4:50 PM with a response time of 2 hours thirty-nine minutes and 20 seconds. e. room [ROOM NUMBER] activated the call light at 3:33 PM with a response time of 2 hours and 42 minutes. f. room [ROOM NUMBER] activated the call light at 3:40 PM with a response time of 2 hours and 33 minutes. g. room [ROOM NUMBER] activated the call light at 4:18 PM with a response time of 2 hours and 1 minute. h room [ROOM NUMBER] activated the call light at 4:32 PM with a response time of 2 hours and 56 minutes. i. room [ROOM NUMBER] activated the call light at 5:27 PM with a response time of 1 hour and 52 minutes. j. room [ROOM NUMBER] activated the call light at 7:24 PM with a response time of 1 hour and 6 minutes. k. An emergency bathroom light in room [ROOM NUMBER] activated at 3:33 PM with a response time of 54 minutes and 46 seconds. During interview on 9/27/23 at 8:20 AM the Surveyor asked Resident #1 do the staff promptly assist you with toileting? The Resident stated Some nights when the 3/11 shift leaves I don't get changed until the day shift comes in. I have to take strong laxatives because I had a bowel obstruction, so I go a lot. Resident #1 said she has been angry in the past when the call light was not answered for 3 hours, and during mealtime the staff tell her they cannot care for her because meals take priority. During interview on 9/27/23 at 8:40 AM Resident #4 said sometimes it takes 3 hours for the call light to be answered, and it happens all the time. During interview on 9/27/23 at 9:30 AM, the Administrator said she recently took over staffing, and it is census based. For the current census the goal is to have 10 - 8 - 6 and that does not include the van driver and restorative. The minimum staffing ratios is used as a guideline. The Surveyor asked what is your facility's process for answering call lights during mealtimes? She said someone is assigned to answer call lights during dinner service and recently the department heads had to stay over and answer call lights. The Surveyor asked why did the facility not meet the PBJ standard the last two months? The Administrator stated, We have had a rough couple of months. During interview on 9/27/23 at 1:15 PM, LPN #1 stated In a perfect world it ' s 2 minutes for a resident's call light to be answered. During interview on 9/27/23 at 1:20 PM, CNA #1 stated the acceptable time a resident should wait before a call light to be answered is not be very long. During interview on 9/27/23 at 1:22 PM, LPN #2 said the acceptable time a resident should wait before a call light is answered is immediately if the staff member is right there. During interview on 9/27/23 at 1:30 PM, LPN #3 said the acceptable time a resident should wait before a call light is answered is maybe 5 minutes. During interview on 9/27/23 at 1:33 PM, CNA #2 stated the acceptable time a resident should wait before a call light is less than 3 minutes. A Policy titled Staffing with a revision date of 10/2017 showed the facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.

Based on record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected anticoagulant use for 5 (Residents #7, #8, #43, #51 and #55) of 5 sampled residents whose MDS assessments were reviewed. The findings are: 1. Resident #7 had a diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery with Angina Pectoris with documented Spasm and Essential (Primary) Hypertension. The Quarterly MDS with an Assessment Reference Date (ARD) of 05/16/23 documented the resident received an anticoagulant medication all 7 days of the 7 day lookback period. a. A Physicians Order dated 02/06/23 documented, Aspirin Oral Tablet (Aspirin,) Give 81 mg [milligrams] by mouth one time a day . 2. Resident #8 had diagnoses of Heart Failure, Unspecified and Acute Myocardial Infarction, Unspecified. The Quarterly MDS with an ARD of 05/12/23 documented the resident received an anticoagulant medication all 7 days of the 7 day lookback period. a. A Physicians Order dated 05/05/23 documented, Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate), Give 1 tablet by mouth one time a day related to Heart Failure, Unspecified . 3. Resident #43 had a diagnosis of Unspecified Atrial Fibrillation. The Quarterly MDS with an ARD of 03/15/23 documented the resident received an anticoagulant medication all 7 days of the 7 day lookback period. a. A Physicians Order dated 11/07/22 documented, Aspirin Capsule 81 MG, Give 81 mg by mouth at bedtime related to Unspecified Atrial Fibrillation . 4. Resident #51 had a diagnosis of Heart Disease, Unspecified. The Quarterly MDS with an ARD of 04/06/23 documented the resident received an anticoagulant medication all 7 days of the 7 day lookback period. a. A Physicians Order dated 10/13/21 documented, Clopidogrel Bisulfate Tablet 75 MG, Give 1 tablet by mouth one time a day related to Heart Disease, Unspecified . 5. Resident #55 had a diagnosis of Heart Disease, Unspecified. The Annual MDS with an ARD of 05/11/23 documented the resident received an anticoagulant medication all 7 days of the 7 day lookback period. a. A Physicians Order dated 09/14/21 documented, Aspirin Tablet Chewable 81 MG, Give 1 tablet by mouth one time a day related to Essential (Primary) Hypertension . 6. On 06/15/23 at 3:14 PM, the Surveyor asked the MDS Coordinator, What drug classification is Clopidogrel/Plavix? The MDS Coordinator stated, It is an anticoagulant. The Surveyor asked, What classification is Aspirin? He stated, It is used as a blood thinner, or an anticoagulant. 7. On 06/15/23 at 3:15 pm, the Surveyor asked the Medicare Manager/MDS Coordinator, What classification is Clopidogrel/Plavix? The Medicare Manager/MDS Coordinator stated, I believe it is an antiplatelet. The Surveyor asked, Would you look at [Resident #7's] Quarterly MDS with an ARD of 05/16/23, and tell me what is charted for medications in the 7-day lookback period? She stated, It shows 7 days of anticoagulant. The Surveyor asked, What do you use as guidance for coding medications on the MDS? She stated, The Resident Assessment Instrument [RAI]. She pulled up the RAI on her computer and stated, Under N0410E it states, 'Do not code antiplatelet medications such as Aspirin/extended release, Dipyridamole or Clopidogrel here.' I knew that, I guess I overlooked that. 8. On 06/15/23 at 10:30 AM, the Nurse Consultant provided a hard copy of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, October 2019, that documented for MDS Item N0410E, Anticoagulant use, .Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period . Do not code antiplatelet medications such as aspirin/extended release . or Clopidogrel [Plavix] here . 47916

Based on observation, interview, and record review, the facility failed to ensure proper Personal Protective Equipment (PPE) was worn for a resident on contact isolation precautions for 1 (Resident #231) of 1 sampled resident who was on Contact Isolation. The findings are: 1. Resident #231 had a diagnosis of Urinary Tract Infection, Site not Specified. a. The Nursing Admit/Readmit Assessment and Care Plan with a date of 06/06/23 revealed Resident #231 was admitted with an infection that required isolation. b. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of June 8, 2023, revealed Resident #231 is frequently incontinent. c. The Care Plan with a revision date of 06/13/23 documented, Continue isolation of resident following completion of antibiotic therapy and results of UA [urinary analysis] for post VRE [Vancomycin-resistant Enterococci] dx [diagnosis] . Continue in private room at this time . d. On 06/12/23 at 10:20 AM, Certified Nursing Assistant (CNA) #2 pushed Resident #231 in a wheelchair from Physical Therapy back to her room. The Surveyor observed isolation personal protective equipment [PPE] outside the door, and a contact precaution sign on the door. The Contact Precaution sign stated that hands were to be cleaned before entering and exiting room, gown before entering and exiting room, do not wear the same gown and gloves for care of more than one person. The Surveyor asked CNA #2 to help the Surveyor understand what Resident #231 was on isolation precautions for and the isolation process. CNA #2 said, I think she has ESBL [Extended Spectrum Beta-Lactamase] in her urine. I do not know when I have to wear a gown. I think only when I am doing personal care. The Surveyor asked what a possible consequence of a resident on isolation precautions being outside their isolation room with staff and neither staff nor the resident wearing PPE. CNA #2 said, She may have touched her private parts, and I could get something. e. On 06/13/23 at 2:00 PM, the Surveyor asked the Rehabilitation Director to walk this Surveyor through therapy with Resident #231 and what precautions were taken when Resident #231 was using the therapy room on 06/12/23 without any PPE in use. The Rehabilitation Director said, Well, I made sure she was the only person in therapy at that time, and the equipment was cleaned with [antibacterial disinfectant] when she left. I thought it was important to her recovery to come stand and use the equipment in therapy. f. On 06/14/23 at 9:50 AM, the Surveyor knocked on Resident #231's door and while opening the door Licensed Practical Nurse (LPN) #1 appeared around the privacy curtain wearing pink scrubs. LPN #1 said, Patient care. When LPN #1 exited Resident #231's room, the Surveyor asked LPN #1 what Resident #231 was on precaution for and to walk this Surveyor through the contact precaution process. LPN #1 said, Vancomycin-resistant enterococci in the urine, well it has not been confirmed yet. This is just precautionary. The Surveyor asked what type of infection control/isolation training she has had. LPN #1 said, I've only been here a few months, and I have not had any training in this. I failed to put on a gown, and it was my own negligence. The Surveyor asked about any possible consequences of not wearing PPE or following contact precautions. LPN #1 said, I am not messing with her urine, so I fail to see any. I was not wearing a gown, so I guess to keep from getting anything on my clothing. g. On 06/15/23 at 8:04 AM, Nursing Assistant (NA) #1 was assisting Resident #231 with meal set up wearing blue scrubs and no PPE. The Surveyor asked NA #1 why she was not wearing PPE, and what the procedure was for contact precautions. NA #1 said, I did not read the sign on the door. I do not know what contact precautions mean. I have been meaning to ask the Assistant Director of Nursing [ADON] about it. The Surveyor asked what the possible negative outcomes could be from not following isolation precautions. NA #1 said, I really do not know. h. On 06/15/23 at 11:38 AM, the Surveyor asked the Assistant Director of Nursing (ADON) to explain the basis of isolation precautions. The ADON said, To prevent the spread of bacteria to other residents. The Surveyor asked if it is appropriate for staff to not follow the isolation precaution policy and what negative outcomes were possible. The ADON said, It is absolutely not appropriate. If they are not following protocol, we are putting the residents at risk by spreading bacteria. The Surveyor asked how the facility cleans when isolation protocol is not followed. The ADON referred the Surveyor to infection control. i. On 06/15/23 at 11:42 AM, the Surveyor asked the Infection Control Preventionist (ICP) if she was familiar with a resident with suspected VRE that was taken to Physical Therapy on Monday 06/12/23, and if test results were finalized. The ICP said, Yes, I am aware. I anticipate sensitivities in the next 24 hours. We have discussed the situation, discussed contact times regarding when [Resident #231] should and should not go to therapy. We have had this conversation before. The Surveyor asked if they had discussed taking Resident #231 prior to her going to Therapy on Monday. The ICP said, We have had this conversation before, but not this time. It has come up in the past. The Surveyor asked the ICP if Physical Therapy had any affected equipment that was sanitized, and what cleaning agent was used. The ICP said, The Therapy Room was cleaned, and they cleaned [Resident #231's] wheelchair and bed. They used [antibacterial disinfectant] to clean with. It is a 10-minute cleaner. They decided to treat her independently in Therapy because she is a lift and is trying to get stronger to go home. 2. A facility policy titled, Policies and Practices - Infection Control, provided by the Administrator on 06/15/23 at 9:30 AM documented, .Policy Interpretation and Implementation .2. Transmission-based precautions are additional measures that protect staff, visitors, and other residents from becoming infected . 5. When a resident is placed on transmission precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware . a. The signage informs the staff of the type of CDC [Centers for Disease Control] precautions(s), instructions for use of PPE [Personal Protective Equipment], and/or instructions to see a nurse before entering the room . Contact Precautions 1. Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident ' s environment . 4. Staff and visitors will wear gloves (clean, non-sterile) when entering room . 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room . 6. When transporting individuals with skin lesions, excretions, secretions, or drainage that is difficult to contain, contact precautions will be taken during resident transport to minimize the risk of transmission . 3. A Contact Isolation Inservice and Signature sheet dated 06/12/23 provided by the Administrator on 06/15/23 at 9:30 AM documented, .1. Gloves and gowns are required. Shoe coverings, Hair covering or goggles/shield if splashing is concern. You must be completely dressed out before entering the door . 5. All isolation residents must remain in room, unless specific consideration is made .

Based on observation, record review, and interview, the facility failed to ensure residents were assessed and deemed safe for self-administration of nebulizer (updraft) treatments for 2 (Residents #25 and #66) of 5 (Residents #20, #25, #31, #64 and #66) sampled residents who had Physician Orders for updraft treatments. This failed practice had the potential to affect 12 residents who had orders for updraft treatments as documented on a list provided by the Administrator on 06/15/23 at 9:00 AM. The findings are: 1. Resident #25 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Unspecified and Emphysema, Unspecified. a. A Care Plan with an initiated date of 8/19/22 revealed Resident #25 has chronic Emphysema/COPD with an intervention to give aerosol or bronchodilators as ordered. The care plan does not mention the resident has been evaluated to self-administer aerosol or bronchodilator treatments. b. Physician Orders dated 09/26/22 documented, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG [milligrams]/3ML [milliliter] 3 ml inhale orally every 4 hours as needed for SOB [Shortness of Breath] or Wheezing via nebulizer; and Ipratropium-Albuterol Solution 0.5-2.5 (3) MG /3ML 3 ml inhale orally two times a day related to Chronic Obstructive Pulmonary Disease, Unspecified . c. Review of the June 2023 Medication Administration Record, (MAR) revealed the inhaled medication was signed as administered twice per day by facility staff. d. On 06/13/23 at 1:58 PM, Resident #25 was reclining in bed wearing an updraft mask. At 2:00 PM, Licensed Practical Nurse (LPN) #2 came into Resident #25 ' s room. LPN #2 said, I was coming to give you this updraft, but it looks like you are already giving yourself one. The Surveyor asked LPN #2 to walk this Surveyor through the process of administering an updraft. LPN #2 said, We start the updraft and stay in the room until it is complete. Then we put the mask in the storage bag. Resident #25 said, They would not get any work done if they did it your way. The Surveyor asked LPN #2 what the possible complications could be of Resident #25 or other residents giving themselves unsupervised updrafts. LPN #2 said, Someone could wear a mask strapped to their face for a long time. 2. Resident #66 had diagnoses of COPD Unspecified, Other Pulmonary Embolism without Acute Cor Pulmonale, Acute Respiratory Failure with Hypoxia and Pneumonia, Unspecified Organism. a. A Physicians Order dated 05/17/23 documented, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally two times a day related to Chronic Obstructive Pulmonary Disease, Unspecified . b. A Care Plan with an initiated date of 5/23/23 revealed the resident has difficulty breathing related to COPD with an intervention to administer medication/puffers as ordered. The care plan does not mention the resident has been evaluated to self-administer bronchodilator treatments. c. Review of the June 2023 MAR revealed the inhaled medication was signed as administered twice per day by facility staff. d. On 06/14/23 at 11:15 AM, the Surveyor asked LPN #1 who was at the bedside, to walk this Surveyor through the process of giving Resident #66 an updraft. LPN #1 said, He gives himself his own updraft and then shuts it off. If I am close by, I am the one that shuts it off. The Surveyor asked if Resident #66 had self-administration rights and what respiratory care training she had received. LPN #1 said, I'm not aware of any self-administration rights. I have not had any training here, but I know what to do from working at other facilities. The Surveyor asked if there were possible complications from Resident #66's updraft machine lying at the foot of his bed near his feet, with the mouthpiece and tubing not in a storage bag. LPN #1 said, The mouthpiece can get dirty, and it will need to be rinsed out. I always rinse it out, but I do not know what anyone else does. 3. On 06/15/23 at 12:40 PM, the Surveyor asked the Nurse Consultant if the facility had a self-administered record. The Nurse Consultant said, No, we do not have anyone that self-administers medications. 4. On 06/15/23 at 3:20 PM, the Surveyor asked the Assistant Director of Nursing (ADON) if it is appropriate for residents to be allowed to administer their own updrafts, or to have the opportunity to start and stop their updraft when they feel it is needed, and why. The ADON said, No that is not appropriate at all. It is against our policy. The Surveyor asked what a possible outcome was of a resident self-administering their updrafts. The ADON said, They may not get the full benefit of their updraft. 5. A facility policy titled, Self-Administration of Medications, provided by the Administrator on 06/13/23 at 3:30 PM documented, 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications . 6. For self-administering residents, the nursing staff will determine who will be responsible (the resident or the nursing staff) for documenting that medications were taken . 12. Nursing staff will review the self-administered medications record on each nursing shift, and they will transfer pertinent information to the medication administration record (MAR) kept at the nursing station, appropriately noting that the doses were self-administered .

Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was properly stored to prevent potential infection for 1 (Resident#66) of 10 (Residents #9, #10, #16, #20, #25, #31, #41, #55, #64 and #66) sampled residents who had Physician Orders for oxygen therapy, and failed to ensure the nebulizer (updraft) machine, mouthpiece and tubing, were properly dated and stored in a bag or other closed container when not in use for 2 (Residents #25 and #66) of 5 (Residents #20, #25, #31, #64 and #66) sampled residents who had Physician Orders for updraft treatments as documented on lists provided by the Administrator on 06/15/23 at 9:30 AM. The findings are: 1. Resident #25 had diagnoses Chronic Obstructive Pulmonary Disease (COPD), Unspecified, and Emphysema, Unspecified. a. A Physicians Order dated 02/22/23 documented, change/date updraft tubing every Sunday every night shift every Sun [Sunday] . b. Review of the June 2023 Medication Administration Record (MAR), revealed the staff documented the updraft tubing was changed on 6/4/23 and 6/11/23. c. On 06/12/23 at 11:10 AM, Resident #25 was sitting up in bed, an updraft machine was sitting on a table at the foot of the bed with a mask in a bag dated 05/21. d. On 06/12/23 at 1:53 PM, Resident #25's updraft machine was sitting on a table at the foot of the bed with a mask stored in a clear plastic bag dated 05/21. 2. Resident #66 had diagnoses of Other Pulmonary Embolism without Acute Cor Pulmonale, Acute Respiratory Failure with Hypoxia, Pneumonia and Unspecified Organism. a. Physicians Order dated 05/25/23 documented, OXYGEN as needed for SHORTNESS OF BREATH 3 LITERS/MIN [minute] PER NASAL CANNULA PRN [as needed] . and OXYGEN every shift for Shortness of Breath ., Change and date o2 [oxygen] tubing and water bottle q [every] week every night shift every Sun . b. On 06/12/23 at 10:30 AM, Resident #66's updraft mouthpiece and machine were lying at the foot of his bed. The Surveyor asked Resident #66 who was responsible for his equipment. Resident #66 said, The nurses are responsible. I had a bag, but I do not know where it is. I had my updraft and when I was done, I laid it at the foot of the bed. The Surveyor observed a nasal cannula in the floor between the concentrator and bed. Resident #66 said, I used oxygen a few days ago and when I was done, I laid the tubing by my pillow. I guess it fell in the floor. The Surveyor asked who is providing care for his respiratory equipment. Resident #66 said, I guess I am. c. On 06/12/23 at 2:09 PM, Resident #66's oxygen tubing with nasal canula was laying in the floor between the bed and the concentrator. The nebulizer machine was lying at the foot of the bed. The mouthpiece and tubing were not in a storage bag. d. On 06/13/23 at 8:10 AM, Resident #66's updraft machine was resting at the foot of the bed with the mouthpiece resting on the linens. Resident #66 said, They put away my oxygen tubing, and I am just sleeping with my updraft machine down there. Resident #66 pointed to the foot of the bed. The Surveyor asked if his feet ever got on the mouthpiece. Resident #66 said, Yes, sure it does. e. On 06/14/23 at 10:53 AM, Resident #66's updraft machine and mask were lying at the foot of the bed. f. On 06/14/23 at 11:15 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, who was at Resident #66 ' s bedside the process of giving Resident #66 an updraft. LPN #1 walked to the foot of the bed and pulled aside the blanket. LPN #1 said, Well first of all the nurse stays during the updraft and puts the mouthpiece in the storage bag when he is done. That didn't happen. Well, I cannot find the storage bag. The Surveyor asked if there was a possibility of any adverse complications from Resident #66's updraft machine laying at the foot of his bed near his feet, without the mouthpiece and tubing in a storage bag. LPN #1 said, The mouthpiece can get dirty, and it will need to be rinsed out. I always rinse it out, but I do not know what anyone else does. 3. On 06/15/23 at 3:00 PM, the Administrator said, We do not have an oxygen storage policy. 4. On 06/15/23 at 3:20 PM, the Surveyor asked the Assistant Director of Nursing (ADON) if it was appropriate for oxygen tubing to be lying on the floor, storage bags not being changed as ordered, Resident #66 to sleep with his nebulizer machine at the foot of the bed, and the updraft mouthpiece not being placed in a storage bag when not in use. The ADON said, No, that is not appropriate. I thought it was standard precautions. Oxygen tubing in the floor should be thrown away. Mouthpieces and oxygen tubing should be placed in a storage bag when not in use and changed weekly. The Surveyor asked what a possible outcome of oxygen tubing lying in the floor, and not storing tubing and updraft mouthpiece properly was. The ADON said, Infection, and not getting the full benefit of updraft therapy. 5. A facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, provided by the Administrator on 06/15/23 at 9:30 AM documented, .Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: .3. After completion of therapy: .7. Store the circuit in plastic bag, marked with date and resident's name, between uses .

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 6 residents who received pureed diets as documented on a list provided by the Food Service Supervisor on 06/13/23. The findings are: 1. On 06/12/23 at 11:28 AM, Dietary Employee (DE) #2 placed 6 servings of oven breaded baked chicken into a blender, added chicken broth and pureed. She poured the pureed chicken into a pan. The consistency of the pureed chicken was gritty and was not smooth. 2. On 06/12/23 at 12:02 PM, DE #2 used a #8 scoop to place 7 servings of enhanced scalloped potatoes into a blender and pureed. She poured the enhanced scalloped potatoes into a pan and placed the pan on the steam table. The consistency of the pureed enhanced potatoes was thick and not smooth. There were pieces of potato visible in the mixture. 3. On 06/12/23 at 12:17 PM, DE #2 placed 8 slices of bread into a blender, added warm whole milk and pureed. At 12:19 PM, she poured the pureed bread into a pan and placed it on the steam table. The consistency of the pureed bread was thick and sticky. 4. On 06/13/23 at 1:40 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1 to describe the consistency of the pureed food items served to the residents who received pureed foods at the lunch meal. CNA #1 stated, Pureed bread, pureed scalloped potatoes and pureed chicken were thick and sticky. 5. On 06/12/23 at 1:46 PM, the Surveyor asked DE #2, to describe the consistency of the pureed food items served to the residents for lunch. She stated, Pureed scalloped potatoes were thick and needed to be blended some more, pureed chicken was gritty. Pureed bread was too thick, needed more fluid.

Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; and dairy products on a shelf in the refrigerator were sealed to prevent the potential for cross contamination. These failed practices had the potential to affect 73 residents who received meals from the kitchen (total census: 79), as documented on a list provided by the Dietary Supervisor on 06/13/23. The findings are: 1. On 06/12/23 at 9:52 AM, the following observations were made in the walk-in refrigerator: a. An opened zip lock bag that contained slices of cheese was not sealed. b. An opened zip lock bag that contained shredded cheese was not sealed. 2. On 06/12/23 at 10:02 AM, Dietary Employee (DE) #1 turned on the hand washing sink faucet and washed her hands. She then turned off the faucet with her bare hands, and pulled out tissue papers and dried her hands, contaminating her hands. She opened a cabinet, removed clean dishes, and placed them on the counter to be used in portioning dessert to be served to the residents for lunch with her fingers inside the dishes. 3. On 06/12/23 at 10:05 AM, DE #1 removed a container of chocolate pie from the refrigerator and placed it on the counter. She removed the plastic wrap around the container of chocolate pie, opened the Janitor's Closet and threw the wrap into the trash can. Without washing her hands, she removed gloves from the glove box and placed them on her hands, contaminating the gloves. She picked up a knife and sliced the pie, then used her contaminated gloved hands to slide slices of cake into individual plates to be served to the residents for lunch. 4. On 06/12/23 at 10:18 AM, DE #1 turned on the hand washing sink faucet and washed her hands. She then turned off the faucet with her bare hands, and pulled out tissue papers and dried her hands, contaminating her hands. She opened the Janitor's Closet and threw away the tissue. She then, opened a cabinet, removed clean dishes, and placed them on the counter to be used in portioning dessert to be served to the residents for lunch with her fingers inside the dishes. 5. On 06/12/23 at 10:19 AM, DE #2 was wearing gloves on her hands. She picked up a pan coating spray bottle and sprayed the inside the pans, contaminating the glove. Without changing gloves and washing her hands, she picked up breaded chicken breasts with her contaminated gloved hand and placed them in the pans to be baked and served to the residents for lunch. 6. On 06/12/23 at 10:20 AM, DE #1 opened the freezer and took out a plastic container of chocolate pie, placed it on the counter and unwrapped the pie. She turned on the hand washing sink faucet and washed her hands. She then turned off the faucet with her bare hands, and pulled out tissue papers and dried her hands, contaminating her hands. She opened the Janitor's Closet and threw away the tissue. She then opened a cabinet, removed pans, and placed them on the counter. Without washing her hands, she picked up clean dishes, and placed them on the trays to be used in portioning dessert to be served to the residents for lunch with her fingers inside the dishes. She removed gloves from the glove box and placed them on her hands, contaminating the gloves. Without changing gloves and washing her hands, she placed her contaminated gloved hands on the chocolate pie while transferring them into individual plates and or bowl. 7. On 06/12/23 at 10:38 AM, DE #1 turned on the hand washing sink faucet and washed her hands. She then turned off the faucet with her bare hands and pulled out tissue papers and dried her hands, contaminating her hands. Without washing her hands, she picked up bowls to be used in portioning pureed dessert and placed them on the counter with her fingers inside the bowls. 8. On 06/12/23 at 10:46 AM, DE #1 turned on the hand washing sink faucet and washed her hands. She then turned off the faucet with her bare hands, and pulled out tissue papers and dried her hands, contaminating her hands. She opened the Janitor's Closet and threw away the tissue. She removed gloves from the glove box and placed them on her hands, contaminating the gloves. Without changing gloves and washing her hands, she placed her contaminated gloved hands on 8 slices of chocolate pie while transferring them into the blender to be pureed and served to the residents who required pureed diets for lunch. 9. On 6/12/23/ at 11:11 AM, DE #1 used a rag to wipe off spilled food on the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets for the lunch meal. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 10. On 06/12/23 at 11:32 AM, DE #3 opened the refrigerator and took out cartons of nectar beverages, pitchers of apple juice and cranberry juice and placed them on the counter by the cold side of the steam table. Without washing her hands, she picked up glasses by the rims and placed them on the counter and poured beverages in them. She placed the glasses on ice on the cold side of the steam table to be served to the residents for the lunch meal. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 11. The facility policy titled, Employee Cleanliness and Handwashing Technique, provided by the Administrator on 06/13/23 at 3:03 PM documented, .Dietary Department employees are required to wash their hands on the occasions listed below: a. before beginning shift . g. after handling dirty dishes . j. any other time deemed necessary .

Based on observation and interview, the facility failed to ensure leftover food items were used properly to maintain food quality and to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 74 residents who received meals from the kitchen (total census: 75), as documented on a list provided by Dietary Supervisor on 3/29/2022 at 11:43 AM. The findings are: 1. On 3/28/22 at 11:35 AM, a zip lock bag that contained pieces of bacon was stored on a shelf in the freezer. A zip lock bag that contained sausage links was stored on a shelf in the refrigerator. The Dietary Supervisor was asked, What do you use these for? She stated, We use bacon for ground meat the next the morning and sausage for pureed meat the next morning. 2. On 3/28/22 at 11:43 AM, Dietary Employee #1 placed tissue papers that she had used to dry her hands in the trash can that was full. She then pushed tissue papers down inside the trash can with her hand and pulled her pants up. Without washing her hands, she picked up glasses by their rims and placed them on the counter and poured beverages in them to serve to the residents for the lunch meal. At 10:03 AM, Dietary Employee #1 was asked, What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, I should have washed my hands. 3. On 3/28/22 at 11:53 AM, Dietary Employee #2 turned on the food preparation and washed inside of the blender bowl. After she had finished washing her hands, she turned off the faucet with her bare hand. She then, used the same contaminated hand to pick up a blade and attached it to the base of the blender. 4. On 3/28/22 at 12:02 PM, Dietary Employee #1 took out blue frozen boards from the freezer that keeps foods cold and placed them on the counter. Without washing her hands, she removed glasses from the cabinet above the food preparation counter and placed them on the blue board. She picked up lids with her fingers touching the interior surfaces as she covered the glasses. 5. On 3/29/22 at 7:48 AM, Dietary Employee #3 had a cup of chicken broth in front of the coffee maker. As she was rinsing a spoon from the hot water dispenser, water started to splash inside the cup that contained the chicken broth. Dietary Employee #5 immediately was informed about what was going on. She stopped Dietary Employee #3 and instructed her to prepare another chicken broth for the resident. 6. On 3/29/22 at 7:53 AM, Dietary Employee #3 picked up cartons of milk, cartons of Mighty Shake and condiments and placed them on the trays. Without washing her hands, she picked up glasses that contained beverages by their rims and placed them on the trays to be served to the residents for breakfast. 7. On 3/29/22 at 11:30 AM, Dietary Employee #3 who was wearing gloves on her hands touched her face mask. Without changing gloves and washing her hands, she picked up a peanut butter sandwich to bag. Dietary Employee #6 immediately was asked, What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, I should have change gloves and washed my hands. 8. The facility policy titled, Hand Washing, provided by the Dietary Supervisor on 3/29/2022 documented, . wash hands after engaging in other activities that contaminate the hands .

Based on record review and interview, the facility failed to ensure a residents' representative was notified in writing of the resident's transfer to the hospital and/or discharge for 1 (Resident #15) of 5 (Residents #27, #56, #67, #62 and #36) sampled residents who were transferred to the hospital in the last three months. The findings are: Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-Day Minimum Data Set (MDS) with an Assessment Reference Date 1/10/22 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status. a. Resident #15's MDSs documented a Discharge with Return Anticipated on 12/15/21 with an Entry on 12/29/21; a Discharge with Return Anticipated on1/3/22 with an Entry of 1/7/22; and a Discharge with Return Anticipated on 3/4/22 with an Entry of 3/10/22. b. The SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers dated 12/15/2021 4:32 PM documented, .Resident with labored, rapid breathing unable to get his oxygen saturation above 80% [percent] on 4L [Liters] of oxygen . Send resident to [Name] ER [emergency room ] for evaluation . c. The SBAR Summary for Providers dated 1/3/2022 5:55 PM documented, .[CONDITION(S)]. PEG [ percutaneous endoscopic gastrostomy] tube clogged. Can't give necessary meds to regulate heart rate . Recommendations: Send to ER for eval [evaluation]. d. The SBAR Summary for Providers dated 3/4/2022 8:10 PM documented, .Altered mental status . Recommendations: send to ER . e. On 3/31/22 at 8:28 AM, the Business Office Manager (BOM) was asked, Who is responsible for completing transfer letter? She replied, I am. She was asked, Is there a reason why the resident's and transfer letter were not completed for 12/15/21, 1/3/22 and 3/4/22? She replied, I missed them. She was asked, When should the transfer letter be processed? She replied, At the time of transfer, unless it's an emergency, but if the resident is transferred and I'm not here it gets done on Monday, or the next morning. f. The Facility Initiated Transfer form provided by the BOM on 4/1/22 at 8:31 AM documented, Complete this form when a resident is temporarily transferred to an acute hospital, emergency room or other location. A copy of this notice must be provided to the resident and resident representative at the time of transfer unless it is an emergency. If an emergency the facility will issue as soon as practicable . g. The facility policy titled, Transfer or Discharge, Preparing a Resident for, provided by the DON on 3/31/22 at 12:31 PM documented, .Nursing services is responsible for: Obtaining orders for . transfer, .The Business office is responsible for: Informing appropriate departments of the resident's transfer .

Based on observation, record review and interview, the facility failed to ensure the call light was placed within the resident's reach to enable the resident to call for assistance when needed for 2 (Residents #71 and #50) of 14 (Residents #71, #50, #27, #26, #42, #52, #62, #16, #67, #10, #29, #23, #4 and #54) sampled residents who used their call light to call for assistance. This failed practice had the potential to affect 35 residents who could use their call lights according to a list provided by the Administrator on 3/31/22 at 8:56 a.m. The findings are: 1. Resident #71 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/21/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS) and required limited physical assistance of one person with bed mobility, transfer, toilet use and personal hygiene. a. The Plan of Care with a revision date of 1/17/22 documented, . is (High) risk for falls . Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . c. On 03/28/22 at 11:53 AM, Resident #71 was in her recliner in her room trying to get out of her chair to go to the bathroom. Her call light was lying on her bed out of reach. d. On 03/28/22 at 11:57 AM, the Activities Director was called to the room by the surveyor with another person to assist Resident #71 to the bathroom. Resident #71 stated that she could use her call light if they had put it within reach. The Activities Director was asked, Should her call light be within reach? She stated, Yes. She was asked, Why was it laying on her bed when she was sitting up in the wheelchair? She stated, I don't know but she can go to the bathroom all by herself without help. She was asked, Should she have something on her bare feet? She stated, Yes, we will put some nonskid socks on her. She was asked, What could have happened if I hadn't come and got you to help her to the bathroom? She stated, She could have fallen. 2. Resident #50 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan with a revision date of 2/11/22 documented, .Encourage the resident to use bell to call for assistance. Call light to left side . b. On 03/28/22 at 11:34 AM, Resident #50 was lying in bed. She was asked, Were is your call light? She fumbled around in her bed and pulled the bed remote from under the blanket. Her call light was on her wheelchair out of reach. She was not able to use her hand in order to reach over to get her call light. She was asked, Can you reach your call from your bed? She shook her head right to left. c. On 3/31/22 at 8:17 AM, Licensed Practical Nurse (LPN) #1 was asked, Should [Resident #50's] call be in reach at all times? She stated, Yes, along with the bed control. 3. The facility policy titled, Answering the Call Light, provided by the Director of Nursing on 3/31/22 at 8:56 a.m. documented, .The purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident .

Based on observation, record review, and interview, the facility failed to ensure fingernails were clean, trimmed and free from jagged edges to promote good personal hygiene and grooming for 2 (Residents #38 and #24) of 23 (Resident #27, #71, #3, #52, #62, #67, #223, #50, #15, #38, #36, #24, #48, #6, #23, #4, #70, #54, #14, #56, #45, #69 and #40) sampled residents who were dependent on staff for nail care. The findings are: 1. Resident #38 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/22/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of one person with bathing and personal hygiene. a. The Care Plan with a revision sate of 2/17/22 documented, .has an ADL [activities of daily living] self-care performance deficit . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary . b. On 3/28/22 at 3:11 PM, Resident #38 was lying in bed. The tips of her fingernails were approximately 1/4 inch long and the nail polish was chipped. The right thumb nail was jagged. c. On 3/29/22 at 8:42 AM, Certified Nursing Assistant (CNA) #4 was asked, Who performs nail care on the residents? She replied, The CNAs, if diabetic the nurses have to trim them. She was asked, When is nail care completed? She replied, Daily as needed, on their shower days and on Sunday. d. The ADL bathing task log documented Resident #38 received a bed bath on 3/29/22 at 12:37 PM. e. On 3/29/22 at 1:58 PM, Licensed Practical Nurse (LPN) #3 was asked, Who does nail care on the residents? She replied, The CNAs, if diabetic the nurses trim them. LPN #3 was asked, When is the nail care completed? She replied, On their shower days and prn [as needed]. LPN #3 accompanied the surveyor to Resident #38's room. Resident #38 was sitting in her wheelchair. LPN #3 was asked, What is that brown substance under her nail tips? She replied, Food. LPN #3 was asked, Does her fingernails need to be, cleaned, trimmed and filed? She replied, Yes, she needs nail care. She was asked to describe Resident #38's nails. She replied, The nail tips are about an ¼ long, her right thumb nail is jaggy, and her nails need to be polished. LPN #3 asked Resident #38, Do you want your nails cut short? Resident #38 stated, Yes. 2. Resident #24 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan with a revision date of 1/28/22 documented, .is at risk for impairment to skin integrity r/t [related to] fragile skin . Avoid scratching . Keep fingernails short . has an ADL self-care performance deficit . BATHING/SHOWERING: Resident requires extensive assist [assistance] of 1 person. Resident is offered bath/shower 3 times per week and PRN . b. On 3/28/22 at 12:15 PM, Resident #24 was lying in bed. The fingernails on her left hand were approximately 1/8 inch long with a brown substance under the nail tips. c. The ADL bathing task log documented Resident #24 received a bed bath on 3/29/22 at 12:40 PM. d. On 3/29/22 at 2:04 PM, LPN #3 accompanied the surveyor to Resident #24's room. Resident #24 was lying in bed. Her fingernails on both hands were approximately 1/8 long with a brown substance under the nail tips. LPN #3 was asked, What is that brown substance under her nail tips? She replied, Looks like food. LPN #3 was asked, Does her fingernails need to be cleaned? She replied, Yes, I will get that done right now. 3. On 3/31/22 at 12:31 PM, the Director of Nursing (DON) was asked, Who performs nail care on the residents? She replied, The CNAs, diabetic the nurses, they have to trim and file the nails. The DON was asked, When is nail care provided on the residents? She replied, On shower days and as needed. She was asked, Who is responsible to ensure the CNAs are performing nail care on the residents as needed? She replied, The floor nurses, me and the ADON [Assistant Director of Nursing]. 4. The facility policy titled, Fingernails/Toenails, Care of , provided by the DON on 3/31/22 at 8:19 AM documented, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.Nail care includes daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed .

Based on observation, record review, and interview, the facility failed to ensure a toolbox containing shaving cream, razors, mouth wash and peri wash was locked on 1 (500 Hall) of 6 (100 Hall, 200 Hall, 300 Hall, 400 Hall, 500 Hall and 600 Hall) Halls to provide a safe environment. The findings are: 1. On 3/28/22 at 12:23 p.m., a black toolbox attached to the linen cart on the 500 Hall had 2 flip locks, one on each side of the front. On the left side the flip lock was in the open position. On the right side the flip lock was in the closed position with a pad lock that was not secured in the lock position. Certified Nursing Assistant (CNA) #3 was stopped and asked, Can you tell me if that lock on the box is securely locked? CNA #3 stated, Yes ma'am, it is locked. CNA #3 was asked, Will you look at it again, closely? CNA #3 stated, Oh, I am sorry, the lock wasn't securely in the lock position, and it should have been. CNA #3 was asked, Can you open the box so I can look in it to see what is being locked up in a box on the hallway? CNA #3 stated, Yes ma'am. Inside the black box were razors, shaving cream, mouth wash, and other personal items used for grooming the residents. CNA #3 was asked, Should the box be locked at all times? CNA #3 stated, Yes ma'am. CNA #3 was asked, What could happen if a resident got into this box? CNA #3 stated, The residents could hurt themselves or ingest some of the chemicals and that is why the box is supposed to be locked up at all times. 2. On 3/29/22 at 3:40 p.m. the Director of Nursing (DON) was asked, Who has keys to the black toolboxes on the halls? She stated, All of the CNA's have access to the supplies in the toolboxes' on each hallway and those toolboxes are supposed to be locked at all times on every hall. The DON was asked, Who was responsible to make sure they were locked at all times? She stated, All of the CNA's were being held accountable for keeping them locked, and now since they haven't been, I have completely taken everything out and they have to walk to the supply room every time they need something now. I have told them and told them and even did education on the importance of keeping the toolboxes locked and no matter how hard you try, there is always that one that is unlocked. I can't tell you how many times I have walked in this building and found at least one of them unlocked. 3. The facility policy titled, Safety and Supervision of Residents, provided by the DON on 3/30/22 at 4:25 p.m. documented, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The QAPI [Quality Assurance Performance Improvement] Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary .

Complaint # (AR 346) was substantiated, all or in part, in these findings. Based on observation, record review, and interview, the facility failed to ensure a van utilized for resident transportation had a properly functioning shoulder strap for residents who were transported in wheelchairs, failed to ensure all staff who drove the van were trained in all aspects of the van usage and how to report needed repairs and failed to ensure that when the shoulder strap malfunctioned during an outing, measures were taken to ensure safety and prevent injury for 1 (Resident #1) of 3 (Residents #1, 2, and 3) case mix residents who were transported in the facility van in the past 30 days. The failed practices resulted in Past Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Resident #1, who was not properly restrained in the van and fell out of her wheelchair while returning from an outing, resulting in a fractured tibia, and had the potential to affect 33 residents who were transported in the facility van in the past 30 days, according to a list received from the Administrator on 7/11/16. The Administrator was informed of the (past) Immediate Jeopardy on 7/12/16 at 11:04 a.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with assessment Reference Date of 6/1/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS); required extensive assistance of 2 persons for bed mobility, transfers, and dressing; extensive assistance of 1 person for personal hygiene; was frequently incontinent of bladder; not steady - only able to stabilize with staff assistance for surface-to-surface transfers; and had no falls. a. The Facility Progress Notes documented, Date and I&A (Incident and Accident) Description: 6/14/16 at 1300 (1:00 p.m.) the facility van was returning to the facility from an outing with the residents. 2 vans were in use and 1 personal vehicle were following each other. The Nurse and the Social Worker in the personal vehicle received a phone call from the Activity Director stating that the resident (Resident #1) had slid out of the chair into the floor and was laying on the floor of the van. When the Nurse pulled up to the van and entered the van the resident was laying on the floor in front of her wheelchair with her feet out in front of her. The resident was laying on her right side at a 90 degree angle. Her left leg was under the seat directly in front of her. Elder's head was resting on the bottom plate of the lift. There was a notable bruise to the right medial wrist and the right outer wrist was noted to have a skin tear that was bleeding. Resident stated that her wrist was hurting but was fine otherwise. Resident stated that she had fallen asleep and that she and her cushion just slid out of her chair. The resident was assessed immediately. Treatment was provided to the skin tear and resident was placed back into the wheelchair by staff (x (times) 3). The facility van was less than a mile from the facility at the time of the incident. Once arriving at the facility x-rays were ordered stat to right hip, ankle knee, foot, elbow, shoulder and wrist. The radiology report dated 6/14/16 documented, Knee (1-2 (views)) AP (anterior/posterior)/Lat (lateral) Right. Impression 1. Acute Proximal Tribial Metaphysical Fracture with mild impaction. 2 Osteoarthritis as above. The Orthopedic Initial Evaluation form dated for 6/24/16 documented, Assessment Medial Tribial Plateau Fracture Right Knee. Plan. Going to put a soft splint on her right knee for comfort and have them keep her bed to chair exclusively at the Nursing Home . b. The Facility Investigation for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities documented, Date and Time Reported to OLTC (Office of Long Term Care): 6/15/16 Time 9:47 AM. Date and Time of Discovery: 6/14/16 at 1300 (1:00 p.m.) . Section II Complete Description of Incident . On 6/14/16 the facility van was returning from .outing when (Resident #1) fell asleep and slid out of the wheelchair in the van . Findings and Action Taken . CNA (Certified Nursing Assistant #1) who was the driver transporting resident was interviewed and stated, 'This morning when loading all residents up for the (outing) we were having trouble with the middle lap/shoulder seat belt because it's been jamming up. (Activity Director) called Maintenance Director, and he came out to look and tried to fix it. (Maintenance Director) came out of the van and stated he needed to order a new part for it. Then we just all loaded up and went to the zoo. When I loaded the residents up leaving the zoo to go back to the facility, I buckled the resident in the back of the van. Four wheelchair straps and the lap/shoulder belt. Then I loaded the middle resident (Resident #1) up and strapped the 4 straps to her wheelchair then I proceeded to try the lap/shoulder seat belt and couldn't get the box to release any of the belt. The wheelchair was locked and strapped in place . When getting off . the (destination) exit I heard a noise and looked back to see the resident on the floor of the van. I pulled over on the side of the road and waved at the other van to come over. They called the nurse that was on the trip with us to come over and check the resident out. We were told to put her back in her wheelchair and I stayed back there with her while Environmental Supervisor drove the Van back to the facility . Administrator interviewed resident and she stated that she did not have her seat belt on and she guess she fell asleep and slid out of the chair . On 7/11/16 at 2:35 p.m., Resident #1 was asked about the incident that occurred on the facility van on 6/14/16. The resident stated that the seat belt wasn't working. The resident was asked if anyone had checked the seat belt. The resident stated, The girl (CNA #1) tried to get it to work. The resident became tearful during the interview and stated, I don't know why they didn't put me on the bench with the other lady. I could sit on the seat. The man checked it, and he said it was working, but it wasn't working. c. On 7/11/16 the following interviews were conducted with staff who were on the facility outing on 6/14/16: 1) At 12:15 p.m., LPN #1 was asked how long she had worked at the facility. The LPN stated, 7 1/2 years. The LPN was asked if she had attended the outing on 6/14/16. The LPN stated, Yes.The LPN was asked what happened on the trip back to the facility. The LPN stated, I was in the private vehicle following the vans, we were a few minutes behind the vans. The (Activity Director) called the Social Director and told her (Resident #1) was on the floor of the white van. I got to the white van and (Resident #1) was lying on the floor in a 90 degree angle with feet straight out and a pool of blood under her right wrist. The resident's head was lying on the left plate. I checked the resident over and asked the resident where she was hurting. The resident stated 'right wrist' and she had a skin tear. The right wrist was cleaned and covered with stretch gauze. She denied any pain. She answered all questions appropriately. Her range of motion was normal. She was requesting to get off the floor. We lifted her off the floor with 3 assistants and placed her back in the wheelchair. The resident continued to deny pain. The LPN was asked if she had asked how the resident fell out of the wheelchair. The LPN stated, No. The LPN was asked if she had checked to see that the resident was secured in the wheelchair after being lifted from the floor of the van, and before the van returned to the facility. The LPN stated, No, that's the CNA's job. 2) At 12:27 p.m., a phone interview was conducted with CNA #1, who stated she had been employed by the facility for approximately 5 or 6 months and had been driving the facility van for approximately 2 weeks prior to the incident on 6/14/16. The CNA was asked about being trained to operate the van. The CNA stated, (Maintenance Director) showed me how to use the lift; that was all I was shown. The CNA was asked if she had been certified to drive the van. The CNA stated, No, I was just thrown in it, because the previous van driver had quit. I had only been driving the van for about 2 weeks. The CNA was asked what happened on the morning of 6/14/16 during the outing. The CNA stated, There were several of us loading the residents. I pulled them in (residents in wheelchairs into the van) to buckle the wheels and shoulder strap. The white van, the middle shoulder/seat belt strap wouldn't come out. I asked the Activity Director to call (Maintenance Director) from her phone. The (Maintenance Director) checked the shoulder strap and said he was tired of messing with it and was going to order a part. The Activity Director and Housekeeping Supervisor were standing outside the van and heard what he said. Then they told me to load up and it was time to go. The CNA was asked if the resident rode to the zoo in the wheelchair without the lap/shoulder strap to secure the resident properly in the van. The CNA stated, Yes, it (shoulder/seat belt strap) wasn't working. The CNA stated that she normally drove the blue van, and this the first time she drove the white van. The CNA was asked how many residents were in the van she was driving. The CNA Stated, Three; two in the wheelchair and 1 on the bench. The CNA was asked if she was by herself, staff-wise, in the van. The CNA stated, Yes, the Activity Director drove the blue van and the Housekeeping Supervisor rode with her. The Social Worker and the Nurse drove private vehicles. The CNA was asked, What happened when you loaded the residents back into the van to return to the facility? The CNA stated, The residents were put back on the white van with (Resident #1) in the middle wheelchair slot. I buckled the wheelchair in place and the shoulder/seat belt strap was still not working. The CNA was asked if she told anyone about the shoulder/strap belt not working before leaving the zoo. The CNA stated, They already knew it wasn't working. (Maintenance Director) stated that it was working, but he knew it wasn't working. When we got to the exit and turned, I heard a noise and (Resident #1) was in the floor. I pulled over and waved the other van and they pulled over and the Activity Director called the nurse to come and assess her. The nurse assessed the resident and we put her back in the wheelchair and the Housekeeping Supervisor drove the van back to the facility, and I stayed with the resident, and the nurse left the van. The CNA was asked if the resident's shoulder/seat belt strap was placed on the resident before proceeding back to the facility. The CNA stated, No, it wasn't working. Then they let me go. 3) At 1:00 p.m., the Activity Director/CNA stated she had been working at the facility for approximately 9 years, and worked as the Activity Director since November 2015. The Activity Director was asked if she had been trained and certified to drive the facility van. The Activity Director stated that she was trained by the previous Maintenance Director, I was certified in 2013 and I was retrained after this incident that occurred on the van. The Activity Director was asked if she had had any issues with the facility van. The Activity Director stated. No. The Activity Director was asked if she went on the outing on 6/14/16. The Activity Director stated, Yes, I drove the blue van. When we were loading up the residents, I was loading up 3 residents on the blue van. The Activity Director was asked, Did you call the Maintenance Director? The Activity Director stated, Yes, I told him they needed him on the white van. I saw (Maintenance Man) come out and get on the white van. I was assuming that he was adjusting the seat belt. I got in the blue van. The Activity Director was asked, Did you hear the Maintenance Man say anything about the white van? The Activity Director stated, No. The Activity Director was asked who was driving the vans. The Activity Director stated, (CNA #1) drove the white van. I drove the blue van with the Housekeeping Supervisor with me. The Activity Director was asked if anyone rode on white van with (CNA #1). The Activity Director stated, No one. The Activity Director was asked how many residents were riding on the 2 vans. The Activity Director stated, Two wheelchairs and 1 resident on the bench seat on each van. The Activity Director was asked if there were any issues during the outing on 6/14/16. The Activity Director stated, On the way back, the white van pulled off on the side road after turning off of the exit and I went to the stop light and turned back down the road. (CNA #1) said (Resident #1) was in the floor. I called (Licensed Practical Nurse (LPN) #1) and got on the van and (Resident #1) asked for me to get her out of the floor. The Activity Director was asked if the shoulder strap was on. The Activity Director stated, I assumed that it wasn't. The Activity Director was asked if she had asked (CNA #1) if the resident had the seat belt on. The Activity Director stated, No. I didn't pay attention to (CNA #1) after that, I just asked (Housekeeping Supervisor) to drive the white van back to the facility. The Activity Director was asked if, after the resident was placed back in the wheelchair, she ensured the seat belt was placed on the resident. The Activity Director stated, No, I went and got back on the blue van with my residents. The Activity Director was asked if she had asked CNA #1 how the resident fell out of the wheelchair. The Activity Director stated, No. The Activity Director was asked if she was aware that the shoulder/seat belt straps were not working on the white van. The Activity Director stated, No. 4) At 1:20 p.m., the Social Director was asked if she was a Certified Nursing Assistant. The Social Director stated, No. The Social Director was asked if she was certified to drive the facility vans. The Social Director stated, Yes. I was trained by the previous Maintenance Director. The Social Director was asked, On the outing (on 6/14/16), did you ride in one of the vans? The Social Director stated, No. I drove a personal vehicle with the wheelchairs, ice chest, and resident supplies, and (LPN #1) rode with me . On the way back we had pulled off at a fast food place to get something to eat, and the (Activity Director) called and said a resident was in the floor of the van. We got to the van in just a few minutes.The Social Director was asked, On the morning that the residents were being loaded onto the vans, did (Maintenance Director) check the white van or say anything about ordering a part for the white van? The Social Director stated, He checked the van, but I didn't hear him say anything. 5) At 2:00 p.m., the Housekeeping Supervisor stated she had worked at the facility since 2004 and had been the Housekeeping Supervisor since 2007. The Housekeeping Supervisor was asked if she had been trained as a van driver. The Housekeeping Supervisor stated, Yes, in 2013 by the previous Maintenance Director. We were trained again in 2014 with the (current Maintenance Director). The Housekeeping Supervisor was asked if she had gone on the outing with the residents on 6/14/16. The Housekeeping Supervisor stated, Yes. The Housekeeping Supervisor was asked if there were any issues with the vans the morning of the outing. The Housekeeping Supervisor stated, I was loading the wheelchairs and ice chest in the truck. I rode on the blue van with (Activity Director). The (Activity Director) drove the blue van and (CNA #1) drove the white van . I didn't know what the issue was; the (Maintenance Director) was talking about a part. I asked him about that later; he said it wasn't for the van, so I really don't know. The Housekeeping Supervisor stated, On the way back, after we turned on the exit, the white van had pulled over and (Activity Director) turned and parked in front of the white van and (Resident #1) was in the floor. I was asked by (Activity Director) to drive the white van back to the facility. 6) At 3:16 p.m., CNA #2 stated she had been employed by the facility for 4 years. The CNA was asked if she had been trained as a van driver and stated, I did drive part time, now I am a full time van driver and I was trained by the previous Maintenance Director and then by the current Maintenance Director after the incident on the van. The CNA was asked if she had any issues with the vans. The CNA stated that the straps on the white van, .would stick . a couple of times at the end of May (2016) and the first part of June (2016). The CNA was asked if she had told anyone. The CNA stated, I filled out a work order in the book and I believe that I verbally told the maintenance man in passing. The CNA was asked if she had told anyone else. The CNA stated, No. The Maintenance Log book was checked at this time, and the CNA stated, I guess that's mine dated 6/13/16; looks like my handwriting. The Work Order dated 6/13/16 documented for the white van, .Seat belt is stuck and won't pull out to go around wheelchair . The form was not signed by any staff member. 7) At 3:47 p.m., a phone interview was conducted with CNA #3, who was asked if she was a van driver for the facility. The CNA stated, Yes, on 3 to 11 (3:00 p.m. - 11:00 p.m. shift), when they needed someone picked up in the afternoon. The CNA was asked if she had been trained or certified as a van driver. The CNA stated, Not really - (Maintenance Director) - I had helped in the past. I did go on a run with the (Maintenance Director) and he did watch me ensure the residents were buckled in and with the seat belts. The CNA was asked if there had been any issues with the facility vans. The CNA stated, On the Saturday before the incident (6/11/16), the seat belt on the middle shoulder strap of the white van was sticking. I wrote out a work order on the following Monday (6/13/16). d. On 7/11/16 at 11:10 a.m., the Administrator was asked for a list of van drivers in the facility. The Administrator provided a list of 3 Certified Nursing Assistants (CNAs #1, #2 and #3). The Administrator was asked for documentation of the training for the staff that were assigned to drive the facility van. The Administrator provided Certifications of Completion for the Sure-Lok Wheelchair Securement and Occupant Restraint Systems Training Program forms dated 6/15/16 and 6/16/16 for 6 staff members who were currently able to drive the van. The Administrator also provided a Certification for Wheelchair and Occupant Restraint System Training Program form dated 6/29/16 for the Maintenance Director; this form was signed by the corporate life safety personnel. The Administrator stated they could not locate any documentation of orientation or training for Certified Nursing Assistant #1. On 7/11/16 at 11:50 a.m., the Administrator provided 3 Certification of Completion forms for successfully completing the, Doing it Right, The Sure-Lok Wheelchair Securement and Occupant Restraint Systems training programs for the Activity Director (dated 5/14/16), the Housekeeping Supervisor (dated 5/8/16) and the Maintenance Director (dated 4/28/14). e. On 7/11/16 at 12:20 p.m., the Administrator stated they were not aware until after the incident on 6/14/16, that the van's equipment was to be sent in to be checked by the van company every 6 months. The Administrator was asked, So this means that in the past 2 years (prior to 6/14/16), that the Maintenance Director has been employed by the facility, the van's equipment has not been checked for functioning by the van company? The Administrator stated, That correct. f. On 7/11/16 at 12:35 p.m., the Maintenance Director stated that the white van had been taken to the van company on 6/16/16 to have the tie downs and seat belts inspected and no problems were found. The van company invoice dated 6/16/16 documented, All adaptive equipment must be serviced every 6 months. At 12:49 p.m., the Maintenance Director stated he had been employed by the facility for 2 years. The Maintenance Director was asked his responsibility regarding the maintenance of the facility vans. The Maintenance Director stated, Check the fluids, check the lights, check the lift, check the tires, tire pressure, the vans body for damage, check the restraints and general cleanliness. The Maintenance Director was asked if there had been any issues related to facility vans. The Maintenance Director stated, The only issue that was on the Work Order on 6/13/16 was the seat belt was sticking and the next morning (CNA #1) asked me to check the shoulder strap. The Maintenance Director was asked about the Maintenance Log, which only documented a date and his initials, with no description of what was checked or repaired. The Maintenance Director stated, If there is a light that needs to be changed, I change it without documenting, and I will top off the fluids; I don't document that. The Maintenance Director was asked who trained the van drivers. The Maintenance Director stated, I do. The Maintenance Director was asked who trained him and certified him as a trainer for the van drivers. The Maintenance Director stated he had been certified at a previous facility and by the previous Maintenance Director. The Maintenance Director then stated, After this incident (6/14/16), I went to the (van) company and was re-certified on 6/28/16. The Maintenance Director was asked if he had trained CNA #1. The Maintenance Director stated, Yes. The Maintenance Director was asked who he had trained as van drivers at this facility. The Maintenance Director stated, Four CNAs, (CNAs #1, #2, #3 and #4). The Maintenance Director was asked what the training included and stated, Watch 2 videos, observation of using the restraints, how to strap down the wheelchairs. The Maintenance Director was asked where the documentation was showing that these employees had been certified as van drivers. The Maintenance Director stated, I don't know where the paperwork is. The Maintenance Director was asked how often the adaptive equipment on the facility van was to be checked. The Maintenance Director stated, I didn't know that the belts were to be checked every 6 months by the company until we got the paper back from where the white van had been checked, and it was documented on the paper that all the adaptive equipment was to be checked every 6 months. The Maintenance Director was asked, You have been employed at this facility for 2 years and a Certified Trainer for the use and maintenance of the facility vans and you did not know that the adaptive equipment was to be checked every 6 months? The Maintenance Director stated, No, I didn't. The Maintenance Director was asked about the morning of 6/14/16 when he was asked to check the seat belts on the white van. The Maintenance Director stated, Yes, (CNA #1) stated that the seat belt wasn't working. I had a work order that was for 6/13/16 and I had checked the belt earlier that morning. I removed the plate and cleaned out the trash. I checked the seat belt that morning when asked, and it worked okay for me. The Maintenance Director was asked if he had stated that he needed to order a part to fix the seat belt. The Maintenance Director stated, No. At 4:15 p.m., the Maintenance Work Order log book entries for the past 5 months were reviewed with the Maintenance Director. There was only one work order for the seat belts sticking in the white van; this work order was dated 6/16/16. The Maintenance Man was asked if any staff had verbally told him that the seat belts on the white van were sticking prior to the incident on 6/14/16. The Maintenance Man stated, No. g. On 7/11/16 at 2:55 p.m., the white van returned to the facility after getting an oil change and the adaptive equipment installed. The shoulder seat belts were checked by this Surveyor, the Maintenance Director, the Administrator, and the Nurse Consultant. The Maintenance Director was on the van. This Surveyor and the Maintenance Director checked the middle shoulder strap. This Surveyor pulled on the shoulder/seat belt strap and the shoulder/seat belt strap stuck and would not release. The Maintenance Man attempted to pull the strap and it would not release. The Maintenance Director removed a portion of the belt and tied the remaining portion of the shoulder/seat belt strap and stated that it would not be used until the van could go in for repairs. h. On 7/12/16 at 10:26 a.m., the van company representative who checked the adaptive equipment on the white van on 6/16/16 stated, The shoulder/seat belt straps were checked and it was reviewed with the man that was with the van that if this type of seat belt was jerked or pulled hard, it was designed to lock down and would stick. My recommendation to prevent this issue was to have the belts changed. I sent the facility a estimate on 6/24/16 for the belts to be changed, and they had to get it approved. It has been approved and the parts are here and it is scheduled to be changed out on 7/18/16. The van company representative was asked how often the seat belts were supposed to be checked by the van company. The van company representative stated, They are to be checked for functioning every 6 months. This was explained to the man that was here with the van on (6/16/16). i. On 7/12/16 at 11:20 a.m., the Maintenance Director provided a copy of the invoice to have the seat belts changed on the white van. The Maintenance Director was asked if he was the one who was with the van on 6/16/16 when the adaptive equipment was checked. He stated, No, I was on suspension, then on vacation. That was the Corporative Life Safety (person) that took the van and picked it up. j. The facility removed the immediate jeopardy and corrected the failed practice prior to the survey, based on the corrective actions below: The white van was placed out of commission upon identification of the inoperable seat belt and was sent to the manufacturer's service provider for evaluation and repair. The service provider prepared an estimate for replacement of the van's shoulder strap restraint on 6/24/16 and had an agreement with the facility and a plan in place to complete the repairs on 7/18/16. All staff members who drove the facility van were re-trained on van safety and required to demonstrate competency via return demonstration on 6/15/16 and 6/16/16. Certifications of Completion for the Sure-Lok Wheelchair Securement and Occupant Restraint Systems Training Program dated 6/15/16 and 6/16/16 were on file at the facility for the 6 employees who drove the van and the Certification for Wheelchair and Occupant Restraint Systems Training Program for the Maintenance Director, signed by the Corporate Life Safety personnel, was dated 6/29/16. There was no evidence the van was utilized for resident transports from 7/8/16 through 7/12/16 (prior to surveyor observation of shoulder strap malfunction) and no incidents or injuries had occurred with either of the facility's vans since the incident on 6/14/16 involving Resident #1. The employee who transported Resident #1 without the shoulder strap in place on 6/14/16 was terminated by the facility.

Based on observation, record review and interview, the facility failed to ensure the necessary care and services were provided to Resident #2 in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care. The facility failed to effectively manage ongoing complaints and signs of wound related pain for 1 (Resident #2) of 3 (Residents #2, #4 and #6) case mix resident who had a pressure ulcer and 1 of 1 (Resident #2) case mix resident who had an abscess to the sacrum. This failed practice resulted in a pattern of harm for Resident #2, who had a pressure ulcer to the right lower extremity and a recurrent abscess to the sacrum and complained of pain and displayed expressions indicating pain during wound care and received no interventions for pain relief. This failed practice also had the potential to cause more than minimal harm for 5 residents with pressure ulcers, according to a list provided by the Administrator on 1/22/15. The findings are: Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 12/4/14 documented the resident scored 5 (0-7 indicates severe cognitive impairment) on the brief interview for mental status, required extensive assistance of two-plus people for bed mobility, transfers and dressing, required extensive assistance of one person for personal hygiene and bathing, was non ambulatory, had limitation in range of motion of an upper and a lower extremity on one side, had an indwelling urinary catheter, had an ostomy, received as needed pain medication, received non-medication intervention for pain, occasionally experienced mild pain during the last 5 days, was at risk for the development of pressure ulcers, had a surgical wound, received surgical wound care and received application of dressings and ointments / medications to the skin. a. A Pain assessment dated [DATE] documented, "...Admission ...Does the Resident have a current [DIAGNOSES REDACTED].? Yes... Is the Resident currently receiving scheduled or PRN (as needed) medications for pain management? No... Current Resident Diagnosis... Likely to Cause Pain... Wounds / ulcer... 12/4/14 (Resident) denies pain at this time. No s/s (signs/symptoms) noted." b. The resident's Care Plan for pain dated 12/4/14 documented, "Pain... Acute... Complaints of pain... Related to... I&D (incision and drainage)... specify site(s): (Left) buttock... (Resident denies pain (at) this time. (No) s/s (signs or symptoms) noted... Monitor (and) report to nurse: Signs and symptoms of pain. Worsening of pain. Report changes in pain location / type frequency/ intensity to physician... Administer and monitor for effectiveness and for possible side effects from: ...PRN (as needed) pain medication (see MAR (Medication Administration Record))... Notify the resident's physician if they do not state / demonstrate relief or reduction of pain after one hour of receiving the first intervention... Make referral to resident's physician to consider premedicating for pain prior to treatments to optimize participation... Intervention: Tylenol as ordered..." c. A physician's orders [REDACTED].) pain inf (infection), drsg (dressing) intact QD." A physician's orders [REDACTED]. D/C (Discontinue) current DTI (Deep Tissue Injury) tx (treatment) to (right) outer LE 2. Culture wound to RLE (right lower extremity). 3. Cleanse US (unstageable) PU (pressure ulcer) to RLE (with) WC, pat dry (with) 4 (by) 4, apply santyl, [MEDICATION NAME], cover (with) [MEDICATION NAME]. (Change) QD / prn. Reeval in 14 days; assess for s/s pain, inf, drsg intact QD." A physician's orders [REDACTED]. D/C current tx (treatment) US PU RLE. 2. Cleanse US PU RLE (with) WC, pat dry (with) 4 by 4, apply Santyl, hydrogel, [MEDICATION NAME], cover (with) [MEDICATION NAME]. (Change) QOD (every other day) / prn Reeval in 14 days; assess for s/s pain, inf, drsg intact QD." A physician's orders [REDACTED]. Cleanse abscess to coccyx midline (with) WC, pat dry (with) 4 (by) 4, apply [MEDICATION NAME] to [MEDICATION NAME] pack strip, pack into wound, cover (with) [MEDICATION NAME]. Sacrum border, (Change) QD (every day) / prn, Reeval in 14 days... assess for s/s pain, inf, drsg intact QD. 2. Culture drainage from coccyx midline abscess (with) C&S (culture and sensitivity)." d. On 1/21/14 at 12:00 p.m., the resident was transferred from the bed to a wheelchair via mechanical lift by Certified Nursing Assistant (CNA) #3 and CNA #4. The resident stated, "Oh, ow" when assisted to roll over to the left side, when the lift pad was being placed. Once the lift pad was placed and connected to the mechanical lift, the resident was raised from the bed. The resident stated, "Oh, ow" while being lifted and placed in the wheelchair. The resident was asked, " Does it hurt you when they get you up? " The resident stated, "Oh yeah." The resident was asked, "Where does it hurt? " The resident stated, "My big toe and my bottom." e. On 1/21/15 at 12:15 p.m., CNA #4 was asked, " Does (Resident #2) moan and say 'ow' every time you get him up? " The CNA stated, "Yes, he just started that in the last week or so. That's the reason we wait until last to get him up and he's the first we put to bed because of that place on his bottom hurts." The CNA was asked, " Have you told anyone (Resident #2) was hurting? The CNA stated, "Yes, we tell the nurse." f. On 1/21/15 at 2:25 p.m., Licensed Practical Nurse (LPN) #1 changed the dressing on the pressure ulcer on the outer aspect of the resident's right lower extremity. The pressure ulcer had yellow tissue in the center of the wound, with the surrounding edges red in color. The LPN cleansed the pressure ulcer with a 4-by-4 gauze and wound cleanser. The resident was moaning and grimacing and stated, "Don't hurt me no more." LPN #1 stated, "You know I'm not doing it on purpose." The resident stated, "Yeah." LPN #1 stated, "Take a deep breath for me; I got to get that slough." When the LPN was finished cleansing the pressure ulcer, the resident stopped moaning and grimacing. After changing gloves, the LPN picked up a 4-by-4 gauze and proceeded to dry the pressure ulcer. The resident started moaning and grimacing and stated, "Ow, that's hurting." The resident was repositioned on the right side. LPN #1 removed an old dressing from the resident's sacrum that had been covering an open abscess, and removed the packing from the wound. After removing the soiled gloves, cleansing her hands with alcohol gel and putting on clean gloves, the LPN picked up the [MEDICATION NAME] gauze and a sterile Q-tip and started placing the gauze into the wound. The resident was jerking, attempting to pull away and grimacing; he stated, "Oh kiss my ass. Oh, ow, that's hurting my butt; I got to get off my butt." The LPN stated, "Take a deep breath" and continued to pack the wound with the gauze. The resident moaned and grimaced while the LPN packed the [MEDICATION NAME] gauze into the wound. g. On 1/21/15 at 3:00 p.m., LPN #1 was asked, "Does (Resident #2) have any medication for pain? " The LPN stated, "He has Tylenol, but he doesn't have pain." The LPN was asked, "When you were cleaning his pressure ulcer on his right leg and he stated 'don't hurt me' and was moaning and grimacing, would you say that was an indicator of pain? " The LPN stated, "Yes." The LPN was asked, "When you were packing the abscess on his bottom and he was jerking, attempting to pull away, stating 'ow that's hurting', would you say that was an indicator of pain? " The LPN stated, "Yes, I guess I need to see if we can get him something for pain." h. On 1/21/15 at 3:40 p.m., the resident was asked, "Does it hurt when they roll you over? The resident stated, "Yeah." The resident was asked, " Where does it hurt? " The resident stated, "All over pretty much." The resident was asked, " When they do the dressing on your bottom, does it hurt? " The resident stated, "Yes." The resident was asked, " Do you still hurt? " The resident stated, "Yes." The resident was asked, " Where? " The resident stated, "My butt." i. On 1/21/15 at 5:00 p.m., the resident was sitting up in a wheelchair in the dining room. The resident was continuously shifting himself from side-to-side, raising his buttocks and hips from the wheelchair, grimacing and saying, "I've got to (lie) down." j. On 1/22/15 at 9:18 a.m., CNA #4 was asked, " Do you help (LPN #1) with (Resident #2) when she changes his dressing? " The CNA stated, "Sometimes." The CNA was asked, " Does he grimace and jerk away like he did yesterday? " The CNA stated, "Sometimes." The CNA was asked, " Do you get (Resident #2) up every day and does he complain of pain? " The CNA stated, "Sometimes he will complain of his bottom hurting because I'll ask him when I get him up." The CNA was asked, " Have you told anyone? " The CNA stated, "I tell the nurse and they give him his medicine." The CNA was asked, " Does it help? " The CNA stated, "Sometimes." k. On 1/23/15 at 9:25 a.m., when the resident's pain was discussed with Physician #1, the physician stated, "Had I been made aware of him having pain, we certainly would have addressed that."

A. Based on observation, record review and interview, the facility failed to ensure Resident #1 received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility failed to ensure routine assessments (to include measurements, staging, condition of surrounding tissue and presence or absence of drainage or odor) were conducted and documented, failed to ensure Certified Nursing Assistants (CNA's) reported newly identified areas of skin breakdown to licensed nursing staff, failed to ensure licensed nurses promptly consulted with the physician and obtained treatment orders to prevent further delays in initiating pressure ulcer treatments and failed to ensure interventions were developed and consistently implemented to decrease the potential for further skin breakdown for 1 (Resident #1) of 8 (Residents #1, 3, 5, 6, 7, 10, 11 and 13) case mix residents who were at risk for skin breakdown or had pressure sores. The failed practices resulted in actual harm to Resident #1, who developed additional Stage II pressure ulcers and two unstageable pressure ulcers, and were likely to cause more than minimal harm to 44 residents who were at risk for developing pressure sores or had existing pressure sores, according to a list provided by the Administrator on 1/13/12. The findings are: Resident #1 had [DIAGNOSES REDACTED]. a. A Plan of Care which was not dated documented, "Skin Integrity: Resident is at risk for skin breakdown. Skin Score #15 (mild risk)... Approach: ...Report changes in skin status ... to physician ... Complete weekly skin check ... Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care..." b. The Weekly Skin Audit Record dated 11/13/11 documented, on a human body diagram an "X" over the shoulder blade area and an "X" over the buttock area, with an arrow pointing to the word, "Excoriated." c. A Nurse's Note dated 11/13/11 documented, "Excoriation noted on R (resident's) back + (and) buttocks. R c/o (complains of) pain 5/10 (Pain level 5 on a scale of 10). New Order: Apply [MEDICATION NAME] cream to affected area BID (Twice a Day) + PRN (as needed). Assess s/s (signs and symptoms) of infection. Assess for pain r/t (related to) excoriation..." d. Physician's Telephone Orders dated 11/14/11 documented, "Clarification: Apply [MEDICATION NAME] Cream to buttocks BID (Twice a Day) + (and) PRN (as needed) ... Apply [MEDICATION NAME] Powder top groin area BID PRN." e. The Plan of Care dated 11/21/11 documented, "Pressure Ulcer: Resident has pressure ulcer(s); Location: R (right) 2nd (second) toe. Approaches: ...Monitor effectiveness of/response to treatment(s) as ordered - (see physician's orders [REDACTED]. or buttocks. f. A Weekly Skin Audit entry dated 11/23/11 had a circle drawn around the buttock and upper thigh areas of the human body diagram, with a line drawn to the word, "Red." g. A Telephone Order Dated 11/29/11 documented, "Change [MEDICATION NAME] Tx (treatment). Apply [MEDICATION NAME] Cream to buttocks BID (twice a day) PRN (as needed)." h. A Weekly Skin Audit entry dated 11/30/11 had a circle drawn around the buttock and upper thigh areas of the human body diagram, with a line drawn to the word, "Red." i. The Telephone Order dated 12/4/11 documented, "1. DC (discontinue) Tx (treatment) orders... [MEDICATION NAME] cream. 2. Cleanse Lower lumbar region of back to upper thigh (with) wound cleanser. Pat dry. Apply [MEDICATION NAME] + (and) cover with [MEDICATION NAME] borders." j. A Telephone Order dated 12/5/11 documented, "1. Clarify tx to buttocks. 2. Clean open area to L (left) buttock (with) wound cleanser. Pat dry (with) 4x4. Apply [MEDICATION NAME] + cover (with) [MEDICATION NAME] Border 3x3. (Change) q (every) Mon (Monday), Wed (Wednesday) Fri (Friday) + PRN (as needed). Reassess in 14 days. 3. Monitor wounds for s/s infection QD (every day). 4. Monitor for pain R/T (related to) wounds & (and) drsg (dressing) intactness QD." k. A Weekly Skin Audit entry dated 12/7/11 had a circle drawn around the buttock and upper thigh areas of the human body diagram, with a line drawn to the word, "Red", and a circle on the right and left buttock areas with a line drawn to the words, "open area". There was no documentation of measurements of the open areas, the condition of the wound bed or presence/absence of drainage. l. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/9/11 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status, required the extensive assistance of two or more persons for bed mobility, transfers and toilet use, had functional limitation in range of motion to both lower extremities and was at risk for pressure sores. The MDS also incorrectly documented the resident had had no pressure sores or other skin problems. m. A Telephone Order dated 12/13/11 at 7:45 a.m. documented, "Apply [MEDICATION NAME] cream to buttocks BID (twice a day) PRN (as needed)." The January 2012 Treatment Record documented the physician order [REDACTED]. n. The Weekly Skin Audit Record dated 12/14/11 documented a circle around the buttock and upper thigh area of a human body diagram, with a line drawn to the word, "Red", and a circle around the left buttock area with a line to the words, "Open Area." There was no entry in the Nurse's Notes or Weekly Pressure Ulcer Treatment Record regarding these areas. No information was documented in the clinical record regarding the size of the wound, the presence and nature of any drainage, or the condition of the wound bed and surrounding tissue. On 1/11/12 at 10:55 a.m., Treatment Nurse #1 was asked, "Did you measure the wound identified on the weekly skin audit on 12/14/11?" Treatment Nurse #1 stated, "No." o. Nurse's Notes dated 12/19/11 at 1:30 p.m. documented, "Assessed pt. (patient). Open area to L (left) buttock healed. N.O. (New Order) D/C Tx to open area to L buttocks..." p. The Interdisciplinary Care Plan Conference dated 12/14/11 documented, "Areas Reviewed: Skin: Comments: ...buttocks red." q. The Weekly Skin Audit Record entries dated 12/21/11, 12/28/11 and 1/4/12 documented a circle around on the back human body diagram a circle around the buttock area of the human body diagram, with a line drawn to the word, "Reddened." r. Nurse's Notes dated 1/8/12 documented, "Pt (patient) c/o (complains of) weakness, has been experiencing severe n/v/d (nausea, vomiting, diarrhea)..." s. On 1/9/12 at 2:34 p.m. during initial rounds, Licensed Practical Nurse (LPN) #1 was asked if the resident had any skin problems. LPN #1 stated, "Excoriation, I think." t. On 1/10/12 at 9:53 a.m., Certified Nursing Assistant (CNA) #2 and CNA #3 were in the resident's room providing incontinent care. The resident was on the right side in the bed. The entire buttock/scrotum area was red and purple in color from near the waist over entire buttock area down into the perineal/scrotum area. Two linear dark crusted wounds were on the left lower buttock/thigh area; one measuring approximately 5 centimeters (cm) long, and another area measuring approximately 2 cm long. The medial aspect of the left buttock had an open area measuring approximately 2 cm in diameter, and the left upper buttock had an open area measuring approximately????? 5x2 cm in diameter. The right lower buttock had an open area approximately 2 cm in diameter with fresh red blood oozing from the wound and blood stains noted on the incontinent brief. CNA #3 took a tube of medication out of the drawer of the bedside table and applied the cream over the open wounds on the buttocks. CNA #3 was asked, "What is that?" CNA #3 stated, "It's something they sent from (hospital)." The tube was labeled [MEDICATION NAME] Cream. CNA #2 was asked, "How long has he had these (sores)?" CNA #2 stated, "Over a week. They look a little better today." There was no dressing on the wounds. u. On 1/11/12 at 9:30 a.m., Treatment Nurse #1 was asked, "Has any CNA reported any open areas on (Resident #1)? Treatment Nurse #1 stated, "No." Treatment Nurse #1 was asked, "Do you have any wound reports or skin audits?" Treatment Nurse #1 stated, "Yes." All assessment documentation for the resident's buttocks was requested. The Treatment Nurse provided the requested documentation and there was no documentation regarding the wounds that had been observed by the surveyor and CNA's #2 and #3 on 1/10/12. v. As of 1/9/12 at 9:50 a.m., there was no documentation in the Nurses Notes or Weekly Skin Audit Records to indicate the wounds had been thoroughly assessed, measured and staged and no documentation regarding the condition of the surrounding tissue and presence or absence of drainage or odor and no documentation the physician was consulted when new areas were identified. w. On 1/11/12 at 10:00 a.m., Treatment Nurse #1 and the Assistant Director of Nursing (ADON) were in the room with CNA #2. The resident was lying on the right side and the brief was removed. CNA #2 stated, "The wounds are worse." CNA #2 was asked, "Did you tell anyone about the wounds we observed yesterday?" CNA #2 stated, "I told him (Treatment Nurse #1) about it, but I don't think I told him it was bleeding." Treatment Nurse #1 had dressing supplies in cardboard trays on the overbed table. There was a new open area bleeding on the left lower buttock, above the linear wound that was seen on 1/10/12. The wound was irregular in shape and measured approximately 2 cm in diameter. There was a new open area that was dark, purple and crusted, measuring approximately 1 cm in diameter on the left buttock, and a new area on the left upper buttock that measured approximately 1.5 cm in diameter. The wound on the right buttock that was bleeding on 1/10/12 was still bleeding, and blood stains were noted on the incontinent brief. A new open area on the right buttock, below and to the right of the bleeding wound, was dark purple in color and crusted and measured approximately 1 cm in diameter. Treatment Nurse #1 was asked, in regard to the dark crusted wounds on the right and left buttocks, "What stage is that?" Treatment Nurse #1 stated, "I am unable to stage them, so they are unstageable." The ADON stated, "Or deep tissue injury." Treatment Nurse #1 assessed the bleeding wound on the right buttock. Treatment Nurse #1 took a gloved finger, stuck it into the wound bed, pressed, released, and pressed and released again. Treatment Nurse #1 stated, "It blanches, so it's a Stage 1." Treatment Nurse #1 was asked, "Is there any skin over it?" Treatment Nurse #1 stated, "No. But it blanches, so it's a Stage 1." The ADON stated, "The wound is a Stage 2." x. On 1/11/12 at 10:00 a.m., the resident was asked, "Has (Hospital) looked at your bottom?" The resident stated, "I haven't had that looked at by (hospital)." The resident was asked, "How long have you had them (the wounds)?" The resident stated, "Since they put that little catheter (suprapubic) in, it has leaked, and it (the wounds) have been worse." (According to Nurse's Notes dated 12/2/11, the resident returned from the hospital on that date after insertion of a suprapubic catheter.) y. On 1/11/12 at 11:50 a.m., Treatment Nurse #1 provided a copy of the Weekly Pressure Ulcer Record for 1/11/12, after the wounds were assessed at 10:00 a.m., which documented the following: Medial L (left).Buttock (B), US (Unstagable), Size in cm 1.0 x 0.5 0, Exudate None, Wound Bed scabbed. Lat (Lateral), R (Right) B, US , size in cm 2.0 x 1.5, Depth none, Exudate none, Wound Bed scabbed. Lower L Buttock Stage II, size in cm 1.0 x 1.8, Depth none, Exudate blood scant, Wound Bed Red. Lat. Lower L Buttock Stage II, size in cm 5.0 x 0.5, Depth none, Exudate none, Wound Bed Red. R Buttock Stage II, size in cm 2 x 1, Depth none, Exudate blood scant, Wound Bed Pink. Upper L Buttocks Stage II, Size in cm 1.0 x 1.5, Depth none, Exudate none, Wound Bed pink. Upper L Buttocks Stage II, Size in cm 1.5 x 2.0, Depth 0.1 cm, Exudate none, Wound Bed pink. The smaller linear shaped wound on the left lower buttock / upper thigh area that was seen on 1/10/12 and 1/11/12 was not documented by Treatment Nurse #1. Two unstageable wounds, on the left and right buttock, that were not present on 1/10/12 were identified by Treatment Nurse #1, in addition to a new Stage 2 bleeding wound on the left buttock. z. On 1/11/12 at 10:10 a.m., the Director of Nursing (DON) stated that she was having the former Treatment Nurse (Treatment Nurse #2) re-measure all the resident's wounds. On 1/12/12 at 8:46 a.m., Treatment Nurse #2 provided copies of the Weekly Pressure Ulcer Record that documented the following: L Upper Buttock #1 Stage II, Size in cm 1.0 x 1.8, Depth 0.2, Ezudate Serosanginous, Wound Bed Red pale. L Buttock Middle #2 Stage II, Size in cm 0.9 x 1.7, Depth 0.2, Exudate Serosanginous, Wound Bed Pale Red. L Buttock Lower #3 Stage II, Size in cm 0.3 x 0.6, Depth 0.1, Exudate Serosanginous, Wound Bed Red L Lateral Buttock #4 Stage DTI, Size in cm 1.0 x 1.6, Exudate none, Wound Bed Dark Purple. L Thigh #5 Stage II, Size in cm 6.8 x 0.5, Depth 0.1, Exudate Bloody, Wound Bed Red L Medial Upper Thigh #6 Stage II, Size in cm 1.2 - 0.9, Depth 0.2, Exudate Serosanginous, Wound Bed Red. L Thigh Lower #7 Stage II, Size in cm 0.3 x 0.5, Depth 0.1, Exudate none, Wound Bed Red R Thigh #8 Stage II, Size in cm 0.2 x 1.0, Depth0.1, Exudate Bloody, Wound Bed Red R Buttocks Medial #9 Stage II, Size in cm 3.1 x 1.5, Depth 0.1, Exudate Bloody, Wound Bed Red R Buttock Lateral #10 Stage DTI, Size in cm 1.2 x 1.3, Depth 0, Exudate none, Wound Bed Dark Purple R Thigh #11Stage II, Size in cm 0.2 x 1.0, Depth 0.1, Exudate Bloody, Wound Bed Red L Thigh Middle #12 Stage II, Size in cm 1.3 x 0.6, Depth 0.1, Exudate none, Wound Bed Red Ten stage II pressure sores and 2 Deep Tissue Injury wounds were identified by Treatment Nurse #2, versus 5 Stage II wounds and 2 unstageable wounds identified on the assessment by Treatment Nurse #1. aa. A physician's orders [REDACTED].#2. The orders documented to clean the wounds with wound cleanser, pat dry with a 4x4, apply [MEDICATION NAME], and cover with a [MEDICATION NAME] border dressing. bb. An Office of Long Term Care (OLTC) Witness Statement dated 1/12/11 and signed by Licensed Practical Nurse (LPN) #2 documented, "I ck (check) resident buttocks on shower days M/W/F (Monday/ Wednesday/Friday) and change dressing on those days if needed. Monday it was red but not opened. Wed. (Wednesday) I found out it was opened on Tuesday night but CNA (Certified Nurse Assistant) forgot to tell me. I put the [MEDICATION NAME] on it (buttocks) from the Tx (treatment) cart (after) his shower Monday night..." cc. On 1/12/12 at 10:00 a.m., CNA #4 was asked, "What did the resident's bottom look like last week?" CNA #4 stated, "Red, but it wasn't bleeding." CNA #4 was asked, "Was the skin peeling back?" CNA #4 stated, "I guess you could call it that." CNA #4 was asked, "Did you report the red bottom to anyone?" CNA #4 stated, "I had already reported; it had already been reported." dd. On 1/12/12 at 10:20 a.m., CNA #2 was asked, "Did you tell anyone (the buttock wound) was open on 1/10/12 at about 9:53 a.m. on Tuesday after providing care?" CNA #2 stated, "I told Tuesday (1/11/12)." CNA #2 was asked, "What did the resident's bottom look like on Monday (1/9/12)?" CNA #2 stated, "The same as you saw on Tuesday." CNA #2 was asked, "What are you taught to do about open areas?" CNA #2 stated, "If we're told to, we put this (package of Skin Sake) on. We were told to go to the Treatment Nurse to report open areas." ee. On 1/12/12 at 10:50 a.m., Treatment Nurse #1 was asked, "The [MEDICATION NAME] was not documented as administered at any time in January. Is there a reason for that?" Treatment Nurse #1 stated, "We haven't had any. We'd ordered it and then we ran out. The resident said he wanted (insurance) to pay for it. That's when I called to get his PCP (Primary Care Physician) to find out who it was to get a dermatology consult. The resident went back to the (hospital) on 1/6/12, and they re-did the suprapubic catheter. It was leaking. That is one cause for the irritation on his coccyx." Treatment Nurse #1 was asked, "How long had it been leaking?" Treatment Nurse #1 stated, "He just got it (the suprapubic catheter) the middle of December. It was leaking, it was clogged, and we sent him to the ER." Treatment Nurse #1 was asked, "Was it still leaking when he came back?" Treatment Nurse #1stated, "Yes, sometimes." Treatment Nurse #1 was asked, "What did you do to minimize the exposure (of urine) to the skin?" Treatment Nurse #1 stated, "Put cream on." Treatment Nurse #1 was asked, "The prescribed cream wasn't applied because you didn't have the cream?" Treatment Nurse #1 stated, "That's right. The pharmacy didn't provide it. They said the insurance wouldn't cover it." Treatment Nurse #1 was asked, "Did you call the doctor to see if a different cream could be used that the insurance would cover?" Treatment Nurse #1 stated, "I tried calling the VA." Treatment Nurse #1 was asked, "Is this documented?" Treatment Nurse #1 stated, "No." Treatment Nurse #1 was asked, "Did you try calling (Physician of Record for the resident)?" Treatment Nurse #1 stated, "No." ff. On 1/12/12 at 11:03 a.m., CNA #3 was asked, "When we saw all those sores on Tuesday (1/10/12), who did you tell?" CNA #3 stated, "I didn't." CNA #3 was asked, "That tube of ointment you took out of the drawer, when did you start using that?" CNA #3 stated, "That was the first time I started using that." CNA #3 was asked, "What was being done to address the urine leaking from the catheter?" CNA #3 stated, "The resident had us put a washrag over his penis and over the tube." CNA #3 was asked, "How often did you change the washcloth?" CNA #3 stated, "Whenever he hit his call light to be changed." CNA #3 was asked, "Whenever a resident has an open area on the skin, what do you do?" CNA #3 stated, "Tell a nurse." B. Based on observation, interview and record review, the facility failed to ensure interventions to decrease the potential for skin breakdown were implemented, as evidenced by failure to ensure barrier cream was applied after an incontinent episode and failure to ensure care was taken to avoid creating shearing forces during removal of an incontinent brief for 1 (Resident #11) of 8 (Residents #1, 3, 5, 6, 7, 10, 11 and 13) case mix residents who were at risk for developing pressure sores. The failed practice was likely to affect 44 residents who were at risk for developing pressure sores, according to a list provided by the Administrator on 1/13/12. The findings are: Resident #11 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 11/30/11 documented the resident had moderately impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status, was incontinent of bowel and bladder, was at risk for developing pressure sores and had no pressure ulcers. a. The Plan of Care updated 12/1/11 documented, "Resident is at risk for skin breakdown Skin Score #13 (Moderate Risk) related to Incontinence... Approaches: Assist PRN (as needed) to reposition / shift weight to relieve pressure. Provide incontinent care after incontinent episodes; apply Barrier Cream PRN (As Needed)..." b. On 1/11/12 at 3:05 p.m., CNA #5 and CNA #6 assessed the resident for incontinence. CNA #6 stated, "She's wet." CNA #6 unfastened the resident's incontinent brief. The brief was wet in the front up to the mid abdomen, and was wet in the back all the way to the waistband. CNA #5 took a dry washcloth from the overbed table and sprayed periwash onto the dry washcloth. The left groin, right groin and inner labia were cleaned, but the upper inner thighs and lower abdomen were not cleaned. Barrier cream was applied to the left and right groin area. The resident was turned onto his left side and the rectal area and inner buttock areas were cleaned, but the outer buttock/hip areas and upper hip/lower back areas were not cleaned. CNA #5 rolled the wet brief up to the resident's buttocks. The wet incontinent brief was underneath the residents left hip. The left front tape tab was visible on the left side of the resident. CNA #5 pulled the brief, stretching the wet absorbent material and plastic underneath the left hip and buttock of the resident creating a shearing force as the wet brief was pulled against the resident's skin. The brief would not come out from underneath the hip. CNA #5 pulled harder, stretching the brief even more. The brief did not budge. CNA #5 pulled again, even harder, and the brief tore away from the part of the brief that was still underneath the resident's left hip, leaving the remaining part of the wet incontinent brief segment underneath the resident's left hip. The resident was turned to the back and then to his right side and the wet torn brief section was removed. A clean brief was placed on the resident. No barrier cream was applied to the resident's buttocks. c. On 1/12/12 at 3:55 p.m., the Assistant Director of Nursing (ADON) was asked, "How are briefs supposed to be removed?" The ADON stated, "Unhook both tapes, then turn the resident to remove."