Every finding on record at Canterbury Health Care Facility

Based on interviews, resident record review, and review of a facility policy titled Transportation Safety, the facility failed to ensure Resident Identifier (RI) #1 was secured in the wheelchair during a transport on 8/10/23 in the facility van. Employee Identifier (EI) #3 Certified Nursing Assistant (CNA) failed to snuggly secure RI #1's waist and shoulder belts. This resulted in RI #1 sliding from the wheelchair during transportation when the driver abruptly applied the vehicle brakes. This had the potential to affect RI #1, one of three residents sampled for transportation safety. This deficient practice is cited as a result of the investigation of complaint/report number AL00045493. Findings include: A facility policy titled TRANSPORTATION SAFETY with an effective date of March 2023 documented: PURPOSE: Have a standardized procedure for safety during transportation. STANDARD: Transportation Drivers have training to decrease the risk of injuries during transportation. PROCESS: . 3. Transportation Drivers must complete the competency on the Validation checklist of skills; (Loading, Securing, and Unloading) residents with returned demonstration . An undated and unsigned facility Competency Validation Checklist: . documented . Securing Passenger and Chair . 3 Attach systems lap belt snuggly around waist. (Adjust if necessary to ensure the catch for shoulder will belt rest to the inside of vehicle on passenger's hip) . RI #1 was admitted to the facility on [DATE] and had diagnoses to include: Amputation of the Right Leg and End Stage Renal Disease. RI #1's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of 7/24/23 documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated there was no impairment with decision making abilities. An incident report for RI #1 documented on 8/10/23 the van driver reported that RI #1 was in a wheelchair during transportation and slid out of the wheelchair unto the floor of the van. RI #1 was assessed for injury and no injury was found. On 10/3/23 at 10:00 AM EI #3 CNA was asked about the incident with RI #1 in the facility van. EI #3 said, the wheelchair should be anchored to the floor with the 4-point anchors then the seat and shoulder belt should be secure and snug to the resident. EI #3 said, RI #1's seat and shoulder belts were not secured snug to the resident. EI #3 said, RI #1 had told him it was too tight so he loosened it. EI #3 said, when RI #1 slid from the chair to the floor of the van, the seat and shoulder belt was still attached to RI #1. EI #3 said, RI #1's head was like leaning against the wheelchair seat not touching anything. EI #3 said, when EI #4 hit the brakes RI #1 slid forward and to the floor in a sitting position. EI #3 stated, RI #1 denied being hurt and wanted to get back into the wheelchair. EI #3 explained. EI #4 parked the van there in the street, put the flashers on, they looked RI #1 over, checked RI #1's arms, legs and anywhere to see if RI #1 was hurt; RI #1 denied being hurt and they used the sling underneath RI #1 to pick RI #1 up and place him/her back into the wheelchair. EI #3 said, they assisted RI #1 back in the seat, put the belts on and made them tighter. EI #3 said the incident could have been avoided possibly if the belts were snug to the resident. On 10/3/23 at 12:00 PM an interview was conducted with EI #4, CNA, the van driver at the time of the incident with RI #1 on 8/10/23. EI #4 said, she was driving and EI #3 was riding along. EI #4 explained, she was returning RI #1 back to the facility somewhere between 1:00 to 1:30 PM. EI #4 said, she was slowing down, the light was changing, she applied the brakes, and RI #1 slid from the wheelchair. EI #4 said, she put the van in park right there in the road, put the flashers on, and went back to check on RI #1. EI #4 explained, EI #3 was already down beside RI #1, the sling was under RI #1, and she looked RI #1 over and asked where he/she hurt. EI #4 said, RI #1 denied being hurt and wanted help to get him/her back up to the wheelchair. EI #4 stated, she looked at RI #1's arms, legs, and looked for any bleeding or injury, there was none so they used the sling under RI #1 and placed RI #1 back in the wheelchair and continued to the facility. EI #4 said, before the incident, EI #3 had placed the seat and shoulder belts, and she heard RI #1 tell EI #3 he/she did not want the belts so tight. EI #4 said, the incident could have been prevented if they had made sure the belts were snug and EI #3 should have said, the belts must fit snug. ***************************************************************************** PLAN Identified Issues Resident slid out of chair during an immediate stop made by the transportation Van Driver 1. On 08/10/2023 upon identification of the incident, the resident was assessed by a licensed nurse and later sent to the hospital for an evaluation and no injuries were noted. 2. Immediate re-education was completed for the drivers with return demonstration and further instruction to call center and alert of any incidents. 3. Face sheet was updated adding the resident daughter as contact, per request. At the time of the incident, the resident was self-sponsored. No other residents' factsheets needed updating. How Center identified others that may be affected by this practice: 1. The Center audited all dialysis residents with routine transfers by the facility van that required transfer with the use of a Hoyer pad to be at risk of slipping/sliding during sudden stops. Any safety risks identified were addressed by modifying transportation to dialysis. What systematic changes will be implemented ensuring deficient practice does not re-occur. 1. Following the incident, one transportation driver returned to the nursing department as a CNA ., but did receive re-education on VIA video and return demonstration by the Maintenance Director prior to the position change on 8/16/23. The DON performed re-education on safety measures following an occurrence on 8/16/23. 2. The second transportation driver received re-education to further ensure knowledge of application securing residents and notifying the center immediately upon any occurrences on 08/17/2023. The DON performed re-education on safety measures following an occurrence on 8/16/23. 3. 3. The newly hired driver received initial education by watching the video and taking the post test and showing a return demonstration to the Maintenance Director before approved to drive. 4. Any future drivers will be educated with return demonstration competency before transporting residents. 5. 5. Center Reviewed and revised and adopted Policy for transportation on 8/16/2023. Describe the Quality Assurance & Process Improvement Program that will be put into place (track and trend data over time to ensure action plan met the initially identified goal). 1. The Maintenance Director and/or Trained Designee has performed and verified secured transportation device 1 x per week x 7 weeks, the QAPI team will review and re-evaluate based on completed observations.

Based on interviews, resident record review, and review of a facility policy titled Transportation Safety, the facility failed to ensure Resident Identifier (RI) #1 was secured in the wheelchair during a transport on 8/10/23 in the facility van. Employee Identifier (EI) #3 Certified Nursing Assistant (CNA) failed to snuggly secure RI #1's waist and shoulder belts. This resulted in RI #1 sliding from the wheelchair during transportation when the driver abruptly applied the vehicle brakes. This had the potential to affect RI #1, one of three residents sampled for transportation safety. This deficient practice is cited as a result of the investigation of complaint/report number AL00045493. Findings include: A facility policy titled TRANSPORTATION SAFETY with an effective date of March 2023 documented: PURPOSE: Have a standardized procedure for safety during transportation. STANDARD: Transportation Drivers have training to decrease the risk of injuries during transportation. PROCESS: . 3. Transportation Drivers must complete the competency on the Validation checklist of skills; (Loading, Securing, and Unloading) residents with returned demonstration . An undated and unsigned facility Competency Validation Checklist: . documented . Securing Passenger and Chair . 3 Attach systems lap belt snuggly around waist. (Adjust if necessary to ensure the catch for shoulder will belt rest to the inside of vehicle on passenger's hip) . RI #1 was admitted to the facility on [DATE] and had diagnoses to include: Amputation of the Right Leg and End Stage Renal Disease. RI #1's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of 7/24/23 documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated there was no impairment with decision making abilities. An incident report for RI #1 documented on 8/10/23 the van driver reported that RI #1 was in a wheelchair during transportation and slid out of the wheelchair unto the floor of the van. RI #1 was assessed for injury and no injury was found. On 10/3/23 at 10:00 AM EI #3 CNA was asked about the incident with RI #1 in the facility van. EI #3 said, the wheelchair should be anchored to the floor with the 4-point anchors then the seat and shoulder belt should be secure and snug to the resident. EI #3 said, RI #1's seat and shoulder belts were not secured snug to the resident. EI #3 said, RI #1 had told him it was too tight so he loosened it. EI #3 said, when RI #1 slid from the chair to the floor of the van, the seat and shoulder belt was still attached to RI #1. EI #3 said, RI #1's head was like leaning against the wheelchair seat not touching anything. EI #3 said, when EI #4 hit the brakes RI #1 slid forward and to the floor in a sitting position. EI #3 stated, RI #1 denied being hurt and wanted to get back into the wheelchair. EI #3 explained. EI #4 parked the van there in the street, put the flashers on, they looked RI #1 over, checked RI #1's arms, legs and anywhere to see if RI #1 was hurt; RI #1 denied being hurt and they used the sling underneath RI #1 to pick RI #1 up and place him/her back into the wheelchair. EI #3 said, they assisted RI #1 back in the seat, put the belts on and made them tighter. EI #3 said the incident could have been avoided possibly if the belts were snug to the resident. On 10/3/23 at 12:00 PM an interview was conducted with EI #4, CNA, the van driver at the time of the incident with RI #1 on 8/10/23. EI #4 said, she was driving and EI #3 was riding along. EI #4 explained, she was returning RI #1 back to the facility somewhere between 1:00 to 1:30 PM. EI #4 said, she was slowing down, the light was changing, she applied the brakes, and RI #1 slid from the wheelchair. EI #4 said, she put the van in park right there in the road, put the flashers on, and went back to check on RI #1. EI #4 explained, EI #3 was already down beside RI #1, the sling was under RI #1, and she looked RI #1 over and asked where he/she hurt. EI #4 said, RI #1 denied being hurt and wanted help to get him/her back up to the wheelchair. EI #4 stated, she looked at RI #1's arms, legs, and looked for any bleeding or injury, there was none so they used the sling under RI #1 and placed RI #1 back in the wheelchair and continued to the facility. EI #4 said, before the incident, EI #3 had placed the seat and shoulder belts, and she heard RI #1 tell EI #3 he/she did not want the belts so tight. EI #4 said, the incident could have been prevented if they had made sure the belts were snug and EI #3 should have said, the belts must fit snug. ***************************************************************************** PLAN Identified Issues Resident slid out of chair during an immediate stop made by the transportation Van Driver 1. On 08/10/2023 upon identification of the incident, the resident was assessed by a licensed nurse and later sent to the hospital for an evaluation and no injuries were noted. 2. Immediate re-education was completed for the drivers with return demonstration and further instruction to call center and alert of any incidents. 3. Face sheet was updated adding the resident daughter as contact, per request. At the time of the incident, the resident was self-sponsored. No other residents' factsheets needed updating. How Center identified others that may be affected by this practice: 1. The Center audited all dialysis residents with routine transfers by the facility van that required transfer with the use of a Hoyer pad to be at risk of slipping/sliding during sudden stops. Any safety risks identified were addressed by modifying transportation to dialysis. What systematic changes will be implemented ensuring deficient practice does not re-occur. 1. Following the incident, one transportation driver returned to the nursing department as a CNA ., but did receive re-education on VIA video and return demonstration by the Maintenance Director prior to the position change on 8/16/23. The DON performed re-education on safety measures following an occurrence on 8/16/23. 2. The second transportation driver received re-education to further ensure knowledge of application securing residents and notifying the center immediately upon any occurrences on 08/17/2023. The DON performed re-education on safety measures following an occurrence on 8/16/23. 3. 3. The newly hired driver received initial education by watching the video and taking the post test and showing a return demonstration to the Maintenance Director before approved to drive. 4. Any future drivers will be educated with return demonstration competency before transporting residents. 5. 5. Center Reviewed and revised and adopted Policy for transportation on 8/16/2023. Describe the Quality Assurance & Process Improvement Program that will be put into place (track and trend data over time to ensure action plan met the initially identified goal). 1. The Maintenance Director and/or Trained Designee has performed and verified secured transportation device 1 x per week x 7 weeks, the QAPI team will review and re-evaluate based on completed observations.

Based on interviews, record review, and facility document review, the facility failed to refer a resident to dental services following complaints of tooth pain for one (Resident #57) of two sampled residents reviewed for dental services. Findings included: A review of an Admission Record indicated Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE]. Further review revealed Resident #57 was their own responsible party (RP), with Medicaid as their primary payor source. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/01/2023, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A review of Resident #57's comprehensive care plans revealed no care plan addressing dental concerns or the need for dental services. A review of Resident #57's dental note, dated 03/25/2022, revealed Resident #57 was not seen for a comprehensive oral evaluation due to awaiting signed consents. Further review revealed a needed follow-up for a comprehensive oral evaluation to be done at a future visit on an undetermined date. During an interview on 05/30/2023 at 11:38 AM, Resident #57 stated they had tooth pain and had requested to see a dentist, but it had been over a year since they had last seen one. A review of a typed statement signed by the Administrator, dated 06/02/2023, indicated, It is our understanding that neither the patient [Resident #57] nor the family completed the necessary consents to obtain [dental] services. A review of email communication between the Social Services Director (SSD) and the dental providers, dated 06/01/2023, confirmed Resident #57 was not enrolled to receive dental services. During an interview on 06/02/2023 at 10:35 AM, Resident #57 said their tooth broke off on the right side about a year prior, causing pain, and they reported it to the facility at that time. Resident #57 stated they told Unit Manager #11 about their tooth pain most recently about three months ago and did not know he/she could tell any other staff member they needed to be seen by a dentist. Resident #57 stated they had not been asked to sign a consent to see the dentist and indicated he/she would have signed it if they had been asked. Resident #57 further stated they could eat normally and had not lost weight related to their broken tooth. During an interview on 06/02/2023 at 10:41 AM, the SSD stated the dentist came to the facility every other month to see residents. The SSD then stated he normally completed the resident's initial dental referral and then the business office became involved for payment. The SSD said if a resident needed to see a dentist, the nurses normally notified him, or the resident could tell him as well, and he got the process started. The SSD further stated Resident #57 had not seen the dentist since the initial paperwork noted in their chart, dated 03/25/2022, and he was not made aware of Resident #57's tooth pain until a few days ago. During an interview on 06/02/2023 at 11:00 AM, Unit Manager #11 stated Resident #57 had not told her about any recent tooth pain. According to Unit Manager #11, the last time Resident #57 verbalized mouth pain, it was related to their gums, not their tooth, and that was about a year ago. Unit Manager #11 stated she thought Resident #57 had seen a dentist since then and was on the list to see them soon. She further stated it was important for residents with gum or tooth pain to see a dentist to help alleviate the pain and to follow-up as needed for proper oral care. During an interview on 06/02/2023 at 11:25 AM, the Assistant Director of Nursing (ADON) stated if a resident verbalized any gum or tooth pain, nursing needed to notify the physician or the SSD to get an appointment set up with a dentist. The ADON said it was ultimately the unit manager's responsibility to notify the physician or the SSD to address the concern. The ADON then stated if there needed to be a signed consent, the family could sign it, or if the resident was alert and oriented, he/she could sign it prior to seeing the dentist. The ADON further stated it was important to follow up on any verbalized oral pain because the facility did not want residents to be in any pain. During an interview on 06/02/2023 at 12:15 PM, the Director of Nursing (DON) stated that when a resident verbalized any tooth or gum pain, she expected the nurses to notify the physician and to make any referrals as needed. The DON further stated the SSD assisted in setting up dental appointments and indicated if the resident was their own RP, they could sign the consent to be seen. The DON then stated it was important to follow up with a dentist on any dental complaints to ensure the resident could eat. During an interview on 06/02/2023 at 3:15 PM, the Administrator stated he expected the nursing staff to assess and address any resident complaints of dental pain. The Administrator further stated if a resident wanted to see a dentist for a concern, he expected a referral to be made.

Based on record review, interviews, and review of the Centers for Medicare & [and] Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to transmit a discharge Minimum Data Set (MDS) assessment within 14 days of the completion date for one (Resident #32) of one resident reviewed for timely submission of MDS assessment. Findings included: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, revealed, Chapter 5: Submission and Correction of the MDS Assessments. Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS) records for all residents in Medicare- or Medicaid-certified beds regardless of the pay source. Skilled nursing facilities (SNFs) and hospitals with a swing bed agreement (swing beds) are required to transmit additional MDS assessments for all Medicare beneficiaries in a Part A stay reimbursable under the SNF Prospective Payment System (PPS). 5.1 Transmitting MDS Data All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. Required MDS records are those assessments and tracking records that are mandated under OBRA and SNF PPS. The RAI Manual further indicated, Transmitting Data: Submission files are transmitted to the QIES ASAP system using the CMS wide area network. The RAI Manual specified that discharge assessments must be submitted by Z0500B [completion date of the assessment] + [plus] 14 [days]. A review of Resident #32's Admission Record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. A review of Resident #32's discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/07/2023, revealed the resident was discharged to the community on 01/07/2023. The completion date of the assessment was 01/12/2023. A review of Resident #32's MDS 3.0 Final Validation Report revealed their discharge assessment was not transmitted until 06/02/2023. During an interview on 06/02/2023 at 8:23 AM, MDS Coordinator #1 stated that MDS Coordinator #2 had completed the discharge assessment but failed to transmit it as required. She said it should have been transmitted within 14 days. During an interview on 06/02/2023 at 11:33 AM, the Director of Nursing (DON) stated that she expected MDS assessments to be transmitted within the timeframes specified by CMS guidelines. During an interview on 06/02/2023 at 3:10 PM, the Administrator stated that he expected MDS assessments to be transmitted in a timely manner.

Based on interviews, record review, and facility policy review, the facility failed to complete a new Level I pre-admission screening and resident review (PASARR) after the resident was identified to have a newly evident mental illness diagnosis for one (Resident #2) of one resident reviewed for PASARR requirements. Findings included: A review of the facility's policy titled, PASRR [sic] Requirements, undated, revealed, In effort of the Health Information Management Coordinator to obtain a completed record, all patients must have a Pre-Admission Screening and Resident Review prior to or immediately upon admission as required by federal and/or a patient/resident specific review process as defined by local State guidelines. The PASRR [sic] is completed to determine provision of appropriate and needed serviced [sic] to individuals who have been diagnosed with MI/MR [mental illness/mental retardation]. A review of Resident #2's Admission Record revealed the resident was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The Admission Record indicated the resident's diagnoses included panic disorder, paranoid schizophrenia, major depressive disorder, and bipolar disorder. Per the Admission Record, the diagnosis of bipolar disorder had an onset date of 10/19/2022. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/07/2023, indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated moderate cognitive impairment. Further review revealed active diagnoses of schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder. A review of Resident #2's comprehensive care plans revealed a care plan, initiated on 10/31/2022, that indicated the resident was receiving behavioral health services due to diagnoses of paranoid schizophrenia, bipolar disorder, major depressive disorder, and panic disorder. A review of a State of Alabama Department of Mental Health PASRR Level I Screening and Results, revealed a new Level I PASARR was not completed following Resident #2's diagnosis of bipolar disorder (which had an onset date of 10/19/2022) until 05/31/2023. During an interview on 06/01/2023 at 9:21 AM, the Corporate Nurse Consultant stated that after Resident #2's PASARR was requested by the surveyor, they identified there was an issue with the Level I PASARR screening not being completed. The Corporate Nurse Consultant indicated they had just completed Resident #2's new Level I screening on 05/31/2023. During an interview on 06/01/2023 at 3:42 PM, the Social Services Director (SSD) said the Admissions Coordinator was responsible for completing the initial Level I PASARR screening, and he was responsible for completing a new Level I screening if there was a change in the resident's condition or after a new diagnosis. The SSD said he just completed the new Level I PASARR screening for Resident #2 on 05/31/2023 due to the new diagnosis of bipolar disorder from October 2022. The SSD said he did not complete one at the time, in October 2022, because it slipped his mind, and he had no process in place to track changes when a resident had a new diagnosis. During an interview on 06/01/2023 at 3:30 PM, the Admissions Coordinator stated when residents were coming from Georgia (another state in close proximity to the facility), she completed the Level I PASARR screening, but if they were coming from Alabama, the hospital completed them. The Admissions Coordinator indicated she would review them for accuracy and complete a new one if there were any inaccuracies identified. The Admissions Coordinator said the SSD completed another Level I screening if there were any changes in the resident's diagnoses. During an interview on 06/02/2023 at 1:42 PM, the Director of Nursing (DON) stated a PASARR was completed by the Admissions Coordinator and signed by a registered nurse, and the SSD reviewed it for accuracy. The DON said if there was a change in a resident's condition, the SSD would review and submit another Level I screening for review to see if the resident qualified for a Level II referral. The DON said she was not aware that a new Level I PASARR screening was not completed in 2022 when Resident #2 had a new mental illness diagnosis and indicated she would have expected one to be done. During an interview on 06/02/2023 at 3:24 PM, the Administrator stated the facility received a referral for all new admissions, and after admission, if there were any changes, a new Level I screening was completed by the SSD. The Administrator said he expected this to be done.

Based on interviews, record review, and facility policy review, the facility failed to complete a discharge summary to include a recapitulation (a concise summary) of the resident's stay for one (Resident #123) of four sampled residents reviewed for discharge requirements. Findings included: Review of a facility policy titled, Discharge Summary Requirements, undated, revealed, Guidelines: To provide for a safe departure from the center and provide a summary of patient service provided during a length of stay and to include applicable continuum of care instructions to the patient and/or next care provider. The policy further indicated, The patient's attending physician should complete a Discharge Summary describing the patient's condition during the period of stay of which that physician was responsible for physician's care and services. 2. A center clinician should complete an Interdisciplinary Discharge Summary User Defined Assessment document that describes pertinent information related to the patient's current length of stay and to provide education to the patient and/or next care provider. Review of an Admission Record revealed the facility admitted Resident #123 on 11/01/2021 with diagnoses that included primary generalized osteoarthritis, muscle wasting and atrophy (weakening, shrinking, and loss of muscle caused by disease or lack of use) of the left and right thigh, chronic kidney disease, shortness of breath, dysphagia (difficulty swallowing), localized edema (swelling caused by fluid in the body's tissues), and chronic congestive heart failure. The Admission Record also indicated Resident #123 was discharged from the facility on 02/09/2022. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/27/2022, revealed Resident #123 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The resident required limited assistance with bed mobility, extensive assistance with transfers, locomotion, dressing, and eating, and was totally dependent on staff for toilet use and bathing. Review of Resident #123's Care Plan, initiated 11/23/2021, revealed the resident wanted assistance in planning to return home safely. This Care Plan directed staff to help the resident contact local agencies as needed and to develop transition strategies to make the discharge go smoothly. Review of Resident #123's Discharge Summary, dated 02/08/2022, revealed section A. Discharge Summary was not completed, with all related areas in this section blank. Section B. Recapitulation of Resident's Stay was incomplete and only had two entries completed in this section related to therapy services and a skin tear to the right lower leg. The Discharge Summary was not signed as completed and there was no acknowledgement that staff had provided and reviewed the discharge instructions with the patient/resident representative. During an interview on 06/02/2023 at 9:03 AM, the Corporate Nurse Consultant stated the discharge summary was a collaborative document opened in the electronic health record system. Each discipline was required to complete their respective sections, and once all sections were completed, that information would become the recapitulation of the resident's stay. The Corporate Nurse Consultant said at the time of a resident's discharge, the nurse should print off the discharge summary and review the information with the resident and the family. She further stated Resident #123's discharge summary was not completed and did not provide a recapitulation of their stay. During an interview on 06/02/2023 at 1:58 PM, the Administrator stated it was his expectation that staff would complete the discharge summary as required.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure one (Resident #25) of three sampled residents reviewed for activities of daily living (ADLs) were shaved and received hair care. Findings included: A review of a facility policy titled, ADL's [activities of daily living], effective August 2021, revealed, Policy: Ensure ADL's are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences. A review of Resident #25's Admission Record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included noninfective gastroenteritis and colitis, diverticulosis of intestine, and gastrointestinal hemorrhage. A review of Resident #25's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/15/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS further revealed Resident #25 required extensive assistance of one staff for personal hygiene and was totally dependent on one staff for bathing. A review of Resident #25's comprehensive care plans revealed a care plan addressing ADLs, initiated on 02/27/2023, that indicated the resident had an ADL deficit in relation to: Left BKA [below knee amputation]; right foot amputation; recent hospital stay per [for] diverticulosis and gastrointestinal hemorrhage; generalized weakness; incontinence; obesity; diabetes. This care plan directed staff to assist with bed mobility, bathing, dressing, grooming, and toileting. On 05/30/2023 at 9:20 AM, an observation was made of Resident #25 lying in their bed. Resident #25's hair was very disheveled and greasy. The resident was also noted to have facial hair approximately 1/16 inch long on both cheeks, the upper lip, and their [NAME]. During an interview at that time Resident #25 stated he/she had received a shower on 05/29/2023, but staff did not shave them or wash their hair. On 05/31/2023 at 8:42 AM, Resident #25 stated staff had just given them a bed bath but did not offer to shave them or wash his/her hair. During an interview on 05/31/2023 at 11:44 AM, Certified Nursing Assistant (CNA) #12 stated she had been caring for Resident #25 and indicated the resident required total care with bathing and grooming. CNA #12 indicated she had not been able to wash the resident's hair, because she had not been able to get the resident to the shower due to the resident requiring a mechanical lift for transfers. CNA #12 said she would have had to get the big boat shower bed, which she indicated was located on the other side of the building. CNA #12 said she tried to use a washcloth during the resident's bed bath to remove the flakes from around their forehead and around their ears. CNA #12 also indicated she had not gotten around to shaving the resident, but said the razors were accessible and located on the hall. CNA #12 acknowledged Resident #25 needed their hair washed and to be shaved. CNA #12 was unsure how long it had been since Resident #25 was shaved. During an interview on 05/31/2023 at 11:54 AM, Licensed Practical Nurse (LPN) #13 said the day and evening shift provided resident's showers, provided hair care, and shaving. She indicated it was the nurse's responsibility to ensure that grooming and personal hygiene were provided. LPN #13 said if there was a problem with providing the care to residents, the CNAs should let the charge nurse know, so they could ensure that it got done. During an interview on 06/02/2023 at 11:26 AM, the Director of Nursing (DON) stated her expectation was for staff to provide ADL care for anything the residents were unable to do themselves. She also indicated that a resident should have access to showers/shampooing hair and said access to the big boat shower chair should not be a barrier to providing the care for the residents. During an interview on 6/02/2023 at 3:08 PM, the Administrator said his expectation was for staff to assist the patients as needed according to their care plans.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure one (Resident #40) of 34 sampled residents were assessed to self-administer their albuterol sulfate inhaler. Findings included: A review of the facility's policy titled, Self-Administration of Medications, revised 11/28/2016, revealed, 2. Facility, in conjunction with the Interdisciplinary Care Team, should assess and determine, with respect to each resident, whether Self-Administration of medication is safe and clinically appropriate, based on the resident's functionality and health condition. A review of Resident #40's Admission Record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/2023, indicated Resident #40 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of Resident #40's comprehensive care plans revealed a care plan, revised on 01/17/2023, that indicated Resident #40 was at risk for shortness of breath related to a diagnosis of chronic obstructive pulmonary disease. This care plan directed staff to administer medications per physician's orders. Resident #40's comprehensive care plans contained no information related to self-administration of medications. A review of Resident #40's current physician's orders revealed an order dated 08/12/2022 for Proventil HFA (a medication used to treat or prevent wheezing and shortness of breath caused by breathing problems). This order did not indicate Resident #40 was assessed to self-administer the medication. On 05/30/2023 at 12:28 PM, Resident #40 was observed in bed. An albuterol sulfate 90 microgram (mcg) inhaler prescribed to Resident #40, dated 03/12/2023, was observed inside a roll of toilet paper on top of the resident's bedside table. On 05/31/2023 at 11:55 AM, Resident #40's albuterol sulfate inhaler was again observed inside a roll of toilet paper on top of the resident's bedside table. Resident #40 stated they had the inhaler for several days and that a night nurse (name unknown) gave it to him/her. Resident #40 said he/she used it mainly at night and that staff had never educated or told them they were not allowed to have medication at their bedside. Resident #40 said a nurse was in their room that morning to administer medications and did not say anything about the inhaler being there. During an interview on 05/31/2023 at 12:01 PM, Registered Nurse (RN) #6 stated she was in Resident #40's room earlier in the morning, around 8:00 AM, and gave the resident their morning medications. RN #6 was not aware Resident #40 had their albuterol inhaler. RN #6 said the albuterol inhaler was an as needed medication, and there was a different scheduled inhaler on the medication cart that the nurses provided on a routine basis. RN #6 confirmed Resident #40 had not been assessed to have medication at the bedside and said Resident #40 was not supposed to have the inhaler. RN #6 said this was not the first time Resident #40 had an inhaler when they were not supposed to. RN #6 stated it was not safe for Resident #40 to have the inhaler due to the resident's confusion. RN #6 stated Resident #40 could use it and not remember using it or not get a full dose. RN #6 also stated it was unsanitary, since the inhaler did not have a cap on it, and it was placed inside a toilet paper roll. During an interview on 06/02/2023 at 1:20 PM, the Assistant Director of Nursing (ADON) stated a nurse should not leave a resident's room until the resident had taken all their medications. The ADON said she expected all nurses to be mindful and aware while they administered medications or interacted with a resident. The ADON said nurses were expected to look in the immediate area of the resident to ensure there were no medications left at the resident's bedside during interactions. The ADON said she had never been informed Resident #40 had medications at the bedside and indicated if a nurse discovered medications at a resident's bedside, they should report that to their unit manager. The ADON said Resident #40 should not self-administer medications due to the resident's declining cognition. The ADON said it was acceptable for a nurse to hand the inhaler to the resident to use, but they should be there to supervise the resident use it and then take the inhaler from the resident before they left the room. During an interview on 06/02/2023 at 1:44 PM, the Director of Nursing (DON) stated there should not be any medications left at a resident's bedside. The DON said she expected staff to be aware and mindful and identify any items that could be a hazard, such as medications on a resident's bedside table. The DON said the concern for Resident #40 having the inhaler would be that either Resident #40 may not take the medication, or they may take the medication wrong due to the resident's cognition issues. During an interview on 06/02/2023 at 3:20 PM, the Administrator said he expected there to be no medications left at a resident's bedside. He also stated he expected all staff to pay attention to everything that went on in a resident's room. The Administrator said he did not know Resident #40 specifically, but indicated if a resident was not deemed safe to self-administer medications, the resident should not have the medication.

Based on interviews, review of Resident Identifier (RI) #154's medical record, review of a facility policy titled Lift 4 Care - Safe 4 All Policy, and review of the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #8 and EI #9, Certified Nursing Assistants (CNAs), used a Hoyer lift, as determined necessary by RI #154's assessment, during a transfer on 03/09/21. During the 3:00 PM to 11:00 PM shift on 03/09/21, EI #8 and EI #9 failed to follow RI #154's plan of care when no Hoyer lift was used when RI #154 was transferred from his/her wheelchair to his/her bed. During the two person manual lift transfer, RI #154 slid from the side of the bed and fell to the floor. RI #154 was transferred to the local hospital to be evaluated after the fall. An X-ray from the hospital showed acute fractures of RI #154's left and right distal femurs which required surgical intervention. The facility concluded in their investigation, RI #154's injuries were caused by the transfer that occurred on 03/09/21, when RI #154 was not transferred using the Hoyer lift. This deficient practice affected RI #154, one of three sampled residents reviewed for accident hazards. Findings include: RI #154 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of Muscle Weakness (Generalized) and [CONDITION(S)] and [CONDITION(S)] following Unspecified [CONDITION(S)] Disease affecting Unspecified Side. A review of a facility policy titled Lift 4 Care - Safe 4 All Policy, with a revision date of 04/16/20, revealed the following: Purpose: To provide residents with the safe assistance by mechanical lifts as indicated by their clinical evaluation and to eliminate unnecessary and possible unsafe manual lifting, transferring and repositioning by team members. Directives/Policies: . 3. The total lift will be used when residents are non-ambulatory and residents cannot bear weight or if they do not qualify for the sit-to-stand lift . 6. Individualized transfer plan is noted on the care guide sheet. RI #154's most recent Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 01/27/21, assessed RI #154 as scoring a 14 on the Brief Interview for Mental Status Score, indicating RI #154 was cognitively intact. This assessment also indicated RI #154 had impairment on both sides of the lower extremities. A review of RI #154's Lift Transfer Evaluation, dated 02/01/21, revealed RI #154 could not transfer, bear weight on a least one leg, turn or pivot and required support for maintaining balance. RI #154 was also assessed as needing to be transferred with a lift with two team members. RI #154's Progress Notes (Nurses Notes), dated 03/09/21 at 5:03 PM, revealed the following: Patient was being assisted to bed, from (his/her) wheelchair and started sliding, (he/she) went to the floor . RI #154's Physician's Orders, dated 03/09/21, documented: Transfer to ER (emergency room ) for evaluation p (after) fall . RI #154's Clinical Report - Nurses Triage report , dated 03/09/21 at 5:20 PM, from the ER of the local hospital revealed the following: . Chief Complaint: FALL: . (Per EMS [Emergency Management System], pt (patient) was dropped out of a wheelchair onto the floor. Pt has shortening and rotation to right leg. pt c/o (complained of) pain to left leg. (pt sent to ER from Canteberry (Canterbury) Nursing home for being dropped onto the floor per EMS. Pt c/o pain to left leg. Pt has shortening and rotation to right leg . PHYSICAL ASSESSMENT . EXTREMITIES: Limited ROM (Range of Motion) present. (He/She) was unable to bear weight . (deformity to right leg, shortened) . RI #154's Clinical Report - Physician/Mid Levels, dated 03/09/21 at 5:20 PM, from the local hospital revealed the following: . HISTORY OF PRESENT ILLNESS Chief Complaint: FALL and PELVIS INJURY. RIGHT and LEFT HIP INJURY. The patient also has injury to right lower extremity (thigh, knee and leg) and left lower extremity (thigh, knee and leg). The injury occurred just prior to arrival. Occurred at a nursing home. fell : The patient complains of severe pain. No blow to the head, neck pain, loss of consciousness or [CONDITION(S)]. (EMS States patient was dropped while being transferred from the chair to the bed by caregivers. patient was in pain and lower extremity was in different directions) . PHYSICAL EXAM . Extremities: Bony tenderness present. (shortened right lower extremity). LABS, X-Rays, AND EKG (Electrocardiogram) X-Rays: Right Femur. Rt (Right) Femur X-ray: Intercondylar fracture of the distal right femur. Lt (left) Femur X-ray: Condylar fracture of the distal left femur. PROGRESS AND PROCEDURES . 18:53 (6:53 PM) 03/09/21 . will admit to orthopedic service . Disposition: . presenting medical condition was determined to be of emergent nature . CLINICAL IMPRESSION Closed oblique, subtrochanteric, intercondylar fracture of the distal, shaft of the right and left femur . RI #154's Radiology Report Details from the local hospital, dated 03/09/21, revealed the following: . Report Text . Clinical data: Fall. left lower extremity pain, right lower extremity pain, pelvic pain . 2 views of the left femur demonstrates an acute fracture of the distal femoral metadiaphysis with mild apex medial angulation. There is advanced [CONDITION(S)] of the most marked in the medical compartment . 2 views of the right femur demonstrates an acute comminuted fracture of the distal femoral diaphysis with one shaft width of anterior displacement of the distal fracture fragment and slight medial displacement of the distal fracture fragment. There is [CONDITION(S)] of the knee . Impression: 1. Acute fracture of the distal right femur. 2. Acute fracture of the distal left femur. 3. Profound osteopenia . RI #154's Discharge Summary, with a discharge date of [DATE], revealed the following: . Admission diagnoses: 1. Closed, displaced right distal femur fracture 2. Closed, displaced left distal femur fracture 3. [CONDITION(S)] secondary to stroke affecting bilateral lower extremities . Procedure performed: Open reduction internal fixation of bilateral distal femur fractures History of present illness: The patient is a [AGE] year-old (male/female) who sustained injury to bilateral lower extremities after (he/she) states 1 of the nursing aides (at) (his/her) nursing home dropped the patient while transferring (him/her) from the wheelchair to the bed. (He/She) had immediate pain that time presented to the emergency room . Radiographs were obtained demonstrating comminuted and displaced distal femur fractures bilaterally. Operative and non operative treatment options were discussed length.recommended operative management to stabilize the fractures to help with transfers secondary to reducing pain. Risks benefits alternatives were discussed (at) length (with) the patient (in) regards to operative management to include open reduction internal fixation. After discussion, the patient wished (to) proceed with surgical management. Hospital course: On March 9, 2021, the patient was admitted on the day of injury . On March 12, 2021, the patient was brought to the operating room where open reduction internal fixation with performed on bilateral distal femur fractures. Patient tolerated the procedure well and there were no complications intraoperatively. Postoperatively, they were transferred to the PACU (Post-Anesthesia Care Unit) in stable condition. During (his/her) hospital stay, the patient does not ambulate at baseline secondary to residual paralysis from stroke . Discharge condition: stable . Contained within the facility's investigation file was EI #8's written statement dated 03/06/21 (03/09/21), which documented: Today (RI #154) was sitting in (his/her) chair, (he/she) wanted to be put (to) bed there was no lift pad under (him/her) so (EI #9) and I had did a two man lift on (him/her) as we got (his/her) butt on the bed (he/she) began to slide that's when I heard (his/her) leg snap. (EI #9) went to inform the nurse while I stayed by (his/her) side . On 04/21/21 at 3:29 PM, a telephone interview was conducted with EI #8, the CNA assigned to care for RI #154 on 03/09/21 on the 3 PM - 11 PM shift. EI #8 said 03/09/21 had been her first day caring for RI #154. EI #8 said when she got to work that day RI #154 was up in his/her wheelchair. EI #8 said EI #9, another CNA, assisted her in putting RI #154 to bed. When asked how she and EI #9 put RI #154 in the bed, EI #8 said she and EI #9 did a two man lift. EI #8 said EI #9 got under one arm and she got under the other arm and they slid RI #154 from the wheelchair over to the bed. EI #8 said RI #154 began to slide and when RI #154 was sliding she (EI #8) heard RI #154's leg snap. The surveyor asked EI #8 which leg snapped. EI #8 said she could not remember. EI #8 said it was so traumatic when she heard the leg snap. The surveyor asked EI #8 why RI #154 was not transferred to bed with a Hoyer lift. EI #8 said no one told her RI #154 was to be transferred with a lift. EI #8 said usually if the resident is a Hoyer lift they will have a Hoyer pad under them. EI #8 said RI #154 did not have a Hoyer lift pad under him/her when he/she was in his/her wheelchair and that is why they assumed RI #154 was not a lift person. EI #8 said she never looked at RI #154's care plan to see how RI #154 was to be transferred before she and EI #9 attempted to transfer RI #154. EI #8 said she was never told RI #154 needed to be transferred with a lift with two people helping. Contained within the facility's investigation file was EI #9's written statement dated 03/09/21, which documented: I (EI #9) and (EI #8) were trying to two man lift (RI #154) to bed before she slip and fell and broke (his/her) leg . On 04/22/21 at 11:45 AM, a telephone interview was conducted with EI #9, the CNA assisting EI #8 to transfer RI #154 to bed on 03/09/21 on the 3 PM - 11 PM shift. EI #9 said when RI #154 was transferred from the wheelchair to the bed on his shift, he and EI #8 did a pivot and stand. EI #9 said he and EI #8 placed their arms under RI #154's arms and sat him/her on the side of the bed. EI #9 said as they got RI #154 on the bed RI #154 started slipping. EI #9 said as RI #154 started slipping RI #154's legs snapped and then RI #154 slid to the floor. EI #9 said as RI #154 starting sliding they tried to hold RI #154 to keep him/her on the bed but RI #154 just kept sliding. EI #9 said after RI #154 slipped he went to get the nurse and EI #8 stayed with RI #154. The surveyor asked EI #9 where would you go to find out how a resident is to be transferred. EI #9 said you would look at the resident's care guide. EI #9 said he looked for RI #154's care guide that evening but could not find it. EI #9 said when the nurse told them to put RI #154 to bed she never told them RI #154 needed to be transferred using a lift. When asked who is ultimately responsible for knowing the type care the resident is to be provided, EI #9 said who ever is assigned to care for the resident. Contained within the facility's investigation file was EI #10's written statement dated 03/09/21, which documented: (EI #8) stated that she was going to put (RI #154) to bed. This nurse told (EI #8) that she needed to wait for someone to help her put (RI #154) to bed that (RI #154) is a lift and it takes two people. (EI #8) states there is no sling under resident. This nurse told (EI #8) that a sling may not be under (RI #154) but resident is a lift and resident can't stand of do nothing. (EI #9) came to help (EI #8) put resident in bed. (EI #9) came out room and called nurse to come in room. This nurse asked (EI #9) what happened and (EI #9) stated (RI #154's) leg is broken. This nurse went in room resident was sitting on the floor with right leg bent back. This nurse went to get unit . manager and DON (Director of Nursing) to come to room. On 04/21/21 at 3:08 PM, the surveyor conducted a telephone interview with EI #10, the LPN (Licensed Practical Nurse) assigned to care for RI #154 on 03/09/21 on the 3 PM - 11 PM shift. The surveyor asked EI #10 what type care did RI #154 require. EI #10 said RI #154 was total care. When asked what happened concerning RI #154 on 03/09/21, EI #10 said RI #154 was up in his/her wheelchair and RI #154 was wanting to go to bed. EI #10 said the CNA (EI #8) assigned to RI #154 said she would go ahead and put RI #154 to bed. EI #10 said she told EI #8 RI #154 was a lift and she would need help putting RI #154 to bed. EI #10 said she then started her med pass. EI #10 said as she was preparing medications for the next resident (EI #9) came to the door of (RI #154's) room and waved for her to come to the room. EI #10 said she asked what was the problem and EI #9 said RI#154's leg was broke. EI #10 said she walked to RI #154's room and RI #154 was in the floor. EI #10 said she asked what happened and EI #9 said RI #154 flipped off the bed. The surveyor asked EI #10 how was RI #154 care planned to be transferred. EI #10 said with a lift. When asked how was RI #154 transferred from the wheelchair to the bed by the CNAs that evening EI #10 said she did not ask EI #8 and EI #9 how they tried to transfer RI #154. EI #10 said she assumed they did it under RI #154's arms because there was no lift in the room. When asked how would anyone caring for the resident know the type care the resident was to receive, EI #10 said by looking at the resident's care card. EI #10 said the care card is kept in the assignment book at the nurses station. On 04/22/21 at 3:26 PM, the surveyor conducted an interview with the Unit Manager/Assistant Director of Nursing, EI #2. EI #2 said RI #154 was dependent on staff for care and was not able to ambulate or stand. The surveyor asked EI #2 when was she made aware of RI #154 being observed on the floor of his/her room on 03/09/21. EI #2 said almost immediately after the occurrence EI #10 hurried to get her to come and assist her and to notify her of what was going on. EI #2 said when she entered RI #154's room she observed RI #154 on the floor between the two beds. EI #2 said RI #154's back was not leaning against the bed and RI #154's wheelchair was toward the foot of the bed away from RI #154's body. EI #2 said RI #154's body was about middle ways of RI #154's bed and RI #154 looked up at her and said his/her legs hurt. EI #2 said she told RI #154 she (EI #2) knew and she was getting him/her some help. EI #2 said RI #154's left leg was out straight with the left foot under the bed and RI #154's right leg was turned just above the knee and was lateral to RI #154's body. EI #2 said she went to call the Nurse Practitioner and was told to go ahead and send RI #154 to the nearest ER. EI #2 said she found out RI #154 had fractured both of his/her legs the next day. EI #2 said the results of the facility's investigation revealed RI #154 had fallen and fractured both legs. EI #2 said as a result of the fall both CNAs were terminated. When asked what was not done that contributed to the fall, EI #2 said the CNAs did not follow the patient care guide which resulted in the tragic fall. On 04/23/21 at 8:35 AM, the surveyor conducted a telephone interview with RI #154. The surveyor asked RI #154 what happened when the CNAs put him/her to bed on 03/09/21. RI #154 said the CNAs got him/her up and when they put him/her to bed he/she fell on the floor. When asked how he/she fell , RI #154 said EI #9 one of the people lifted his/her lower body and the little girl (EI #8) lifted him/her at the top. RI #154 said he/she told them they needed to use the lift but they did not listen to him/her. EI #154 said the CNAs normally transfer him/her by putting the sling under him/her and then transfer him/her with the Hoyer. RI #154 said he/she told them that but they did not listen to him/her. RI #154 said the CNAs did not do what they were supposed to. EI #154 said he/she told the CNAs before they started they had to have the Hoyer lift. On 04/23/21 at 9:10 AM, the surveyor conducted an interview with EI #11, the former DON. EI #11 said the facility was a no manual lift facility meaning if the resident could not stand or pivot they had to be lifted with a Hoyer lift. EI #11 said when doing the facility's investigation, the CNAs putting RI #154 to bed said they were doing a two man lift on RI #154 and when they sat RI #154 on the side of the bed RI #154 slipped off. EI #11 said when doing the facility's investigation it was revealed EI #8 and EI #9 did not follow RI #154's care guide. EI #11 said EI #8 and EI #9 were even told by the nurse (EI #10) RI #154 was a total lift. ************************* .The surveyors determined current facility compliance by: 1) Review and verification of the facility's Action Plan as outlined in general terms below: STEP 1 What immediate interventions were initiated for resident identified? CNAs failed to comply with Care Plan to transfer resident as total lift for transfers, resulting in a fall, which required the resident to be transferred to the hospital. CNAs were placed on administrative leave pending the results of the investigation. Ad Hoc QAPI (Quality Assurance and Process Improvement) meeting was held on 3/10/2021 to discuss the root cause analysis for the incident. The root cause was found to be staff failed to follow the care plan and care guide for transfer . STEP 2 What immediate actions were taken to identify all residents potentially affected? What continued and immediate interventions were implemented for identified residents? All resident lift transfer evaluations were reviewed . for accuracy on 3/10/2021. No issues/discrepancies were identified. All resident care plans were reviewed . for correct transfer status and updated as needed on 3/10/2021. All resident care guides were reviewed . to ensure correct transfer status on 3/10/2021. No issues/discrepancies were identified. STEP 3 What system changes were made or modified? What systemic education was completed to enhance knowledge development of team members? Nursing staff were educated . on the lift transfer program to include following the resident care plan and following the resident care guide, Education to be completed by 3/31/2021. Lift transfer competencies with return demonstration will be performed on nursing staff by 3/31/2021. Education on transfers completed on hire and at least annually. STEP 4 Continued Quality Assurance audits implemented to ensure enhanced system compliance? Monitoring plan? Lift Monitoring Audit Tool will be done . on up to 5 residents per unit per week for 4 weeks (through April 9); then every other week for 4 weeks (through May 7) to monitor/ensure compliance with the lift transfer program. Any discrepancies will result in immediate correction, reeducation, and/or disciplinary action. Results of the monitoring tool will be reviewed by QAPI for continued compliance with changes made as necessary. 2) Review of the facility's Progressive Disciplinary Forms indicating both EI #8 and EI #9 were terminated as of 03/16/21 due to a serious violation of safety rules. 3) Various interviews with current staff verifying they have received education and were aware of policies in place regarding care plans, care guides, and resident transfers. 4) Observations during survey of staff using appropriate transfer methods in accordance with resident care plans and care guides. ************************* This deficiency was cited as a result of the investigation of complaint/report number AL 331.

Based on interviews, review of Resident Identifier (RI) #154's medical record and review of the facility's investigation file, Employee Identifier (EI) #8 and EI #9, Certified Nursing Assistants (CNAs) failed to follow RI #154's plan of care/care guide when RI #154 was transferred from the wheelchair to the bed on 03/09/21. RI #154 is care planned for a two person assist with transfers using the Hoyer lift. On 03/09/21 on the 3 PM - 11 PM shift, RI #154 was transferred by being picked up under the arms and placed on the side of the bed. Once on the bed, RI #154 slid to the floor. RI #154 was transferred to the ER (emergency room ) for evaluation. An X-ray from the hospital showed acute fractures of RI #154's left and right distal femurs. This deficient practice affected RI #154, one of 37 sampled residents whose plans of care were reviewed. Findings include: RI #154 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #154's care plan titled I require assistance with ADLs (Activities of Daily Living) such as . transfers . related to DX (diagnoses): muscle weakness, other lack of coordination . impaired mobility . with an initiated date of 05/04/18, had an intervention of . *I use a lift for transfers x (times) 2 person assist/med (medium) sling . This care plan intervention was initiated on 11/26/18. RI #154's most recent Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 01/27/21, assessed RI #154 as scoring a 14 on the Brief Interview for Mental Status Score, indicating RI #154 was cognitively intact. This assessment also indicated RI #154 had range of motion impairment on both sides of the lower extremities. A review of RI #154's Lift Transfer Evaluation dated 02/01/21, revealed RI #154 could not transfer, bear weight on a least one leg, turn or pivot and required support for maintaining balance. RI #154 was also assessed as Total Lift Required, with Two Team Members required and used the medium size sling. A review of RI #154's care guide dated 3/2021 revealed RI #154 was marked as a Fall Risk and was to be transferred with a lift with the assist of two individuals. RI #154's Progress Notes (Nurses Notes), dated 03/09/21 at 4:58 PM, revealed the following: Patient was being assisted to bed, from (his/her) wheelchair and started sliding, (he/she) went to the floor . This note was made by EI #2, Registered Nurse (RN) Unit Manager/Assistant Director of Nursing (ADON). RI #154's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The local hospital documentation indicated RI #154 was admitted to the hospital on 03/09/21 at 5:20 PM with an admit diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #154's HISTORY OF PRESENT ILLNESS indicated .Chief Complaint: FALL and PELVIS INJURY. RIGHT and LEFT HIP INJURY . The injury occurred just prior to arrival. Occurred at a nursing home. fell : . (EMS [Emergency Medical Services] States patient was dropped while being transferred from the chair to the bed by caregivers. patient was in pain and lower extremity was in different directions) . PHYSICAL EXAM . Extremities: Bony tenderness present. shortened right lower extremity). PROGRESS AND PROCEDURES . 18:53 (6:53 PM) 03/09/21 . will admit to orthopedic service . CLINICAL IMPRESSION Closed oblique, subtrochanteric, intercondylar fracture of the distal, shaft of the right and left femur . Contained within the facility's investigation file was a document dated 03/15/21, which revealed an interview was conducted by EI #1, the Administrator with RI #154's sponsor. The interview revealed RI #154 reported to the sponsor he/she had been picked up without the lift being used and was dropped on the floor. On 04/21/21 at 3:29 PM, a telephone interview was conducted with EI #8, the CNA assigned to care for RI #154 on 03/09/21 on the 3 PM - 11 PM shift. EI #8 said 03/09/21 had been her first day caring for RI #154. The surveyor asked EI #8, if she as a CNA had never cared for a resident before, where would she go to find out the type care the resident should receive. EI #8 said on the resident care plan. When asked if she looked at RI #154's care plan before she and EI #9, another CNA, attempted to transfer RI #154, EI #8 said no. EI #8 said she did not know where the care plans were kept. The surveyor asked EI #8 did she ask anyone where RI #154's care plans were. EI #8 said no. EI #8 said usually if the resident is a Hoyer lift they will have a Hoyer pad (sling) under them. EI #8 said RI #154 did not have one under him/her when he/she was in the wheelchair. EI #8 said that is why she and EI #9 assumed RI #154 was not a lift person. The surveyor asked EI #8 when she was in orientation was she told the CNAs are supposed to look at the residents' care guide to see the type care (use of the lift) a resident was to receive. EI #8 said she did not receive any of that information in orientation. A review of EI #8's personnel file indicated the CNA began her employment with the facility on 02/03/21. On 02/03/21, EI #8 signed a TEAM MEMBER ORIENTATION GUIDE RECEIPT AND ACKNOWLEDGEMENT FORM indicating the facility's Safe Lift Program had been discussed with her, signed a Team Member Acknowledgement of Diversicare's Lift Program Policy and Procedure, and signed that she had been informed of the facility's SAFE -WORKING PRACTICE AGREEMENT which indicated 1. It is your responsibility to know your job responsibilities and how to perform these tasks safely. If you need direction or assistance you must notify you supervisor immediately. 2. All employees must know and observe all safety rules and safe practice policies, which are in place at the facility to create a safe working environment. 3. You must . use the mechanical lifting devices for those residents who have been assessed as unable or unwilling to assist in movement . On 04/22/21 at 11:45 AM, a telephone interview was conducted with EI #9, the CNA assisting EI #8 to transfer RI #154 to bed on 03/09/21 on the 3 PM - 11 PM shift. EI #9 said it had been a long time since he last cared for RI #154. The surveyor asked EI #9 when he cared for RI #154, how did he transfer RI #154. EI #9 said when he cared for RI #154 he/she was always in the bed. When asked where the CNA would go to find out how a resident was to be transferred, EI #9 said you would go to the report sheet (care guide) right next to where the CNA assignment sheets were kept. The surveyor asked EI #9 how RI #154 was transferred from the wheelchair to the bed on that shift. EI #9 said he and EI #8 did a pivot and stand. EI #9 said they placed their arms under RI #154's arms and sat RI #154 on the side of the bed. The surveyor asked why RI #154 was not transferred to bed with a Hoyer lift when he/she was cared planned for that. EI #9 said they were just told to put RI #154 to bed by the charge nurse. EI #9 said the nurse never told them to use a lift. When asked who was ultimately responsible for knowing the type care the resident is to be provided, EI #9 said whoever was assigned to care for the resident. On 04/21/21 at 3:08 PM, the surveyor conducted a telephone interview with EI #10, the LPN (Licensed Practical Nurse) assigned to care for RI #154 on 03/09/21 on the 3 PM - 11 PM shift. The surveyor asked EI #10 how would anyone caring for the resident know the type care the resident was to receive. EI #10 said by looking at the residents care guide. EI #10 said the resident's care guide was kept in the assignment book at the nurses' station. EI #10 said the CNAs have access to the assignment book. EI #10 said the CNAs caring for RI #154 that evening never asked her anything about RI #154's care guide. EI #10 said if the resident used a lift it should be two people assisting with the transfer. The surveyor asked EI #10 if RI #154 was care planned to have a lift for transfer with two people helping and that was not done, was RI #154's plan of care followed that evening. EI #10 said no. On 04/22/21 at 3:26 PM, the surveyor conducted an interview with the Unit Manager/Assistant Director of Nursing, EI #2. The surveyor asked EI #2 how RI #154 was care planned to be transferred in and out of bed. EI #2 said with a lift and the assist of two staff to transfers. When asked how the CNA caring for RI #154 would know RI #154 was to be transferred with a lift with the assist of two people, EI #2 said all residents have a care guide at the nurses' station and it was available to all nursing staff. EI #2 said EI #8 and EI #9 did not follow RI #154's care guide which resulted in the tragic fall. EI #2 said when EI #8 and EI #9 signed the Safe Working Practice Agreement they were agreeing to the fact that it was their responsibility to know their job requirement to perform all work tasks safely. EI #2 said when they both came out of RI #154's room she asked them did they know where the residents care guides were, and they were able to tell her they knew that the information about the lift was in the care guides. On 04/22/21 at 3:57 PM, the surveyor conducted an interview with EI #1, the Administrator. EI #1 said he was made aware of the fall involving RI #154 immediately after it happened. EI #1 said the finding from the investigation done by the facility revealed the aides did not follow the care guide, which resulted in a fall with injuries. The surveyor asked EI #1 what did the facility put in place to ensure an incident like this one would not recur. EI #2 said the facility reviewed all the patients care plans, lift transfer evaluations and care guides for accuracy. EI #1 said staff were re-educated on the lift transfer program and the need to follow the residents care guide. EI #1 said the facility also established a tool to monitor and ensure compliance with the lift transfer program and the tool was being used to monitor compliance. EI #1 said the facility was monitoring how staff transferred the residents (return demonstrations). EI #1 said five residents were being monitored per unit per week, for four weeks, then every other week for four weeks. On 04/23/21 at 8:35 AM, the surveyor conducted a telephone interview with RI #154. RI #154 said when EI #8 and EI #9 got her up from the wheelchair and put him/her on the bed he/she fell on the floor. RI #154 said she told them to use the lift, but they did not listen to him/her. On 04/23/21 at 9:10 AM, the surveyor conducted a telephone interview with EI #11, the former DON. EI #11 said when new employees are orientated they are told the facility is a no manual lift facility, meaning if the resident cannot stand or pivot they have to be lifted using a Hoyer lift. EI #11 said each resident is evaluated by the nurse on admission, when there is a change and at least quarterly on their need for a lift and the type lift to be used. EI #11 said this is communicated to the CNAs in the residents' care guide. EI #11 said the care guides are kept at each nurses' station in front of the assignment book. EI #11 said the CNAs have access to the residents' care guide and are to look at the care guides every shift. EI #11 said even if the CNA is familiar with the resident they are to look at the care guide every day because something may have changed. EI #11 said when the facility completed their investigation it was found out EI #8 and EI #9 did not follow RI #154's care guide. ************************* .The surveyors determined current facility compliance by: 1) Review and verification of the facility's Action Plan as outlined in general terms below: STEP 1 What immediate interventions were initiated for resident identified? CNAs failed to comply with Care Plan to transfer resident as total lift for transfers, resulting in a fall, which required the resident to be transferred to the hospital. CNAs were placed on administrative leave pending the results of the investigation. Ad Hoc QAPI (Quality Assurance and Process Improvement) meeting was held on 3/10/2021 to discuss the root cause analysis for the incident. The root cause was found to be staff failed to follow the care plan and care guide for transfer . STEP 2 What immediate actions were taken to identify all residents potentially affected? What continued and immediate interventions were implemented for identified residents? All resident lift transfer evaluations were reviewed . for accuracy on 3/10/2021. No issues/discrepancies were identified. All resident care plans were reviewed . for correct transfer status and updated as needed on 3/10/2021. All resident care guides were reviewed . to ensure correct transfer status on 3/10/2021. No issues/discrepancies were identified. STEP 3 What system changes were made or modified? What systemic education was completed to enhance knowledge development of team members? Nursing staff were educated . on the lift transfer program to include following the resident care plan and following the resident care guide, Education to be completed by 3/31/2021. Lift transfer competencies with return demonstration will be performed on nursing staff by 3/31/2021. Education on transfers completed on hire and at least annually. STEP 4 Continued Quality Assurance audits implemented to ensure enhanced system compliance? Monitoring plan? Lift Monitoring Audit Tool will be done . on up to 5 residents per unit per week for 4 weeks (through April 9); then every other week for 4 weeks (through May 7) to monitor/ensure compliance with the lift transfer program. Any discrepancies will result in immediate correction, reeducation, and/or disciplinary action. Results of the monitoring tool will be reviewed by QAPI for continued compliance with changes made as necessary. 2) Review of the facility's Progressive Disciplinary Forms indicating both EI #8 and EI #9 were terminated as of 03/16/21 due to a serious violation of safety rules. 3) Various interviews with current staff verifying they have received education and were aware of policies in place regarding care plans, care guides, and resident transfers. 4) Observations during survey of staff using appropriate transfer methods in accordance with resident care plans and care guides. ************************* This deficiency was cited as a result of the investigation of complaint/report number AL 331.

Based on observations, interviews, and a review of facility policies titled, Equipment Cleaning Schedules and Frozen Storage, the facility failed to ensure: 1) dust was not on the ceiling, walls and light fixtures in the kitchen; and 2) food items in the kitchen freezer were labeled. This had the potential to affect 108 of 108 residents receiving meals from the kitchen. Findings Include: 1) A review of a policy titled, Equipment Cleaning Schedules with an Effective Date: August 1, 2012 revealed: . POLICY It is the policy of this facility to assign cleaning schedules on a daily, weekly, and monthly basis. PROCEDURE All equipment will be identified for cleaning. The frequency and position assigned the item should be designated on the schedule. Ceiling As needed. Walls Monthly and weekly as needed. Light fixtures As needed . On 04/20/21 at 8:17 AM, the surveyor along with Employee Identifier (EI) #4, the Dietary supervisor toured the kitchen. The surveyor and EI #4 observed large amount of dust and grease in the ceiling. The surveyor observed dust on the walls and light fixture at the tray line, over the ice cream cooler there was dust on the walls, dust in the ceiling and on the light fixture. There was dust on the wall as you enter the kitchen, exit the kitchen and on the wall over the reach in refrigerator. On 04/21/21 at 3:59 PM, an interview was conducted with EI #4, the Dietary Supervisor. EI #4 was asked what was on the ceiling and light fixture at the steam table. EI #4 replied, grease and lint. EI #4 was asked how much lint and grease was on the ceiling and light fixture. EI #4 replied, a medium amount. EI #4 was asked what was on the hook that was hanging from the ceiling. EI #4 replied, lint. EI #4 was asked when was the ceiling last cleaned. EI #4 replied, six months ago. EI #4 was asked who was responsible for cleaning the ceiling. EI #4 replied, maintenance. EI #4 was asked what was the facility's policy regarding cleaning before six month. EI #4 replied, he would have to look that up. EI #4 was asked what was under the ceiling where the lint and grease was. EI #4 replied, the food tray and drinks. EI #4 was asked to clarify was it lint or dust on the ceiling. EI #4 replied, we will go with dust. EI #4 was asked why was it important that dust and grease was not in the ceiling over the residents food trays and drinks. EI #4 replied, because it had a tendency to fall on the trays. EI #4 was asked where else was there dust in the kitchen ceiling. EI #4 replied, in the dishwashing area, main entrance to the kitchen on the wall, over the ice cream box, on the exit wall going into the dining room and dust was on the wall over the reach in cooler. EI #4 was asked how much dust was in these area. EI #4 replied, a medium amount. EI #4 was asked should there have been dust in the ceiling, on the wall and on the light fixture. EI #4 replied, no, it should not have been. On 04/21/21 at 4:42 PM, an interview was conducted with EI #5, the Maintenance Supervisor. EI #5 was asked what was in the top of the ceiling and on the light fixture in the kitchen. EI #5 replied, it look like lint, dust. EI #5 was asked when was the ceiling and light fixture last cleaned. EI #5 replied, he could not tell the surveyor when it was last cleaned. EI #5 was asked who was responsible for cleaning the ceiling and the light fixture. EI #5 replied, he did not know. EI #5 replied, he would say Dietary. EI #5 continued to say if they gave him the work order he would be responsible for the kitchen. EI #5 was asked who was responsible for cleaning the walls in the kitchen. EI #5 replied, again he would have to say dietary, unless he received a work order. EI #5 was asked how often should the walls and the light fixture be cleaned. EI #5 replied, as needed. EI #5 was asked what kitchen equipment was under the ceiling and light fixture. EI #5 replied, there was a steam table. 2) A review of a policy titled, Frozen Storage with an Effective Date of August 1, 2021 revealed: POLICY It is the policy of this facility to store, prepare and serve food in accordance with federal state and local sanitary codes. PROCEDURE . 3. All frozen food will be properly wrapped, dated and labeled. On 04/20/21 at 8:17 AM, the surveyor observed some type meat in the freezer in a medium bag on the top shelve on the left side of the freezer. There was no name or date on the bag and nothing identifying what was in the bag. The bag was next to the fan in the freezer. There was another medium bag on the left side of the freezer next to the fan with no label on it as well. EI #4 stated in the the bags were diced beef and chicken tortilla. On 04/21/21 at 4:11 PM, an interview was conducted with EI #4, the Dietary Supervisor. EI #4 was asked what was in the freezer with no label on it. EI #4 replied, chicken tortilla and diced beef. EI #4 was asked why there were no labels on the food items. EI #4 replied, it was overlooked. EI #4 was asked who was responsible for labeling food items. EI #4 replied, who ever puts the food item in the freezer. EI #4 was asked what was the facility policy regarding labeling. EI #4 replied, date and label items before you put them in the refrigerator or freezer. EI #4 was asked why was it important that fool items be labeled. EI #4 replied, because we will know when the food item went in and when to throw them out. EI #4 continue to say before food items are put in the freezer or refrigerator, the date and time has to be placed on the food item.

Based on interview, review of the facility's Record of Medication Destruction forms, and review of a facility policy titled Disposal of Medications Controlled Drug Destruction, the facility failed to ensure the Record of Medication Destruction forms for Controlled Medications contained the required signatures. This was noted on 10 of 10 of the Record of Medication Destruction forms for controlled medications reviewed for the month of March 2021. Finding include: Review of facility policy titled Disposal of Medications Controlled Drug Destruction, dated 03/11, revealed: 4.4: CONTROLLED DRUG DESTRUCTION . Procedures . 7. The Record of Medication Destruction should have the signatures of witnesses (three required for controlled substances - pharmacist, registered nurse, and a third person who may be a law enforcement official, a management or supervisory personnel, i.e. (for example) Administrator, LPN (Licensed Practical Nurse) charge nurse, etc . On 04/22/21 at 8:50 AM, the surveyed reviewed the facility's Record of Medication Destruction forms for controlled medications. 10 of 10 sheets for the month of March 2021 did not have the three required signatures. On 04/23/21 at 10:16 AM, the surveyor conducted an interview with Employee Identifier (EI) #2, the Assistant Director of Nursing. The surveyor asked EI #2 how many signatures were required to be on the Record of Medication Destruction forms for controlled medications. EI #2 said she heard it was supposed to be three. The surveyor asked EI #2, when looking at the Record of Medication Destruction forms for controlled medications for the month of March 2021, how many forms did not have the required three signatures. EI #2 said all 10. EI #2 said apparently it was over looked and not signed. When asked by the surveyor why it was necessary to have the required signatures on the Record of Medication Destruction forms for controlled medications, EI #2 said it was evidence of destruction of the medication. EI #2 said there was a potential for drug diversion when the required signatures are not obtained.

Based on observations, interviews, and medical record review, the facility failed to ensure the oxygen tubing and humidification bottle for Resident Identifier (RI) #75 was dated. This affected RI #75, one of one resident sampled for respiratory care. Findings include: RI #75 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #75's care plan titled I have potential for shortness of breath related to DX (diagnosis) [CONDITION(S)] . revealed an intervention dated 08/18/20 to . change oxygen tubing weekly and as needed . A review of RI #75's Order Summary report, listing Active Orders as of 04/21/21, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/20/21 at 9:25 AM, the surveyor observed RI #75 receiving O2 at 2L via nasal cannula. The humidification bottle and the oxygen tubing for RI #75 were not dated. On 04/21/21 at 8:11 AM, RI #75 was again observed receiving O2 at 2L via nasal cannula, and the humidification bottle and tubing remained not dated. On 04/21/21 at 5:20 PM, RI #75's humidification bottle and tubing were again observed without a date, while in use by RI #75. On 04/21/21 at 5:35 PM, an interview was conducted with Employee Identifier (EI) #2, Registered Nurse (RN)/Unit Manager/Assistant Director of Nursing (ADON). EI #2 was asked what date she observed on RI #75's humidification bottle and oxygen tubing. EI #2 replied, none. EI #2 was asked how often humidification bottles and oxygen tubing were changed. EI #2 replied, weekly. EI #2 was asked who was responsible for changing and dating the humidification bottles and oxygen tubing weekly. EI #2 replied, the night shift Charge Nurse. EI #2 was asked what the potential risk to the resident was when the humidification bottles and the oxygen tubing were not changed and dated. EI #2 replied, infection. On 04/21/21 at 5:58 PM, an interview was conducted with EI #3, a Licensed Practical Nurse (LPN)/Charge Nurse. EI #3 was asked if RI #75 required oxygen with a humidification bottle. EI #3 replied, yes. EI #3 was asked if she observed a date on RI #75's humidification bottle or oxygen tubing. EI #3 replied, no. EI #3 was asked who was responsible for ensuring that humidification bottles and oxygen tubing were changed and dated. EI #3 replied, the Charge Nurse. EI #3 was asked why it was important to change and date humidification bottles and oxygen tubing. EI #3 replied, bacteria can get inside.

Based on observations, interviews, review of a facility policy titled, Food Holding Temperature on Food Service Line, and review of the temperature log for the [DATE] lunch meal, the facility failed to ensure: 1. Cordon Bleu Chicken was not stored in the freezer without an open or use by date; and 2. staffed checked the temperatures of the second batch of fish and french fries that were placed on the tray line for meal service on [DATE]. This had the potential to affect 109 of 109 residents who received meals from the kitchen. Findings Include: 1) On [DATE] at 6:06 p.m., Employee Identifier (EI) #1, the Dietary Manager (DM), and the surveyor toured the kitchen. EI #1 and the surveyor observed five Cordon Bleu Chickens in large bag in the freezer. There was no open or use by dates on the Cordon Bleu Chicken. On [DATE] at 8:38 a.m., an interview was conducted with EI #1. EI #1 was asked what was in the freezer with no open or use by date on it. EI #1 replied, Chicken Cordon Bleu. EI #1 was asked, why was it in the freezer with no use by date on it. EI #1 replied, it was over looked. EI #1 was asked, who was responsible for labeling food items in the freezer. EI #1 replied, everyone who put something in there and everyone in dietary. EI #1 was asked, how should food items be labeled in the freezer. EI #1 replied, first in and first out. EI #1 replied, every time they use something it should be labeled, dated and put back in the freezer. EI #1 was asked, why should food items be labeled in the freezer. EI #1 replied, so they would know if it had expired. 2) A review of a policy titled, Food Holding Temperature On Food Service Line, with an effective date of (MONTH) 1, (YEAR) revealed: . PR[NAME]EDURE . 3. Once food is on the steam table, the temperature will be taken prior to each meal service . 5. Temperatures will be recorded on the Food Temperature by Meal form (temperature log) . On [DATE] beginning at 10:15 a.m., the surveyor observed tray line proceedings for the lunch meal. The surveyor observed staff place a second batch of fish and french fries onto the tray line for meal service without checking the temperatures. The Food Temperature By Meal temperature log for the lunch meal on [DATE] revealed no temperatures had been recorded for the second batch of fish or french fries. On [DATE] at 9:17 a.m., an interview was conducted with EI #1, DM. EI #1 was asked, what was the temperature of the second batch of fish. EI #1 said they had not taken it. EI #1 was asked what was the temperature of the french fries. EI #1 replied, there was not a temperature recorded for the french fries on the Temperature by Meal form. EI #1 was asked, when should food temperature be taken at the tray line. EI #1 replied, 15 minutes prior to serving. EI #1 was asked, who was responsible for taking the temperatures of foods on the tray line. EI #1 replied, the Cook and DM. EI #1 was asked, why did they not take the temperatures of the second batch of fish and french fries. EI #1 replied, he assumed they all were the same temperatures. On [DATE] at 10:01 a.m., EI #2, Cook, was asked, what was the temperature of the second batch of fish. EI #2 replied, she did not take it. EI #2 was asked, who was responsible for taking the temperature at the tray line. EI #2 replied, the Cook. EI #2 was asked, who took the temperature of the french fries on [DATE]. EI #2 replied, no one took the temperature of the french fries. EI #2 was asked, when should food temperatures be taken at tray line. EI #2 replied, 10 or 15 minutes before serving. EI #2 was asked, why was it important that food temperatures be taken at the tray line. EI #2 replied, to make sure the residents get good, hot food.

Based on interviews, a review of the facility policy titled, Trust Fund Policy and record reviews, the facility failed to ensure residents or their representatives were notified when their trust fund accounts reached $1,800.00. This affected Resident Identifier (RI) #1 and RI #3, two of 121 residents with trust fund accounts managed by the facility. Findings Include: A review of an undated facility policy titled, Trust Fund Policy revealed: Effective (MONTH) 2019, The Business Office Manager will contact families of residents who have a trust fund account balance of $1500 or higher. The attempts to reach families for notification are done by first attempting a phone call. If we do not communicate by phone with the said families, we then mail a letter. RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 3/20/19, Employee Identifier (EI) #1, Business Office Manager provided a copy of the 121 resident trust fund account balances for (MONTH) (YEAR), (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019. Review of the resident trust fund account balances revealed RI #1 had a balance greater than $2,000 from (MONTH) (YEAR) to (MONTH) 2019. Further review also revealed RI #3's trust fund account balances were greater than $2,000 in (MONTH) (YEAR) and (MONTH) (YEAR). On 3/20/19 at 1:10 PM, during an interview with EI #1, she stated she was unable to provide evidence of notification of residents or their representatives of trust accounts approaching the $2,000 limit. When asked why she could not, EI #1 stated, I guess the person in this job didn't document them. This deficiency was cited as a result of the investigation of complaint/report #AL 152.

Based on observation, interview, review of facility document titled Hand Hygiene Care Audit and a facility policy titled [MEDICAL CONDITION], the facility failed to ensure: 1. a Certified Nursing Assistant (CNA) did not pass ice on the east hall without washing her hands after leaving each resident room prior to entering another resident room, and 2. the same CNA put on Personal Protective Equipment (PPE) prior to entering two resident rooms, who were on isolation, when delivering ice and water. This was observed on 1/22/19 and affected Resident Identifiers (RI) # 81, 101, 5, 78, 105, 86, 104, 115, 37, and 119; 10 of 21 residents on the hall. Findings Include: A review of an undated facility document titled Hand Hygiene Care Audit revealed . Hand Hygiene 1. Hand washing is done before and after each resident contact . 4. Hand washing is done every time you go from a dirty area to a cleaner area. A review of a facility policy titled [MEDICAL CONDITION] with an revised date of (MONTH) (YEAR) revealed: . Appropriate precautions will be taken when caring for individuals known or suspected to have infection . RI # 81 was admitted on [DATE] with a [DIAGNOSES REDACTED]. RI #101 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #5 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #78 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #105 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #86 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of a laboratory report, verified date 01/12/19, for RI #86 revealed .Urine Culture .is ESBL ( Extended Spectrum Beta-Lactamases ) Positive. This resident was noted on contact isolation. RI #104 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #115 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #37 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #119 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of a lab report for RI #119, date reported 1/15/19, revealed .Urinalysis . Comment: ESBL PRODUCER ., an organism which required contact precautions. This resident was noted on contact isolation. On 1/22/19 at 2:45 PM, the surveyor observed Employee Identifier (EI) 4, CNA on the hall at rooms 1-21 passing ice. EI #4 entered RI # 81's room, the was door open. The surveyor observed EI #4 returning to the ice cart and prepared a large stryofoam cup of ice and returned to RI #81's room. EI #4 left RI #81's room, without washing her hands. EI #4 then entered RI #101's room. The surveyor heard EI #4 say the resident did not need water and exited the room without washing her hands. EI #4 walked across the hall and entered RI #5's room. EI #4 brought the cup to the ice cart and filled it with ice and water. EI #4 exited RI #5's room without washing her hands. EI #4 entered RI #78's room and picked up the ice water cup. EI #4 was heard saying RI #78 did not need water. EI #4 exited the room without washing her hands. EI #4 entered RI #105's room then returned to the ice cart. EI #4 picked up a clean Styrofoam cup and filled it with ice and returned to RI #105's room. EI #4 exited RI #105's room without washing her hands. EI #4 entered RI #86's room, a room with isolation items in a box hanging on the door. EI #4 did not put on any PPE before entering the room. EI #4 exited the room and returned to the ice cart, got a clean cup and filled it with ice and returned to RI #86's room. EI #4 exited RI #86's room without washing her hands. EI #4 continued down the hall entering RI #104's room. EI #4 then exited RI #104's room and went into RI #115's room, took the ice cup out of the room to the ice cart and filled it with ice. EI #4 exited the room and did not wash her hands. EI #4 entered RI #37's room brought the water cup from the room and filled it with ice and returned it to RI #37's room. EI #4 exited the room without washing her hands. EI #4 entered RI #119's room, a resident on isolation. The PPE was in a box hanging on the door. EI #4 did not put on PPE prior to entering the room, nor wash her hands upon exiting the room. EI #4 entered all the rooms, touched water cups and exited rooms without washing her hands. EI #4 entered two rooms of residents who were noted to be on isolation and did not put on PPE. On 1/22/19 at 3:06 PM, an interview was conducted with EI #4, CNA. EI #4 was asked how long she had been a CNA. EI #4 replied, over a year. EI #4 was asked what was the policy on passing ice and water. EI #4 replied, she was to give a new cup with ice if they needed it. EI #4 was asked, for the residents that she did not give a new cup to, what was the policy on touching their cup then returning to the ice cooler and cart. EI #4 replied, they should wash their hands after each one. EI #4 was asked if she washed her hands after each resident. EI #4 replied, no. EI #4 was asked why not. EI #4 replied, she did not know. EI #4 was asked how many residents did she give ice to without washing her hands. EI #4 replied, all of them on that hall (Rooms 1 -20). EI #4 was asked what was the policy when entering an isolation room. EI #4 replied, they should put on a gown and gloves. EI #4 was asked if she put on a gown and gloves before entering. EI #4 replied, no. EI #4 was asked if she entered isolation rooms to check those residents ice cup. EI #4 replied,yes. EI #4 was asked if she washed her hands after leaving the rooms of the residents on isolation. EI #4 replied, no. EI #4 was asked how many resident rooms did she go in that were on isolation. EI #4 replied, two. EI #4 was asked what were the residents on isolation for. EI #4 replied, she did not know. EI #4 was asked what was the harm in not washing her hands after leaving a resident room when passing ice. EI #4 replied, she could spread germs from one to the next. EI #4 was asked what was the harm in not putting on proper protective equipment when entering the room of a resident on isolation. EI #4 replied, she could spread the infection to her self and others. On 1/24/19 at 1:47 PM, an interview was conducted with EI #3 Registered Nurse, Infection Control. EI #3 was asked when should staff wash their hands while passing ice. EI #3 replied, every time they go in a resident room and touch a cup, they should then wash their hands before leaving the room; if they go in and touch a resident's cup and do not bring it out for more ice, they should wash their hands before leaving that resident room. EI #3 was asked what would the harm be in staff not washing their hands before leaving a resident room then entering another resident room. EI #3 replied, cross contamination and infection issues. EI #3 was asked what was the procedure for passing ice to residents on isolation. EI #3 replied, they should put on the gown and gloves, get a fresh cup with ice take it in the room discard the old cup, remove the gown and gloves and wash their hands before leaving the room. EI #3 was asked what would be the harm in staff not putting on PPE before entering a resident room for care or to give ice. EI #3 replied, the staff could pick up the germ and transfer it to another resident.

Based on observation, interview and a record review of the facility's policy titled, Enteral Tube Administration, the facility failed to ensure a Licensed Practical Nurse/LPN, diluted crushed medications in water prior to administration of the medication via Percutaneous Endoscopic Gastrostomy (PEG) Tube. This affected one of one resident, Resident Identifier (RI) #89, observed during medication pass with a PEG tube. Findings Include: A review of the facility's policy titled, Enteral Tube Administration dated 03/11, revealed the following: Policy Medications are administered via feeding tube in a safe and accurate manner . Procedures . 6. Medications can be diluted with water and flushed . RI #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #89's (MONTH) (YEAR)'s Physician order [REDACTED]. On 02/28/18 at 3:40 PM, the following was observed during medication pass: EI #7, LPN, obtained and crushed [MEDICATION NAME] 25 mg for PEG tube administration to RI #89. EI #7 attached a 60 cc (cubic centimeter) syringe to RI #89's PEG tube. EI #7 administered the following: 30 cc water into the 60 cc syringe, then 5 cc of water, and then the crushed medication into the syringe. EI #7 did not dilute the crushed medication before pouring the medication into the syringe. Residue of the medication was observed inside the crush bag; and inside the barrel and around the rim of the syringe. EI #7 then administered 5 cc (cubic centimeters) of water and then 30 cc of water into the syringe. Medication residue was still observed in the barrel and around the rim of the syringe. On 02/28/18 at 4:55 PM, during an interview with EI #7, the surveyor asked what was left in the crush bag and the inner upper aspect of the syringe. EI #7 replied some of the medication. EI #7 stated she should have diluted the medications with water. The surveyor asked what was the policy for administering medications via PEG tube to ensure all medication is given. EI #7 stated to make sure the medications is diluted with water to ensure all of the medication is given. EI #7 replied that was not what she had done and policy and not been followed.

Based on staff interviews, and a review of a facility's policy titled, MEDICATION ADMINISTRATION - GENERAL GUIDELINES, the facility failed to ensure licensed staff documented administration of Resident Identifier (RI) #111's pain medication on the Medication Administration Record (MAR). Findings Include: A review of a facility's policy titled, MEDICATION ADMINISTRATION - GENERAL GUIDELINES dated 03/2011 documented: . Procedures . 1. Medications are administered . by licensed nursing, . 22. After administration, . document administration on the Medication Administration Record . RI #111 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #111's Admission Minimum Data Set with an Assessment Reference Date (ARD) of 07/12/2017 revealed RI #111's Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. A review of RI #111's (MONTH) (YEAR) MAR documented . [MEDICATION NAME] 50 MG TABLET . AS NEEDED FOR PAIN . EVERY SIX HOURS . The (MONTH) (YEAR), MAR documented [MEDICATION NAME] was administered on the following: 08/07/2017 at 9:08 AM 08/08/2017 at 12:17 PM 08/12/2017 at 1:13 PM 08/13/2017 at 10:57 AM and 5:39 PM 08/15/2017 at 6:08 PM 08/19/2017 at 10:21 PM 08/28/2017 at 10:13 PM A review of RI #111's . CONTROLLED SUBSTANCE RECORD . documented [MEDICATION NAME] 50 mg ([MEDICATION NAME] 50 mg) was administered by Employee Identifier (EI) #10, Registered Nurse/RN, on the following: 08/08/2017 at 6:00 PM 08/11/2017 at 11:16 AM 08/16/2017 at 6:00 PM 08/17/17 at 12:00 PM and 6:00 PM The above dates and times of administration were not documented as administered on RI #111's (MONTH) MAR. On 03/01/2018 at 3:52 p.m., during an interview EI #10, the surveyor provided RI #111's [MEDICATION NAME] Controlled Substance Record and RI #111's (MONTH) MAR to review and asked, EI #10 what days in (MONTH) did you administer [MEDICATION NAME] 50 mg. After reviewing the MAR, EI #10 said 08/07/2017 at 9:08 a.m., 08/08/2017 at 12:17 p.m., 08/12/2017 at 1:13 p.m., 08/13/2017 at 10:57 a.m., 08/13/2017 at 5:39 p.m., and 08/17/2017 at 6:30 p.m. The surveyor asked on 08/07/2017 at 6:00 p.m., where was the evidence to reflect that she administered the [MEDICATION NAME] to RI #111. EI #10 said it was not documented on the MAR, it is documented on the narcotic record. The surveyor asked on 08/08/2017 where was the evidence to reflect that she administered the [MEDICATION NAME] to RI #111. EI #10 said it was documented on the narcotic sheet, but it was not documented on the MAR. EI #10 was asked on 08/11/2017, 08/16/2017, 08/17/2017 where was the evidence to reflect that she administered the [MEDICATION NAME]. EI #10 said it was documented on the narcotic sheet, but it was not documented on the MAR. The surveyor asked EI #10 what was the facility policy when signing out narcotics. EI #10 said sign off on the MAR and the narcotic sheet. The surveyor asked was the policy and procedure followed for signing out narcotics. EI #10 said sign off on the MAR and the narcotic sheet, but that was not what she had done. On 03/01/18 at 4:16 p.m., during an interview with EI #6 RN, Director of Nursing (DON). EI #6 was asked when an oncoming nurse has a resident that needs a narcotic but is unable to access the computerized system because the previous nurse did not sign out on the MAR, what should the oncoming nurse do to ensure that the drug was administered. EI #6 said the nurses are to do a nursing note in conjunction with the Controlled Substance Record. On 03/01/18 at 4:32 p.m., during an interview with EI #12, RN/Assistant Director of Nursing (ADON), the surveyor informed EI #12 of the nurses signage on the controlled substance record and not signing out on the MAR and asked was the policy for signing out narcotics followed. EI #12 said no. The surveyor asked was the controlled substance record evidence that the medication was administered. EI #12 said no.

Based on interviews and a review of the facility's policy titled, Antibiotic Stewardship the facility failed to ensure Resident Identifier (RI) #43 received a urine culture and sensitivity for continued use of an antibiotic. This affected one of 25 sampled residents whose lab results were reviewed. Findings Include: A review of the facility's policy titled, Antibiotic Stewardship dated (MONTH) 1, (YEAR), revealed the following: POLICY STATEMENT Antibiotics will be prescribed and administered to residents under the guidance of the center's Antibiotic Stewardship Program. POLICY INTERPRETATION AND IMPLEMENTATION . 3. Appropriate indications for use of antibiotics include: a. Criteria met for clinical definition of active infection; and b. Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). RI #43 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #43's current Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 6, indicating severe impairment in cognition. The MDS revealed RI #43 as always incontinent of bladder. A review of RI #43's physician's orders [REDACTED]. 2/10/[MEDICATION NAME] mg (milligram) 1 tab (tablet) p.o. (by mouth) BID (twice a day) x (time) 3 days . A review of the facility's Departmental Notes revealed the following: .2/10/2018 10:39 AM Role: Nursing . Incontinent of . bladder with cloudy yellow discharge noted . (name of hospice) called notified of discharge. 2/10/2018 12:21 PM Role: Nursing Resident received new orders from hospice nurse . [MEDICATION NAME] twice a day times three days . On 03/02/18 at 10:37 AM, during an interview with Employee Identifier (EI )#8, Registered Nurse/RN/Infection Control Nurse and EI #9, RN, the surveyor asked what was the facility's policy and procedure regarding antibiotic usage. EI #9 replied resident should have a diagnosis, a positive test and/or symptoms for the physician or the nurse practioner to have a reason to put the resident on antibiotics. The surveyor asked should both symptoms and a positive lab test be available before start of an antibiotic. EI #8 requested to obtain and review the policy for antibiotic usage. EI #8 and EI #9 reviewed the Antibiotic Stewardship policy and EI #8 stated both symptoms and a positive lab test should be available, but not always. The surveyor asked what does the Center for Disease Control document to ensure that the right antibiotic is used for a particular infection. EI #9 stated a lab test will show if an infection is there, and would indicate the right drug or a selection of drugs to be use. The surveyor asked was that important. EI #9 replied yes because antibiotics are used for different types of bacteria. The surveyor asked what, when and why was RI #43 prescribed antibiotics. EI #8 replied the resident had a yellow discharge noted in the urine and was confused. EI #8 reviewed RI #43's physician's orders [REDACTED].#43 was ordered to [MEDICATION NAME] mg on 02/10/18 one tablet BID x 3 days. The surveyor asked what lab was done and what were the results. EI #8 stated she did not see an order for [REDACTED].#9 stated yes, to ensure the resident receives the appropriate antibiotic, a urinalysis should have been done. EI #9 stated that was part of the facility's antibiotic stewardship program. EI #9 also stated the resident should have had a urinalysis and a culture and sensitivity done as well, which is also part of the facility's antibiotic stewardship program. The surveyor asked was the policy followed for the facility's antibiotic stewardship program. EI #9 replied, No, because this is the policy, so going by this criteria, it was appropriate for a lab test to be done.

Based on review of Employee Identifier (EI) #1, the Administrator and EI #2, the Director of Nursing's job description and staff interviews, the administrative staff failed to have a system in place to ensure weekly wound assessments were completed after the Treatment Nurse, EI #3, left the faciity on [DATE] The Administrator, EI #1, revealed in an interview, the facility's system was broken. This failure placed RI #1 in immediate jeopardy of serious injury, harm or death and affected RI #2, two of nine sampled residents reviewed for pressure ulcer care. On 8/14/2017 at 1:28 p.m., EI #1, the Administrator and EI #2, the Director of Nursing (DON) were notified of the findings of immediate jeopardy level of K in the area of Administration, F 490. Findings include: Refer to F 282 and F 314 The undated job description of EI #2, the DON, documented . ACCOUNTABILITY OBJECTIVE Manages the Department of Nursing in accordance with policy and procedure, state and federal regulations to promote high quality care and service to the facility and community . KEY RESPONSIBILITIES . 1. Implements policies/procedures with follow-up and supervision of staff to ensure compliance; . 7. responsible to develop systems . 12. Ensures medical services are provided as required by regulation . During an interview on 8/11/2017 at 4:30 p.m., EI #2, the DON was asked who was responsible after the Treatment Nurse (EI #3) left to ensure wound/skin assessments were completed. EI #2 replied, it was the responsibility of the Unit Manager. When asked if wound/skin assessments were being done after the Treatment Nurse left in May 2017, EI #2 said no. When asked why not, EI #2 stated she was not sure. EI #2 explained wound care was being done as she reviewed the Treatment Administration Record (TAR) documentation. EI #2 was asked when did she become aware that wound/skin assessment were not being done. EI #2 stated she became aware about one to two weeks prior to last survey (July 2017). EI #2 explained that she conducted an audit and found that assessments were not being documented. When asked what prompted this audit, EI #2 stated nothing prompted the audit she just had gotten around to reviewing that system. EI #2 explained she thought the Treatment Nurse (EI #3) was going to return; however, it was not until the latter part of June that EI #2 became aware that the Treatment Nurse (EI #3) was not coming back. In a follow-up interview with EI #2, the DON on 8/13/2017 at 12:45 p.m., she stated on 7/7/2017 she became aware that wound/skin assessments were not being done. When asked for documentation regarding the audit conducted, EI #2 stated she didn't have any written evidence of an audit or the audit findings. EI #2 again explained the nurses on the hall were doing the wound care; however, there was no one to conduct weekly wound/skin assessments. When asked about RI #1's physician order [REDACTED].#2 stated EI #5, the RN Unit Manager overlooked the order and it didn't get transcribed. The job description of EI #1, the Administrator, dated 1/4/2017 documented . Accountability Objective Directs, oversees and manages the 24/7 day to day operations of the Diversicare post-acute care center . Key Responsibilities . Ensures compliance with State and Federal Regulations . On 8/11/2017 at 4:40 p.m., EI #1, the facility's Administrator was asked who was responsible to ensure the system regarding every aspect of wound care to include assessments, nutrition, prevention, etc. was implemented. EI #1 replied, she was. EI #1 explained that is was not until the last survey (July 2017) that she found out that wound/skin assessments were not being done. EI #1 stated she thought it was picked up by the other nurses. When asked how did she ensure that assessments were done after the Treatment Nurse (EI #3) left the facility, EI #1 stated she relied on her DNS. EI #1 was asked, as the administrator of the facility, based on the fact wound/skin assessments were not done, has she maintained the residents' highest level of well being. EI #1 answered, No, the system was broke and now it is fixed. ************************* On 8/15/2017 at 8:00 p.m., the facility submitted an acceptable Allegation of Credible Compliance which documented: 1. RI #1 was discharged from the facility on 7/6/17. RI #2 wound assessment was completed on 7/18/17 with weekly documentation to 8/14/17 by the Registered Nurse Unit Manager. Pressure Ulcer care plans for RI #2 have been reviewed and revised by the Minimum Data Set (MDS) Coordinator on 8/15/17 to assure implementation of weekly wound/skin assessments were completed and documented and observation of interventions are in place. The Registered Dietician Consultant reviewed the Nutrition assessment for RI #2 on 8/15/17 for accuracy of supplements with no negative findings. 2. Canterbury Health and Rehabilitation Center does not have any residents that are utilizing a wound vac for Pressure Ulcer treatment as of 8/14/17. As of 8/15/17 all current Residents with identified pressure ulcers have a wound assessment completed and documented in the electronic health record by the Licensed Practical Nurse UM and Registered Nurse UM. On 8/15/17 the Registered Dietician Consultant reviewed 11 Residents with Pressure Sores for completion of Registered Dietician recommendations for Protein supplements with all completed, to include a review of RI #2. On 8/15/17 the Dietary Manager completed an audit of Registered Dietician recommendations over the past 30 days to assure Registered Dietician recommendations were implemented for RI #2. On 8/14/17 the Director of Clinical Education, Director of Nursing, Registered Nurse Supervisor and Director of Clinical Operations provided an In-service education for the Licensed Nurses on completion and documentation of the center's weekly wound assessments. No Licensed Nurse will work after 8/15/17 until education has been completed. On 8/15/17 an In-service education provided to the Facility Director of Nursing Services and Administrator by the Senior Director of Clinical Operations on the Facility guideline for Skin Care and Registered Dietician recommendations for residents with Pressure Ulcers. On 8/15/17 the Facility Administrator assured that the facility maintains compliance with state and federal rules and regulations by reviewing the facility's quality indices to include the facility's weekly wound/skin assessments and Registered Dietician recommendations weekly to include follow up in the Quality Assurance Process Improvement (QAPI) Meeting minutes. Non-compliance with state and federal rules and regulations was (has) been addressed with an Allegation of Credible Compliance. On 8/15/17 the Administrator developed a schedule to meet with Department Managers individually to discuss department functions/concerns as it relates to resident care improvement and identify any resources that may be needed. The Administrator will assure that she utilizes the Facility's resources effectively and efficiently to attain or maintain the highest physical, mental, and psychosocial well-being of each resident by utilizing the expertise of the Facility staff as well as the Corporate Office. ************************* After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 490 was lowered to a E level on 8/15/2017, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report AL 237.

Based on a review of Resident Identifier (RI) #1's medical record, review of www.webmd.com, the facility's policies titled Care System Guideline Skin Care, Medication Policies Prescriber Medication Orders and Supplements and resident and staff interviews, the facility failed to: 1) complete an initial wound assessment of RI #1's infected Stage IV sacral pressure ulcer. RI #1 was admitted to the facility on [DATE] with an infected Stage IV pressure ulcer to the sacral region. The admission nurse failed to conduct an initial wound assessment of the resident's pressure ulcer. The only wound/skin assessment found within RI #1's medical record was a Skin Inspection Report dated 6/6/2017 that documented Skin Not Intact - Existing; 2) transcribe the admission wound care orders to change the wound vac on Mondays and Thursdays. RI #1's wound care orders were not transcribed until 6/8/2017 with a start date of 6/12/2017. When questioned why the delay in wound care orders, the admission nurse, Employee Identifier (EI) #9 stated she forgot; 3) consistently change the wound vac as ordered. A review of the electronic Treatment Administration Record (eTAR) and staff interviews revealed, the resident's wound vac was not changed as ordered by the physician; 4) conduct subsequent wound/skin assessments of RI #1's infected Stage IV sacral pressure ulcer. During the course of RI #1's stay at the nursing facility, from 6/5/2017 until 7/6/2017, there was no evidence the licensed nursing staff conducted weekly wound/skin assessments as listed in the facility's policy and RI #1's care plan. The weekly wound assessments, that was the responsibility of the Treatment Nurse, were not done. The facility's Treatment Nurse left the faciity on [DATE] and the administrative staff had no system in place to ensure wound/skin assessments were completed weekly; and 5) follow the Registered Dietician's (RD) recommendation and physician's orders [REDACTED].#1, to aid in the healing of the resident's sacral pressure ulcer. The licensed nurse overlooked the order dated 6/19/2017, thus the resident never received the Juven and protein supplement that was recommended by the RD and ordered by the physician to aid in wound healing. The facility further failed to ensure RI #1's at risk for skin integrity care plan accurately reflected the resident's status. RI #1's care plan with a problem onset date of 6/5/2017 indicated the resident refused at times to be repositioned. Staff interviews revealed this was inaccurate. The facility also failed to ensure documentation contained within RI #1's medical record was correct. The licensed nurse documented on 6/5/2017 that RI #1's wound vac in progress; however, during interview she revealed the wound vac was not attached to the resident. These failures placed RI #1, one of nine sampled residents reviewed for pressure ulcer care in immediate jeopardy as it was likely to cause serious harm, injury or death. Furthermore, the facility failed to conduct weekly wound/skin assessments of RI #2, a resident admitted to the facility with an unstageable sacral pressure ulcer from 5/1/2017 until 7/18/2017. This deficient practice affected RI #2, one of nine residents reviewed for pressure ulcer care. On 8/14/2017 at 1:28 p.m., Employee Identifier (EI) #1, the Administrator and EI #2, the Director of Nursing (DON) were notified of the findings of substandard quality of care at the immediate jeopardy level of J in the area of Quality of Care, F 314. Findings include: 1) The facility's policy titled Medication Policies Prescriber Medication Orders dated March 2011, documented . Procedures . 4. Written transfer orders/readmission orders [REDACTED]. Unless the order is unclear or incomplete, implement a transfer order without further validation if it is signed and dated by the resident's current attending physician. If the order is unclear, incomplete, or a discrepancy is noted, the order should be clarified with the physician and a new order obtained. B. If the order is unsigned or signed by another prescriber, the receiving nurse verifies the order with the current attending physician . RI #1 was admitted to the facility on [DATE] from a local hospital with a [DIAGNOSES REDACTED]. According to www.webmd.com, [DIAGNOSES REDACTED] is an infection of the bone. The PHYSICIAN ORDERS [REDACTED].#1 documented Transfer to SNF (skilled nursing facility) . Change (wound) Vac Monday & Thursday . RI #1's PHYSICIAN ORDERS [REDACTED]. with a start date of 6/12/2017. In an interview on 8/12/2017 at 4:11 p.m., EI #10, a Registered Nurse (RN) Minimum Data Set (MDS) Coordinator acknowledged that RI #1's physician's orders [REDACTED].#9. EI #10 stated the orders should have been entered on 6/5/2017 with a start date of 6/8/2017. In a telephone interview on 8/12/2017 at 5:20 p.m., EI #9, the Licensed Practical Nurse (LPN) who was responsible for admitting RI #1 into the facility on [DATE], was asked why RI #1's order to change the wound vac was dated 6/8/2017 and not 6/5/2017. EI #9 stated she forgot to put the order in the computer. When asked to explain why the order was dated 6/8/2017 with a start date of 6/12/2017, EI #9 stated she did not know. EI #9 explained the order should have been dated 6/5/2017 with a start date of 6/8/2017. 2) RI #1's care plan titled I am at risk for impaired skin integrity and I have a Stage 4 pressure ulcer to sacrum. I refuse at times to reposition to relieve pressure off my wound with a problem onset date of 6/5/2017 had the following approaches Reposition me every 2 hours or as pt (patient) allows . * I need a wound care as ordered by <my> physician . * Offer me supplemental nutritional support as needed . * I need a weekly evaluation of wound healing . * I need a full skin evaluation weekly . * Adjust my treatment plan if wound no (not) healing within 2-4 weeks. During an interview on 8/12/2017 at 4:11 p.m., EI #10, a RN MDS Coordinator was asked was there any evidence in RI #1's medical record that the resident refused at times to reposition as listed in the care plan. EI #10 answered, no ma'am. EI #10 explained there was one entry in RI #1's medical record dated 6/17/2017 that the resident refused to be repositioned. When asked if the care plan statement dated 6/5/2017 that the resident refused at times to reposition a correct statement, EI #10 replied, no. EI #10 explained RI #1's care plan was a general care plan that the facility uses for all residents until an issue has been identified. 3) RI #1's care plan titled I am at risk for impaired skin integrity and I have a Stage 4 pressure ulcer to sacrum . with a problem onset date of 6/5/2017 had the following approach . * I need a wound care as ordered by <my> physician . RI #1's PHYSICIAN ORDERS [REDACTED]. with a start date of 6/12/2017. A review of RI #1's electronic Treatment Administration Record (eTAR) for June 2017 revealed, RI #1's wound vac was not changed on 6/8/2017 and 6/29/2017. During an interview on 8/10/2017 at 12:05 p.m., EI #13, a LPN acknowledged she was assigned to care for RI #1 on 6/29/2017. EI #13 reviewed RI #1's eTAR and acknowledged that she did not sign the eTAR as changing RI #1's wound vac on 6/29/2017 (a Thursday). A review of RI #1's eTAR for July 2017 revealed, RI #1's wound vac was not changed on 7/6/2017. In an interview on 8/10/2017 at 11:30 a.m., EI #12, a RN was asked if she ever worked the medication (med) cart. EI #12 said yes. When asked if a resident has a wound vac and she was on the med cart, whose responsibility was it to change the wound vac, EI #12 stated it was her responsibility. According to EI #12 she worked the med cart on Thursday, 7/6/2017. When asked if she changed RI #1's wound vac on 7/6/2017, EI #12 reviewed the eTAR and stated it didn't look like she did. EI #12 was asked why she did not change RI #1's wound vac. EI #12 answered that she truly couldn't say why but perhaps she did not look at the eTAR. EI #12 further explained that she worked all day, there was no excuse that she didn't do it. In a telephone interview on 8/13/2017 at 5:45 p.m., RI #1 stated the facility didn't change the wound vac often when asked how often the wound vac was changed. 4) RI #1's Departmental Notes dated 6/5/2017 9:27 p.m., written by EI #9, a LPN, documented . (RI #1) admitted . via stretcher from . Hospital . Wound vac in progress for Stage IV sacral wounds . During a telephone interview on 8/12/2017 at 5:20 p.m., EI #9, a LPN acknowledged that RI #1 was admitted to the facility on [DATE] with orders for a wound vac for a Stage IV pressure ulcer. When asked if the wound vac was in place when the resident was admitted , EI #9 said no. According to EI #9, the wound vac arrived in the facility a couple of hours after RI #1 arrived in the facility. EI #9 stated she could not apply the wound vac so she left it for the next shift. EI #9 stated she only worked in the facility as needed on the rehab unit and didn't feel comfortable with the wound vac, so she left it for the next shift's charge nurse. When asked if the Departmental Notes dated 6/5/2017 9:27 p.m., correct when it stated the wound vac was in progress, EI #9 said it was not correct as she left the wound vac for the next shift, 11:00 p.m., to 7:00 a.m., to apply. In an interview on 8/10/2017 at 6:25 p.m., EI #21, a RN acknowledged the Departmental Notes written by EI #9, a LPN was incorrect when it documented RI #1's wound vac was in progress. According to EI #21, EI #9 had never done a wound vac before and when she arrived into work the wound vac was still in the box. EI #21 stated she did not remember the exact time, she connected RI #1's wound vac but certain it was not applied by EI #9. 5) RI #1's care plan titled I am at risk for impaired skin integrity and I have a Stage 4 pressure ulcer to sacrum . with a problem onset date of 6/5/2017 had the following approaches . * I need a weekly evaluation of wound healing . * I need a full skin evaluation weekly . * Adjust my treatment plan if wound no (not) healing within 2-4 weeks. RI #1's Skin Inspection Report indicated on 6/6/2017 EI #9, a LPN assessed RI #1's skin. The report documented Skin Not Intact - Existing. In an interview on 8/9/2017 at 12:43 p.m., EI #6, the RN Unit Manager was asked where were the wound notes and weekly wound assessments for RI #1. EI #6 reviewed the computer and stated there were none. When asked when should the wound assessments have been done, EI #6 stated upon admission, weekly and if there were any changes in the residents' skin condition. EI #6 stated the only body audit was done on 6/6/2017 and it indicated the resident's skin was not intact - existing. According to EI #6, existing meant present on admission. When asked what was present on admission, EI #6 stated that she would have to review RI #1's medical record. After review of RI #1's medical record, EI #6 stated RI #1 had a sacral pressure ulcer. EI #6 was asked was there a description of the sacral pressure ulcer. EI #6 replied that would have been in the wound assessment and there was none. When asked why not, EI #6 stated they were not done. When asked who was responsible for completing, EI #6 stated the Treatment Nurse, EI #3. EI #6 then explained that EI #3 was not employed in the facility during the time RI #1 was a resident, so the person responsible would have been EI #5. EI #6 was asked what was the facility's policy and procedure for wound assessments. EI #6 replied, that measurements and wound assessments should be completed weekly and documented in the wound assessment manager. When asked if RI #1 had weekly measurements and wound assessments, EI #6 said no. In a follow-up interview on 8/13/2017 at 12:25 p.m., EI #6, the RN Unit Manager was asked what evidence the facility had to show RI #1's sacral pressure ulcer was assessed weekly/observed for signs of healing. EI #6 stated, there was none. EI #6 explained during the resident's entire stay in the facility there were no wound care assessments done. 6) The facility's policy titled Supplements with an effective date of 1/1/2017, documented POLICY It is the policy of this center to provide supplements to residents/patients in accordance with the current diet order PR(NAME)EDURE . 2. Nutritional supplements are usually given to help resolve an identified nutritional problem. Examples are: . a. to increase calories for residents/patients . who have an increased need for calories due to injury, infection or stress b. to increase protein to facilitate the healing of decubiti; wounds . RI #1's care plan titled I am at risk for impaired skin integrity and I have a Stage 4 pressure ulcer to sacrum . with a problem onset date of 6/5/2017 had the following approach . * Offer me supplemental nutritional support as needed . RI #1's Departmental Notes dated 6/13/2017 9:40 a.m., written by EI #8, the Registered Dietician (RD) documented . Resident was admitted to facility with DX (diagnosis): . Stage IV to sacrum . Resident has increased cal (calorie) and protein needs to aid healing . PLAN: add juven BID (twice a day) and 30cc (cubic centimeter) protein supp (supplement) BID. RI #1's physician's orders [REDACTED]. 2) Juven BID to aid in healing 3) 30cc protein supp BID to aid healing. During an interview on 8/9/2017 at 12:43 p.m., EI #6, the RN Unit Manager was asked about RI #1's physician order [REDACTED]. In an interview on 8/10/2017 at 10:25 a.m., EI #8, the RD, was asked what should have occurred after the physician order [REDACTED].#1 to have Juven and protein supplement. EI #8 stated the Juven and protein supplement should have been implemented. When asked why the Juven and protein supplement was recommended for RI #1, EI #8 stated she recommended the Juven and the protein supplement to aid in wound healing because the resident had a Stage IV pressure ulcer. On 8/10/2017 at 5:15 p.m., a telephone interview was conducted with EI #7, the former RN Unit Manager was asked about RI #1's physician order [REDACTED]. EI #7 stated she couldn't recall what happened with the order as to why the resident never received Juven and the protein supplement. 7) The facility's undated policy titled Care System Guideline Skin Care documented Purpose: To provide a system for evaluation of skin at risk, identify individual interventions to address risk and process for care of changes/disruption in skin integrity: Process: . * Weekly review of the patient's skin will be completed by the nurse and documented in the electronic medical record . *DNS (Director of Nursing Service) or designee will be responsible to implement and monitor the skin integrity program . When an open area is identified: . * Document evaluation of wound in electronic medical record including: *Location and staging *Size (length x width/depth) presence and location of undermining and tunneling * Exudate/if present: type, color, odor, and appropriate amounts . * Wound bed: color & type of tissue/character including evidence of healing (granulation) or necrosis (slough and eschar). * Reassess, re-evaluate and revise interventions when progress is not noted within 14 days. * Any deterioration of wound status initiate comprehensive re-evaluation, . Key Elements: . Interventions are observed in place . Weekly skin observations are completed . RI #1's care plan titled I am at risk for impaired skin integrity and I have a Stage 4 pressure ulcer to sacrum . with a problem onset date of 6/5/2017 had the following approaches . * I need a weekly evaluation of wound healing . * I need a full skin evaluation weekly . * Adjust my treatment plan if wound no (not) healing within 2-4 weeks. During a telephone interview on 8/10/2017 at 4:45 p.m., EI #3, the facility's former Treatment Nurse acknowledged that she was employed in the facility from November 2016 to 5/15/2017. EI #3 stated as the Treatment Nurse she was responsible for conducting wound assessment and following the physician's orders [REDACTED].#3 stated she assessed the wound for changes; conducted weekly measurements; observed for signs/symptoms of infection, drainage, and pain. EI #3 stated all information regarding a resident's wound was documented in the wound assessment section of the computer. When asked if she had an assistant to help perform the duties assigned to her, EI #3 said no. When asked who was responsible for conducting weekly wound assessment/wound care when she left the facility, EI #3 stated she didn't know. In an interview on 8/11/2017 at 2:00 p.m., EI #6, the RN Unit Manager was asked after the Treatment Nurse, EI #3, left the facility, what system was in place to ensure weekly wound/skin assessments were completed. EI #6 replied there was no system/protocol in place. EI #6 explained the nurses on the floor performed wound care but there was no system or person identified to conduct weekly wound/skin assessments. During an interview on 8/11/2017 at 4:30 p.m., EI #2, the Director of Nursing (DON) was asked who was responsible after the Treatment Nurse (EI #3) left to ensure wound/skin assessments were completed. EI #2 replied, it was the responsibility of the Unit Manager. When asked if the wound/skin assessment were being done after the Treatment Nurse left in May 2017, EI #2 said no. When asked why not, EI #2 stated she was not sure. EI #2 explained wound care was being done as she reviewed the Treatment Administration Record (TAR) documentation. EI #2 was asked when did she become aware that wound/skin assessment were not being done. EI #2 stated she became aware about one to two weeks prior to last survey (July 2017). EI #2 explained that she conducted an audit and found that assessments were not being documented. When asked what prompted this audit, EI #2 stated nothing prompted the audit she just had gotten around to reviewing that system. EI #2 explained she thought the Treatment Nurse (EI #3) was going to return; however, it was not until the latter part of June that EI #2 became aware that the Treatment Nurse (EI #3) was not coming back. In an interview on 8/11/2017 at 4:40 p.m., EI #1, the facility's Administrator was asked who was responsible to ensure the system regarding every aspect of wound care to include assessments, nutrition, and prevention was implemented. EI #1 replied, she was. EI #1 explained that is was not until the last survey (July 2017) that she found out that wound/skin assessments were not being done. EI #1 stated she thought it was picked up by the other nurses. When asked how did she ensure that assessments were done after the Treatment Nurse (EI #3) left the facility, EI #1 stated she relied on her DON. EI #1 was asked, as the administrator of the facility, based on the fact wound/skin assessments were not done, has she maintained the residents' highest level of well being. EI #1 answered, No, the system was broke and now it is fixed. In a follow-up interview with EI #2, the DON on 8/13/2017 at 12:45 p.m., she stated on 7/7/2017 she became aware that wound/skin assessments were not being done. When asked for documentation regarding the audit conducted, EI #2 stated she didn't have any written evidence of an audit or the audit findings. EI #2 again explained the nurses on the hall were doing the wound care; however, there was no one to conduct weekly wound/skin assessments. When asked about RI #1's physician order [REDACTED].#2 stated EI #5, the RN Unit Manager overlooked the order and it didn't get transcribed. 8) RI #2 was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #2's Annual Minimum Data Set with an assessment reference date of 8/1/17, indicated RI #2 had a pressure ulcer greater than a stage I and to have an unstageable pressure ulcer. A review of RI #2's medical record revealed no weekly wound assessments from 5/1/17 through 7/18/17. RI #2's Wound Assessment Report dated 5/1/17, documented . Wound Location Sacrum present on admission . Stage Unstageable due to suspected deep tissue injury . Measurements Length - 6.80 cm Width - 9.80 cm Depth - 0.10 cm . RI #2's Wound Assessment Report dated 7/18/17, documented . Wound Type Pressure Ulcer . Wound Location Sacrum . Stage 2 . Measurements Length - 5.00 cm Width - 10.0 cm Depth - 0.00 cm . On 8/10/17 at 3:30 p.m., the surveyor conducted an interview with EI #2, the Director of Nursing (DON). The surveyor asked EI #2 who was responsible for performing the weekly wound assessments for RI #2. EI #2 stated, (EI #3) the wound nurse up to May 1, 2017, afterwards the unit charge nurse and managers. The surveyor asked EI #2 if the weekly wound assessments were being performed from 5/1/17 through 7/18/17. EI #2 stated, no. The surveyor asked EI #2 if the weekly wound assessments were being conducted by the charge nurses and unit managers. EI #2 stated, No sir it was not. On 8/10/17 at 4:49 p.m., the surveyor conducted a telephone interview with EI #3, the former Treatment Nurse. The surveyor asked EI #3 who was responsible for RI #2's weekly Wound Assessment Reports from 5/1/17 through 7/18/17. EI #3 said she was the treatment nurse. EI #3 said she left the facility 5/15/17. The surveyor asked EI #3 after she left the facility who was responsible for doing the wound assessment reports for RI #2. EI #3 said she was not sure. On 8/14/17 at 1:42 p.m., the surveyor conducted an interview with EI #5, the former RN Unit Manager. The surveyor asked EI #5, after the treatment left, when was she made responsible or informed the Registered Nurses were responsible for the weekly wound and skin assessments. EI #5 she was never told this. ************************* On 8/15/2017 at 8:00 p.m., the facility submitted an acceptable Allegation of Credible Compliance which documented: 1. RI #1 was discharged from the facility on 7/6/17. RI #2 wound assessment was completed on 7/18/17 with weekly documentation to 8/14/17 by the Registered Nurse Unit Manager. Pressure Ulcer care plans for RI #2 have been reviewed and revised by the Minimum Data Set (MDS) Coordinator on 8/15/17 to assure implementation of weekly wound/skin assessments were completed and documented and observation of interventions are in place. 2. Canterbury Health and Rehabilitation Center does not have any residents that are utilizing a wound vac for Pressure Ulcer treatment as of 8/14/17. As of 8/15/17 all current Residents with identified pressure ulcers have a wound assessment completed and documented in the electronic health record by the Licensed Practical Nurse UM and Registered Nurse UM. On 8/15/17 the Registered Dietician Consultant reviewed 11 Residents with Pressure Sores for completion of Registered Dietician recommendations for Protein supplements with all completed, to include a review of RI #2. On 8/15/17 the Dietary Manager completed an audit of Registered Dietician recommendations over the past 30 days to assure Registered Dietician recommendations were implemented for RI #2. 3. On 8/14/17 the Director of Clinical Education, Director of Nursing, Registered Nurse Supervisor and Director of Clinical Operations provided an In-service education for the Licensed Nurses on completion and documentation of the center's weekly wound assessments. No Licensed Nurse will work after 8/15/17 until education has been completed. On 8/15/17 an In-service education provided to the Facility Director of Nursing Services and Administrator by the Senior Director of Clinical Operations on the Facility guideline for Skin Care and Registered Dietician recommendations for residents with Pressure Ulcers. ************************************************** After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 314 was lowered to a D level on 8/15/2017, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficient practice was cited as a result of the investigation of complaint/report AL 237.

Based on a review of Resident Identifier (RI) #1's medial record, interview with the resident and staff interviews, the facility failed to implement the care plan of RI #1, a resident admitted to the facility with a Stage IV pressure ulcer to the sacral region. RI #1's care plan titled I am at risk for impaired skin integrity . had interventions to provide wound care as ordered, offer supplemental nutrition and weekly evaluation of wound healing. These interventions were not implemented as care planned. RI #1 was admitted to the facility on [DATE] and discharged home on[DATE]. During RI #1's entire stay in the nursing facility, the licensed nursing staff failed to conduct weekly wound/skin assessments of RI #'1 Stage IV pressure ulcer to the sacral region. RI #1 was ordered to have the wound vac changed on Mondays and Thursdays. A review of RI #1's electronic Treatment Administration Record (eTAR) and staff interviews revealed, RI #1's wound vac was not consistently changed as ordered and care planned. Also, it was recommended and ordered by the physician on 6/19/2017 for RI #1 to have Juven and a protein supplement to aid in wound healing. This intervention was not implemented and RI #1 never received the recommended and ordered Juven and protein supplement. These deficient practices placed RI #1, one of nine sampled residents reviewed for pressure ulcer care, in immediate jeopardy as these failures could have caused serious harm, injury or death. On 8/17/2017 at 4:25 p.m., EI #1, the Administrator was informed the scope and severity of F 282, Comprehensive Care Plan was increased to an immediate jeopardy level J. Findings include: RI #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #1's care plan titled I am at risk for impaired skin integrity and I have a Stage 4 pressure ulcer to sacrum . with a problem onset date of 6/5/2017 had the following approaches . * I need a wound care as ordered by <my> physician . * Offer me supplemental nutritional support as needed . * I need a weekly evaluation of wound healing . * I need a full skin evaluation weekly . 1) RI #1's PHYSICIAN ORDERS [REDACTED]. with a start date of 6/12/2017. In a telephone interview on 8/12/2017 at 5:20 p.m., Employee Identifier (EI) #9, the Licensed Practical Nurse (LPN) who was responsible for admitting RI #1 into the facility on [DATE], was asked why RI #1's order to change the wound vac was dated 6/8/2017 and not 6/5/2017. EI #9 stated she forgot to put the order in the computer. When asked to explain why the order was dated 6/8/2017 with a start date of 6/12/2017, EI #9 stated she did not know. EI #9 explained the order should have been dated 6/5/2017 with a start date of 6/8/2017. A review of RI #1's electronic Treatment Administration Record (eTAR) for June 2017 revealed, RI #1's wound vac was not changed on 6/8/2017 and 6/29/2017. During an interview on 8/10/2017 at 12:05 p.m., EI #13, a LPN acknowledged she was assigned to care for RI #1 on 6/29/2017. EI #13 reviewed RI #1's eTAR and acknowledged that she did not sign the eTAR as changing RI #1's wound vac on 6/29/2017 (a Thursday). A review of RI #1's eTAR for July 2017 revealed, RI #1's wound vac was not changed on 7/6/2017. In an interview on 8/10/2017 at 11:30 a.m., EI #12, a Registered Nurse (RN) was asked if she ever worked the medication (med) cart. EI #12 said yes. When asked if a resident has a wound vac and she was on the med cart, whose responsibility was it to change the wound vac, EI #12 stated it was her responsibility. According to EI #12 she worked the med cart on Thursday, 7/6/2017. When asked if she changed RI #1's wound vac on 7/6/2017, EI #12 reviewed the eTAR and stated it didn't look like she did. EI #12 was asked why she did not change RI #1's wound vac. EI #12 answered that she truly couldn't say why but perhaps she did not look at the eTAR. EI #12 further explained that she worked all day, there was no excuse that she didn't do it. During a telephone interview on 8/13/2017 at 5:45 p.m., RI #1 was asked how often did the facility change the wound vac. RI #1 stated the facility didn't change the wound vac often. 2) RI #1's Departmental Notes dated 6/13/2017 9:40 a.m., written by EI #8, the Registered Dietician (RD) documented . Resident was admitted to facility with DX (diagnosis): . Stage IV to sacrum . Resident has increased cal (calorie) and protein needs to aid healing . PLAN: add juven BID (twice a day) and 30cc (cubic centimeter) protein supp (supplement) BID. RI #1's physician's orders [REDACTED]. 2) Juven BID to aid in healing 3) 30cc protein supp BID to aid healing. During an interview on 8/9/2017 at 12:43 p.m., EI #6, the RN Unit Manager was asked about RI #1's physician order [REDACTED]. In an interview on 8/10/2017 at 10:25 a.m., EI #8, the RD, was asked what should have occurred after the physician order [REDACTED].#1 to have Juven and protein supplement. EI #8 stated the Juven and protein supplement should have been implemented. When asked why the Juven and protein supplement was recommended for RI #1, EI #8 stated she recommended the Juven and the protein supplement to aid in wound healing because the resident had a Stage IV pressure ulcer. On 8/10/2017 at 5:15 p.m., a telephone interview was conducted with EI #7, the former RN Unit Manager, was asked about RI #1's physician order [REDACTED]. EI #7 stated she couldn't recall what happened with the order as the why the resident never received Juven and the protein supplement. When asked what type of review did she do to ensure the physician's orders [REDACTED].#7 stated she didn't remember and explained that was a reason she was no longer employed at the facility because she didn't have time to document. 3) A review of RI #1's medical record revealed no weekly wound/skin assessments during the time RI #1 resided at the facility. During an interview on 8/9/2017 at 12:43 p.m., EI #6, the RN Unit Manager was asked where were RI #1's weekly skin evaluations (assessments). EI #6 stated there were none. According to EI #6, an initial Braden scale was done but there no weekly wound/skin assessments. When asked when should the wound assessments be done, EI #6 stated upon admission, weekly and if there were any changes in the resident's skin condition. EI #6 was asked who was responsible for conducting weekly wound/skin assessments. EI #6 replied, when the Treatment Nurse, EI #3, left the facility, the person responsible was EI #7, the RN Unit Manager, who recently quit working at the facility. EI #6 stated she was now responsible. In a follow-up interview with EI #6, the RN Unit Manager on 8/13/2017 at 12:25 p.m., she stated there were no wound care assessments done for RI #1 during the resident's admission/stay here at the facility. ************************* On 8/15/2017 at 8:00 p.m., the facility submitted an acceptable Allegation of Credible Compliance which documented: 1. RI #1 was discharged from the facility on 7/6/17. RI #2 wound assessment was completed on 7/18/17 with weekly documentation to 8/14/17 by the Registered Nurse Unit Manager. Pressure ulcer care plan for RI #2 have been reviewed and revised by the Minimum Data Set (MDS) Coordinator on 8/15/17 to assure implementation of weekly wound/skin assessments were completed and documented and observation of interventions are in place. 2. Canterbury Health and Rehabilitation Center does not have any residents that are utilizing a wound vac for Pressure Ulcer treatment as of 8/14/17. As of 8/15/17 all current residents with identified pressure ulcers have a wound assessment completed and documented in the electronic health record by the Licensed Practical Nurse UM and Registered Nurse UM. On 8/15/17, the Registered Dietician Consultant reviewed 11 residents with pressure sores for completion of Registered Dietician recommendations for Protein supplements with all completed. On 8/15/17, the Dietary Manager completed an audit of Registered Dietician recommendations over the past 30 days to assure Registered Dietician recommendations were implemented. 3. On 8/14/17, the Director of Clinical Education, Director of Nursing, Registered Nurse Supervisor and Director of Clinical Operations provided an in-service education for the Licensed Nurses on completion and documentation of the center's weekly wound assessments. No Licensed Nurse will work after 8/15/17 until education has been completed. On 8/15/17, an in-service education provided to the facility Director of Nursing Services and Administrator by the Senior Director of Clinical Operations on the facility guidelines for Skin Care and Registered Dietician recommendations for residents with pressure ulcers. ************************* After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 282 was lowered to a D level on 8/15/2017, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 237.

Based on staff interviews and review of the facility's policy titled Guideline QAPI (Quality Quality Assurance Performance Improvement), the facility failed to implement an action plan when it was determined weekly wound/skin assessments were not being done. Employee Identifier (EI) #2, the Director of Nursing, responsible for leading the QA committee, and EI #1, the Administrator, both were aware weekly wound/skin assessments were not being done since the Treatment Nurse left the facility; however, no action plan had been implemented to correct the identified deficient practice. This failure placed RI #1 in immediate jeopardy of serious injury, harm or death and affected RI #2, two of nine sampled residents reviewed for pressure ulcer care. On 8/14/2017 at 1:28 p.m., EI #1, the Administrator and EI #2, the Director of Nursing (DON) were notified of the findings of immediate jeopardy level of J in the area of Quality Assessment and Assurance, F 520. Findings include: Refer to F 282, F 314 and F 490. The facility's undated policy titled Guideline QAPI (Quality Quality Assurance Performance Improvement) documented Purpose: QAPI is a data driven, proactive approach to improving the quality of life, care and services in ours centers. The activities of QAPI involve team members at all levels of the organization to identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor the effectiveness of our interventions. QAPI is consistent with our Service Standard: We continually strive to improve personal and company performance Guidelines for completion: QAPI meeting are held monthly . Once the meeting is held with analysis of data and plans of action documented the finished template is posted on the center's shared drive. Five Elements of QAPI: Element 1: Design and Scope . When fully implemented, QAPI program addresses all systems of care and management practices, and includes clinical care, quality of life, and resident choice Element 4: Performance Improvement Projects (PIPS) A performance Improvement Project (PIP) is a concentrated effort on a particular problem in one area of the center or center wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements. The center conducts PIPs to examine and improve care or services in areas identified as needing attention. Element 5: Systematic Analysis and Systemic Action The center uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. Centers will demonstrate proficiency in the use of Root Cause Analysis. Systemic Actions look comprehensively across all involved systems to prevent future events and promote sustained improvement . In an interview on 8/9/2017 at 8:30 a.m., Employee Identifier (EI) #1, the Administrator identified EI #2, the Director Of Nursing, as the person responsible for leading the Quality Assurance (QA) committee. During an interview on 8/11/2017 at 4:30 p.m., EI #2, the DON was asked if wound/skin assessments were being done after the Treatment Nurse left in May 2017, EI #2 said no. When asked why not, EI #2 stated she was not sure. EI #2 explained wound care was being done as she reviewed the Treatment Administration Record (TAR) documentation. EI #2 was asked when did she become aware that wound/skin assessment were not being done. EI #2 stated she became aware about one to two weeks prior to last survey (July 2017). EI #2 explained that she conducted an audit and found that assessments were not being documented. When asked what prompted this audit, EI #2 stated nothing prompted the audit she just had gotten around to reviewing that system. EI #2 explained she thought the Treatment Nurse (EI #3) was going to return; however, it was not until the latter part of June that EI #2 became aware that the Treatment Nurse (EI #3) was not coming back. When asked about QA, EI #2 stated the topic of wound/skin assessments was a concern of hers but she was trying to get a Wound Care (Treatment) Nurse. In an interview on 8/12/2017 at 1:05 p.m., EI #1, the Administrator was asked what evidence did the facility have to verify the topic of wound/skin assessments were discussed in QA and an action plan was implemented to address the issue of the licensed nursing staff not performing weekly wound/skin assessments. EI #1 replied she didn't have anything but a plan of correction from when the State Agency left the faciity on [DATE]. ************************* On 8/15/2017 at 8:00 p.m., the facility submitted an acceptable Allegation of Credible Compliance which documented: On 8/15/17 an In-service education was provided to the Administrator and Director of Nursing by the Area Vice President on the Facility guideline for Quality Assurance Process Improvement to assure Quality Assurance Process Improvement is data driven, a proactive approach to improving the quality of life, care and services in our Facility. Quality Assurance Process Improvement involves staff at all levels to identify opportunities for improvement; address gaps in systems or processes and develop and implement an improvement or corrective plan and continuously monitor the effectiveness of our interventions. On 8/15/17 an In-service education was provided to the Facility Director Nursing Service and Administrator by the Senior Director of Clinical Operations to address ongoing completion of Pressure Ulcer/skin assessments as well as review and follow up of Registered Dietician recommendations for residents with Pressure Ulcers, Review/revise and development of care plans for identified concerns; review of Physician orders [REDACTED]. On 8/15/17 a Quality Assurance Process Improvement meeting was held with the Administrator, Director Nursing Service, and Regional Vice President, Director of Clinical Education, Registered Nurse Unit Manager, Licensed Practical Nurse UM, Director of Rehab and Medical Director per phone. This meeting reviewed the Allegation of Credible Compliance that was developed effective 8/15/17. Reviewed Quality of Care and Administration for Wound care assessments and documentation, current status of education, no licensed staff will work after 8.15.17 until training is completed. ************************* After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 520 was lowered to a D level on 8/15/2017, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation/report of complaint/report number AL 237.

Based on interviews and record review, the facility's administrative staff failed to ensure there were policies and procedures that directed the staff how to follow-up on laboratory tests ordered by the physician. This deficient practice affected Resident Identifier (RI) #29, RI #12, RI #33 and RI #36, four of five sampled residents reviewed for infection control. This failure placed RI #29 in immediate jeopardy, as it was likely to cause serious injury, harm and/or death. Immediate Jeopardy is a situation in which the facility's noncompliance with one or more requirements of participation has allowed/caused/resulted in, or is likely to allow/cause/result in serious injury, harm, impairment, or death to a resident; and requires immediate correction, as the facility either created the situation or allowed the situation to continue by failing to implement preventative or corrective measures. On 5/11/2016 at 5:53 PM, the facility's interim Administrator was notified of the findings of immediate jeopardy level of K in the area of Administration, F 490. Findings include: The Administrator's job description dated October 2015, documented . GENERAL PURPOSE Directs and oversees the 24/7 day to day operations of the Diversicare post-acute care centers. ESSENTIAL JOB DUTIES . * Ensures compliance with State and Federal Regulations . * Ensures that quality care and services is provided to all patients, residents and that it meets the satisfaction of the patient, resident, family, physicians and other partners . The undated Director of Nursing (DON)'s job description documented . ACCOUNTABILITY OBJECTIVE Manages the Department of Nursing in accordance with policy and procedure, state and federal regulations to promote high quality care and service to the facility and community . KEY RESPONSIBILITIES . Implements policies/procedures with follow-up and supervision of staff to ensure compliance . Cross reference F 224 and F 281 RI #29 was admitted to the facility and the staff suspected the resident had a [MEDICAL CONDITION] (C. diff) infection. On 2/25/2016, the physician ordered a stool specimen to be collected. This laboratory test was not obtained until 3/8/2016, 12 days later. On 3/1/2016, the resident was ordered [MEDICATION NAME], an antibiotic medication, to be administered four times a day for 10 days for a [DIAGNOSES REDACTED] infection. RI #29 only received approximately half of the ordered antibiotic medication. Once the laboratory test confirmed a positive [DIAGNOSES REDACTED]. During this period of time, the resident still only received approximately half of the ordered antibiotic medication. The facility staff acknowledged, they did not monitor the bowel movements of RI #29, a resident diagnosed with [REDACTED]. On 3/10/2016, RI #29 was diagnosed with [REDACTED]. diff and was ordered to have Intravenous (IV) Therapy of Normal Saline (NS). After three unsuccessful attempts of IV insertion, the facility made no further attempts to initiate RI #29's IV Therapy. The facility did receive an order to push oral hydration for the night; however, they did not document how much fluids were offered to the resident nor did they document how much fluids the resident consumed, when it was ordered to push oral hydration on 3/10/2016. During a [MEDICAL TREATMENT] treatment on 3/14/2016, four days later, RI #29 had to be sent to the local hospital for a decreased blood pressure. After receiving IV therapy of NS, the resident's blood pressure increased and he/she was discharged back to the nursing facility. On 3/25/2016, RI #36 complained of painful urination and was ordered a urinalysis and urine culture. This ordered urinalysis and urine culture was not collected by the nursing staff until three days later, 3/28/2016. On 3/31/2016, RI #12 was ordered to have a stool specimen collected to rule out and/or confirm a [DIAGNOSES REDACTED]. This laboratory test was not collected until 4/4/2016, four days later. On 4/8/2016, RI #33 was ordered to have a stool specimen collected to rule out and/or confirm a [DIAGNOSES REDACTED]. This laboratory test was not collected until 4/14/2016, six days later. In an interview on 4/13/2016 at 2:30 PM, Employee Identifier (EI) #27, a Licensed Practical Nurse (LPN) was asked, what was the facility's procedure for lab collections. EI #27 stated, for stool and urine samples, the nursing staff collected it and someone from the lab came to pick up it. EI #27 acknowledged that the facility did not keep evidence of requested lab orders, but stated since EI #29 (interim Director of Nursing Service) came to the facility, the nursing staff is now transcribing physician orders [REDACTED]. During an interview on 4/15/2016 at 3:43 PM, EI #29, the interim Director of Nursing Service (DNS) acknowledged that prior to her coming to the facility, the facility had no evidence of how they followed up to ensure physician ordered laboratory tests was collected as ordered. EI #29 stated since she had been in the facility, she had instructed the nursing staff to place all physician ordered laboratory (lab) tests on the MAR, once the order is written, so that there would be some type of accountability. When the facility's policy and procedure was requested, the State Agency was given the laboratory contract, which did not indicate how the nursing staff would obtain, process and follow through with physician ordered lab work. ******************** Refer to submitted Acceptable Allegation of Compliance for F 224 and F 281 ******************** This deficiency was cited as a result of the investigation of complaint/report number AL 380.

Based on interviews and record reviews, the facility failed to adequately monitor and intervene when Resident Identifier (RI) #29 was admitted to the facility and the staff suspected the resident had a [MEDICAL CONDITION] (C. diff) infection. On 2/25/2016, the physician ordered a stool specimen to be collected. This laboratory test was not obtained until 3/8/2016, 12 days later. On 3/1/2016, the resident was ordered [MEDICATION NAME], an antibiotic medication, to be administered four times a day for 10 days for a [DIAGNOSES REDACTED] infection. RI #29 only received approximately half of the ordered antibiotic medication. Once the laboratory test confirmed a positive [DIAGNOSES REDACTED]. During this period of time, the resident still only received approximately half of the ordered antibiotic medication. The facility staff acknowledged, they did not monitor the bowel movements of RI #29, a resident diagnosed with [REDACTED]. On 3/10/2016, RI #29 was diagnosed with [REDACTED]. diff and was ordered to have Intravenous (IV) Therapy of Normal Saline (NS). After three unsuccessful attempts of IV insertion, the facility made no further attempts to initiate RI #29's IV Therapy. The facility did receive an order to push oral hydration for the night; however, they did not document how much fluids were offered to the resident nor did they document how much fluids the resident consumed, when it was ordered to push oral hydration on 3/10/2016. During a [MEDICAL TREATMENT] treatment on 3/14/2016, four days later, RI #29 had to be sent to the local hospital for a decreased blood pressure. After receiving IV therapy of NS, the resident's blood pressure increased and he/she was discharged back to the nursing facility. These deficient practices placed RI #29, one of four sampled residents reviewed for Infection Control in Immediate Jeopardy, as it was likely to cause serious injury, harm and/or death. Immediate Jeopardy is a situation in which the facility's noncompliance with one or more requirements of participation has allowed/caused/resulted in, or is likely to allow/cause/result in serious injury, harm, impairment, or death to a resident; and requires immediate correction, as the facility either created the situation or allowed the situation to continue by failing to implement preventative or corrective measures. On 4/15/2016 at 8:39 PM, the facility's Vice President of Operation, Corporate Registered Nurse, interim Administrator, Administrator in Training, interim Director of Nursing Services, and Unit Manager were notified of the findings of substandard quality of care at the immediate jeopardy level of J in the area of Resident Behavior & Facility Practices, F 224. Findings include: On 4/8/2016, the State Agency received a complaint, which alleged a resident had diarrhea and a stool culture was ordered. According to the complainant, the stool culture was either not collected or lost and it had to be ordered again. According to the Centers for Disease Control and Prevention (CDC), [MEDICAL CONDITION] is a germ that can cause diarrhea. Most cases of [DIAGNOSES REDACTED] infection occur in patients/residents taking antibiotics. The most common symptoms of a [DIAGNOSES REDACTED] infection include: watery diarrhea, fever, loss of appetite, nausea and belly pain and tenderness. [DIAGNOSES REDACTED] is a common cause of acute diarrhea in nursing homes. The elderly and people with certain medical problems have the greatest chance of getting [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] spores can live outside the human body for a very long time and may be found on things in the environment such as bed lines, bed rails, and medical equipment. [DIAGNOSES REDACTED] infection can spread from person-to-person on contaminated equipment and on the hands of doctors, nurses, other healthcare providers and visitors. RI #29 was admitted to the facility on [DATE] with a medical history to include: End Stage [MEDICAL CONDITION], Dependency on [MEDICAL TREATMENT], Muscle Weakness, Anorexia and Dysphagia. RI #29's Departmental Notes dated 2/25/2016 12:19 PM, written by Employee Identifier (EI) #13, an Licensed Practical Nurse (LPN) documented, . Resident was admitted to facility last night . Resident is having very lose (loose) stools and . confused to time and place . During an interview on 4/14/2016 at 2:13 PM, EI #13, an LPN stated when she saw the resident on 2/25/2016, she smelled the resident's bowel movement and told the nurse practitioner and the charge nurse that the resident's bowel movement smelled as if the resident had [DIAGNOSES REDACTED]. RI #29's physician's orders [REDACTED]. This order was noted and faxed by EI #27, an LPN. In an interview on 4/13/2016 at 2:30 PM, EI #27, an LPN was asked, what was the facility's procedure for lab collections. EI #27 stated, for stool and urine samples, the nursing staff collected it and someone from the lab came to pick up it. EI #27 was asked to review RI #29's medical record and find evidence that the stool sample ordered on [DATE] was collected. According to EI #27, these lab tests were not collected until 3/8/2016, 12 days later. When asked, if the test was ordered on [DATE], when should the labs be collected, EI #27 stated for the stool specimen, the next time the resident had a bowel movement. RI #29's Certified Registered Nurse Practitioner (CRNP)'s progress note dated 2/29/2016 indicated RI #29 was having regular bowel movements. RI #29's physician's orders [REDACTED].#29 was ordered [MEDICATION NAME] 500 milligram (mg) one tablet by mouth (po) four times a day (QID) for 10 days for [DIAGNOSES REDACTED]. According to an article titled Clinical Practice Guidelines for [MEDICAL CONDITION] Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) electronically published 3/22/2010, [MEDICATION NAME] ([MEDICATION NAME]) is the drug of choice for the initial episode of mild-to-moderate [MEDICAL CONDITION] infection. The dosage is 500 mg orally three times per day for 10-14 days. RI #29's eMAR (electronic Medication Administration Record) for March 2016, indicated on 3/1/2016, the resident was ordered to receive [MEDICATION NAME] 500 mg four times a day, at 5:00 AM, 1:00 PM, 5:00 PM and 9:00 PM for 10 days. Of the 40 scheduled doses, RI #29 only received 29 doses. RI #29 was not administered 11 doses -- six doses were refused by the resident; four doses were not administered because the resident was at [MEDICAL TREATMENT] and one dose was not administered because the nurse indicated the resident was no longer on contact isolation. In an interview on 4/15/2016 at 11:52 AM, EI #5, the Registered Nurse (RN) Unit Manager of the unit RI #29 resided on was asked, when a resident is scheduled for [MEDICAL TREATMENT], what does the facility do with the medications that were ordered to be administered during the time the resident is out at [MEDICAL TREATMENT]. EI #5 replied, one of two things, either the nurse would hold the medication until the resident returned or contact the physician and ask for a different time for the medication to be administered. EI #5 was ask, how would the nurse know to do this and she replied, they wouldn't. When asked, whose responsibility was it to get the physician to change the times the medication was to be administered, EI #5 said first the nurse, then the Unit Manager should have picked up on it. EI #5 acknowledged that she was the Unit Manager. When asked, who monitored the nurses, EI #5 said the Unit Managers. EI #5 was then asked, should she have informed the nurses to hold RI #29's medications until the resident returned from [MEDICAL TREATMENT] or called the physician to have the administration times changed. EI #5 replied, Yes. When asked, was there any reason, she didn't do it, EI #5 replied it was probably because she was in transition, but explained that she still should have known. When asked, if anyone questioned RI #29 as to why the resident refused medications, EI #5 reviewed RI #29's medical record and replied that she had not seen any documentation. RI #29's CRNP's progress note dated 3/3/2016, documented . Interval History: . Pt (patient) reported to have had diarrhea last week, & orders sample for CDiff test, but I don't see the results . ASSESSMENT and Plan: . recollect stool sample for[DIAGNOSES REDACTED] . RI #29's physician's orders [REDACTED]. On 3/3/2016 (no time listed), EI #5, the RN Unit Manager, wrote a verbal physician's orders [REDACTED]. RI #29's Departmental Notes dated 3/4/2016 12:30 PM, written by EI #5, the RN Unit Manager, documented . addendum: I spoke with (RI #29's sponsor), and notified (him/her) that isolation was d/c'd (discontinued) today because (RI #29) has had formed stools for the last two days . RI #29's BM - details Roster for the time period 2/24/2016 through 3/28/2016, revealed there was no recorded bowel movements for RI #29 for 2/27/2016, 2/28/2016, 2/29/2016, 3/1/2016, 3/2/2016 and 3/3/2016. During an interview on 4/15/2016 at 11:52 AM, EI #5, the RN Unit Manager was asked, who monitored the Certified Nursing Assistants (CNAs) to ensure they provided and charted the care a resident received. EI #5 replied, the nurses. EI #5 explained, the facility had been having problems with the staff not documenting as they should. EI #5 was given RI #29's medical record to review, then asked to provide evidence that RI #29 was having formed stool as she indicated in the physician's orders [REDACTED].#5 stated, there was no documentation. EI #5 explained that she only saw one entry on 3/17/2016 that indicated the resident has a loose stool. EI #5 acknowledged that the facility did not monitor the bowel movements of RI #29, a resident diagnosed with [REDACTED]. RI #29's CRNP's progress note dated 3/7/2016, documented . Interval History: . Staff c/o (complain) pt having loose stools (with) foul odor, worried about CDiff. Pt seen lying in bed says (he/she) is tired today . Assessment and Plan: Diarrhea . (1) Stool sample for CDiff . was ordered on 2/25 but (no) results . RI #29's clinical laboratory report indicated RI #29's stool specimen was collected on 3/8/2016 at 4:45 PM, the lab received the stool specimen on 3/9/2016 and on 3/10/2016 it was confirmed that RI #29 tested positive for [DIAGNOSES REDACTED] toxins and the [DIAGNOSES REDACTED] [MEDICATION NAME]. RI #29's CRNP's progress note dated 3/10/2016, documented . Interval History: . still c/o (complain of) diarrhea, stool culture for CDiff pending . Stool positive for CDiff . ASSESSMENT and Plan: . Dehydration Diarrhea (arrow down) appetite . CDiff . (1) Pt on 10th day of [MEDICATION NAME] (2) [MEDICATION NAME] 500 mg . (3) IV (at) NS @ (at) 50cc/hr . RI #29's physician's orders [REDACTED]. (1) start IV (2) NS (Normal Saline) @ 50cc/hr - dehydration secondary to CDiff . Isolation d/t (due to)[DIAGNOSES REDACTED] . RI #29's Departmental Notes dated 3/10/2016 10:40 PM, documented Attempted to start IV x3 unsuccessful. Notified (EI #5), RN on call. MD on (call) notified spoke with (name) Hold IVF (IV) for tonight and push oral hydration for the night. Will continue to monitor. Call bell within reach. RI #29's physician's orders [REDACTED]. During an interview on 4/15/2016 at 10:39 AM, EI #38, the Registered Dietician (RD) was asked, based on the fact that RI #29 had [DIAGNOSES REDACTED], what were the resident's estimated fluid needs. EI #38 explained that RI #29 was a [MEDICAL TREATMENT] resident, so the resident's estimated fluid needs were assessed to be 1450-1550 ml daily. When asked, how she ensured RI #29 would be offered the estimated daily fluid needs, EI #38 stated through beverages offered three times a day with each meal. EI #38 explained that she had no way of knowing exactly what RI #29 would have been offered. When asked, was she aware that RI #29 was ordered an IV on 3/10/2016, EI #38 said no. When asked, what was meant by push oral hydration, EI #38 said, encourage the resident to take fluids, but nothing different from what the staff already did. EI #38 was asked, how the staff would monitor to ensure that oral hydration was pushed and she stated she was not sure, that it could have been a nursing policy. RI #29's Meal and Snack Intake . record dated 2/24/2016 through 3/28/2016, revealed the staff did not document the amount of fluids offered or the amount of fluids consumed by the resident during each meal. In a telephone interview on 4/14/2016 at 10:35 AM, RI #29's sponsor stated the physician ordered the facility to start an IV for fluids for the resident. According to RI #29's sponsor, the facility staff said they were not able to find a vein, so they never started the IV. The sponsor then stated, she was told by the CRNP that the facility would push fluids. The sponsor then stated, she asked the CRNP, how was the facility going to push fluids on someone who did not want to eat or drink. The sponsor stated she did not receive an answer from the CRNP. RI #29's sponsor explained how the cans of fluids the facility was supposed to administer to the resident, sat on the resident's over bed table lined up in a row, untouched. During an interview on 4/15/2016 at 11:52 AM, EI #5, the Registered Nurse (RN) Unit Manager acknowledged that after 3/10/2016, the facility did not attempt to insert an IV in RI #29 for hydration. When asked, should the facility staff have attempted to insert an IV after 3/10/2016, EI #5 said yes. EI #5 was asked, did anyone contact the physician and inform him that the IV was not inserted and the resident needed to be sent to the local hospital for IV insertion, EI #5 said no. When asked to explain, how the staff pushed oral hydration, EI #5 stated every two hours offer 240 cc of fluids to the resident. EI #5 explained, this approach should have been placed on the MAR (Medication Administration Record) so the nurses would know and the Certified Nursing Assistants (CNAs) could help. EI #5 stated this would have been the right thing to do. When asked, was that done, EI #5 said no. RI #29's March 2016 eMAR (electronic Medication Administration Record) did not indicate how much fluids were offered to the resident nor did it include the amount of fluids the resident consumed, when it was ordered to push oral hydration on 3/10/2016. A review of RI #29's Departmental Notes for March 2016, did not indicate how much fluids RI #29 was offered nor did it indicate how much fluids, RI #29 consumed from 3/10/2016 to 3/28/2016. According to an article titled, C. difficile infection published by the Mayo Clinic dated 7/15/2013, . Complications of [DIAGNOSES REDACTED]icile infections include: Dehydration. Severe diarrhea can lead to a significant loss of fluids and electrolyte. This makes it difficult for your body to function normally and can cause blood pressure to drop to dangerously low levels . RI #29's eMAR (electronic Medication Administration Record) for March 2016, the resident was scheduled to receive [MEDICATION NAME] 500 mg four times a day, at 5:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. Of the 24 scheduled doses, RI #29 only received 14 doses. RI #29 was not administered 10 doses -- five doses were refused by the resident and five doses were not administered because the resident was at [MEDICAL TREATMENT]. In an interview on 4/15/2016 at 8:06 PM, EI #34, a Licensed Practical Nurse (LPN) acknowledged that she administered medications to RI #29 while the resident was in the facility. When asked, if the resident had any problems with taking his/her medications, EI #34 stated, the resident took the smalls pills, but struggled to take the large pills. EI #34 was asked, if the physician was notified, that the resident refused medications and she stated, Not by me. During a telephone interview on 4/16/2016 at 12:30 PM, EI #37, the LPN who documented RI #29 did not receive [MEDICATION NAME] on 3/13/2016 at 1:00 PM, because the resident stated the medication made him/her sick, acknowledged that she remembered RI #29. EI #37 stated she offered the medication three times and when the resident refused it, she documented the reason on the eMAR. When asked, was the physician notified when RI #29 refused medication, EI #37 admitted , she did not notify the physician. According to a CDC article titled [MEDICAL CONDITION] Infection Information for Patients last updated 2/24/2015, . Antibiotics can be life-saving medicines . complete the prescribed course of treatment . In a telephone interview on 4/14/2016 at 10:35 AM, RI #29's sponsor was asked, if the resident ever refused medications. RI #29's sponsor stated, yes. When asked why, RI #29's sponsor stated, the resident's stomach hurt and the resident thought the medication was caused his/her stomach to hurt. In an interview on 4/15/2016 at 11:52 AM, EI #5, the RN Unit Manager was asked, if anyone at the facility tried to determine why RI #29 refused medications. EI #5 reviewed RI #29's medical record and stated, that she didn't see any documentation to prove that someone did. During a [MEDICAL TREATMENT] treatment on Monday, 3/14/2016 RI #29 was sent to the local emergency room (ER) for a decreased blood pressure. According to the local hospital's emergency department record, on 3/14/2016 around 2:52 PM, RI #29 arrived in the ER from [MEDICAL TREATMENT] with complaints of low blood pressure and the resident was only able to complete two hours of [MEDICAL TREATMENT]. RI #29's blood pressure was listed as 85/59. RI #29 received a bolus IV of 500 ml of Normal Saline (NS). After the bolus IV of NS, the resident's blood pressure increased to 105/68. RI #29 was discharged back to the nursing facility at 11:22 PM on 3/14/2016. ******************** On 4/16/2016 at 2:00 PM, the facility submitted an Acceptable Allegation of Compliance, which documented: Canterbury Health Care Facility Allegation of Compliance 4/15/2016 Re: Resident #29 admitted [DATE] Discharge 3/28/2016 F224-Date of alleged immediacy removal 4/16/2016 1. Audit all resident lab orders to identify any stool culture orders that have not been collected. a. One resident identified that had a pending stool culture order. Stool was collected within 24 hours of obtaining order. Lab results were obtained 4/16 and were negative. 2. Audit all resident physician orders [REDACTED]. a. One resident was identified in the facility as having an order for [REDACTED]. Identify any resident refusing current [MEDICATION NAME] order. a. No residents were identified to be refusing [MEDICATION NAME] 3. Pull BM (bowel movement) flowsheets on all residents and audit for any resident having loose stools. a. All resident BM sheets were reviewed and residents with recorded loose stools were identified. Nursing reviewed nurse's notes and medication list as well as interviewed staff to see if any s/s (signs/symptoms) of CDiff were present other than an occasional loose stool. No residents with s/s of CDiff were identified. 4. In-Service nurses and CNAs (Certified Nursing Assistants) on proper BM documentation a. In-service page to all nursing staff was sent out 4/15. b. All staff in house overnight on 4/15 were in-serviced. c. In-services to remainder of nursing staff will be on going as staff come in to work for their shift. 5. In-Service nurses on proper supporting documentation when discontinuing isolation. a. In-service page to all nursing staff was sent out 4/15. b. All staff in house overnight on 4/15 were in-serviced. c. In-services to remainder of nursing staff will be on going as staff come in to work for their shift. 6. In-Service nurses on notification of MD (Medical Doctor) when residents refuse medication. a. In-service page to all nursing staff was sent out 4/15. b. All staff in house overnight on 4/15 were in-serviced. c. In-services to remainder of nursing staff will be on going as staff come in for their shift. 7. All Residents on [MEDICAL TREATMENT] to have medication review and a plan on how to administer any medications while they are at [MEDICAL TREATMENT]. a. 13 Residents were identified to be receiving [MEDICAL TREATMENT] services. b. DNS (Director of Nursing Service) or designee are contacting physician's for all 13 residents to obtain orders to rearrange medication and treatments to a time that resident is at the facility as most of these residents are unable to manage their medications while out at [MEDICAL TREATMENT]. 8. DON (Director of Nursing) or designee will monitor CNA documentation during daily clinical start up and address missing documentation accordingly. ******************** After reviewing the facility's information provided in their Allegation of Compliance (AOC), inservice records completed as of 4/16/2016 and interviews with facility staff, it was determined the facility had implemented their AOC, the immediate jeopardy was relieved and the scope and severity was lowered to a D level on 4/16/2016 at 4:45 PM. This deficiency was cited as a result of the investigation of complaint/report number AL 380.

Based on interviews and record reviews, the facility failed to administer medications and collect laboratory tests as ordered by the physician: On 2/25/2016, the physician ordered a stool specimen to be collected on Resident Identifier (RI) #29, after it was suspected the resident had a [MEDICAL CONDITION] (C. diff) infection. This laboratory test was not collected until 3/8/2016, 12 days later. On 3/10/2016, it was confirmed that RI #29 tested positive for the [DIAGNOSES REDACTED] [MEDICATION NAME] and the [DIAGNOSES REDACTED] toxin. On 3/25/2016, RI #36 complained of painful urination and was ordered a urinalysis and urine culture. This ordered urinalysis and urine culture was not collected by the nursing staff until three days later, 3/28/2016. On 3/31/2016, RI #12 was ordered to have a stool specimen collected to rule out and/or confirm a [DIAGNOSES REDACTED]. This laboratory test was not collected until 4/4/2016, four days later. On 4/8/2016, RI #33 was ordered to have a stool specimen collected to rule out and/or confirm a [DIAGNOSES REDACTED]. This laboratory test was not collected until 4/14/2016, six days later. These deficient practices affected RI #29, RI #12, RI #33 and RI #36, four of five sampled residents reviewed for infection control. The failure to follow the physician's orders [REDACTED]. Immediate Jeopardy is a situation in which the facility's noncompliance with one or more requirements of participation has allowed/caused/resulted in, or is likely to allow/cause/result in serious injury, harm, impairment, or death to a resident; and requires immediate correction, as the facility either created the situation or allowed the situation to continue by failing to implement preventative or corrective measures. On 4/15/2016 at 8:39 PM, the facility's Vice President of Operation, Corporate Registered Nurse, interim Administrator, Administrator in Training, interim Director of Nursing Services, and Unit Manager were notified of the findings of immediate jeopardy level of J in the area of Resident Assessment, F 281. The facility further failed to follow a physician's orders [REDACTED].#15's Peripherally Inserted Central Catheter (PICC) line, to change RI #13's PICC line dressing and RI #20's catheter. These deficient practices affected RI #13 and RI #15, two of three residents identified by the facility as having a PICC line; and RI #20, one of three sampled residents with a catheter. Findings include: Chapter 23 titled Legal Implications in Nursing Practice page 305 of Fundamentals of Nursing Eighth Edition with a copyright date of 2013, documented Health Care Providers' Orders. The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe the orders are in error or harm patients . 1) On 4/8/2016, the State Agency received a complaint, which alleged a resident had diarrhea and was ordered a stool culture. According to the complainant, the stool culture was either not collected or lost and it had to be ordered again. RI #29 was admitted to the facility on [DATE] with a medical history to include: End Stage [MEDICAL CONDITION], Dependency on [MEDICAL TREATMENT], Muscle Weakness, Anorexia and Dysphagia. RI #29's Departmental Notes dated 2/25/2016 12:19 PM, written by Employee Identifier (EI) #13, a Licensed Practical Nurse (LPN) documented . Resident was admitted to facility last night . Resident is having very lose (loose) stools and . confused to time and place . During an interview on 4/14/2016 at 2:13 PM, EI #13, a LPN stated when she saw the resident on 2/25/2016, she smelled the resident's bowel and told the nurse practitioner and the charge nurse that the resident's bowel smelled as if the resident had [DIAGNOSES REDACTED]. RI #29's physician's orders [REDACTED]. This order was noted and faxed by EI #27, a LPN. In an interview on 4/13/2016 at 2:30 PM, EI #27, a LPN was asked, what was the facility's procedure for lab collections. EI #27 stated, for stool and urine samples, the nursing staff collected it and someone from the lab came to pick up it. EI #27 was asked to review RI #29's medical record and find evidence that the stool sample ordered on [DATE] was collected. According to EI #27, these lab tests were not collected until 3/8/2016, 12 days later. When asked, if the test was ordered on [DATE], when should the labs be collected, EI #27 stated for the stool specimen, the next time the resident had a bowel movement. RI #29's CRNP's progress note dated 3/3/2016, documented . Interval History: . Pt (patient) reported to have had diarrhea last week, & orders sample for CDiff test, but I don't see the results . ASSESSMENT and Plan: . recollect stool sample for[DIAGNOSES REDACTED] . RI #29's physician's orders [REDACTED]. On 3/3/2016 (no time listed), EI #5, the RN Unit Manager, wrote a verbal physician's orders [REDACTED]. RI #29's Departmental Notes dated 3/4/2016 12:30 PM, written by EI #5, the RN Unit Manager, documented . addendum: I spoke with (RI #29's sponsor), and notified (him/her) that isolation was d/c'd (discontinued) today because (RI #29) has had formed stools for the last two days . RI #29's BM - details Roster for the time period 2/24/2016 through 3/28/2016, revealed there was no recorded bowel movements for RI #29 for 2/27/2016, 2/28/2016, 2/29/2016, 3/1/2016, 3/2/2016 and 3/3/2016. During an interview on 4/15/2016 at 11:52 AM, EI #5, the RN Unit Manager was given RI #29's medical record to review, then asked to provide evidence that RI #29 was having formed stool as she indicated in the physician's orders [REDACTED].#5 stated, there was no documentation. RI #29's CRNP's progress note dated 3/7/2016, documented . Interval History: . Staff c/o (complain) pt having loose stools (with) foul odor, worried about CDiff. Pt seen lying in bed says (he/she) is tired today . Assessment and Plan: Diarrhea . (1) Stool sample for CDiff . was ordered on 2/25 but (no) results . RI #29's clinical laboratory report indicated RI #29's stool specimen was collected on 3/8/2016 at 4:45 PM, the lab received the stool specimen on 3/9/2016 and on 3/10/2016 it was confirmed that RI #29 tested positive for [DIAGNOSES REDACTED] toxins and the [DIAGNOSES REDACTED] [MEDICATION NAME]. ******************** On 4/16/2016 at 2:00 PM, the facility submitted an Acceptable Allegation of Compliance, which documented: Canterbury Health Care Facility Allegation of Compliance 4/15/2016 Re: Resident #29 . F281 1. In-Service nurses on following physician orders [REDACTED]. a. In-service page to all nursing staff was sent out 4/15. b. All staff in house overnight on 4/15 were in-serviced. c. In-services to remainder of nursing staff will be ongoing as staff come in for their shift. 2. Audit all resident lab orders to identify any stool cultures orders that have not been collected. a. One resident identified that had a pending stool culture order. Stool was collected within 24 hours of obtaining order. Lab results pending . ******************** After reviewing the facility's information provided in their Allegation of Compliance (AOC), inservice records completed as of 4/16/2016 and interviews with facility staff, it was determined the facility had implemented their AOC, the immediate jeopardy was relieved and the scope and severity was lowered to a E level on 4/16/2016 at 4:45 PM. 2) RI #33 was readmitted to the facility on [DATE]. On 4/8/2016, the physician ordered a stool specimen to be collected on RI #33 to rule out and/or confirm a [DIAGNOSES REDACTED]. RI #33's clinical laboratory (lab) report indicated the stool specimen was collected and received on 4/14/2016. The lab report further indicated on 4/15/2016, RI #33 was negative for the [DIAGNOSES REDACTED] toxin and the [DIAGNOSES REDACTED] [MEDICATION NAME]. In an interview on 4/16/2016 at 1:46 PM, Employee Identifier (EI) #22, a Registered Nurse (RN) Unit Manager acknowledged that on 4/8/2016, RI #33 was ordered a stool specimen to be collected for [DIAGNOSES REDACTED]; however, the it was not until 4/14/2016 that the specimen was collected. When asked if RI #33 had a bowel movement, EI #22 reviewed RI #33's bowel movement flow sheet and stated, RI #33 had a bowel movement every day. EI #22 was asked, why was there a delay in collecting the stool specimen and he stated, he did not know. 3) RI #36 was admitted to the facility on [DATE]. RI #36 was seen by the Nurse Practitioner, Employee Identifier (EI) #12, on 3/25/2016 as documented in the Progress Notes. The nurse practitioner noted: .per therapy- pt (patient) reports pain when urinating . The Nurse Practitioner ordered a urinalysis with culture due to [DIAGNOSES REDACTED]. This order was also documented on the written physician's order [REDACTED]. On 03/28/2016 a second order was written by EI #12 for the following: . UA (urinalysis) C&S (culture and sensitivity) (if not collected 3/25) . On 3/29/2016, RI #36 was seen by the physician due to urinary tract infection [MEDICAL CONDITION] symptoms and pain. The physician noted the urine culture was still pending but diagnosed the resident with a UTI. Review of the laboratory report for RI #36 ' s urine culture revealed the specimen was not collected until 3/28/2016 at 7:00 PM, after the second order was written. Employee Identifier (EI) #5, the Registered Nurse (RN) Unit Manager of the unit RI #36 resided on, was interviewed on 4/16/2016 at 3:30 PM. She stated RI #36's urine culture was not collected until 3/28/2016 after a second order was written. When asked how collecting the urine specimen when it was ordered could have impacted RI #36's treatment, EI #5 stated the resident could have received treatment sooner. 4) RI #12 was admitted to the facility on [DATE].RI #12's physician's orders [REDACTED].A Departmental Note for RI #12 documented: 3/31/2016 6:31 PM Role: Nursing . Call placed to (name of sponsor) to inform her of new order to collect stool specimen for [MEDICAL CONDITION] .A review of RI #12's BM (Bowel Movement) - details Roster revealed RI #12 had a large loose stool on 3/31/2016, a medium soft stool on 4/1/2016, a medium soft stool on 4/2/2016 and a medium soft stool on 4/3/2016.RI #12's Departmental Notes dated 4/4/2016 12:09, indicated stool for collected for RI #12's [DIAGNOSES REDACTED] culture. On 4/16/2016 at 2:27 PM, the surveyor conducted a phone interview with EI #32, the Certified Nursing Assistant (CNA) caring for RI #12 on 4/1/16 when RI #12 had a medium soft stool. The surveyor asked EI #32, when a resident needs a stool sample, how do the nurses communicate that to the CNAs. EI #32 said the nurses give the CNAs a specimen cup for the stool sample and a plastic bag to place it in after collection. EI #32 said she did not recall a nurse telling her RI #12 needed a stool sample.On 4/16/2016 at 1:18 PM, the surveyor conducted a phone interview with EI #33, the CNA caring for RI #12 on 4/2/16 when RI #12 had another medium soft stool. The surveyor asked EI #33 did she remember a nurse asking her to get a stool sample on RI #12. EI #33 said not that she recalled. EI #33 said if a nurse had asked her to get a stool sample on RI #12 she would have.On 4/16/2016 at 1:53 PM, a phone call to EI #27, the Licensed Practical Nurse (LPN) who noted the order for RI #12's stool sample for [DIAGNOSES REDACTED], was placed; however, EI #27 did not answer and no return call was made prior to the survey team exiting the facility on 4/16/2016. 5) RI #13 was readmitted to the facility on [DATE]. On 2/25/16, the facility received a physician's orders [REDACTED].#13's PICC line dressing weekly on Friday. During an observation on 3/20/16 at 6:20 PM and 3/21/16 at 8:34 PM, RI #13's PICC line dressing was dated 3/11/16. In an interview on 3/22/16 at 5:37 PM, Employee Identifier (EI) #5, a Registered Nurse (RN) was asked, who was responsible for changing a resident's PICC line dressing. EI #5 said a nurse. When asked, when RI #13's PICC line dressing should have last been changed, EI #5 said on 3/18/16. EI #5 was asked, why RI #13's PICC line dressing had not been changed since 3/11/16. EI #5 answered, it really was an oversight. When asked, what the potential harm could be from not changing the PICC line dressing as ordered, EI #5 said, the resident could be put at risk for an infection. 6) RI #15 was readmitted to the facility on [DATE]. RI #15's physician's progress note dated 1/14/16, documented . PICC line area (L) breast. Order to remove it. Sutures removed from PICC line . Gentle pressure wouldn't remove catheter. No other attachment device seen . Will need maybe excision at site. Will send out for this . RI #15's physician's orders [REDACTED]. removal of old PICC (L) (left) SC ([MEDICATION NAME]). RI #15's physician's orders [REDACTED].@ (at) (local hospital) for PICC removal left SC. RI #15's physician's progress note dated 3/1/16, documented . (RI #15) c/o (complained of) PICC line needing to be taken out. Will set this up ASAP (as soon as possible) . RI #15's physician's orders [REDACTED]. RI #15's PROGRESS NOTE from the local hospital dated 3/3/16 10:20 AM, indicated RI #15's PICC line was removed. RI #15's Departmental Notes dated 3/3/16 11:00 AM, documented Returned from PICC line removal via stretcher. Dressing to left chest dry, intact. In an interview on 3/22/16 at 4:09 PM, Employee Identifier (EI) #3, a Licensed Practical Nurse (LPN) was asked, why RI #15's physician's orders [REDACTED]. EI #3 said, he wasn't aware of the order. During an interview on 3/22/16 at 2:22 PM, EI #22, a Registered Nurse (RN) Supervisor, offered no answers as to why RI #15's physician's orders [REDACTED]. 7) RI #20 was readmitted to the facility on [DATE]. RI #20's March 2016 physician's orders [REDACTED]. CHANGE OUT FOLEY [MEDICATION NAME] (CATHETER) EVERY MONTH ON THE 3RD . According to RI #20's March 2016 eMAR (electronic Medication Administration Record), the space where the staff would document, they had changed out RI #20's catheter on 3/3/16 was blank. In an interview on 3/21/16 at 2:40 PM, Employee Identifier (EI) #13, the Licensed Practical Nurse/Treatment Nurse, was asked when was RI #20's catheter changed. EI #13 said she didn't know. When asked, when should the catheter have been changed, EI #13 said on 3/3/16. EI #13 acknowledged that she took full responsibility for not changing out the resident's catheter as ordered by the physician. When asked, what potential harm could occur in not changing the catheter as ordered, EI #13 said infection and the catheter could become worn. This deficiency was cited as a result of the investigation of complaint/report number AL 343 and AL 380.

Based on interviews and record review, the facility failed to provide sufficient fluids to maintain Resident Identifier (RI) #29's hydration status. The facility further failed to monitor the resident's intake of fluids and the output of urine; and notify the physician that an ordered Intravenous (IV) Therapy was not completed to prevent further dehydration. This deficient practice affected RI #29, one of seven residents reviewed for hydration. Findings include: The facility's policy titled Hydration (including Dehydration Risk Factors and Identification dated 8/1/2012, documented PURPOSE It is the policy of this facility that each resident will be provided with sufficient fluid* intake through dietary and nursing interventions to maintain proper hydration. PROCEDURE . If the staff recognizes that the resident is at risk for possible dehydration a problem shall be immediately noted on the care plan and approaches designed and implemented to promote and ensure adequate hydration. Approaches shall include (as a minimum) notification of the physician, consultation with the resident (or legal guardian/family, if appropriate), placement on Intake and Output monitoring and notification of dietary for their Intake and Output monitoring as indicated and notification of dietary for their enlistment in assistance with fluid provision as necessary . RI #29 was admitted to the facility on [DATE] with a medical history to include: End Stage [MEDICAL CONDITION], Dependence on [MEDICAL TREATMENT], Dysphagia and Anorexia. RI #29's February and March 2016's physician orders, indicate RI #29 went to [MEDICAL TREATMENT] three times per week on Monday, Wednesday and Friday. RI #29's physician's orders [REDACTED].@ 50 cc (cubic centimeter)/hr (hour) - dehydration secondary to[DIAGNOSES REDACTED] ([MEDICAL CONDITION]) . RI #29's Departmental Notes dated 3/10/2016 10:40 PM, documented Attempted to start IV x3 unsuccessful. Notified (EI #5), RN on call. MD on (call) notified spoke with (name) Hold IVF (IV) for tonight and push oral hydration for the night. Will continue to monitor. Call bell within reach. RI #29's physician's orders [REDACTED]. According to RI #29's *REGISTERED DIETICIAN EVALUATION . dated 3/1/2016, EI #38, the Registered Dietician (RD) estimated RI #29 required 1450 - 1550 milliliter (ml) of fluid to meet the daily fluid requirements. During an interview on 4/15/2016 at 10:39 AM, EI #38, the RD was asked, based on the fact that RI #29 had[DIAGNOSES REDACTED], what were the resident's estimated fluid needs. EI #38 explained that RI #29 was a [MEDICAL TREATMENT] resident, so the resident's estimated fluid needs were assessed to be 1450-1550 ml daily. When asked, how she ensured RI #29 would be offered the estimated daily fluid needs, EI #38 stated through beverages offered three times a day with each meal. EI #38 explained that she had no way of knowing exactly what RI #29 would have been offered. When asked, was she aware that RI #29 was ordered an IV on 3/10/2016, EI #38 said no. When asked, what is meant by push oral hydration, EI #38 said, encourage the resident to take fluids, but nothing different from what the staff already did. EI #38 was asked, how the staff would monitor to ensure that oral hydration was pushed and she stated she was not sure, that it could have been a nursing policy. RI #29's Meal and Snack Intake . record dated 2/24/2016 through 3/28/2016, and it revealed the staff did not document the amount of fluids offered or the amount of fluids consumed by the resident during each meal. In a telephone interview on 4/14/2016 at 10:35 AM, RI #29's sponsor stated the physician ordered the facility to start an IV for fluids for the resident. According to RI #29's sponsor, the facility staff said they were not able to find a vein, so they never started the IV. The sponsor then stated, she was told by the CRNP that the facility would push fluids. The sponsor then stated, she asked the CRNP, how was the facility going to push fluids on someone who did not want to eat or drink. The sponsor stated she received no answer from the CRNP. According to RI #29's sponsor, the cans of fluids the facility was supposed to administer to the resident, sat on the resident's over bed table lined up in a row, untouched. During an interview on 4/15/2016 at 11:52 AM, EI #5, the Registered Nurse (RN) Unit Manager acknowledged that after 3/10/2016, the facility did not attempt to inset an IV in RI #29 for hydration. When asked, should the facility staff have attempted to insert an IV after 3/10/2016, EI #5 said yes. When asked, what the facility did to prevent further dehydration, EI #5 stated, all the facility could do was to notify the physician, Registered Dietician and [MEDICAL TREATMENT] clinic. When asked, if the physician, RD and [MEDICAL TREATMENT] clinic were notified, EI #5 said no. EI #5 was asked, did anyone contact the physician and inform him that the IV was not inserted and the resident needed to be sent to the local hospital for IV insertion, EI #5 said no. When asked to explain, how the staff pushed oral hydration, EI #5 stated every two hours offer 240 cc of fluids to the resident. EI #5 explained, this approach should have been placed on the MAR (Medication Administration Record) so the nurses would know and the Certified Nursing Assistants (CNAs) could help. EI #5 stated this would have been the right thing to do. When asked, was that done, EI #5 said no. RI #29's March 2016 eMAR (electronic Medication Administration Record) did not indicate how much fluids were offered to the resident nor did it include how much fluid the resident consumed, when it was ordered to push oral hydration on 3/10/2016. A review of RI #29's Departmental Notes for March 2016, did not indicate how much fluids RI #29 was offered nor did it indicate how much fluids, RI #29 consumed from 3/10/2016 to 3/28/2016. During a telephone interview on 4/15/2016 at 10:35 AM, the representative at the [MEDICAL TREATMENT] clinic where RI #29 was dialyzed at, stated RI #29 was ordered to receive [MEDICAL TREATMENT] for three hours and 30 minutes. According to the representative on 3/14/2016, RI #29's weight at the beginning of [MEDICAL TREATMENT] was 64 kilograms (140.8 pounds) and the resident's weight at the conclusion of [MEDICAL TREATMENT] was 63 kilograms (138.6 pounds). The representative further stated that RI #29 only received two hours of the scheduled three hours and 30 minutes [MEDICAL TREATMENT] treatment. During a [MEDICAL TREATMENT] treatment on Monday, 3/14/2016 was sent to the local ER for a decreased blood pressure. The local hospital's emergency department record, indicated on 3/14/2016 around 2:52 PM, RI #29 arrived in the ER from [MEDICAL TREATMENT] with complaints of low blood pressure and the resident was only able to complete two hours of [MEDICAL TREATMENT]. RI #29's blood pressure was listed as 85/59. RI #29 received a bolus IV of 500 ml of Normal Saline (NS). After the bolus IV of NS, the resident's blood pressure increased to 105/68. RI #29 was discharged back to the nursing facility at 11:22 PM on 3/14/2016. This deficiency was cited as a result of the investigation of complaint/report number AL 380.

Based on record reviews and interviews the facility failed to ensure Resident Identifier (RI) #31 received the prescribed medications for [DIAGNOSES REDACTED]. On 9/16/2015, RI #31 was discharged from a local hospital on with [DIAGNOSES REDACTED]. The local hospital gave discharge instructions to the facility to continue the prescribed medications that were listed on the Discharge Summary order sheets. The Discharge summary sheets listed four Hypertension medications; three Cardiac medications; two Anticoagulant/[MEDICAL CONDITION] medications; two Insulin medications; one Cholesterol medication, one Diuretic; one Cerebral stimulant; one Antifungal medication; and one Gastrointestinal/ proton pump inhibitor, a total of 16 medications. The facility failed to ensure medications were administered as order. According to interviews and record reviews, fifteen medications, with the exception of one Anticoagulant/[MEDICAL CONDITION] medication ([MEDICATION NAME]), were not started until 9/22/2015, seven days later. The delay in starting the medications as ordered resulted in the RI #31 missing multiple doses. On 9/23/2015, the facility documented RI #31 started bleeding from the Percutaneous Gastrostomy (PEG) site. The resident's INR level was 1.4, below the recommend normal ranges of 2.0 - 3.0. The [MEDICATION NAME] was held as a result of the lab results. The resident continued to bleed from the PEG site on 9/24/2015. On 9/24/2015 all blood thinner medication was held due to active bleeding. This affected one of three sampled residents receiving anticoagulant therapy and placed RI #31 in Immediate Jeopardy as it was likely to cause serious injury, harm, or death. On 10/30/2015 at 6:30 PM Central Standard Time (CST), the facility's Administrator, EI #1 and the Director of Nursing, EI #2 were notified of the findings of substandard quality of care at the Immediate Jeopardy level of J, past non-compliance, in the area of Quality of Care, F 333. The Immediate Jeopardy began on 9/16/2015 and was relieved on 9/24/2015 when the facility implemented corrective actions to remove the immediate risks and to prevent any further recurrence. Findings Included: Cross reference F 329. A review of the facility policy Medication Policies Prescriber Medication Orders dated 03/11 revealed the following: . Procedures . 4. Written transfer orders . (sent with a resident by a hospital .) A. Unless the order is unclear or incomplete, implement a transfer order without further validation if it is signed and dated by the resident's current attending physician. If the order is unclear, incomplete, or a discrepancy is noted, the order should be clarified with the physician and a new order obtained. B. If the order is unsigned or signed by another Prescriber, the receiving nurse verifies the order with current attending physician before medications are administered. The nurse documents verification . RI #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #31 had a history of [REDACTED]. RI #31's Care plan, with a problem date of 09/16/2015: documented, Medication Alert: I am at risk for abnormal bleeding related to anticoagulant therapy . Administer medication per (by) MD (Medical Doctor) order . Monitor labs (laboratory) and notify MD of results . A review of RI #31's hospital discharge records revealed, PHYSICIAN'S ORDER FORM dated 9/16/15 Discharge pt (patient) to . DC (discharge) meds (medications) per DC (Discharge) Summary and Med (medication) rec (reconciliation) . RI #31's discharge medication orders dated 9/16/2015 documented: Discharge to Acute/Chronic Medical Facility Medication Orders revealed medications as follows: Four Hypertensive medications: [REDACTED] [MEDICATION NAME] 5 mg (Milligrams) 2 tablets daily Carvedilol ([MEDICATION NAME]) 12.5 mg 2 tablets every 12 hours [MEDICATION NAME] ([MEDICATION NAME]) 1 patch [MEDICATION NAME] (to chest wall) every 7 days [MEDICATION NAME] 100 mg 1 tablet three times a day Three Cardiac medications: [REDACTED] Aspirin 325 mg 1 tablet daily [MEDICATION NAME] 30 mg 3 tablets four times a day [MEDICATION NAME] 10 mg 1 tablet every 8 hours One Anticoagulant/[MEDICAL CONDITION]: [MEDICATION NAME] ([MEDICATION NAME]) 2 mg, 3 tablets daily Two Diabetes Mellitus: Insulin [MEDICATION NAME] *Low-Dose* subcutaneous every 6 hours Insulin detmir ([MEDICATION NAME]) 8 units subcutaneous two times a day One Antilipidemic (reduces cholesterol level) Atorvastatin 10 mg daily at bedtime One Loop Diuretics [MEDICATION NAME] ([MEDICATION NAME]) 40 mg half tablet (0.5 tabs) daily One Cerebral Stimulant: Modafinil ([MEDICATION NAME]) 100 mg 1 tablet every AM One Antifungal: [MEDICATION NAME] 5 (ML) milliliters four times a day One Gastrointestinal/Proton Pump Inhibitor: Pantoprazole ([MEDICATION NAME]) 40 mg delayed release tablet daily The discharge medication orders received from the hospital were not started by the facility until 09/22/15, seven days after RI #31's admission. A review of RI #31's Physician's Orders for the month September 2015 revealed RI #31 was admit to the Skilled Nursing Facility and treat as indicated. [MEDICATION NAME] ([MEDICATION NAME]) 100 mg/ml syringe SQ (subcutaneous) was ordered for 9 AM and 9:00 PM. A review of RI #31's Departmental Notes documented the following: 9/16/2015 6:21 PM . admitted via (by way of) ambulance . bp (blood pressure) 195/78 . 9/20/2015 12:42 PM . BP (blood pressure) 230/100 . 9/22/2015 10:09 PM . Late entry for 7 am to 7 pm shift - At 9:30 am pt (patient) blood pressure noted to be 256/104 . BP was reassessed and (at) 12:00 pm and was 208/98 . A phone interview was conducted on 10/30/2015 at 2:00 PM CST (Central Standard Time) with EI #6, Admission Nurse who admitted RI #31 to the facility on [DATE]. When asked about RI #31's admitting orders, EI #6 replied, I read DC meds as discontinue medications verses discharge medications. EI #6 stated he was aware RI #31 was not receiving any medication. EI #6 was asked what would the harm be in the resident not getting medications as ordered. EI #6 explained that harm could come to anyone if they do not get their medications. On 10/30/15 at 9:15 AM and 11:30 AM (CST) interviews were conducted with EI #7, Registered Nurse. EI #7 was aware RI #31 ' s admission orders [REDACTED]. When asked what was the harm in a resident not getting medications as ordered, EI #7 replied, the conditions they have would not be treated as ordered. EI #7 was asked if she was aware of RI #31's elevated blood pressure. EI #7 replied, yes that was when she (EI #7) asked the Nurse Practioner to see RI #31. EI #7 said that was when it was discovered that the medications on discharge from the hospital were not being given as ordered. On 10/30/15 at 5:00 PM CST in an interview the DON, EI #2. The DON was asked what was the potential harm for RI #31 not getting the resident's medication as ordered. EI #2 replied a resident could have complications related to their diagnoses. Review of facility's MEDICATION ERROR REPORT dated 9/22/2015 completed by the DON, EI #2, revealed . Date(s) of error: 09/16/15 .What was physician's order? Resume all hospital Discharge Medications . Outcome to the resident? RI #31 medications not received as ordered since admit . Which part of the medication administration system failed? Two nurses verify orders on admit was not done. ******************************************************* ALLEGATION OF COMPLIANCE FOR TAG 333 1. RI #31 ADMISSION\MEDICATIONS ORDERS WERE REVIEWED AND RECONCILED AND ADMINISTERED AS ORDERED. 2. ALL ADMISSIONS\READMISSIONS HAVE THE POTENTIAL TO BE IMPACTED BY FAILURE TO ACCURATELY TRANSCRIBE ADMISSION\REadmission orders [REDACTED]\READMISSION REPORT AND PULLED ALL ADMISSION\READMISSION CHARTS FROM 9-16-15 THROUGH 9-28-15 AND ALL WERE AUDITED FOR ACCURACY AND COMPLETENESS. 3. ON 9-22-15, UNIT MANAGER, (EI #7), RN AND (NAME OF EI#4), LPN, INITIATED INSERVICES ON THE FOLLOWING: ADMISSION\READMISSION ORDER ACCURACY, TWO LICENSED NURSES REVIEWING ADMISSION\REadmission orders [REDACTED]\REadmission orders [REDACTED]\REadmission orders [REDACTED]. DISCIPLINARY ACTION WAS DONE ON THE UNIT MANAGER AND ADMISSION NURSE THAT WERE RESPONSIBLE FOR FAILURE TO CORRECTLY TRANSCRIBE ORDERS FOR RI #31. 4. CHART CHECKS WILL BE DONE 5 DAYS A WEEK BY UNIT MANAGER\DESIGNEE AND RESULTS ENTERED ON MONITORING TOOL. DIRECTOR OF NURSING\DESIGNEE WILL REVIEW MONITORING TOOL WEEKLY FOR COMPLIANCE AND ACCURACY. RESULTS OF AUDITS WILL BE REVIEWED BY QAPI (QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT) COMMITTEE MONTHLY TIMES THREE MONTHS AND AS NEEDED.

Based on interviews and record review, the facility failed to ensure RI (Resident Identifier) #1, a resident totally dependent on staff for bed mobility and transfers, who also had a history of [REDACTED]. On 04/14/13, a facility CNA (Certified Nursing Assistant), EI (Employee Identifier) #1, observed RI #1 on the side of the bed with her right arm entangled in the siderail and on her knees. According to EI #1, she left the room, closed the door, and went to get assistance from other staff to help with RI #1. EI #1 said she was not out of the room for more than 2 minutes. EI #1 stated when she and the other staff entered the room, RI #1 was lying on the floor on her left side. In an interview with EI #3, the LPN (Licensed Practical Nurse) assigned to care for RI #1 on the evening of 04/14/13, EI #3 stated RI #1 was complaining of pain to her left leg when she observed the resident on the floor. EI #3 stated an x-ray was obtained confirming RI #1 had sustained a fracture to her left leg. RI #1 was sent to a local ER (emergency room ) for evaluation and treatment of [REDACTED]. Findings Include: RI #1 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #1's Initial MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 03/08/2013, identified RI #1 to have a BIMS (Brief Interview Mental Status) score of 14, indicating no cognitive impairment. RI #1 was assessed as being totally dependent on staff for bed mobility and transfers and having an impairment, on both sides, to the lower extremities. Departmental Notes for RI #1 documented: "04/14/2013 11:34 PM Role: Nursing ... LATE ENTRY FOR 4/14/13 @ (at) 730 (7:30) PM: WRITER CALLED TO ROOM BY CNA (CERTIFIED NURSING ASSISTANT) STATING THAT PATIENT WAS ON THE FLOOR. PATIENT NOTED RESTING ON HER LEFT SIDE ON THE FLOOR. UPON ASSESSMENT, PATIENT COMPLAINED OF PAIN TO HER LEFT HIP/LEG ... CALLED (CALL) PLACED TO MOBILE-X FOR X-RAY OF LEFT HIP D/T (DUE/TO) PAIN ... PATIENT GIVEN ULTRAM PER PRN (AS NEEDED) ORDER FOR PAIN ... Addendum 4/14/2013 11:59 PM WRITER ASKED PATIENT WHAT HAPPENED, SHE STATED SHE WAS ON HER SIDE AND BEGAN TO SLIP OFF THE BED AND COULDN'T CATCH HERSELF ..." A review of RI #1's Radiology Report dated 04/14/2013 at 10:19 PM, documented: " ... Exam: HIP UNI-LAT (LATERAL) MIN 2V (View), Left Results: There is a subtrochanteric fracture with modest displacement ... Conclusion: Displaced left hip fracture as described above. " Departmental Notes for RI #1 documented: "4/14/2013 11:49 PM Role: Nursing ... RECEIVED X-RAY REPORT, CONCLUSION: DISPLACED LEFT HIP FRACTURE-THERE IS A LEFT SUBTROCHANTERIC FRACTURE WITH MODEST DISPLACEMENT ... PLACED CALL TO ON-CALL MD (MEDICAL DOCTOR) ... INFORMED HER OF THE X-RAY RESULTS, GAVE ORDER TO SEND HER (RI #1) TO THE ER FOR EVAL (EVALUATION) ... " RI #1's physician's orders [REDACTED]. "Send to (name of local hospital) ER for eval, tx (treatment) as indicated R/T (Related To) (L) (left) hip fracture." Departmental notes for RI #1 documented: "04/15/2013 12:25 AM Role: Nursing: ... SPOKE WITH (NAME OF NURSE) RN (REGISTERED NURSE) AT (NAME OF LOCAL HOSPITAL) AND GAVE HER REPORT THAT PATIENT WAS BEING TRANSFERRED THERE FOR EVAL R/T DISPLACED LEFT HIP FRACTURE. SPOKE WITH (NAME OF AMBULANCE PERSONNEL) AT (NAME OF AMBULANCE SERVICE) FOR TRANSPORT TO (NAME OF LOCAL HOSPITAL) AND AWAITING THEIR ARRIVAL." A review of RI #1's History and Physical from the local hospital with a date of admission of 04/15/2013, and a patient seen time of 5 a.m., documented: "CHIEF COMPLAINT: Left hip pain. HISTORY OF PRESENT ILLNESS: ... The patient presents with injury to the left hip ... It appears that she took a fall ... PAST SURGICAL HISTORY: 1. Right hip surgery. 2. Cervical disk surgery ... EXTREMITIES: Left lower extremity is shortened and externally rotated. There is significant pain over the left hip. NEUROLOGICAL: Patient is oriented to person and place. She has good movement of the upper extremities. She is limited to the lower extremities ... ASSESSMENT: 1. Left hip fracture ... PLAN: The patient will be admitted for continued care and evaluation of the above. Of utmost important is pain management at this time. The patient does wish to have surgery if this will lessen her discomfort ..." A review of RI #1's Consultation report from the local hospital dated 04/15/2013, documented: " ... REASON FOR CONSULTATION: Left hip fracture. HISTORY OF PRESENT ILLNESS: This is a [AGE] year-old female who was admitted through the emergency room last night due to new onset of a left hip fracture ... The patient appears to be paraplegic and has been nonambulatory since 1993 ... PLAN: The patient is not a surgical candidate as she has minimal pain. There is no significant reason to subject her to the risks of surgery when her pain can be controlled with analgesics ... She is at extremely high risk for increasing the risk of infection in her hip with surgical intervention. The plan is to send the patient back to (name of nursing home) ... Control pain with oral medications ... " Departmental notes for RI #1 documented: "04/15/2013 7:02 PM Role: Nursing ... Resident readmitted to facility from (name of local hospital), resident is status [REDACTED]. On 06/12/13 at 4:30 PM, the surveyor conducted an interview with EI #1, the CNA caring for RI #1 on 04/14/13 on the 2:30 PM - 6:30 PM shift. EI #1 confirmed she did care for RI #1 on 04/14/13. EI #1 stated when she went to check on RI #1, she was wet. EI #1 stated she told RI #1 she would be back. EI #1 stated she was going to get some sheets and someone to help her. The surveyor asked EI #1, when she came back to the room to explain how she found RI #1. EI #1 stated RI #1 was on her knees with her right arm in the side rail. EI #1 stated she asked RI #1 what happened. EI #1 stated RI #1 said she didn't know, just hurry up and get her up. EI #1 stated she went and got EI #2 and EI #3. EI #1 stated when they got back to RI #1's room she was lying on the floor on her left side. EI #1 stated RI #1 said her left leg was a little sore. On 06/12/13 at 6:05 PM, the surveyor conducted an interview with EI #2 (CNA), one of the staff members helping to assist RI #1 off the floor on 04/14/13. EI #2 confirmed she did help to assist RI #1 off the floor. The surveyor asked EI #2 how she became aware that RI #1 was on the floor. EI #2 stated EI #1 told her. EI #2 stated EI #1 asked her to help. The surveyor asked EI #2 where she was when she was asked to help. EI #2 stated she was standing at the computer charting. The surveyor asked EI #2 when she entered the room where was RI #1. EI #2 stated RI #1 was on the floor on the right side of the bed. The surveyor asked EI #2 was RI #1 complaining of pain. EI #2 stated, "Yes. She was rubbing her left leg." On 06/12/13 at 6:55 PM, the surveyor conducted an interview with EI #3, the LPN assigned to care for RI #1 on 04/14/13 on the 2:30 PM - 6:30 PM shift. When asked by the surveyor if RI #1 had a fall from her bed on 04/14/13, EI #3 stated, "She did." The surveyor asked EI #3 how she became aware of the fall. EI #3 stated the CNA, EI #1, came to the desk (nurses station) and told her. EI #3 stated EI #1 had been to the desk earlier to tell her RI #1's dressing on her bottom needed to be changed, then she (EI #1) came back and told her RI #1 had fallen. EI #3 stated when she went into the room, RI #1 was lying on her left side on the floor on the side of the bed. The surveyor asked EI #3 if RI #1 complained of pain. EI #3 stated, "Yes, to her left hip/leg. I gave her Ultram." EI #3 stated when RI #1 complained of pain to her leg she went ahead and ordered an x-ray. The surveyor asked EI #3 what the x-ray revealed. EI #3 stated, "A fracture of the hip." The surveyor asked EI #3 why did she think RI #1 fell from the bed. EI #3 stated RI #1 was a patient that didn't move on her own so she didn't know. The surveyor asked EI #3 if she thought RI #1 was too close to the edge (of the bed when she fell ). EI #3 stated she could have been. The surveyor asked EI #3 if she asked RI #1 what happened. EI #3 stated she did. EI #3 stated RI #1 said she was about to slip out of the bed, felt herself slipping and tried to hang on but couldn't. On 06/13/13 at 12:17 PM, the surveyor conducted an interview with EI #4, the LPN Unit Manager on the unit RI #1 resided. The surveyor asked EI #4 how she became aware RI #1 had fallen from her bed on 04/14/13. EI #4 stated the incident happened over a weekend (04/14/13) and she was notified on Monday (04/15/13). The surveyor asked EI #4 how she thought RI #1 ended up on her knees on the side of the bed. EI #4 stated she didn't know. EI #4 stated she didn't think it was intentional. EI #4 stated she thought it may have been from just the way RI #1 came from the bed. The surveyor asked EI #4 when EI #1 came in the room and saw RI #1 on her knees, what should she have done. EI #4 stated EI #1 should have hollered for help. The surveyor asked EI #4 should EI #1 have left the room. EI #4 stated, "No, unless she was sure the patient was in a safe position." On 06/13/13 at 5:14 PM, the surveyor conducted an interview with EI #5, the LPN Risk Manager. The surveyor asked EI #5 when she was made aware RI #1 had fallen from the bed. EI #5 stated she would have been notified that Monday (04/15/13). EI #5 stated when she read EI #1's statement, EI #1 basically said RI #1 was centered in bed with her legs positioned on top of each other. EI #5 stated EI #1 said she realized RI #1 was wet so she went to get clean linen and when she returned to the room she realized RI #1 was on the side of the bed facing the door with her arm between the side rail as if she was hanging on. EI#5 stated EI #1 said she asked RI #1 what happened and RI #1 said she didn't know, "Baby just help me up." The surveyor asked EI #5 what did EI #1 do at that time. EI #5 stated EI #1 said she told RI #1 she would be right back and ran to get help. EI #5 stated EI #1 said she went to the nurses station and got EI #3 and EI #2 to help her. The surveyor asked EI #5 what should EI #1 have done when she observed RI #1 on her knees. EI #5 stated, "She (EI #1) should have pressed the call light and asked for assistance." On 06/13/13 at 6:06 PM, the surveyor conducted a second interview with EI #1. The surveyor asked EI #1 what should she have done when she observed RI #1 on her knees. EI #1 stated, "Hit the call button for help. This is the first time something like that has happened to me. I panicked. I wasn't gone 2 minutes. I went down to the nurses station. I did close the door behind me." On 06/13/13 at 6:32 PM, the surveyor conducted an interview with EI #6, the facility's DON (Director of Nursing). The surveyor asked EI #6 when was she made aware RI #1 had fallen from the bed. EI #5 stated she actually thought it was immediately. EI #6 stated it was EI #3 that called her to let her know RI #1 had fallen and was complaining of pain and that she (EI #3) was calling the family and sending her (RI #1) to the hospital. The surveyor asked EI #6 when did she find out RI #1 was observed on her knees. EI #6 stated when the facility did their investigation. The surveyor asked EI #6, what should EI #1 have done when she observed RI #1 on her knees. EI #6 stated personally, she would have called on the call light, and had she gone to the door, she would have just yelled for help. EI #6 stated she would have never left the patient. The surveyor asked EI #6 would she have expected her staff to do the same thing. EI #6 stated, "Yes." On 06/13/13 at 7:19 PM, the surveyor conducted an interview with EI #7, the facility's Administrator. The surveyor asked EI #7, according to her interview with EI #1, what did EI #1 say happened when she saw RI #1 on her knees. EI #7 stated EI #1 said RI #1 was on the side of the bed facing the door and was positioned on her knees with her arm between the side rail and the bed. EI #7 stated EI #1 said it looked like RI #1 was hanging on to the side rail of the bed. EI #7 stated EI #1 said after asking RI #1 what happened, RI #1 said "Baby I don't know." EI #7 stated what EI #1 said was at that point, she told RI #1 to hang on and she was going to get help and be right back which is what she said she did. The surveyor asked EI #7, what should EI #1 have done when she observed RI #1 on her knees. EI #7 stated, "I think she (EI #1) reacted at that moment and what we inserviced her to do in the future was if she found a resident in a similar situation to never leave them, press the call light and wait for assistance. In an emergency to call out." A review of the facility's investigative file revealed an inservice was conducted with facility licensed staff on 04/15/13. A page titled, "Fall Prevention/Emergency Response" documented: "When you enter a room and find a resident on the floor, NEVER leave them. You should press the call light and wait for assistance. In an EMERGENCY situation, call out for help. When providing care to a resident on the air mattress, ensure they are positioned in the center. An uneven distrubution of weight may cause the mattress to shift which could result in the resident rolling out of the bed. When providing care, residents should NEVER be left on the edge of any bed when you are leaving the room. Residents found half in/out of the bed should always be lowered to the floor immediately. Place the bed in the lowest position if possible in an attempt to prevent injury to yourself and the resident ..." ******************************************************** Below is the facility's Plan Of Correction to the Past-Noncompliance Citation for F 323: 4/14/13 at 7:30 pm resident noted to be on floor, on left side with c/o (complained of) pain, new order for x-ray to be completed to left hip, as needed Ultram given. When resident was asked what happened by staff nurse resident stated was on side and began to slip off bed and couldn't catch herself.4/14/13 at approximately 11:49 pm resident x-ray completed and resulted noting a left subtrochanteric fracture with modest displacement. New order to send to ER for evaluation.4/14/13 at approximately 12:25 am resident report given to ER aware of pending arrival, resident sent to (name of local hospital)for evaluation.4/15/13 at approximately 5pm resident readmitted to facility from (name of local hospital), resident was noted to not be a surgical candidate due to osteo[DIAGNOSES REDACTED].4/15/13, Facility wide Nursing and C.N.A. staffing education began on proper turning and repositioning of residents.4/15/13, Staff education began on use of wedge for positioning and what to do in an emergency type situation of (RI #1's name).4/15/13, resident was referred to therapy for positioning and safety of resident.4/15/13, specialty air mattress with bolstered sides ordered for resident's use.4/19/13, resident was placed on specialty air mattress with bolstered sides.4/25/13, discharged to the hospital. ******************************************************** On 06/12/13, care was observed being provided to RI #5 and on 06/13/13, care was observed being provided to RI #4. The residents were not left unattended during care. On 06/13/13, inservice sheets were reviewed. Staff assigned to care for RI #1 on 04/14/13 had been inserviced on what to do when observing a resident half in and out of the bed. On 06/12/13 0 06/13/13, interviews were done with additional staff to ensure staff were aware of what to do when observing a resident half in and out of the bed. All staff interviewed responded as knowing what to do. This deficiency was written as a result of the investigation of complaint/report #AL 073.