Every finding on record at Bethany Home

Based on observation, clinical record review, document review, procedure review, manufacturer use manual, and staff interview, the facility failed to ensure Certified Nursing Assistants (CNAs) locked wheelchair brakes during pivot and full body mechanical lift transfers for 1 of 4 residents reviewed (Resident #23). This failure resulted in Resident #23 falling and sustaining a left ulna fracture (a break in the ulna is one of the two long bones in the forearm (running along the pinky-finger side). The facility identified a census of 63 residents.Findings include:1.The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #23 exhibited a long/short memory problem, and had severely impaired daily decision-making ability. Resident #23 did not exhibit behaviors. Resident #23 did not exhibit upper/lower functional limitations in range of motion. She utilized a wheelchair and was dependent upon staff for chair/bed to chair transfers. The MDS listed diagnoses of Alzheimer's Disease, arthritis, osteoporosis, anxiety, and depression. The MDS listed one fall without injury since the last assessment. A Nursing Assistant Orientation Form dated [DATE] documented Staff A, CNA received Chair to Toilet Transfer orientation training which was signed off by Staff B, Certified Medication Aide (CMA). The Activities of Daily Living (ADL) Self-Care Performance Care Plan for Resident #23 directed as of [DATE] to provide a one assist for transfers and toileting. An Incident Report dated [DATE] written by Staff C, Licensed Practical Nurse (LPN) documented at 5:10 PM Resident #23 sustained a fall in her room which resulted in a skin tear on the left forearm and a bump on the back of her head. The CNA was transferring the resident from the toilet to the wheelchair. The wheelchair rolled out from under the resident as the wheelchair brakes were not locked. The Resident fell back onto the bathroom floor. Resident #23 stated her arm and head hurt. The Incident Report further documented Resident #23 was cleaned up, placed in the wheelchair, and taken out to the dining room table for dinner. The Resident's Vitals Signs were temperature 98.6, pulse 75 beats per minute (BMP), respirations 18, blood pressure 166/86, and oxygen saturation 95% on room air. A [DATE] Fall Prevention Intervention Document written by Staff C documented equipment placement, mobility, and brakes off on the wheelchair as possible contributing factors as to why the fall occurred. The root cause of the fall was the brakes were not locked on the wheelchair, and more assistance was needed. A Employee Notice of Discipline form dated [DATE] for Staff A documented on [DATE] Staff A completed an unsafe transfer by not locking the wheelchair brakes which resulted in a resident falling and sustaining an ulna fracture. Staff A documented that she forgot to lock the wheelchair. The Form specified the Action to be Taken was one to one training with a therapist. A Wound Weekly Observation Form dated [DATE] documented Resident #23 with a left forearm skin tear that measured 5 Centimeters (CM) length by 5.5 CM width x 0 CM depth, acquired on [DATE].Review of the [DATE] X-ray report documented Resident #23 had a left forearm x-ray, two views due to swelling, pain and warm to touch post fall. The X-ray Impression documented an outside distal ulnar fracture.Review of a Physician Order and Progress Note dated [DATE] documented a left distal ulna (wrist) fracture. The Provider ordered a short arm cast for two weeks, non-weight bearing to the left upper extremity, ice as needed and follow up with the provider in two weeks.An Undated, Unsigned Statement for Staff A documented it was about 4:50 PM. She had gone to Resident #23's room to get her up for dinner. Staff A sat Resident #23 on the side of the bed placed the gait belt and transferred the resident into the wheelchair and wheeled her into the bathroom. Staff A transferred Resident #23 to the toilet. Resident #23 sat for a few minutes, then became antsy and wanted to leave. Staff A pulled the wheelchair to her right side which was the resident's left side. Resident #23 was wanting to get up and go and was moving toward the wheelchair which wasn't locked. The wheelchair turned and spun away and Resident #23 fell, bumping her left arm off of the wheelchair and bumping her head. An Undated, Unsigned Statement for Staff C documented she was on duty the evening of [DATE]. She saw Resident #23's call light on and started walking toward her room. Resident #23's family member informed her the resident had fallen in the bathroom. Staff A was with the resident in the bathroom. Staff C assessed the resident's range of motion which was within normal limits.An Undated, Unsigned Document identified the facility Corrective Actions for Staff A to do an hour of 1 to 1 training with the Occupational Therapist (OT) on [DATE] from 1:30 - 2:30 PM. After, OT provided Staff A with written notes to review and asked Staff A to write down things she learned. The Director of Nursing (DON) and Administrator met with Staff A to discuss how the training went and what she learned. The Restorative Nurse then watched Staff A completed resident transfers on [DATE] and Staff A did well. The Document further specified Staff A would meet with OT again on [DATE] for role play and various scenarios with residents that Staff A may encounter for safety. On [DATE] at 1:53 PM, Staff D, CNA reported wheelchair brakes were to be locked before a transfer was started, before the resident got up or sat down in the wheelchair. On [DATE] at 2:41 PM, Staff E, Licensed Practical Nurse (LPN) reported wheelchair brakes should be locked before the resident stood up or sat down in the wheelchair during a transfer. On [DATE] at 8:08 AM, Staff C stated she was the nurse on duty the night of Resident #23's fall. The resident's call light came on around suppertime and she was walking that way to see if the resident needed help. Resident #23's family member was standing outside the room and informed her the Resident had fallen. Staff C assessed Resident #23's vital signs, range of motion, pain, and skin tear to the left forearm. The resident was trying to get up off the toilet and it happened so fast and Staff A forgot to lock the wheelchair brakes. The resident lost her balance and went to the ground. Staff C explained the CNA's are to have the gait belt on, wheelchair brakes locked, and have the chair or bed right next to the resident transferring to the resident's strong side with the right amount of assistance. During an interview on [DATE] at 9:50 AM, Staff F, Director of Nursing (DON) verbalized she was contacted by phone and updated on Resident #23's fall by Staff C. When queried on the root cause of the fall, Staff F voiced Staff A did not lock the wheelchair brakes during the transfer. Staff A should have locked the wheelchair brakes for the transfer.In an interview on [DATE] at 9:54 AM, the Administrator reported the wheelchair brakes were to be locked during transfers to the wheelchair. Interview on [DATE] at 10:02 AM, Staff F and Staff G both voiced they expected the staff to lock the wheelchair brakes during 1-2 person pivot transfers. The Patient Transfers (Procedure), undated, under Environmental Setup specified before starting to confirm patient readiness, apply the gait belt, ensure proper footwear, and lock the wheelchair brakes. 2. Resident #23's MDS dated [DATE] documented Resident #23 was rarely/never understood, exhibited a long/short memory problem, and had severely impaired daily decision-making ability. The MDS documented Resident #23 utilized a wheelchair and was dependent on chair/bed to chair transfers. The MDS further documented Resident #23 had sustained one fall without injury and one fall with injury (not major injury) since the prior assessment.The ADL Self-Care Performance Deficit Care Plan intervention dated [DATE] directed Resident #23 did not walk, and the intervention dated [DATE] revealed the resident utilized a wheelchair for all locomotion. The Full Body Mechanical Lift (Brand Specific) User Manual, provided by the facility, Transferring to a Wheelchair included the following steps:-Ensure the legs of the lift are in the open position.-Move the wheelchair into position.-Engage the rear wheel locks of the wheelchair to prevent movement of the chair.The Full Body Mechanical Lift (Brand Specific) User Manual included a WARNING! The wheelchair wheel locks MUST be in a locked position before lowering the patient into the wheelchair for transport. Observation on [DATE] at 10:55 AM revealed Staff H, CMA and Staff I, CNA placed a full body mechanical lift sling under Resident #23. Staff I raised Resident #23 in the full body mechanical lift and positioned the lift base around the wheelchair. Neither Staff H or I locked the wheelchair brakes before Resident #23 was lowered into the wheelchair. Observation on [DATE] at 1:10 PM revealed Staff H and I placed the wheelchair inside the base of the full body mechanical lift. Staff H and I attached the lift sling to the spreader bar. Neither CNA locked the brakes on the wheelchair. Staff H stood behind the wheelchair and Staff I lifted the resident up via the full body mechanical lift. Both staff steadied Resident #23 as the wheelchair moved slightly as Resident #23 was lifted up out of the wheelchair to the bed. On [DATE] at 1:14 PM, Staff H reported she had seen a few CNAs transfer residents with the wheelchairs unlocked but it had been a long time ago. She stated the facility had the therapist come in and provide transfer training including locking the brakes on the wheelchair. She hadn't seen any problems since that time. On [DATE] at 8:08 AM, Staff C queried if the wheelchair was supposed to be locked during full body mechanical lift transfers and responded, Yes.During an interview on [DATE] at 9:40 AM, Staff J, CMA explained when provided a full body mechanical lift, they ensured the resident was positioned correctly in the lift sling, and attached the sling to the lift. One aide pulled the lift out while the second aide guided the resident off the bed, and the resident was then lowered into the wheelchair. The brakes were to be locked on the wheelchair when the resident was lowered into the wheelchair so the wheelchair doesn't move back during the transfer. If the wheelchair moved during the transfer, the resident could fall or be injured.During an interview on [DATE] at 10:10 AM, Staff F reported the wheelchair brakes were supposed to be locked during the full body mechanical lift transfers. The Safe Resident Handling/Transfer Policy, revised [DATE], specified to ensure residents were handled and transferred safely to prevent or minimize risks of injury and provide and promote a safe, secure and comfortable experience for the resident in accordance with current standards and guidelines. The Policy Explanation stated all residents require safe handling when transferred to prevent or minimize the risk for injury to themselves. The Policy directed staff would perform mechanical lifts/transfers according to the manufacturer's instructions for the use of the device.

Based on observation, resident record review, and staff interview, the facility failed to administer medications in a means that care and medication administration services had been provided according to accepted standards of clinical practice within a locked Memory Care Unit and secondly after a resident had received an ophthalmology procedure and returned to the facility with new orders. The facility reported a census of 67. Findings include: 1. A continuous observation had taken place on 3/28/23 from 8:14 AM to 8:20 AM. On 3/28/23 at 8:14 AM the dietary staff entered the Memory Care Unit with the steamer cart server to provide residents breakfast. On 3/28/23 starting at 8:16 AM, Staff E (RN) had left the area where the medication cart had been and from where medications had been administered by Staff E to residents individually. The medication cart had been left approximately 15 feet from seven Memory Care Residents who had gathered at the round dining room tables. Staff E had been observed leaving the medication cart to enter the unit's kitchenette. Staff E had not been able to view the medication cart. Staff E could be heard opening cupboards in the kitchenette. Again, the medication cart had not been viewed by Staff E. Observed, there had been a clear cup of medications that had been removed from a medication punch card. The cup had been observed to contain approximately seven to eight oral medications. One of the medications had appeared to be one-half a tablet. At 8:19 AM Staff E returned from the kitchenette to the medication cart. Staff E had then put the clear medication cup of oral medications in a drawer of the med cart. Staff E then exited outside of the locked unit for a couple minutes. On 03/28/23 at 8:30 AM Staff E was asked who the medications were for that had been on top of the medication cart, and Staff E hesitated to answer then stated the residents name and stated that the observation could not have been seen from over there. Staff E then pointed to an area across the room. During the continuous observation, the position of the surveyor had changed while Staff E was in the kitchenette. Staff E further verbalized fear of the incident being documented and again stated the observation could not have been seen from the surveyor. 2. On 3/29/23 review of Resident #8 Physician Orders had shown that Resident #8 received ophthalmology care on 3/23/23 for the left eye and had been discharged with a change in medication orders. Resident #8 had new orders to discontinue Refresh Celluvisc gel one-percent eye drops administered to the left eye for 3/23/23 and for 3/24/23. Administration to the right eye remained unchanged. On 3/29/23 Review of the Electronic Medication Administration Record (EMAR) had shown Resident #8 had been administered Refresh Celluvisc one-percent eye drop, instill one drop in both eyes six times a day for dry eyes on 3/23/23 and 3/24/23. 03/29/23 at 10:30 AM an interview completed with Staff F (LPN) who identified a signature on the EMAR for administration of Resident #8 Refresh Celluvisc 1% eye drop, instill one drop in both eyes six times a day for 3/24/23 at 7:00 AM. When asked if the eye drops had been administered to both eyes on that date and time Staff F stated having signed out the medication, then yes the administration would have been to both eyes. Staff F stated Resident #8 had been knowledgeable about ongoing ophthalmic procedures and after care however if the EMAR indicated both eyes then Yes, both eyes would have been administered. Staff F then reviewed the paper document provided by the Ophthalmology clinic that had stated to hold the left eye Refresh Celluvisc gel eye drops for 3/23 and 3/24/23. On 3/29/23 at 12:10 PM and interview had been completed with Staff G (RN) and Staff H (RN). Both Staff G and H were asked about expectations of staff who passed medications and the situation of when medications had been punched out and put in a medication cup to administer however the staff had to leave the immediate medication area and what would the expectation be for staff concerning the medication. Staff G stated the nurse would have been expected to put another medication cup over the cup containing the medications and then the cup should have been placed in a locked drawer in a locked medication cart. Staff H stated the medications couldn't have been left unsupervised and would need to have been put in a locked med cart and the computer screen would need to be closed. During the interview the process of medication orders had been discussed, review of Resident #8 EMAR had taken place. Both Staff G and Staff H were unaware of the hold for 2 days on the left eye drops, Refresh Celluvisc, and acknowledged staff asked for clarification of the new order for antibiotic eye drops only. On 3/29/23 a review of the facility policy titled, Medication Administration Policy, listed in the first paragraph that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician, and in accordance with professional standards of practice. The Medication Administration Policy further stated guidelines listed as Number 1 through Number 22. Statement number 22 stated: If a nurse or C.M.A. must leave medications prior to administration, label medication cup, cover with an empty medication cup, and place in a locked medication cart until able to return.

Based on observation, interview, and policy review the facility failed to have dietary male staff wear beard restraints, according to the current standards of practice per the Food Code of the FDA (Food and Drug Administration), food service staff must wear hair restraints (e.g., hairnet, and/or beard restraint) to prevent hair from contacting food while they were working in the kitchen to prevent hair from contacting food while cooking, preparing and assembling food for all facility residents. The facility reported a census of 67 residents. Findings include: On 3/27/23 at 9:28 AM, an initial tour of the kitchen was conducted with the Dietary Manager. During observations the Dietary Manager introduced a male cook, Staff A, who wore a hairnet and facial mask however no beard restraint. Staff A had visible beard hair on left and right side of their face exposed. Further observation revealed on 3/27/23 at 9:30 AM that Staff B (dietary aide) who wore a hairnet and facial mask however no beard restraint, assembling food for resident consumption. Staff B had beard hair on the left and right side of his face exposed. Staff C (dietary aide) was also observed with a hairnet and facial mask in place however lacked a beard restraint. Staff C had beard hair on the left and right side of his face exposed. Staff C had been observed in the resident food prep area of the kitchen. During an observation on 3/28/23 at 9:57 AM, Staff D (dietary aide) observed with a hairnet and facial mask in place however lacked a beard restraint. Staff D had beard hair on the left and right side of his face exposed. Staff D had been observed preparing food in the kitchen at the time of observation. During an observation on 3/28/23 at 11:50 AM, Staff D did not have a beard restraint on while in the kitchen and preparing facility resident food. During an interview on 3/28/23 at 2:10 PM, asked the Dietary Manager about the policy of hairnets and beard restraints. When asked if male staff with beards should wear a beard restraint the Dietary Manager stated having never really thought about it. The Dietary Manager had asked, should they? Again, the Dietary Manager had been asked what was the expectations for the male staff with beards and again the Dietary Manager stated being unsure. The Dietary Manager stated the belief that facial masks covered enough of the face. The Dietary Manager stated the facility had beard restraints in the kitchen inventory. The Dietary Manager had been asked if the facility had a policy for hairnets and beard restraints and again stated not knowing as employment began in October of 2022 and not all of the policies had been reviewed by the manager. The Dietary Manager was asked to provide a facility policy for Hair Nets and Beard restraints. During an observation on 3/29/23 at 6:50 AM Staff A and Staff B were observed in the kitchen preparing residents breakfast with a hairnet and facial mask in place however no beard restraints. On 3/29/23 at 11:30 AM the Dietary Manager was asked again for a facility policy about staff wearing hairnets, beard restraints, the Dietary Manager stated Administration had been going to gather the facility policy. The facility provided an undated policy titled Dietary Staff Uniform and it directed staff to utilize a hair net which covers the entire head of hair and/or beard must be worn.

Based on observation, clinical record review, and staff interview, the facility failed to provide adequate supervision and failed to implement safety interventions to prevent an elopement for 1 of 12 residents sampled (Resident #43) for supervision. The resident had a history of leaving the unit without staff knowledge. The resident exited the second floor elevator and then exited the ground floor ambulance door without staff knowledge. Staff F found Resident #43 in his pajamas, bath robe, and slippers on the street behind the facility. Resident #43 stated he was lost. The failure resulted in Immediate Jeopardy to the health, safety, and security of the residents. The facility identified 17 residents as independently mobile and cognitively impaired. The facility reported a census of 61. Findings include: The Minimum Data Set (MDS) for Resident #43 dated 6/28/21 documented diagnosis including [CONDITION(S)] (Stroke), [CONDITION(S)], and Type 2 Diabetes Mellitus. The MDS documented a Brief Interview for Mental Status (BIMS) score of 8, indicating cognitive impairment. The MDS documented the resident was independent with ambulation and locomotion around the unit but needed limited assistance of 1 person for locomotion off the unit. The Care Plan revealed Resident #43 had a self-care deficit and moderately impaired cognition related to dementia. The Care Plan revealed Resident #43 independent ambulation with his walker and directed staff to cue, reorient and supervise as needed. A Progress Note dated 7/16/2020 at 2:37 PM, revealed the staff placed a wander guard bracelet Resident #43 due to an incident where he left the floor. Resident #43 made comments that if his wife wasn't here he would go outside and leave. An Order Note dated 8/20/20 at 5:23 PM, revealed the wander guard discontinued, removed and the staff notified the family. Progress Note dated 8/24/21 documented the resident walked to the nurse's station and when the nurses left the area, the resident got on the elevator and went downstairs and exited the facility. An off going nurse found the resident in the street behind the facility at 6:15 AM. The nurse walked the resident to safety and called the facility to have someone bring a wheel chair down. The resident stated he was confused and had tears in his eyes. A wander guard bracelet was applied. Progress Note written 8/24/21 at 9:00 AM, documented the staff left a voicemail for Resident #43's son to inform him of the incident. Two of the resident's daughters were notified and a condition report was sent to the physician to request an order for the wander guard. Progress Note dated 8/24/21 at 9:54 AM documented the resident had a wander guard placed on 7/8/20 to enhance safety. The resident's family request it be removed as it was upsetting to the resident and unnecessary. The wander guard was removed on 8/20/20. The resident had no wandering episodes prior to 8/24/21. Progress Note dated 8/24/21 at 11:43 AM documented the son wanted the neurologist notified regarding confusion and memory loss. Progress Note dated 8/24/21 at 2:34 PM documented the resident was placed on the Urinary Tract Infection ([CONDITION(S)]) Protocol. His temperature was 97.7 degrees Fahrenheit. Progress Note dated 8/24/21 at 10:20 PM documented no further wandering episodes. Review of the Clinical Record showed there was no documentation of a physical assessment or complete set of vital signs (temperature, heart rate, blood pressure, respirations or oxygen saturation) for the resident. The Clinical Record lacked a wandering assessment for Resident #43. The summary of the incident dated 8/24/21 documented per camera footage the resident got on the elevator and left the floor unattended/unnoticed at 6:00 AM. The resident left the facility through the ambulance door at 6:05 AM. The resident was found in the street behind the facility by a Staff F when leaving after her shift. There was no physical assessment documented. During an interview on 12/8/21 at 12:11 PM, Staff F, Licensed Practical Nurse, stated she left work that morning (8/24/21). While walking to her car she saw the resident in the street. She stated she didn't realize who it was at first but as she got closer she realized it was Resident #43. Resident #43 had on his pajamas, a bath robe and slippers. Resident #43 stated he was lost. Staff F walked Resident #43 out of the street and called the facility to let them know he was outside and to bring a wheelchair. She stated the resident was confused, upset, and had tears in his eyes. He looked like he just didn't know where he was or where to go. Staff E and Staff H arrived with a wheelchair and assisted Resident #43 to sit in the wheelchair. Staff H pushed him on the sidewalk back into the building. Staff F reported Resident #43's gait unsteady and he had shortness of breath. Staff F reported Resident #43 didn't wander earlier that day. She stated he had some confusion in the past. During an interview on 12/9/21 at 12:53 PM, Staff H, Certified Nurse Aide, stated she took a wheelchair down and brought the resident back into building. She stated when she got outside, the resident was in the street at the curb at the back of the building. She stated Staff F was standing with him. He said he was going to church. She stated Resident #43 was a little confused which was unlike him. A wander guard was put on and a urine sampled collected for evaluation. During an interview on 12/8/21 at 11:39 AM, Staff E, Licensed Practical Nurse, stated she arrived to work at 6:00 AM on 8/24/21. Resident #43 approached the window at the desk during report. He greeted the staff, knew he was going for his bath, had his clothes on his walker and did not seem out of the ordinary. The nurses went to the medication room and then the Staff F left the facility. Staff F called the floor and stated she found Resident #43 at the end of the block. Staff E stated the resident was not known to wander prior to that day. She stated she was not aware of any attempts to leave via elevator before and the resident was not confused prior to that day or prior to exiting. When he returned to the floor, she placed a wander guard for safety. She called son and left a message for him to return call and called the daughter to inform her of the incident. She called the physician to notify him of incident and got the order for the wander guard. She stated when the resident returned to the floor, she checked vitals and made sure he was ok. She stated she may not have documented the vitals. When Resident #43 returned to the floor, she stated cognitively he appeared normal. He laughed about it, stating he got confused. During an interview on 2/8/21 at 2:25 PM/21 Staff G, Certified Nurse Aide, stated it was his bath day. Resident #43 wasn't there at his usual. Staff H brought the resident in and stated the resident had been outside. She asked the resident where he was going and he knew he was going to the tub, but stated he got confused. He stated he forgot where he was going and knew had a bath but thought he was going to church. A skin check is a normal routine and part of bathing. The resident had no skin concerns. Staff G stated Staff E told her she needed to walk with Resident #43 to make sure he got where he needed to go. During an interview on 12/8/21 at 2:07 PM, Staff D, Director of Nurses, stated a wander guard was placed on the resident's wrist to prevent reoccurrence. She stated he was assessed for a [CONDITION(S)] due to increased confusion. It was out of his norm to leave the floor. He was confused that day and was subsequently treated for [CONDITION(S)]. She stated that any residents that have any wandering behaviors are assessed and wander guard if needed to prevent elopement. She stated no additional interventions were in place to protect residents from leaving the floor. She reported high staff levels at the time of the incident, as 1st shift was fully staffed and there were still some 3rd shift staff on site. She stated the resident was independent at the time of the incident and did not require supervision to go to the bath. She stated he had no previous attempts to leave the facility and the wander guard placed on his wrist in July 2020 was due to a misunderstanding. She stated the family asked him to go down stairs. Staff D stated she did staff interviews at the time of investigation but did not document them. She stated she summarized what was said in the incident summary. She stated the ambulance door is not alarmed, it's a public access door. She stated no wander assessment or elopement assessment was completed on resident before or after his elopement. During an interview on 12/8/21 at 3:12 PM, Staff D stated the cameras are not staffed and are used for look back reference only. During an interview on 12/9/21 at 10:30 AM Staff D stated there was no policy for wander assessments. She stated they just started doing wander assessments a couple months ago. She stated they are done on admission and 72 hours later. She stated wander assessments had not been completed on all residents and were not completed quarterly with the MDS. Facility Policy titled Resident Safety/Elopement last revised on 3/15/21 directed staff to complete a thorough examination upon the resident's return to the building. During an interview on 12/8/21 at 10:15 AM, the Administrator stated the incident had not been reported to the state. According to the State Climatologist email dated 12/8/21 at 1:45 p.m. the weather on 8/24/21 between 5:30 AM and 6:30 AM revealed clear skies, visibility at 10 miles, no precipitation, winds out of the south at 9 miles per hour, and 73 degrees Fahrenheit. According tohttps://www.timeanddate.com/sun/@ 61?month=8&year=2021 sunrise on 8/24/21 was at 6:20 AM. The video obtained on 12/14/21 at 10:25 a.m. revealed a route from Resident #43's room to the location staff found Resident #43. The residential street behind the facility had cars parked on both sides of the street and contained uneven and cracked surfaces throughout the street. The State Agency informed the facility of the Immediate Jeopardy on December 9, 2021 at 1:25 p.m. The Facility removed the Immediate Jeopardy on December 9, 2021 by implementing an alarm on the elevator doors and providing staff educated staff on ensuring alarms on continuously. The scope lowered from K to E at the time of the survey after ensuring the facility implemented education and their policy and procedure.

Based on observation, record review, policy review, and staff interview, the facility failed to administer medications within professional standards for 1 of 12 residents observed (Resident #24) during medication administration. The facility reported a census of 61. Findings include: Observation during medication pass on 12/7/21 at 12:24 PM, Staff I, Certified Medication Aide, placed Resident #24's medication cup on his/her tray table. The medication cup contained [MEDICATION(S)] 40 mg and Dairy Relief 3000 units. Staff I stated she was going to lunch and would have Staff J check on the resident to make sure she took her medications as she likes to take them with food. Staff I exited Resident #24's room at 12:33 PM and closed the door. Continuous observation showed no one entered Resident #24's room until 12:44 PM. At 12:44 PM, Staff J entered the resident's room with her lunch plate and asked the resident if she took her medications. Resident #24 stated she did take the medication. Staff J, Registered Nurse, stated it is a common practice to leave medications with Resident #24 to take on her own without direct supervision. Step number 16 in the Medication Administration Policy dated 10/1/21 directed staff to observe consumption of medication. During an interview on 12/9/21 at 2:10 PM, Staff D, Director of Nurses, stated she would expect staff to follow all facility policies. She stated she would not expect mediations to be left at bedside.

Based on observation, clinical record review, policy review and staff interview the facility incorrectly served ground meat to 2 of 3 residents (Resident #6 and #32) in lieu of the physician ordered pureed ordered diet. The facility reported a census of 61 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 9/13/21, showed Resident #6 had long//short term memory impairment and severely impaired decision making. The resident required extensive assistance with eating. The MDS documented a diagnosis of Alzheimer's Disease, late onset. A Physician Request Form, signed by the Provider on 6/29/21, showed a physician order for a pureed diet. A Care Plan, with a revised goal date of 9/14/21, directed the staff to provide the diet as (physician) ordered. 2. The MDS for Resident #32 showed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive loss. The resident required supervision and set up for eating a mechanically altered diet ( e.g., pureed food, thickened liquids). The MDS listed a diagnosis of esophagitis. A Discharge/Transfer Form, dated 1/12/21, documented to admit the resident to the facility with a physician order for a level 1 dysphagia diet, pureed diet with extra sauce/gravy. A Care Plan, revised 10/21/21, identified Resident #32 had a swallowing problem related to an [CONDITION(S)] stricture from prior [CONDITION(S)] therapy and directed all staff to be informed of the resident's special dietary and safety needs. The Care Plan instructed for the resident to eat in an upright position, eat slowly, chew each bite thoroughly and monitor/document/report as needed any signs or symptoms of dysphagia: pocketing (of food), choking, coughing, drooling, holding food in mouth, several attempts at swallowing, or refusing nectar thickened liquids. The Care Plan directed the resident to have a pureed diet with gravies. A review of the dietary menu for 12/07/21 listed a main entrée for 3 ounces (oz.) of roast beef for the regular diet and one serving for the pureed diet. During an observation on 12/07/21 at 9:29 a.m. Staff A, Cook, measured out 12 oz. (4 servings) of roast beef, placed the meat in a robo, added water and thickening powder to pureed. Staff A measured a total volume of 2.75 cups of pureed meat. Staff A verified the measured volume with the Surveyor. The Dietary Supervisor checked the Pureed Diet Portion Sizes/Scoops Chart and had Staff A write a #8 (4 oz.) scoop size. A review of the Pureed Diet Portion Sizes/Scoops Chart for 4 servings, 2.75 cups showed a scoop size of a #6 scoop (5 1/3 oz). During an observation on 12/07/21 at 11:50 a.m. Staff A checked the temperature of the pan of pureed roast beef which had been placed at the back of the steam table on the left hand side. Staff A confirmed the pan was the pureed roast beef when taking the temperature. Staff A temped the steam pan of ground roast beef located at the front of the steam table pan. The pans were marked with roast beef and a #8 scoop size written on the foil cover the pans. On 12/07/21 at 12:05 p.m. Staff B, and Staff C, Dietary Aides, took the steam cart up to the second floor to the long-term care. Staff B and C placed serving utensils into the steam pans. A 3 oz. scoop was placed in the pureed roast beef steam pan. Staff B started to plate food at 12:08 p.m. Staff B asked Staff C about the roast beef before plating the first ground roast beef portion. Staff B plated out multiple 3 oz. servings of pureed meat to residents on a ground meat diet. At 12:16 p.m. Staff B placed a #8 scoop of ground meat, pureed tomatoes, mash potatoes and gravy on a plate and staff served out to Resident #32. At 12:17 p.m. Staff B placed a #8 scoop of ground meat, pureed tomatoes, mash potatoes and gravy on a plate and staff served out to Resident #6. At 12: 20 p.m. Staff B and C asked to have the nursing staff call the kitchen as they were out of ground meat. During an observation on 12/07/21 at 12:25 p.m. the Dietary Supervisor brought a pan of ground roast beef to the second floor dining room and looked at the pans on the steam table. The Dietary Supervisor stated to Staff B and C they had served out the pureed roast beef as the ground meat. The ground meat had been served out as the pureed meat. Resident #6 and #32 had also been served the ground roast beef in place of the pureed roast beef. The Dietary Supervisor removed Resident #6 and #32's plates from the tables after prompted by the Surveyor. The Dietary Supervisor informed Staff B and C she would prepare more pureed roast beef. During an observation on 12/07/21 at 12:29 p.m. the Dietary Supervisor measured out four, 3 ounce servings ( 12 oz. total) of roast beef and pureed with beef juice. The total volume of the mixture measured 2 cups. She compared with the Pureed Diet Portion Sizes/Scoops Chart and stated a #8 scoop should be used. She verbalized it was the same measure as the pureed meat from the morning pureed meat prep. She returned to the second floor dining room. Resident #6 received the correct pureed roast beef consistency and portion at this time. Resident #32 had left the dining room and told staff that she did not want any more food. During an interview on 12/07/21 at 1:12 p.m. the Dietary Supervisor reported she had already talked to staff B and she said they normally write the consistency and the scoop size on the foil on top of the steam pan. That had not been done this time, only the scoop size had been written on the foil. She stated this is the first time this has happened. She thought the pureed and ground meats had a similar consistency, but she would expect the staff to serve out the physician ordered diet. On 12/07/21 at approximately 2:00 p.m. the Dietary Supervisor presented a copy of the pureed food preparation policy and stated the policy does not address writing the food item, consistency and scoop on the top foil, and they should probably add that in the policy. She stated the facility didn't have a policy regarding physician orders and diets. The Puree Food Preparation Policy with a revised date of 01/10/20 lacked direction to the staff to write the food item, consistency, and the scoop size on the top foil of the pan after food preparation.

Based on observation, clinical record review and staff interview, the facility failed to update the plan of care for two of five residents reviewed (Resident #1 & #39) for unnecessary medication use. The facility census was 67 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], showed Resident #39 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], showed the resident had no anxiety and received an anti-anxiety medication. The Care Area Assessment for [MEDICAL CONDITION] Drug Use, in the MDS, triggered for identification of those medications in the resident's care plan. The Care plan dated 9/13/19 failed to identify any use of anti-anxiety medication signs and symptoms to watch for, and or behaviors to report and monitor the usage of the anti-anxiety medication. A Physician order [REDACTED].) 3 times a day. A gradual dose reduction approved by the physician and changed the [MEDICATION NAME] to 15 mg.-1/2 pill 2 times a day. The Medication Administration Record (MAR) dated 9/1/19 through 9/30/19 showed the resident received [MEDICATION NAME]. The MAR dated 10/1/19 through 10/31/19 showed the resident received the anti-anxiety medication of [MEDICATION NAME]. During interview on 10/30/19 at 1:45 p.m., the MDS Coordinator reported the resident came in with the anti-anxiety medication and she did not know the reason for having the medication. She noted she should have probably checked the resident's history better and possibly check with the Pharmacist. The MDS Coordinator noted if the MDS triggered for identification in the care plan for [MEDICAL CONDITION] medication use, then the care plan should identify this as a focus. During interview on 10/30/19 at 3:43 p.m. the Director of Nursing reported if the Care Area Assessment showed the focus area as use of [MEDICAL CONDITION] medication , it is expected to be in the resident's care plan. 2. The MDS assessment dated [DATE], documented Resident #15 had [DIAGNOSES REDACTED]. A Physician order [REDACTED]. The Medication Administration Record (MAR) dated 10/19, directed the staff to administer [MEDICATION NAME] 50 mg 1/2 tab daily. Review of the Care Plan dated 8/2/19, lacked direction for what adverse effects staff should monitor for the scheduled opioid. The Care Plan lacked direction for the staff to monitor the resident for adverse effects related to the use of an opioid. During an interview on 10/30/19 at 1:43 p.m., the MDS Coordinator reported not addressing opioid in the Care Plan because it was documented on the MAR. During interview on 10/31/19 at 8:19 a.m., the Director of Nursing reported with an opioid staff are expected to monitor for side effects of dizziness, change behaviors, mood, sleep pattern, pain and bowel status.

Based on clinical record review and staff interview, the facility failed to complete or submit a discharge MDS (Minimum Data Set) in a timely manner for one of one resident reviewed. (Resident #1) The facility census was 67 residents. Findings include: 1. Progress notes dated 6/5/19, documented Resident #1 was discharged to independent living on 6/5/19. Review of the MDS completion record revealed the resident did not have a discharge assessment completed. During interview on 10/30/19 at 8:08 a.m., the MDS Coordinator revealed the discharge assessment was not completed and when a resident was discharged it was communicated by Social services with a telephone message to administrative staff and she missed it. Typically would follow RAI (Resident Assessment Instrument) guidelines to complete resident assessments in a timely manner. During interview on 10/30/19 at 11:33 a.m., the Director of Nursing stated she would expect for the MDS to be done correct and submitted in a timely manner.

Based on observation and staff interview, the facility failed to ensure staff delivered clean laundry using proper infection control practices. The facility census was 66 residents. Findings include: 1. During observation on 8/6/18 at 9:56 a.m., Staff A, Laundry Aide pushed an uncovered hanging laundry cart towards room [ROOM NUMBER] -208. 2. During observation on 8/7/18 at 10:32 a.m., Staff A pushed an uncovered hanging laundry cart down the hall past the Director of Nursing's (DON) office through the dining room to deliver clothes. 3. During observation on 8/8/18 at 10:16 a.m., Staff B, Laundry Aide pushed an uncovered hanging laundry cart down the A hall while delivering clothes. During interview on 8/8/18 at 1:38 p.m., Staff A reported the not covering residents personal laundry with delivery. During interview on 8/8/18 at 1:42 p.m., the Administrator reported not knowing why the personal clean laundry cart was not covered during delivery. The Administrator stated the expectation would be to cover laundry during transportation.

Based on clinical record review and staff interview, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) for three of three residents reviewed (Resident # 22, Resident # 52, and Resident # 217). The facility census was 66 residents. Findings include: 1. Clinical record review revealed Resident #22 did not receive the Centers for Medicare and Medicaid Services (CMS) form (NOMNC) when skilled services stopped. 2. Clinical record review revealed Resident #52 did not receive the Centers for Medicare and Medicaid Services (CMS) form (NOMNC) when skilled services stopped. 3. Clinical record review revealed Resident #271 did not receive the Centers for Medicare and Medicaid Services (CMS) form (NOMNC) when skilled services stopped. During interview on 8/7/18 at 1:02 p.m., the Social Worker (SW) reported giving Skilled Nursing Facility (SNF) resident's the CMS form , but failed to provide residents with the NOMNC. During interview on 8/7/18 at 1:47 p.m., the Administrator reported not knowing the facility needed to provide both forms CMS and the NOMNC to residents ending skilled services.

Based on clinical record review and staff interview, the facility failed to notify 2 out of 3 resident Physician's regarding a significant weight loss. (Resident #3 and 4). The facility census was 76 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #4 had a [DIAGNOSES REDACTED]. The resident's Care Plan dated 5/8/17 showed the resident had a potential for inadequate nutrition related to inadequate calorie/fluid intake and had interventions in place. Nutrition/Dietary Notes dated 11/10/16, 1/12/16 & 5/11/17, showed the resident had significant weight loss and had interventions in place. Nurse Progress notes dated 11/10/16, 1/12/17 & 5/11/17, failed to document any physician notification of the significant weight loss. During interview on 5/23/17 at 8:03 a.m., the MDS Coordinator reported the Dietician notified the Director of Nursing (DON) and the MDS Coordinator regarding the significant weight loss. The MDS Coordinator reported it was the responsibility of the DON to notify the resident's Physician of the significant weight loss or delegate it to a staff person. During interview on 5/23/17 at 8:27 a.m., the DON reported they failed to notify the Physician. 2. The MDS assessment dated [DATE], documented Resident #3 had [DIAGNOSES REDACTED]. The resident's Care Plan dated 3/24/17, showed the resident had a nutritional problem or potential problem and had interventions in place. Nutrition/Dietary Notes dated 3/30/17 and 5/18/17, documented the resident had a significant weight loss and had interventions in place. Nurse Progress notes dated 3/30/17 and 5/18/17, failed to document any physician notification of the weight loss. During interview on 5/23/17 at 1:30 p.m., the DON reported they failed to call the resident's Physician regarding the significant weight changes.

Based on observations, record reviews and staff interviews the facility failed to obtain physician orders [REDACTED].#1, 4, and 10). The facility identified a census of 65 residents. Findings include: 1. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified the resident with a [DIAGNOSES REDACTED]. A score of 15 indicates no memory loss. Observation on 5/10/16 at 9:10 a.m. showed Staff A, Registered Nurse, administered Dorzolamide (for [MEDICAL CONDITION]) 2 percent (%) 1 drop to both eyes of the resident. The physician's orders [REDACTED]. The POS dated 2/18/16 and 4/21/16 failed to direct the staff to administer Dorzolamide 2% eye drops to Resident #10 twice daily. The Medication Administration Record [REDACTED]. An interview on 5/10/16 at 12:35 p.m. Staff A reported the 3rd shift nurse matches the resident's POS with the their MAR's to see it is correct. Staff A agreed the physician's orders [REDACTED]. An interview on 5/10/16 at 12:42 p.m. the Pharmacist reported their pharmacy prints the POS and sends them to the physicians for signatures. The Pharmacist reported due to a computer glitch some medications were dropped. Staff A and the Pharmacist agreed the POS did not have an order to administer Resident #10's eye drops. The Pharmacist indicated the 3rd shift nurse should have caught the error when checking the physician's orders [REDACTED]. An interview on 5/10/16 at 3:15 p.m. the Director of Nursing (DON), Registered Nurse, reported they don't see the POS until after the physician signs it. The DON reported of finding about the computer glitch just today, after having it come to his/her attention. The DON stated the 3rd shift nurse is suppose to check the POS with the current MAR's to make sure it is correct and matches. If there is a problem they send a facsimile to the physician for correction. The DON noted the glitch has been fixed by the pharmacy today. 2. Resident # 1's Minimum Data Set (MDS) assessment on 3/21/16 identified [DIAGNOSES REDACTED]. The history and physical dated 4/20/16 identified the resident with depression, anxiety, and dementia. The POS dated 1/28/16 directed staff to administer [MEDICATION NAME] (anti-dementia medication) 28 milligrams (mg.) every day. The POS dated 2/18/16 and 4/20/16 failed to identify [MEDICATION NAME] (generic-Memantine) medication to be administered. The MAR's for the month of December 2015 identified [MEDICATION NAME] 28 mg. given until 12/23/15 where the physician changed the order to Memantine (generic form) 10 mg. twice day. The MAR's for 2/2016, 3/2016, 4/2016, and 5/2016 showed the Memantine 10 mg. medication administered twice a day. For the months of 2/2015, 3/2016, 4/2016, and 5/2016 staff failed to have physician's orders [REDACTED]. 3. Resident #4's MDS assessment dated [DATE] identified the resident with [DIAGNOSES REDACTED]. A score of 15 indicates no memory loss. The POS dated 4/20/16 failed to direct staff to administer Senna S tablets (laxative)-2 tablets twice a day, hold for loose stools. The MAR's dated for the months of 4/2016 and 5/2016 showed staff administered Senna S tablets-2 tablets twice a day, hold for loose stools, without physician's orders [REDACTED]. An interview on 5/10/16 at 12:42 p.m. the Pharmacist and Staff A noted the POS for 4/20/16 failed to identify the medication Senna S to be administered.

Based on resident interview and staff interview the facility failed to offer all residents a snack at bedtime (HS) as required by Federal regulations. The facility census was 66 residents. Findings include: During the Group Interview conducted on 7/14/15 at 9:30 a.m. 4 of 4 residents in attendance, identified as interviewable by the facility, all stated that staff offer them snacks every afternoon but no snacks are offered in the evenings after the evening meal by normal bedtime. During an interview 7/15/15 at 12:45 p.m. the facility Dietary Supervisor, when asked about resident snacks, stated that the Dietary department prepares a cart of assorted snacks for staff to offer residents every afternoon and the cart is sent to facility nursing staff at 2:30 p.m. and verified that a snack cart is not prepared and sent at any other time on a daily basis. The Dietary Supervisor, at 2:27 p.m., added that the units are stocked with food/snack items to be offered to residents in the evenings by staff but is not personally here to know if it is being done routinely. Review of the current MDS (Minimum Data Set) assessment for Resident #3 dated 6/1/15 revealed a BIMS (Brief Interview for Mental Status) score of 15 of 15 meaning the resident is cognitively intact. During a 1:1 interview 7/14/15 at 2:25 p.m. Resident #3 stated that they are offered a snack every day in the mid-afternoon but never offered a snack in the evenings before bedtime. Review of the current MDS (Minimum Data Set) assessment for Resident #9 dated 7/7/15 revealed a BIMS (Brief Interview for Mental Status) score of 15 of 15 meaning the resident is cognitively intact. During a 1:1 interview 7/15/15 at 2:45 p.m. Resident #9 stated that they are offered a snack every day in the mid-afternoon but not offered a snack in the evenings before bedtime. During an interview 7/15/15 at 2:23 p.m. Staff C (CNA) stated snacks come up from Dietary every day between 2:30 and 2:40 p.m. and staff take them around to residents at that time and offer them snacks, nothing comes from Dietary in the evenings but diabetic residents are given evening snacks by nurses. During an interview 7/15/15 at 2:30 p.m. Staff D (CNA) stated they offer residents snacks every afternoon and that they have certain residents that are offered a Magic Cup or other supplements, these are residents who have a weight loss or diabetic, and there is plenty of food items on the unit to give other residents a snack in the evening if they want something.

Based on observation, document review, and interviews, the facility failed to dispose of 76 outdated syringes of influenza vaccine from 1 of 3 medication rooms reviewed. The facility reported a census of 66 residents. Findings include: 1. Observation in the Health Care 1 medication room on 7/14/15 at 9:20 a.m. revealed a total of 76 syringes of influenza vaccine which the director of nursing (DON) verified had expired June 2015. During an interview on 7/14/15 at 9:23 a.m., the DON reported nurses had the responsibility for checking the medication room on a monthly basis for outdated medications. During an interview on 7/14/15 at 10:40 a.m., the DON reported the nurses were responsible for checking and documenting the Advocate List, which directed nurses to check the Health Care 1 medication room to ensure the refrigerator, and freezer was clean and check for outdated medications. He checked the forms at the end of each month to ensure staff completed all tasks however, did not keep the completed forms. He also reported the facility did not have a policy to check for outdated medications in the medication rooms. Review of the advocate form for July 2015 revealed Staff A, LPN initialed the form showing staff had checked the Health Care 1 medication room. During an interview on 7/14/15 at 2:06 p.m., the consultant pharmacist reported the nurses had the responsibility of checking the medication rooms for outdated medications monthly and she completed spot checks on a quarterly basis. During an interview on 7/15/15 at 2:40 p.m., Staff A, LPN reported when checking the medication refrigerator, she should check if it's clean and make sure there are no outdated medications. When asked if she was aware 76 syringes of flu vaccine outdated June 2015 Staff A stated that Staff B told her she had already checked the medications for outdates. During an interview on 7/16/15 at 1:37 p.m., Staff B, RN reported when checking the medication refrigerator, she should check medications for outdated medication. When asked when she checked the medication room this month in the Health Care 1 unit if she noted any expired medications, she reported she checked the suppositories and insulin but did not check the flu vaccines and was not aware that they had outdated.

Based on clinical record review, resident and staff interviews, the facility failed to provide adequate supervision to protect Resident #1 from hazards during transfers for one (1) of four (4) residents. The resident's care plan directed staff to assist him/her with ambulation and during transfers. Interview with Resident #1 revealed staff did not assist him/her when walking and he/she lost his/her balance and fell backwards. Resident #1 sustained a right hip fracture from the fall and a laceration to his/her right elbow. Staff interview revealed the staff had let go of the resident's gait belt during the incident. The facility identified a census of 66 current residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment, dated [DATE] Resident #1 had been diagnosed with [REDACTED]. The MDS identified the resident with a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating no memory impairments. The resident required assistance of one staff person with transfers and ambulation in the room. The MDS showed the resident had no limitations with range of motion to the lower extremities, and had no falls. The Care Plan dated [DATE] showed the resident required assistance with activities of daily living (ADL) related to stroke and fatigue. The care plan indicated the resident used a walker and required 1 staff person for assistance with ambulation (walking). The resident required 1 staff assistance for transfers between surfaces as necessary. Communication with the Physician on [DATE] reported the resident had edema to both the lower extremities. The resident unable to move the right leg, but can move the toes. The resident cannot pick up the leg and facial grimaces are noted with attempted range of motion. Progress Notes include: On [DATE], the resident returned from physician's office with orders to wrap his/her legs with ace wraps for compression and remove at bedtime. On [DATE], the resident continued to have right knee pain with ambulation, and refused ice or heat (for treatment). The resident reported it felt like he/she twisted his/her knee when getting in/out of a car for a doctor appointment on Wednesday. The resident denied pain while at rest or when standing and stated he/she only had pain with ambulation(walking), and wanted to rest (his/her knee) for a couple of days. On [DATE], staff called the nurse to the resident's room. The nurse observed the resident on the floor next to the dresser, in front of the medication cabinet. The CNA stated the resident walked from the bathroom to the recliner and fell backwards. The resident complained of back pain when assessing range of motion, unable to move the right leg or pick it up. Facial grimacing by the resident noted with the attempt of range of motion. The resident had a skin tear to the right elbow, approximately 2.5 centimeters circular size. The Incident Reporting Form dated [DATE] at 1:30 p.m., (written by Staff I, Registered Nurse (RN)) documented Resident #1 fell when walking to the recliner according to Staff J/Certified Nurse Aide (CNA). The resident had been observed by on the floor in his/her room in front of his/her dresser. The resident reported he/she fell backwards and the nurse assessed the resident and determined he/she had pain on his/her right side and back pain. The nurse documented the resident had right side swelling and a skin tear to the right elbow. The Hospital Report dated [DATE] documented today the resident had been ambulation when he/she lost his/her balance and fell . The resident landed on his/her right side and eventually hit his/her head against an object as he/she fell . The Paramedics reported at the time of transfer, Resident #1 showed severe pain in the right hip. The head CT showed no acute abnormalities. The assessment & radiology report dated [DATE] identified Resident #1 sustained a right hip fracture (comminuted intertrochanteric fracture of the proximal right femur) and had surgery. The resident returned to the nursing home on [DATE]. The Hospital Discharge summary dated [DATE] showed orders from Physical Therapy Evaluation for the resident to use touch weight bearing to the right leg and may use a Hoyer (mechanical lift) for transfers. The Falls Prevention Intervention form completed by Staff I/(RN) on [DATE] revealed the resident's fall occurred as a result of his/her unsteadiness and when the resident lost his/her balance. The form listed a question as to whether the resident had received the assistance & or the designated care plan intervention; and Staff I documented, "Yes", and wrote "assist of one (with) ambulation" even though this had not occurred. An interview on [DATE] at 11:02 a.m., Resident #1 reported of coming from the bathroom going to the lounge chair on [DATE]. Resident #1 reported the CNA was not holding on to him/her at all. The resident reported the CNA walked ahead, not holding onto the resident. The CNA put the foam pillow from the wheelchair into the recliner. Resident #1 took a couple of steps backwards and fell . The resident's right hand hit the dresser. The resident laid on the floor until the ambulance arrived and noted he/she fractured his/her right hip. An interview on [DATE] at 9:05 a.m., Staff J (CNA), reported of transferring the resident on [DATE] around noon to 1:00 p.m., from the bathroom to the recliner. Before she walked the resident, she had moved the foam pillow from the wheelchair into the recliner. The resident requested the foam pillow be turned around in the recliner. Staff J stated 'without thinking', she reached over to turn the pillow and let go of the gait belt. The resident fell backwards and hit the dresser on the way to the floor. The resident landed on the right side of his/her body. Staff I, Registered Nurse (RN), came to assess the resident and they moved the resident from the right side to the backside. An interview on [DATE] at 9:39 a.m., Staff I, RN, reported being called into Resident #1's room around 1:00 p.m. on [DATE]. She found the resident lying on his/her right side, on the floor, by the dresser, facing the medication cabinet. The resident had a gait belt on. Staff J and her rolled the resident from the right side to the backside to do an assessment. The resident couldn't move his/her right leg and grimaced when trying to move it. Staff I reported there was some swelling in the resident's lower abdominal right side. The resident reported a pain level of 6 on a scale of 1 through 10. Staff I felt it could be higher than 6 due to the resident's sweaty and painful appearance. Staff I asked Staff J what happened. Staff J reported she walked the resident from the bathroom to the recliner when the resident asked the pillow be readjusted in the recliner, so she let go of the gait belt and in a split second the resident fell backwards, as she adjusted the pillow. An interview on [DATE] at 9:44 a.m., Staff H, LPN, reported gait belts are used for resident who need help with transfers. If a resident requests something, you need to seat them before assisting them. Staff are never to let go of the gait belt unless the resident is safely seated. It's always been standard practice to hold onto the gait belt with transfers or ambulation. An interview on [DATE] at 8:50 a.m., Staff F, CNA, reported using a gait belt for residents who can't transfer themselves. If a resident requests something during a transfer with a gait belt, you will tell them that you'll help them after they sit down. An interview on [DATE] at 8:33 a.m., Staff D, CNA, reported the only time to let go of the gait belt is when a resident is sitting, it's too dangerous otherwise. An interview on [DATE] at 3:59 p.m., Staff B, CNA, reported the facility use gait belts that have loops on the belt for staff to hold onto with transfers and ambulation. She reported you should hold onto the loop the whole time you are ambulating with residents. If the resident requests something, you tell them after they are situated you will take care of their request. An interview on [DATE] at 4:10 p.m., Staff C, CNA, reported you hold onto the loops on the gait belt when walking with a resident. If a resident requests something, you tell them after they sit down, you will assist them. An interview on [DATE] at 8:15 a.m., the Director of Nursing reported the resident had no fall risk evaluations completed. The DON stated Resident #1 was not at risk for falling and he/she had no falls since admission. The resident would have a difficult time in changing positions from sitting to standing, but steadied on ce standing. An interview on [DATE] at 3:00 p.m., with the Administrator, reported the incident as an unfortunate accident. As Staff J, CNA, transferred the resident from the bathroom to the recliner, the resident requested the pillow be moved in the recliner. Staff J let go of the resident's gait belt, to move the pillow, the resident fell , fractured the hip and required surgery. The resident has had a difficult time with controlling pain, but also has a lot of other issues going on. The facility's Policy for Gait Belt Usage showed the purpose to help facilitate safer transfers for resident and staff when transferring/ambulating. The Procedure included: - apply the gait belt snugly around the waist of a resident. - hold onto the gait belt tightly to support the resident's weight. -proceed to ambulate or transfer the resident.

Based on clinical record review, resident and staff interview, the facility failed to ensure staff followed one of four residents plan of care as directed. (Resident #1). The facility census was 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required limited assistance of one person with transfers and ambulation in the room. The Care Plan dated [DATE], documented the resident with a self care deficit due to stroke and fatigue. The plan of care documented the residents required the assistance of one staff and walker for ambulation and the assistance of one staff to move between surfaces as necessary. A Home Incident Reporting Form dated [DATE] at 1:30 p.m., documented the resident was on the floor by the dresser. Staff J, Certified Nurse Aide, CNA noted the resident fell when walking to the recliner. The report documented the resident reported falling backwards. The resident had back pain, right side swelling and a skin tear to the right elbow. An interview on [DATE] at 11:02 a.m., the resident reported coming from the bathroom to go to the lounge chair on [DATE]. The resident reported the CNA (Staff J) walked ahead and did not hold onto the resident. The CNA put the foam pillow from the wheelchair into the recliner. The resident took a couple of steps backwards and fell . The resident's right hand hit the dresser. The resident laid on the floor until the ambulance arrived and sustained a fracture to the right hip. An interview on [DATE] at 8:15 a.m., the Director of Nursing reported the resident would have a difficult time in changing positions from sitting to standing, but steadied on ce standing. An interview on [DATE] at 9:05 a.m., Staff J, CNA reported transferring the resident on [DATE] around noon to 1:00 p.m., from the bathroom to the recliner. Before Staff J walked the resident she had to move a foam pillow from the wheelchair into the recliner. The resident requested the foam pillow be turned around in the recliner. So, 'without thinking', Staff j reached over to turn the pillow and let go of the resident. The resident fell backwards and hit the dresser on the way to the floor.

Based on observation and staff interview the facility failed to maintain a sanitary environment in the kitchen. The facility reported a census of 67 residents. Findings Include: 1. During the initial dietary tour on 3/11/13 at 8:50 a.m. to 9:30 a.m. with Staff C, Head Cook, the following issues noted: a. Observed an approximate 30 inch circular Marley Industrial Product stand fan in the dish room dirty with grease and dust on the grate of the fan with 1/2 inch dust filaments hanging off the grate. b. Noted the 7 grates in top/back of the hood area in the kitchen above the stoves covered with grease and dust along the entire edges of the grates. During an interview on 3/11/13 at 9:20 a.m., Staff C indicated the maintenance department responsible for clearing the hood grates and thought completed once a week. During an interview on 3/11/13 at 11:10 a.m., the Food Services Director concurred that the grates to the hood in the kitchen dirty and needed to be cleaned. During an interview on 3/11/13 at 2:20 p.m., the Food Services Director reported the maintenance department responsible to clean the grates in the hood every 3 weeks and do keep logs of the cleaning. The Food Services Director indicated maintenance staff in the kitchen last week and noted the grates and stated needed to get back and clean the grates. The Food Services Director reported the grates now cleaned by maintenance after the initial dietary tour. During an interview on 3/12/13 at 11:20 a.m., Staff D, maintenance worker, provided the cleaning log of the grates of the hood for 2013. The task entitled Grease Filter Wash completed on 1/22/13, 2/20/13 and 3/11/13. Staff D explained the process completed to clean the grates to the hood to include to remove the grates, spray with degreaser, and put the grates through the dishwasher. This cleaning to be completed every 3 weeks.

Based on record review and staff interview, the facility failed to provide and document non-drug interventions completed for 3 of 8 residents (Resident #1, #5, #6, #13) reviewed. The facility identified a census of 67 residents. Findings include: 1. The undated Admission Sheet identified Resident #13 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment tool dated 02/04/13 identified the resident with a cognitive score of 8 out of 15 indicating moderate impairment with making daily decisions, independent with most cares and did not exhibit any signs of behaviors. The physician's orders [REDACTED]. The resident's Care Plan dated 02/05/13 identified a problem of anxious depression and included the intervention to administer antidepressant/anti-anxiety medications as ordered. According to the PRN (as needed) Medication Record the resident received [MEDICATION NAME] on 01/09/13 and 01/15/13. The reason for administrating the medication was noted for [MEDICAL CONDITION]. Record Review of the resident's Nursing Notes dated 01/09/13 and 01/15/13 failed to note the resident received the [MEDICATION NAME] medication for [MEDICAL CONDITION]. The Nurse's Notes failed to include any interventions performed for the resident before the anti-anxiety medication was given. Record Review of the resident's record for [MEDICAL CONDITION] Medication Monitor flowsheets failed to note any interventions completed. 2. The undated Admission Sheet identified Resident #1 with [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident with short and long term memory loss, severe impairment with making daily decisions and dependent on staff for cares and did not exhibit signs of behaviors. The physician's orders [REDACTED]. The resident's Care Plan dated 01/20/13 identified the use of [MEDICAL CONDITION] medication and to administer medications as ordered and document on [MEDICAL CONDITION] flowsheet. The Medication Administration Records dated 12/01/12 through 03/31/13 directed staff to administer [MEDICATION NAME] 0.125 ml every hour as needed. Record Review of the resident's Nurses Notes dated 12/07/12 through 03/13/13 noted the resident received the [MEDICATION NAME] medication 23 times for anxiety and/or behaviors. Out of 23 times only 9 times documented various interventions by staff before administering the medication. Fourteen of the times staff administered the medication without any documentation of interventions attempted. Interventions as repositioning, toileting, snacks, change from bed to chair, music, ambulation or 1 to 1 conversation/interaction were among the attempt in the past for the resident. Record review of the Nursing Notes or the monthly Medication Monitor flowsheets failed to note any intervention that were successful or unsuccessful or if the behavior occurred at a certain time of the day. The record failed to contain a behavior flowsheet with interventions. During an interview on 03/12/13 at 11:20 a.m., Staff A, Registered Nurse, stated when giving an anxiety or [MEDICAL CONDITION] medication the standard is to document the interventions tried for the resident before giving the medication. Staff A noted they try several interventions before administrating the medications. Staff A also remarked there was not a daily behavior sheet to follow but the MDS Coordinator tracks the medication used and follows up as needed. 3. The undated Admission Sheet identified Resident #5 with [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident with a cognitive score of 8 out of 15 indicating moderate impairment with making daily decisions, dependent on staff for cares and noted verbal behavioral symptoms directed at others occurred. The physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The PRN Medication Record dated 12/30/12 through 03/13/13 documented staff administered either medications for a total of 28 times. The resident's Care Plan dated 02/03/13 identified the use of [MEDICAL CONDITION] medication and to administer medications as ordered and document on [MEDICAL CONDITION] flowsheet as necessary. Review of the Nurses Notes dated 12/07/12 through 03/13/13 noted staff did not document interventions completed by staff before administering the anti-anxiety and/or [MEDICAL CONDITION] medication 19 of the 28 times the medication was given. Interventions as repositioning, toileting, snacks, change from bed to chair, ambulation or 1 to 1 conversation/interaction were among the attempt in the past for the resident. Record review revealed a [MEDICAL CONDITION] Medication Monitor flowsheet completed on a monthly basis. The record noted the use of the medication but failed to identify any patterns or interventions that were successful or not successful. During an interview on 03/13/13 at 8:49 a.m. the MDS Coordinator stated the [MEDICAL CONDITION] flowsheet is done every month for resident's with the anti-depressant, anti-anxiety, hypnotics and [MEDICAL CONDITION] medications. The flowsheets follow the usage, resident's status/behaviors, side effects and follow up with changes or assessment for more needs (such as a physician visit,etc.). The MDS Coordinator stated there was no daily behavioral sheet for documentation of behaviors and interventions for residents. During an interview on 03/13/13 at 11:30 a.m., the Director of Nursing acknowledged the lack of documentation for non-drug interventions completed for the residents with the required medications and noted a need for improvement. Grimm, Theresa A. 4. According to the Physician order [REDACTED]. The MDS dated [DATE] indicated Resident #6 with long term memory problems and moderately impaired decision skills. Resident #6 required minimum assist of 1 staff for bed mobility, transfers, dressing and hygiene, and was independent in ambulation in room or the hallway. The resident's Care Plan dated 3/4/13 directed the nursing staff to always keep the resident informed of what was to be done or going to be done, administer appropriately related medications as ordered, keep the resident unhurried with frequent contact, provide diversional activities and to remain with the resident during episodes of severe anxiety or agitation. Review of the resident's POS dated 2/21/13 revealed Resident #6 received [MEDICATION NAME] ([MEDICATION NAME]) 0.5 milligram (mg) 1/2 tab by mouth twice a day at 8:00 a.m. and 12:00 noon. The resident also received [MEDICATION NAME] 0.5 mg 1/2 tab by mouth every 4 hours as needed for agitation (ordered on [DATE]), and [MEDICATION NAME] 12.5 mg by mouth at 8:00 a.m., 25 mg by mouth at noon and 5:00 p.m. an increased dose on 3/11/13 of the noon and 5:00 p.m. doses. Review of a psychiatric evaluation of Resident #6 on 10/24/12 indicated the resident to have occasional increased anxiety and paranoia and hallucinations present but tolerable. Review of the PRN Medication Administration Records for Resident #6 revealed no PRN [MEDICATION NAME] given in November 2012 or December 2012. Review of the January 2013 PRN Medication Record indicated the [MEDICATION NAME] 0.5 mg 1/2 tab by mouth every 4 hours as needed for agitation given on 1/25/13, 1/28/13, and 1/29/13 Review of the February 2013 PRN Medication Record indicated [MEDICATION NAME] administered 2/12/13, 2/13/13 and twice on 2/22/13. Review of the March 2013 PRN Medication Record indicated the [MEDICATION NAME] given on 3/03/13, 3/06/13, 3/07/13, 3/8/13, and 3/10/13. Review of the January 2013 Nurses Notes 2013 revealed no documentation of the PRN [MEDICATION NAME] given on 1/28/13 to the resident for increased paranoia but no diversional activities, 1:1 time, or redirection given to the resident prior to administration. Review of the Nurses Notes revealed on 2/12/13 at 3:00 p.m., the resident out in the dining room insisting on speaking to someone about the other woman who has her room. The resident redirected to room and 1:1 provided. At 7:00 p.m., the resident unwilling to have bedtime cares provided stated, "this is her room." PRN [MEDICATION NAME] by mouth for anxiety, no interventions utilized. On 2/22/13 the PRN [MEDICATION NAME] given twice to the resident and documented as offered as something to help calm the resident and for sleep but no interventions utilized and another entry reported given for hallucinations.

Based on observation, record review and staff interview the facility failed to store, distribute and serve food under sanitary conditions from the main kitchen. The facility identified a census of 66 residents. Findings include: 1. Observation on 03/06/12 at 9:00 a.m., on initial kitchen tour with the Food Service Supervisor (FSS), the following was revealed: a. A Raetone stand up freezer contained a 12 inch Boston Creme pie, loosely covered and undated. Upon moving the pie around to view the label the unsecured plastic lid came off easily. b. 1 quart sized cooking pan with the bottom of the pan dented in all over. c. 4 gallon sized coking pans contained dents all over the bottom of the pans. All around the outside of the pans revealed black carbon build up material. d. 1 large (18 to 20 inch) silver, frying pan contained some yellow, dried food particles inside the bottom. The inside bottom of the pan contained severe dug in markings and scratchings, discoloration and dried food particles. The outside of the pan contained black carbon build up material. The FSS agreed with the observation and stated the pans were very old and difficult to clean. The FSS removed the pans and stated they would be discarded. e. A very large white walk in freezer contained food debris, dried and sticky spots of food drippings, pieces of hard, dehydrated food particles (radishes) lying on the metal floor under the shelves. The floor contained particles of dust and debris. There was a large area of built up frost (approximately 1 to 2 inches thick) covering the left corner and side of the air fans, blowing towards the ceiling. The metal floor revealed a dull, unclean appearance. The FSS stated maintenance routinely checked the freezer fans. f. A large white walk in refrigerator revealed a tray of 4 small bowls of grapefruit covered but undated on a shelf. The FSS removed the tray of bowls. The metal floor contained food, onion skins, plastic paper, dust and debris, along with dried spots of drippings from food. The metal floor revealed a dull, unclean appearance. g. A knife holder on the wall contained 2 large (10 inch) silver knives with several yellow spots of dried food. 4 of the knives had blades that wavered edges. 2 of the knives had bent tips. All the knives revealed dented, marked up plastic handles. The FSS removed the knives. h. The dry storage room contained approximately 8 to 10 feet high metal framed shelves on each far wall for a total of 6 with 6 to 7 shelves each which contained rust, debris, spotting and dust when touched. The entire floor of the storage room contained paper, dust, dry onion skins and debris. i. A dietary staff person was pushing a 3 shelved cart which contained 3 large cans (6 pound/6 ounces weight)of asparagus and 2 cans of carrots. The cans were opened with the lids still attached and liquid from the contents of the cans spilling onto the top of the lids. The staff person stated she opened the cans in the other room and brought them into the cooking area. The staff person stated the lids to the cans were not washed prior opening them. The FSS asked the staff person to dispose those cans and obtain new cans of vegetables to be used for the meal. j. The FSS checked the sanitizer sink of the 3 compartment sink and revealed 800 mmm/parts. The Supervisor stated of checking the sink every day but replied the log sheet may be irregular. k. A clipboard on the wall near the dishwasher noted log sheets for dishwater recorded temperatures. A black note written below stated the dishwasher to check temperatures three times a day. The log sheet revealed no dishwater temperatures taken March 1st, 2nd, or 3rd. The FSS remarked, the staff failed to check the temperatures. l. When asked how often the sanitizer was checked in the 3 compartment sink, the FSS stated every day. When asked to see the reports, the FSS stated it was documented at random. m. The dishwasher required high water temperature and a record flowsheet of the dishwasher's daily temperatures hung on the wall near the dishwasher. The flowsheet for March indicated no documented temperatures for March 1st, 2nd, and 3rd. The FSS stated apparently the temperatures were not done. The clip board holding the flow sheets had a written note in black magic marker that said, Dishwashers to check 3 times a day. Record review of the Dishwasher Record-High Temperature for the month of March documented no temperatures for March 1, 2, or 3rd. The record for the month of February failed to document the temperature 5 times. Record review of an untitled duty flow sheet hanging in the main kitchen area listed areas to clean but failed to note any cleaning for the freezers, refrigerators or floor care. Record review of the 3 compartment sink documented the sanitizer was tested on [DATE] and 02/21/12. During an interview on 03/08/12 at 6:15 a.m., Staff C, Cook, stated the floor for the walk in freezer should be washed every month and the walk in refrigerator washed every day.

Based on observation, record review and staff interviews, the facility failed to maintain infection control practices to prevent the development and transmission of disease and infection for 3 of 3 whirlpool tubs. The facility reported a census of 66 residents. Findings Include: Observations made on environmental tour on 3/8/12 between 2:00 p.m. and 3:40 p.m. revealed 2 Cascade whirlpool tubs and one Parker whirlpool tub in 3 different shower rooms. Penner Patient Care disinfectant bottles were located in the dispensing compartments of both Cascade tubs, with label that stated a 10 minute wet surface contact time was required for complete disinfection. A spray bottle with Lemon Kleen was located in the shower room with the Parker whirlpool and an instruction sheet located on the wall directed staff a 10 minute wet contact time required for the Lemon Kleen product. An undated "whirlbath disinfecting solution - Lemon-Kleen" procedure directed staff: 1. Thoroughly cover surface of tub with disinfectant solution, (concentration 2 oz per gallon of water). 2. Apply with a coarse sprayer, cloth or mop. 3. Let solution remain on the surface for a minimum of 10 minutes. 4. Rinse or wipe dry with a clean cloth and allow to finish air drying. Staff interviews about whirlpool disinfection procedures revealed: 3/8/12 at 3:08 p.m., Staff E, certified nursing assistant (CNA) stated a button on the side of the Cascade tub is pressed, after about 1 inch of liquid in the tub (disinfectant) then fills the tub with hot water to a level above the jets, turns on whirlpool, allow to run for 5 minutes and a brush used to clean surfaces, then drain tub and rinse with water. 3/8/12 at 3:16 p.m., Staff F, CNA, stated he/she used a spray bottle with Lemon Kleen to disinfect the Parker tub, all surfaces sprayed and brush used, contact time of a couple of minutes, then rinsed and wiped with a cloth. 3/8/12 at 3:35 p.m., Staff G, CNA, stated to sanitize the Cascade tub he/she pushed disinfectant button and allowed tub to fill with solution, a brush used to scrub all surfaces, a contact time of 5 minutes required, then tub drained and rinsed. During an interview on 3/9/12 at 11:30 a.m., the Director of Nursing stated nursing staff would be educated as needed regarding disinfection of the whirlpool tubs.