Every finding on record at Childserve Habilitation Center

Based on observation, clinical record review, staff interview, and policy review, the facility failed to lock the wheelchair during a transfer for 2 of 58 residents dependent on mechanical lift transfers (#4, #57). The facility reported a census of 69 residents.Findings include: 1 Resident #57's Minimum Data Set (MDS) dated [DATE] did not include a Brief Interview for Mental Status (BIMS). The MDS documented that Resident357 (R57) had difficulty with short-term and long-term memory recall. It included diagnoses of spinal cord nerve loss with progressive muscle weakness, chronic respiratory failure, osteoporosis, and scoliosis. It indicated she was dependent with all Activities of Daily Living (ADLs) and mobility. It also indicated she used a wheelchair for mobility.The Care Plan revised 8/07/24 directed staff to use a 2-person side-by-side, mechanical lift for wheelchair transfers.Observation on 6/17/26 at 10:05 AM, included the following; Staff F, Certified Nurse Aide (CNA) and Staff G, Certified Medication Aide (CMA) transferred Resident #57 from her bed to a wheelchair. Staff H, Licensed Practical Nurse (LPN) was present in the room and partially assisted with the transfer. Both Staff F and Staff G positioned the resident on a mechanical lift sling, connected the sling to the mechanical lift, and transferred her to the wheelchair. The wheelchair was unlocked when the resident was lowered and seated in it.On 6/17/26 beginning at 12:09 PM, consecutive interviews revealed Staff I, Registered Nurse (RN) stated resident wheelchairs should be locked when transferring a resident to or from it.At 12:19 PM, Staff J, Registered Nurse (RN) also stated resident wheelchairs should be locked when transferring a resident to or from it.At 12:26 PM, Staff K, Certified Nurses Aide (CNA) also stated resident wheelchairs should be locked when transferring a resident to or from it.At 12:28 PM, Staff L, CNA also stated resident wheelchairs should be locked when transferring a resident to or from it. 2. Resident #4's MDS 3/20/26 did not perform a BIMS because the resident was rarely or never understood. The MDS documented that Resident#4 (R4) had difficulty with short-term and long-term memory. It included diagnoses of cerebral palsy, seizure disorder, and asthma. It indicated he was dependent with all ADLs and mobility. It also indicated he used a wheelchair for mobility.The Care Plan revised 10/27/23 directed staff to use a mechanical lift for wheelchair transfers.On 6/17/26 at 12:44 PM, Staff F, CNA transported Resident #4 to his room in his wheelchair. She pulled the mechanical lift into the room, connected the resident to the lift, and transferred the resident to his bed. The wheelchair was not locked during the transfer.At 12:55 PM, Staff F stated the residents' wheelchairs should've been locked but she left them unlocked because it made it easier to get the wheelchair out of the way once the residents were raised on the mechanical lift.At 1:03 PM, Staff G, CMA stated the wheelchair should've been locked when the resident was transferred to it. She also stated since there were so many staff in the room at the time of the transfer, each member could've thought one of the other staff locked it.The mechanical lift user manual revised 4/01/16 indicated the wheels on a mobile lift must NOT be locked during transfers.On 6/18/26 at 1:03 PM, the Administrator indicated the facility did not have a policy specific to locking wheelchairs during mechanical lift transfers.On 6/18/26 at 1:13 PM, the Clinical Director stated staff should've locked the wheelchair when transferring residents in and out of them.

Based on observation, staff interview, and policy review, the facility failed to implement infection prevention strategies by failing to place the protective cap on the tube feeding tubing connector between feeding schedules for 1 of 2 residents (#26), failing to wear appropriate Personal Protective Equipment (PPE) when providing care for 1 adult resident with invasive devices (#57), and failing to perform hand hygiene during resident care for 1 resident (#57). The facility reported a census of 69 residents.Findings include: 1 Resident #26's Minimum Data Set (MDS) assessment dated indicated a Brief Interview for Mental Status (BIMS) should not be conducted because the resident was rarely or never understood. It included diagnoses of cerebral palsy with spastic quadriplegia (paralysis with involuntary muscle spasms), epilepsy, and asthma. It revealed he was dependent with all aspects of Activities of Daily Living (ADLs) and mobility. It also revealed he had an abdominal feeding tube.The Care Plan initiated 1/16/24 directed staff to follow CDC guidelines for all precautions as needed.A Physician's Order dated 4/24/26 Nutrition. Bolus Feed: Give 212 mL (milliliters) Jevity 1.2 + 85 mL water at 300 mL/hr 4x/day on kangaroo pump via GT (gastric tube = stomach tube) closed system four times a day for Nutrition. Give feeds when up in chair or in chair position in bed.The Medication Administration Record (MAR) revealed the resident received the tube feeding on 6/15/26 at 5:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM.On 6/15/26 at 2:39 PM, the tube feeding tubing tip was not being used and was disconnected from the resident's gastric tube. The transition tip (tip of the tubing that connects directly to the gastric tube entry port) was uncapped and hanging from a pole in the room.On 6/16/26 at 2:31 PM, the resident's tube feeding tubing was uncapped and dangling from a pole. Staff A, Registered Nurse (RN) dated the bottle 6/16.On 6/16/2026 at 2:49 PM, Staff B, Certified Medication Aide (CMA) stated Staff C, RN was the day shift nurse and did not report that Resident #26 did not get his 11:00 AM tube feeding; which she interpreted as he received it.On 6/16/2026 at 3:22 PM, Staff B stated when connecting the resident's tube feeding, there should be a plastic cap on the end of the tubing between uses. She stated she did not notice a cap on the end of the tubing. She also stated she probably should not have used the tubing since there had not been a cap on the end between uses.On 6/16/2026 at 3:38 PM, Staff D, Registered Nurse (RN) stated the facility usually does not have a cap on the tubing tip. She also stated if the tip is on something contaminated, it is cleaned with soap and water or whatever is available at the room sink. She further added the facility does not use caps on tube feeding tubing because the caps sometimes come up missing.On 6/17/26 at 4:00 PM, the Staff E, [NAME] Unit Manager stated staff should be using the tube feed tubing caps as a protective device for the tubing tip.On 6/16/2026 at 4:09 PM, the Quality Assurance Nurse (QA) stated caps come with the tubing transition tip and staff should not use the tubing if the tip cover has not been used between feedings. She also stated the tubing should be thrown away and a new set obtained. She further stated Enhanced Barrier Precautions (EBP) should be used for residents on tube feeding when staff are connecting the tube feeding.2. Resident #57's Minimum Data Set (MDS) dated [DATE] did not include a Brief Interview for Mental Status (BIMS). It included diagnoses of spinal cord nerve loss with progressive muscle weakness, chronic respiratory failure, osteoporosis, and scoliosis. It indicated she was dependent with all Activities of Daily Living (ADLs) and mobility. It also indicated she used a wheelchair for mobility. The MDS documented that Resident#57 received 51% or more of total calories and average fluid intake per day by tube feeding.A Physician's Order dated 6/13/25 for Nutrition: Beneprotein Order. Give 7g (1 scoop/1 packet) Beneprotein via JT (a tube directly into the second part of the small intestines) daily. It also included a Physician's Order dated 3/16/26 included an order for Trach Care: Place Optifoam and 2x2 (gauze dressing) on trach stoma to avoid air leaks after cleansing skin under trach with soap and water and drying thoroughly. Apply thin layer of clear aid to stoma site. Foam to Right side of neck under ties every day and night shift AND as needed for when ties are soiled.The Care Plan revised 12/24/25 revealed the resident had a multidrug resistant organism (MDRO) on her ear and directed staff to place her in isolation as needed. A Care Plan revision dated 1/29/25 directed staff to change the trach ties daily, after baths and as needed and to leave room for 1 finger between the trach ties and neck.On 6/17/2026 at 9:53 AM, Staff H, Licensed Practical Nurse (LPN) administered Resident #57's Beneprotein and performed her tracheostomy care. She entered the resident's room and Staff F, Certified Nurse Aide (CNA) and Staff G, CMA were performing Resident #57's hygiene care while she was in bed. Staff H administered the resident's Beneprotein liquid into the resident's J-tube, changed her gloves and completed the resident's tracheostomy care. Hand hygiene was not performed between glove changes. No staff wore PPE gowns throughout resident care.On 6/17/26 at 1:55 PM, Staff H stated she forgot to perform hand hygiene between changing her gloves during resident care.A policy titled Infection Prevention and Control Program dated 12/29/25 defined CDC-targeted MDROs as pathogens identified by the Centers for Disease Control and Prevention (CDC) as having significant public health importance due to their resistance to multiple classes of antimicrobial agents, potential for rapid transmission in healthcare settings, and association with increased morbidity, mortality, and limited treatment options and directed staff to apply enhanced barrier precautions for patients colonized with CDC-targeted and <facility>-targeted multidrug resistant organisms. It also indicated gloves are used to protect hands from contact with blood, body fluids, secretions, excretions, mucous membranes, non-intact skin, and contaminated surfaces/equipment and indicated PPE must be worn when anticipating contact with blood, body fluids, mucous membranes, non-intact skin, or contaminated equipment/surfaces (patient care equipment, dishware and eating utensils). It further directed staff to perform hand hygiene when removing PPE.The CDC's EBP signage indicated:PROVIDERS AND STAFF MUST ALSO:Wear gloves and a gown for the following High-Contact Resident Care Activities.DressingBathing/ShoweringTransferringChanging LinensProviding HygieneChanging briefs or assisting with toiletingDevice care or use:central line, urinary catheter, feeding tube, tracheostomyWound Care: any skin opening requiring a dressingOn 6/18/26 at 1:17 PM, the Clinical Director stated staff should follow the policy.

Based on clinical record review, observation, staff interview and policy review, and guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to implement Enhanced Barrier Precautions (EBP) to prevent cross contamination during routine cares for 3 of 4 residents reviewed for indwelling medical devices (Residents #2, #3 and #4). The facility reported a census of 70.Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed that Resident #2 had diagnoses of Multidrug-Resistant Organism (MDRO), cerebral palsy and severe hypoxic ischemic encephalopathy (a critical neonatal brain injury caused by severe oxygen deprivation and restricted blood flow (asphyxia) around the time of birth). It also indicated he received tracheostomy care (a surgically created opening in the neck leading into the trachea (windpipe) to assist with breathing) and had a gastrostomy (a medical procedure to insert a feeding tube (G-tube) through the abdomen directly into the stomach, allowing for nutrition, fluids, or medication to bypass the mouth/esophagus).The Care Plan initiated 10/27/23 directed staff to follow EBP for MDRO: Pseudomonas aeruginosa.2. The MDS dated [DATE] revealed that Resident #3 had diagnoses of MDRO and respiratory failure. It also indicated that she had a feeding tube, received tracheostomy care and required an invasive mechanical ventilator (a machine that moves air into and out of the lungs to assist or replace spontaneous breathing).The Care Plan initiated 10/27/23 indicated that Resident #3 had MDRO: Pseudomonas aeruginosa and lacked documentation of EBP use.The Electronic Health Record listed Resident #3's date of birth as 11/2/2002 indicating she was [AGE] years of age.3. The MDS dated [DATE] revealed that Resident #4 had diagnoses of MDRO and cerebral palsy. It also indicated that he required a feeding tube.The Care Plan initiated 2/5/24 indicated that Resident #4 had MDRO: Pseudomonas aeruginosa and directed staff that EBP would be indicated. During observation on 4/2/26 at 1:25 PM, Staff A, Respiratory Therapist, wore a surgical mask. Staff A sanitized her hands and donned a pair of gloves. Resident #3 was lying in bed with head of bed (HOB) up and had a ventilator connected to her trach. Staff A applied a vest around the resident's chest and back, then connected the hose to a machine to provide chest percussion for 10 minutes. At 1:40 PM, Staff A removed the hose connecting the ventilator to the trach tube, attached a PDI adaptor (device used to connect an inhaler directly to a ventilator circuit) and an albuterol inhaler, then administered 2 puffs of the inhaler through the trach. Staff A removed the adapter and inhaler and reattached the hose from the ventilator to the resident's trach. Staff A then suctioned the resident's trach. Staff A disconnected the suction from the trach suction tube and reconnected the ventilator to the resident's trach. Staff A removed her gloves and sanitized her hands.During an observation on 4/2/26 at 3:09 PM Staff B, RT put on gown and gloves to enter Resident #2's room to do suction and chest percussion. Upon entering, Staff C, Certified Nursing Assistant (CNA) was finishing cares on Resident #2. She was not wearing a gown.During an observation on 4/2/26 at 3:10 PM Staff B, RT began suctioning Resident #2. Staff E, RN entered the room and gave Resident #2 what appeared to be liquid medication through the residents gastrostomy tube. The bed was elevated so she had to lean against the covers to get to the residents gastrostomy tube. Staff B did not wear a gown. In an interview on 4/2/26 at 3:05 PM Staff B, Respiratory Therapy (RT) stated that Resident #2 had an MDRO, and that is why the resident had a shield added to his standard precautions sign. Not sure about EBP, she just knew the shield meant MDRO.During an observation on 4/2/26 at 3:10 PM Staff B, RT began suctioning Resident #2. Staff D, CNA entered the room with Resident #4, Resident #2's roommate, and began providing cares including peri care and transfer to his bed with a mechanical lift. He had a gastrostomy tube with feeding attached to his wheel chair. She did not wear a gown.In an interview on 4/2/26 at 3:25 PM Staff B, RT stated that the 2 other staff that assisted Resident #2 were not taking care of the tracheostomy that could be aerosolized or dealing with urine so they did not need gowns.In an interview on 4/2/26 at 3:34 PM Staff D, Certified Nurses Aide (CNA) stated that Resident #4 was in standard precautions and not EBP. EBP has a separate sign.In an interview on 4/6/26 at 8:40 AM with Staff F, Registered Nurse (RN), Staff G, RN, and Staff F, RN stated that if a resident had an MDRO, their standard precautions sign would have a gold shield on it as well. If they did not have an MDRO, they would just have a standard precautions sign on the door. Did not think that wound, tracheostomies or gastrostomy tubes counted for EBP. Staff G stated that she agreed with everything Staff F had stated.In an interview on 4/6/26 at 10:00 AM Staff H, Infection Preventionist (IP) stated that they follow EBP but also follow modified EBP for pediatric residents. This is based on the CDC question and answer page under question number 6 located at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html on the CDC website. When specifically questioned on Resident #2 and Resident #4 she stated that they should both be in EBP and not modified EBP due to MDROs. She then stated that #3 would be on modified EBP. When the surveyor questioned about Resident #3 having an MDRO and not being a pediatric resident as she was 26, she stated she should be in regular EBP and staff should be wearing gowns for cares.In a document titled EBP risk assessment, it indicated that EBP would be indicated for residents with a colonized Centers for Disease Control and Prevention (CDC) or ChildServe-Targeted MDRO and modified EBP would be indicated for residents with no targeted MDRO colonization and/or indwelling device.The Centers for Disease Control and Prevention (CDC) indicated document dated June 2021 titled Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities that skilled nursing facilities should consider EBP for residents with wounds or indwelling medical devices, regardless of Multi Drug Resistant Organisms (MDRO) colonization status or infection or colonization with an MDRO. Consistent with 2019-2020 CDC EBP interim guidance, examples of indwelling medical devices include central line, urinary catheter, feeding tube, and tracheostomy/ventilator; examples of high contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. The link can be found at: https://www.cdc.gov/infection-control/media/pdfs/EnhancedBarrierPrecautions-508.pdf

Based on observations, staff interviews and policy review, the facility failed to secure prescribed medications from the possibility of unauthorized access. The facility reported a census of 70 residents. Findings included: Observations on 4/30/2025 revealed the following events; On 4/30/25 at 11:38 AM, Staff A, Licensed Practical Nurse (LPN) walked away from her medication cart in the patient care hallway and entered a storage room. A key was observed lying on top of the medication cart. At 11:40 AM, Staff A walked past the medication cart with water and entered a resident's room. There was one resident present but unable to manipulate the key or the medication cart. When Staff A returned to the medication cart, she confirmed the key was used to unlock the medication cart and stated she didn't realize she left it on the cart. At 11:41 AM, Staff A removed medications from her cart, locked the cart and entered a resident's room. The key was observed lying on top of the medication cart. At 11:43 AM, another staff member entered the hallway where Staff A's medication cart was stationed. She confirmed she was a Respiratory Therapist and that she does not access the medication cart. At 1:29 PM, Staff B, Registered Nurse (RN) demonstrated the medication cart key also accesses the controlled substance drawer on the respective cart. On 5/01/25 at 9:44 AM, Staff A's medication cart was examined. The controlled substance drawer contained Oxycodone (opioid) and Nayzilam nasal spray (benzodiazepine - central nervous system depressant) used to treat seizures. On 5/01/25 at 1:11 PM, the Inpatient Clinical Director (ICD) stated staff should not have left the key on the cart. Staff should have the med cart keys with them. A policy titled Medication Administration dated 12/14/23 indicated: c. Controlled Substances (CII) i. A separate locked area for controlled medications is provided in a locked cabinet (double-locked). The cabinet has a special lock and key and must be kept locked at all times. ii. The controlled substance key will be kept with a designated staff member at all times or locked in a lockbox with restricted access.

Based on observations, staff interviews, and policy review, the facility failed to implement the Infection Prevention and Control Program (IPCP) by staff not discarding Personal Protective Equipment (PPE) immediately after use nor appropriately performing hand hygiene. The facility reported a census of 70 residents. Findings include: On 4/30/25 at 7:45 AM, Staff C, Housekeeping (HSKG) entered a resident's room, that displayed a contact/droplet isolation sign, wearing gloves but no other Personal Protective Equipment (PPE). She grabbed the trash bag out of the trashcan closest to the entry, tied it in a knot, then grabbed the trash bag from the other trashcan against the furthest wall, tied it in a knot, and brought them out of the residents' room. She placed the bags of trash in a large container then entered another room with a standard precautions sign displayed, collected the trash bags, brought them out of the room, and placed them in the large container. She grabbed the roll of trash bags from the adjacent cart, separated two (2) trash bags from the roll, then handed the roll to Staff D, HSKG. Staff C re-entered the second room and placed the trash bags in the trash containers while Staff D separated a trash bag off of the roll she grabbed from Staff C. Staff C and Staff D entered a third resident's room to replace the trash bags. No hand hygiene or glove change was performed during the observation. At 7:50 AM, both Staff C and Staff D stated they received infection prevention education upon hire and confirmed the education included transmission-based precautions. They also confirmed the education included hand hygiene and appropriate use of PPE. They stated the reason they didn't don any PPE, change gloves, or wash their hands between the contact/droplet room and standard precaution rooms was they were trying to keep up with their schedule. At 7:53 AM, Staff E, Facility Operations Manager (FOM) explained to Staff C and Staff D that PPE must be worn when indicated and hand hygiene and glove changes must occur between resident rooms. At 5/01/25 at 1:12 PM, the Inpatient Clinical Director (ICD) stated staff should not be wearing the same PPE between patient rooms. A policy titled Infection Prevention & Control dated 12/14/23 indicated: b. Hand Hygiene i. Indications for hand hygiene: 1. Before touching a patient; 2. Before clean/aseptic procedures; 3. After body fluid exposure/risk; 4. After touching a patient; and 5. After touching patient surroundings.

Based on clinical record review and staff interviews, the facility failed to notify the long term care ombudsman for resident transfer to an acute care hospital for 6 of 6 (Res #22, #26, #46, #54, #56, #70) residents reviewed for hospitalization . Findings include: The Minimum Data Set (MDS) of Resident # 22 documented a discharge, return anticipated, to an acute care hospital on 12/5/23 and 5/2/24. The MDS of Resident #26 documented a discharge, return anticipated, to an acute care hospital on 2/5/24, 3/31/24, 4/10/24 and 4/13/24. The MDS of Resident #46 documented a discharge, return anticipated, to an acute care hospital on 12/19/23 and 3/23/24. The MDS of Resident #54 documented a discharge, return anticipated, to an acute care hospital on 3/1/24, 4/13/24, 4/18/24 and 5/19/24. The MDS of Resident #56 documented a discharge, return anticipated, to an acute care hospital on 5/19/24. The MDS of Resident #70 documented a discharge, return anticipated, to an acute care hospital on 3/9/24 and 4/11/24. The document provided by the facility titled Monthly Discharge Template, Ombudsman Notify, failed to reflect any of the above hospital transfers. On 7/2/24 at 12:41 pm, the Administrator stated the facility had changed to a different electronic health record (EHR) in November of 2023. He stated all inpatient residents still have records in the prior EHR as both programs are still used for different things in the facility. He stated transfer outs were not being tracked correctly. He stated they have now added a different tracking log to remedy that. On 7/2/24 at 4:17 pm, via email, the Administrator stated the facility did not have policy regarding ombudsman notifications.

Based on observation, record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing enteral tube feedings, nasal and tracheostomy suctioning for 2 of 7 residents observed (Resident #57 & #60). The facility reported a census of 69 residents. Findings include: 1. Observation on 6/30/24 at 12:05 PM revealed Staff A, RN, was not wearing gloves, standing at Resident #57's bedside, setting up enteral tube feeding by pouring measured formula into feeding bag that runs into a pump, tubing from the pump connects to Resident #57's feeding tube (g-tube). Staff A rolled Resident #57 toward herself noticing mucus drainage from his nose. Staff A, not wearing gloves, used a nasal cannula attached to a suction machine and suctioned mucus from Resident #57's nose. Staff A, then used hand sanitizer, completed feeding set up and connected Resident #57's feeding tube port to the tubing from the pump and started the feeding. The Minimum Data Set (MDS) dated [DATE] revealed Resident #57's age as 10 months old, fully dependent for cares and mobility, diagnosis of chronic respiratory failure, feeding problems of newborn, has feeding tube, tracheostomy with oxygen and a mechanical ventilator. Resident #57's Care Plan dated 2/8/24, revealed Resident #57's interventions for infection control included: Following CDC guidelines for all precautions as needed, Follow facility's process for infection control, including hand washing, gown, mask and glove. Interventions for nutrition/fluid maintenance included: Administer feedings and water flushes as ordered to ensure adequate nutrition and hydration. Interventions for respiratory/ventilator included: suctioning as needed. Review of Resident #57's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for July 2024 revealed an order for enteral continuous feed administered by pump via G-tube (gastrostomy tube, feeding tube) 2. Observation on 7/2/24 at 2:53 PM revealed Staff B, CNA, providing secretion suction for Resident #60's tracheostomy. Staff B used a closed suction catheter (protected catheter tube covered with a sterile plastic sleeve) without wearing gloves. The MDS dated [DATE] revealed Resident #60 as [AGE] years old, nonverbal, fully dependent for cares and mobility, diagnosis of diabetes mellitus, seizure disorder, chronic respiratory failure, anoxic brain damage, had feeding tube, tracheostomy with oxygen and a mechanical ventilator. Resident #60's Care Plan dated 6/25/24, revealed Resident #60's interventions for infection control included: Following CDC guidelines for all precautions as needed, Follow facility's process for infection control, including hand washing, gown, mask and glove. Interventions for respiratory/ventilator included: suctioning as needed. Interventions for tracheostomy included: Suction PRN (as needed) with catheter per Respiratory Therapy (RT) recommendations. On 7/2/24 at 4:22 PM the Administrator stated his expectations are for all staff to wear gloves when providing care for tracheotomies, g-tube feedings, and g-tube cares. He said his expectations are for all staff to follow standard precautions. The facility Infection Prevention & Control Handbook, with revision date 1/31/24, revealed Standard Precautions are an approach to infection control that combines the major features of universal precautions and body substance isolation and applies them to all children regardless of their diagnosis or infections status. Standard precautions apply to: blood, all body fluids, secretions, and excretions (except sweat) regardless of whether or not they contain visible blood. Non-intact skin, and mucous membranes. Review of Hand Hygiene Education Session, provided to staff by the facility stated, wear gloves according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur.

Based on observation, clinical record review, staff interviews, and policy review, the facility failed to provide timely notification to the physician or family when changes occurred in the resident's physical or mental condition for 2 of 3 residents reviewed (#1 & #3). The facility reported a census of 61 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was rarely or never understood and a Brief Interview for Mental Status (BIMS) score was not obtained. The MDS included diagnoses of Seizure disorder, Receptive-Expressive Language Disorder, dependence on supplemental oxygen, and Failure to Thrive. The MDS also indicated the resident was dependent in all areas of care. On 1/4/24 at 7:53 AM, Staff A, a Licensed Practical Nurse (LPN) documented a Nursing Assessment indicating the resident was on room air with a documented oxygen saturation (O2 sats) of 85%. The Care Plan dated 7/8/19 directed staff to communicate any changes in condition to the physician and to use oxygen to keep O2 sats greater than 90%. The EHR contained a Physician Order entry directing staff to use up to 5 Liters per minute (LPM) of oxygen as needed for keeping O2 sats greater than 90%. On 1/4/24 at 1:45 PM, the Primary Care Physician (PCP) documented the resident was on 2 LPM of oxygen with O2 sats between 96% - 99% and between 91% - 93% on room air. The PCP adjusted Resident #1's respiratory treatments. The Respiratory Assessment on 1/4/24 at 8:00 PM indicated the resident increased to 4 LPM of oxygen through a mask and had an O2 sat of 98%. The EHR O2 sat summary review revealed Resident #1's oxygen was documented at 10 LPM on 1/4/24 at 8:20 PM and had an O2 sat of 91% while on BiPAP. The Progress Notes revealed the PCP wasn't notified until 1/5/24 at 1:46 AM regarding the resident's respiratory concerns and transferred the resident to a higher level of care on 1/5/24 at 2:24 AM. On 1/5/24 at 7:25 AM, Staff B, Registered Nurse (RN) entered a Nursing Assessment and indicated the resident was receiving 6 LPM of oxygen through a mask but no alternate date or time were referenced. On 1/24/24 at 11:05 AM, the Pediatric Long-Term Care Inpatient Clinical Manager (PLTCICM) stated the physician should have been notified prior to 1:46 AM based on the precipitating events. The facility did not have a policy for notifying a physician other than adverse events. 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was rarely or never understood and a Brief Interview for Mental Status (BIMS) score was not obtained. The MDS included diagnoses of spastic quadriplegic Cerebral Palsy, seizure disorder, and gastro-esophageal reflux disease without esophagitis (GERD). The MDS indicated the resident was dependent in all areas of care. On 1/22/24 at 4:55 AM, Resident #3's monitor alarmed due to an elevated heart rate (HR) of 155 beats per minute (BPM) and Staff D, Registered Nurse (RN) entered the resident's room. At 4:59 AM, Staff D, RN stated Resident #3 vomited at 7:10 PM, 7:45 PM, 8:18 PM, and 10:00 PM. She stated she notified the physician, held his tube feeding (TF) for one hour, and started the resident on a hydration plan. The Electronic Health Record (EHR) Progress Notes revealed the resident had an elevated temperature of 100.5 degrees F and had a 15-minute seizure at 1:35 AM and was tachycardic (HR above 100) most of the night. It also indicated the nurse notified the physician but not the family. The EHR Progress Notes revealed Resident #3's family wasn't notified until 4:59 PM. The Care Plan dated 12/24/23 indicated the resident's family was involved in his care and directed staff to continue good communications with the family while the resident was assigned to the current unit. On 1/22/24 at 2:00 PM, the Pediatric Long-Term Care Inpatient Clinical Manager (PLTCICM) stated the family should know when there was a change in the resident's condition. She stated, in this scenario, the family should have been contacted at least by the end of the shift. A process manual titled Parent/Guardian Notification dated 1/20/23 directed staff to immediately notify the parent or guarding by telephone for a significant change in the resident's physical, mental, or psychosocial status OR a need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment). It also directed staff to notify the parent or guardian by their preferred method as soon as possible for a new or discontinued provider order.

Based on clinical record review, staff interview, and policy review the facility failed to ensure physician's orders were followed for 2 of 3 residents reviewed (#1 & #2). The facility identified a census of 61 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was rarely or never understood and a Brief Interview for Mental Status (BIMS) score was not obtained. The MDS included diagnoses of Seizure disorder, Receptive-Expressive Language Disorder, dependence on supplemental oxygen, and Failure to Thrive. The MDS also indicated the resident was dependent in all areas of care. The Care Plan dated 7/8/19 directed staff to communicate any changes in condition to the physician and to use oxygen to keep O2 sats greater than 90%. On 1/4/24 at 7:53 AM, Staff A, a Licensed Practical Nurse (LPN) documented a Nursing Assessment indicating the resident was on room air with a documented oxygen saturation (O2 sats) of 85%. The EHR contained a Physician Order entry directing staff to use up to 5 Liters per minute (LPM) of oxygen as needed for keeping O2 sats greater than 90%. The Electronic Health Record (EHR) indicated Staff A, LPN failed to initiate oxygen to Resident #1 after documenting an O2 sat of 85%. On 1/4/24 at 1:45 PM, the Primary Care Physician (PCP) documented the resident was on 2 LPM of oxygen with O2 sats between 96% - 99%. The EHR O2 sat summary review revealed Resident #1's oxygen was documented at 10 LPM on 1/4/24 at 8:20 PM and had an O2 sat of 91% while on BiPAP. On 1/22/24 at 12:23 PM, Staff C, a Respiratory Therapist (RT) stated she found the resident on 10 LPM of oxygen at the beginning of her shift with no documentation of when it was initiated. 2. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was rarely or never understood and a Brief Interview for Mental Status (BIMS) score was not obtained. The MDS included diagnoses of Cerebral Palsy, Seizure disorder, functional quadriplegia, and dysfunction of the autonomic nervous system. The MDS also indicated the resident was dependent in all areas of care. The Care Plan directed staff to provide the resident with oxygen while he was asleep and to refer to the EHR for the current order. On 1/22/24 at 5:32 AM, an observation revealed Resident #2 received 3 LPM through a trach ring while asleep. The Electronic Health Record (EHR) physician orders directed staff to apply oxygen at 2 3/4 LPM when the child is asleep every shift. On 1/5/24 at 5:47 AM, Staff D, Registered Nurse (RN) entered a Nursing Assessment and indicated the resident was receiving 3 LPM of oxygen through a trach ring. On 1/22/24 at 6:20 AM, Staff E, RT, stated there was a way to document 2 3/4 LPM into the EHR. On 1/22/24 at 2:00 PM, the Pediatric Long-Term Care Inpatient Clinical Manager (PLTCICM) stated if a Physician Order is an actual order, as opposed to something mentioned in conversation, the nurse is expected to follow the order. She stated sometimes the nurse and the physician would have a conversation and the physician would comment on a recommendation but the nurse would be expected to clarify whether that conversation constituted an official order. A policy titled Physician/Nurse Practitioner/Physician Assistant Orders dated 12/14/23 indicated compliance with physician/nurse practitioner/physician assistant; orders must be evidenced in the child/young adult's care file. Documentation must demonstrate that physician/nurse practitioner/physician assistant; orders were followed as ordered.

Based on observation, clinical record review, staff interviews, and policy review, the facility failed to provide a complete, accurate, and detailed record for the resident's physical condition to maintain the resident's highest practical well-being for 2 of 3 residents reviewed (#1 & #2). The facility reported a census of 61 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was rarely or never understood and a Brief Interview for Mental Status (BIMS) score was not obtained. The MDS included diagnoses of Seizure disorder, Receptive-Expressive Language Disorder, dependence on supplemental oxygen, and Failure to Thrive. The MDS also indicated the resident was dependent in all areas of care. The Care Plan dated 7/8/19 directed staff to use oxygen to keep O2 sats greater than 90%. On 1/4/24 at 7:53 AM, Staff A, Licensed Practical Nurse (LPN) documented a Nursing Assessment indicating Resident #1 was on room air with a documented oxygen saturation (O2 sats) of 85%. The EHR contained a Physician Order entry directing staff to use up to 5 Liters per minute (LPM) of oxygen as needed for keeping O2 sats greater than 90%. The Electronic Health Record (EHR) had no documentation of oxygen being initiated during the morning shift on 1/4/24. On 1/4/24 at 1:45 PM, the Primary Care Physician (PCP) documented the resident was on 2 LPM of oxygen with O2 sats between 96% - 99% with no documentation of when the oxygen was initiated. The EHR O2 sat summary review revealed Resident #1's oxygen was documented at 10 LPM on 1/4/24 at 8:20 PM and had an O2 sat of 91% while on BiPAP. On 1/22/24 at 12:23 PM, Staff C, a Respiratory Therapist (RT) stated she found the resident on 10 LPM of oxygen at the beginning of her shift with no documentation of when it was initiated. She also stated she did not document her findings. 2. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was rarely or never understood and a Brief Interview for Mental Status (BIMS) score was not obtained. The MDS included diagnoses of Cerebral Palsy, Seizure disorder, functional quadriplegia, and dysfunction of the autonomic nervous system. The MDS also indicated the resident was dependent in all areas of care. The Care Plan directed staff to provide the resident with oxygen while he was asleep and to refer to the EHR for the current order. The Electronic Health Record (EHR) Physician Orders directed staff to apply oxygen at 2 3/4 LPM when the child was asleep every shift. On 1/21/24 at 7:45 PM, Staff F, RT completed a Respiratory Assessment and indicated the resident was on 2 LPM of oxygen through a trach ring. On 1/22/24 at 5:32 AM, an observation revealed Resident #2 was receiving 3 LPM of oxygen through a trach ring while he was asleep. On 1/22/24 at 5:47 AM, Staff D, Registered Nurse (RN) entered a Nursing Assessment and indicated the resident was receiving 3 LPM of oxygen through a trach ring. The EHR lacked documentation of when the resident's increased oxygen was initiated prior to the 3 LPM oxygen observed at 5:32 AM. A policy titled Documentation revised 5/21/21 directed staff to specifically state in the body of your note the time that events occurred and the actions taken and indicated thorough, accurate documentation decreases the potential for miscommunication and errors. On 1/24/24 at 11:05 AM, the Pediatric Long-Term Care Inpatient Clinical Manager (PLTCICM) stated documentation should reflect the information at the time it was available to the staff. She stated documentation should reflect the time treatment was done. She indicated the above oxygen adjustments should have been documented when they were initiated.

Based on record review, staff interview, and policy review the facility failed to immediately put effective measures in place to ensure further potential abuse or mistreatment does not occur for 1 of 1 dependent residents (Resident #52) when four (4) employees observed questionable physical and verbal abuse by Staff A, Respiratory Therapist (RT) to Resident #52. The facility reported a census of 61 residents. Findings include: On 9/13/23 at 9:58 AM Staff B, Certified Nurse Aid (CNA) described her observation she had of Resident #52 and Staff A's interaction on 4/23/23 as follows; Resident #52 was in sun room sitting on the floor and she pulled at her medical device on her neck, I was washing my hands at the sink, and Staff A pulled Resident #52 hand away, and she said something like, stop doing that, this is the fourth (4th) time I had to put a new one on you today, in a not nice tone. She then informed Resident #52 got up and walked off, and she looked sad, and she knew she had been yelled at. I felt it was inappropriate because Resident #52 is really grabby and she does that a lot, for the RT to be annoyed with it, was pointless. I think Staff A prevented Resident #52 from doing a normal behavior, and she should not be punished for that, in that sense I do feel like it was abusive. Once the facility was made aware they terminated Staff A and when I talked to my Supervisor I was instructed I should of said something right then when it happened, and not waited. I was with Resident #52 the rest of the day, and she seemed ok the rest of the day, just sad at the time of the incident. After this incident the facility did a meeting and we all reviewed the same policy, and staff were directed to even if you think you see something, to call management because we are all mandatory reporters. She then informed Staff A continued to work with Resident #52 the rest of the shift and the next day. On 9/14/23 at 11:28 AM with the facilities Licensed Nursing Home Administrator (LNHA) revealed staff informed her Resident #52 looked sad after Staff A spoke to her that way, like she had been disciplined, the nursing staff assessed her and no injuries, but she looked sad. She then informed she would of immediately removed Staff A from working with any individuals they serve if they were made aware of the situation immediately. On 09/14/23 10:44 AM with the Director of Nursing (DON) stated she would of expected Staff A to be removed immediately from caring for any individual once possible abuse was suspected. She revealed if she was aware of the incident she would of immediately removed Staff A on 4/23/23 if she would of known. She reported they would of removed Staff A immediately before even investigating the alleged abuse to ensure safety of all individuals they serve.

Based on record review, staff interviews, and policy review the facility failed to ensure 1 of 1 residents (Resident #52) reviewed was treated with respect and dignity by all staff, when Staff A, Respiratory Therapist, scolded Resident #52 for grabbing at her medical device. The facility reported a census of 61 residents. Findings include: The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #52 documented she has short-term and long-term memory problems, inability to recall current season, location of room, staff names and faces, and that she is in a nursing facility, and severely impaired cognitive skills for daily decision making. The MDS also documented she is totally dependent on 1 staff member for dressing, eating, toilet use, and personal hygiene. The MDS documented the diagnosis of seizure disorder or epilepsy, anxiety, dysphasia, hearing loss. Record review of an undated document titled, Care Investigation Summary informed the following Summary of Event(s): a. Child (Resident #52) from Long Term Care (LTC) unit was receiving routine care on 4/23/2023 when she removed her heat and moisture exchanger from her tracheostomy. Staff A, a travel Respiratory Therapist (RT) allegedly slapped the child's hands and yelled at her. Event was witnessed by several staff. b. Resident #52 did not sustain any physical injury, but she appeared visibly upset following the event. She received a dose of Tylenol. c. The event was reported to Department of Inspections, Appeals, and Licensing (DIAL) on 4/26/23 (delayed reporting). Staff reported the event to their supervisor, but it was not immediate, per policy. Once the supervisor was notified of the event, she promptly shared information with the Licensed Nursing Home Administrator (LNHA) and the alleged Respiratory Therapist was removed from the facility and her contract was immediately terminated. d. Response by staff in reporting incident did not meet policy requirements. Staff need to be encouraged to immediately share with supervisor when they witness an interaction with a resident that doesn't seem right. There was some reluctance to report this event right away because the alleged perpetrator was having a stressful day and the unit was stressed overall that day. During an interview on 9/13/23 at 9:58 AM with Staff B, Certified Nurse Aid (CNA) described the following observation she had of Resident #52 and Staff A's interaction on 4/23/23. Resident #52 was in sun room sitting on the floor and she pulled at her medical device on her neck, I was washing my hands at the sink, and Staff A (Respiratory Therapist) pulled Resident #52 hand away, and she said something like, stop doing that, this is the fourth (4th) time I had to put a new one on you today, in a not nice tone. She then informed Resident #52 got up and walked off, and she looked sad, and she knew she had been yelled at. I felt it was inappropriate because Resident #52 is really grabby and she does that a lot, for the RT to be annoyed with it, was pointless. I think Staff A prevented Resident #52 from doing a normal behavior, and she should not be punished for that, in that sense I do feel like it was abusive. Once the facility was made aware they terminated Staff A and when I talked to my Supervisor I was instructed I should of said something right then when it happened, and not waited. I was with Resident #52 the rest of the day, and she seemed ok the rest of the day, just sad at the time of the incident. After this incident the facility did a meeting and we all reviewed the same policy, and staff were directed to even if you think you see something, to call management because we are all mandatory reporters. She then informed Staff A continued to work with Resident #52 the rest of the shift and the next day. During an interview on 9/14/23 at 10:42 AM with the Director of Nursing stated regarding any individuals they serve, if they were observed being visibly sad after a possible alleged abuse incident she would constitute that as abuse. During an interview on 9/14/23 at 11:28 AM with the facilities Licensed Nursing Home Administrator (LNHA) reported staff informed her Resident #52 looked sad after Staff A spoke to her that way, like she had been disciplined, the nursing staff assessed her and no injuries were found, but she looked sad. The LNHA stated that if she had been informed of the incident with Staff A and Resident#52 immediately, Staff A would have been removed from working right away. Record review of the facilities policy, Resident Abuse Prevention, Identification, Investigation, and Reporting in Nursing Facilities, last revised 6/22/23 directed staff as follows; Initial/Immediate Protection During Facility Investigation a. Upon receiving a report of an allegation of resident abuse, neglect, exploitation, or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involves a allegation of abuse by an staff, this will be accomplished by separating the staff accused of abuse from all residents through the following or a combination of the following, if practicable: i. Suspending the staff; ii. Segregating the employee by moving the staff to an area of the facility where there will be no contact with any residents of the facility; and in rare instances, iii. Separating the staff accused of abuse from the resident alleged to have been abused, but allowing the staff to care for and have contact with other residents, only if there is a second staff who remains with and accompanies the staff accused of abuse at all times to supervise all contacts and interactions with the residents. b. Following completion of the facility investigation, if the facility concludes that the allegations of resident abuse are unfounded, the staff may be allowed to return to job duties involving resident contact, but the staff must maintain a separation and have no contact with the resident alleged to have been abused, by reassigning the accused staff to an area of the facility where no contact will be made between the accused staff and the resident alleged to have been abused. This separation must be maintained until the Department concludes its investigation and issues the written results of its investigation.

Based on record review, staff interviews, and policy review the facility failed to report alleged physical and verbal abuse without bodily injury for 1 of 1 residents (Resident #52) within 24 hours of the incident to the state agency. The facility reported a census of 61 residents. Findings include: Record review of an undated document titled, Care Investigation Summary informed the following Summary of Event(s): a. Child (Resident #52) from Long Term Care (LTC) unit was receiving routine care on 4/23/2023 when she removed her heat and moisture exchanger from her tracheostomy. Staff A, a travel Respiratory Therapist (RT) allegedly slapped the child's hands and yelled at her. Event was witnessed by several staff. b. Resident #52 did not sustain any physical injury, but she appeared visibly upset following the event. She received a dose of Tylenol. c. The event was reported to DIAL on 4/26/23. Staff reported the event to their supervisor, but it was not immediate, per policy. Once the supervisor was notified of the event, she promptly share information with the Licensed Nursing Home Administrator (LNHA) and the alleged Respiratory Therapist was removed from the facility and her contract was immediately terminated. d. Response by staff in reporting incident did not meet policy requirements. Staff need to be encouraged to immediately share with supervisor when they witness an interaction with a resident that doesn't seem right. There was some reluctance to report this event right away because the alleged perpetrator was having a stressful day and the unit was stressed overall that day. During an interview on 9/13/23 at 9:58 AM Staff B, Certified Nurse Aid (CNA) described her observation she had of Resident #52 and Staff A's interaction on 4/23/23 as follows; Resident #52 was in sun room sitting on the floor and she pulled at her medical device on her neck, I was washing my hands at the sink, and Staff A pulled Resident #52 hand away, and she said something like, stop doing that, this is the fourth (4th) time I had to put a new one on you today, in a not nice tone. She then informed Resident #52 got up and walked off, and she looked sad, and she knew she had been yelled at. I felt it was inappropriate because Resident #52 is really grabby and she does that a lot, for the RT to be annoyed with it, was pointless. I think Staff A prevented Resident #52 from doing a normal behavior, and she should not be punished for that, in that sense I do feel like it was abusive. Once the facility was made aware they terminated Staff A and when I talked to my Supervisor I was instructed I should of said something right then when it happened, and not waited. I was with Resident #52 the rest of the day, and she seemed ok the rest of the day, just sad at the time of the incident. After this incident the facility did a meeting and we all reviewed the same policy, and staff were directed to even if you think you see something, to call management because we are all mandatory reporters. She then informed Staff A continued to work with Resident #52 the rest of the shift and the next day. During an interview on 9/14/23 at 10:41 AM with the Director of Nursing (DON) stated that she absolutely expected staff to report the alleged abuse that occurred on 4/23/23 within less than 24 hours. On 09/14/23 at 11:21 AM the facilities LNHA reported the 4/23/23 alleged abuse event should have of been reported to the state agency, DIAL, no later then 24 hours from the time of event. Record review of the facilities policy titled Resident Abuse Prevention, Identification, Investigation, and Reporting in Nursing Facilities last revised 6/22/23 directed staff as follows: D. Reporting Abuse a. All allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation should be reported immediately to the staff ' s supervisor. The supervisor is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. b. All allegations of resident neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation shall be reported to the Iowa Department of Inspections and Appeals, not later than two (2) hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury. c. If there is a reasonable suspicion that the allegation of abuse also constitutes a crime committed against the resident by any person, whether or not the alleged perpetrator is employed by the facility, the Elder Justice Act requires the matter must also be reported to law enforcement. While the federal regulations require all abuse allegations be reported to DIA within 2 hours, the Elder Justice Act has a different time frame for reporting to the police/sheriff. i. If the allegation of abuse (that results from a crime) results in serious bodily injury to a resident, a report must be made to law enforcement not later than two (2) hours after the allegation is made. ii. If the allegation of abuse does not result in serious bodily injury, a report must be made to law enforcement not later than twenty-four (24) hours.

Based on observation, clinical record review, resident and staff interview, a physician interview and facility policy review the facility failed to provide the necessary nursing supervision for a dependent patient who fell out of a crib that required staff assistance to maintain the safety for 1 of 3 patients reviewed. (Resident #1) The facility identified a census of 37 patients. Findings include: A Quarterly Minimum Data Set (MDS) assessment form dated 11.2.22 revealed Resident #1 as a 4 and 1/2 year old patient with diagnosis that included respiratory failure, atrial septal defect (hole in the wall of the heart's upper chambers), congenital sacral dimple (lump on the bottom of the back), other deletions of autosomes, renal agenesis (absence of one or more kidneys) gastrostomy and a tracheostomy. The assessment indicated the patient rarely made self understood or understood others, required supervision with bed mobility, non-ambulatory and no toilet use and as dependent on staff with all other activities of daily living (ADL's). A Care Plan dated 5.2.19 identified the resident with a problem with safety. The interventions included the following: a. Bed rails up at all times when patient in bed. (not dated) An Incident Management Quality Improvement form dated 11.8.22 at 5:25 p.m. revealed the following entry by Staff A, Registered Nurse (RN): RN in patients room to put ventilator away and had the crib side rail down as she helped the patient. The patient had been on the ventilator but woke up and had taken the vent off so the RN tried to get the patient back onto the wall oxygen. RN turned away for a second and the patient fell out of bed. RN immediately picked up the patient and performed an assessment. The patient cried immediately and the RN assessed for consciousness and bumps and bruises on the patient's head. No signs of injury noted. A Physician's Note dated 11.9.22 included the following documentation: Evaluated this morning following a fall from her bed -3-4 ft, last evening when bed rail was not all the way up during cares. Reportedly cried immediately after the event. No loss of consciousness. Assessed at that time by nursing without findings concerns for fracture. Reported no marks or bruising. Overnight acted like normal self per staff report. Awake for majority of the night and fell asleep that morning. Reportedly used both arms, both legs as her usual. No vomiting, no excessive sleepiness. During an interview 3.30.23 at 2:49 p.m. Staff A stated she helped the patient because as the patient had been positioned in bed she connected the oxygen tubing because the patient had a tracheostomy. The staff member turned her back to the patient when she hooked up the oxygen from the wall unit and the patient fell out of bed. When the patient fell out of bed she cried, the staff member picked her up off her back right away and then assessed the patient and found no injuries. When asked the staff member if there had been anything she could have done differently she stated even though it had been only for seconds she would not have turned her back to the patient. The staff member described the incident as human error and the patient as one of those wild child children. During an interview 3.30.23 at 1:05 p.m. the [NAME] President of Inpatient Services confirmed the nurse should have kept a hand on the patient but the thought process for that second had been the patient initially slept. During an interview 3.30.23 at 1:40 p.m. the Director of Nursing (DON) confirmed if a staff member turned or reached for something while they cared for a child they should have always had a hand on them. If they crossed the room the crib/bed rail should have always been positioned upward. During an interview 3.30.23 at approximately 3:15 p.m. the patient's Physician described the incident from a medical standpoint as negligent from the nurse's standpoint.

Based on observation, facility policy review and staff interview, the facility failed to have sanitizable cutting boards and failed to ensure staff had proper hair coverings. The facility census was 54 residents. Findings include: 1. Observation on 12/29/19 at 9:20 a.m., revealed Staff A, cook, had 3 inches of exposed hair on the back of their neck not covered by a hairnet. Staff B, cook, had 2 inches of exposed hair not covered by a hairnet on the back of their neck. Observation revealed three cutting boards, yellow, green and white with deep grooves and fuzz making them unsanitizable. Observation on 12/30/19 at 10:03 a.m., revealed Staff A, cook, had 2 inches of exposed hair not covered by a hairnet. Staff B, cook, had 2 inches of hair not covered by a hairnet. Staff C, cook, was noted to have 2 inches of exposed hair not covered by a hairnet. Staff D, cashier in dietary had exposed hair coming through large open squares of the hairnet. During interview on 12/30/19 at 10:20 a.m., the Certified Dietary Manager acknowledged the exposed hair and stated all hair should be covered and the cutting boards would be replaced. Facility policy, titled Dietary Staff Dress Code, dated 11/29/07 documented dietary staff must wear hairnets by regulation. If a hat is worn, the hairnet should be covering any hair not covered by the hat. Hair nets are required in the food prep area, serving area, and are required when working the cash register.

Based on observation, clinical record review, facility policy review and staff interviews, the facility failed to provide adequate incontinence care for one of four residents observed during personal cares (Resident #3). The facility census was 50 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had [DIAGNOSES REDACTED]. A skin integrity care plan problem directed staff to provide peri-care per facility protocol, change incontinent pads as soon as possible when soiled and keep skin clean and dry. Observation on 12/6/17 at 11:30 a.m., revealed Staff A, certified nurse aide, CNA and Staff B, CNA provided urinary incontinence care to the resident as the resident stood in the bathroom. Staff A used cleansing wipes and cleansed the residents buttocks area, cleansed each hip area and cleansed the central frontal area. The care provided did not cleanse all skin surfaces exposed to urine. Staff B confirmed the resident was incontinent of urine prior to the care performed. On 12/7/17 at 9:52 a.m., Staff D, registered nurse, RN, stated she expected staff to provide complete incontinence care after each incontinent episode, to make one pass with the cloth from front to back, and to cover all surfaces of skin that was wet/exposed to urine. A Perineal Care policy, dated 5/21/13, directed staff: Use cleansing wipes to clean any area that has come in contact with urine or feces. This includes the thighs, buttocks, legs and hips.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure equipment used for enteral medication administration was sanitary and changed at appropriate intervals as directed by facility policy for one medication administrations observed (Resident #3). The facility census was 50 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had [DIAGNOSES REDACTED]. A gastrointestinal problem identified on the nursing care plan directed staff to administer feedings and fluids as ordered and administer medications as ordered. Medication orders included polyethylene [MEDICATION NAME] (a fiber laxative), 34 Grams, administered in 4 to 8 ounces of water via gastrostomy tube every morning. Observation on 12/7/17 at 7:14 a.m., revealed Staff C, registered nurse, RN administer the resident's medications via the gastrostomy tube. Staff C obtained a large bulb syringe from a bag that was dated 12/3/17, attached the syringe without the bulb to the gastrostomy tube and administered the polyethylene [MEDICATION NAME]. During interview at that time, Staff C stated the bulb syringe and enteral feeding bag was supposed to be changed daily and discarded the bulb syringe. On 12/7/17 at 10:11 a.m., Staff E, RN stated she expected staff to change the bulb syringe used for gastrostomy tubes daily and inspect the dates on the equipment prior to use. The Enteral Tube Feedings, Intermittent or Bolus, Pediatric policy dated 11/11/15 directed staff to change the enteral feeding administration set and disposable supplies every 24 hours to prevent bacterial overgrowth.

Based on observation and staff interview, the facility failed to ensure the resident environment was well maintained and homelike. The facility census was 55 residents. Findings include: 1. During tour in the CCU on 7/31/17 at 2:45 p.m., with the Administrator and Admissions Manager a chartreuse reclining chair in the lounge had an approximate 8 inch long tear on the lower left front foot rest, an approximate 4 inch tear on the lower left side and a smaller tear on the lower right side with foam exposed in all three areas, leaving the chair unsanitizable. 2. During the Medication room check in the CCU on 7/31/17 at 3:15 p.m., with the Unit Manager the floor in the west hall in front of the medication room revealed the seam weld spit approximately 4 feet long exposing the subfloor and the floor in the west hallway along the base cove across from the medication room had a buildup of dirt along the edge. During interview at the time, the Administrator agreed the areas needed repaired on the chair and did not know if a work order had been entered. During interview at the time of the medication room check the Unit Manager did not know if a work order had been entered to correct the areas.

Based on record review, observations and staff interviews, the facility failed to provide adequate supervision and ensure all fire exit doors were alarmed or locked to ensure 4 out of 4 cognitively impaired and mobile residents had no access to leave the building unattended. The facility also failed to secure prescription medications for 1 of 16 Residents (Resident #16) reviewed. The facility reported a census of 54 residents. Findings include: 1. On 8/8/16 at 4:45 p.m., the Administrator reported the B entrance/exit doors located by the inpatient unit were locked until 7:30 a.m. The Administrator reported if building access needed before 7:30 a.m., the visitor pushed a button by the entry door and waited until staff opened the door remotely. Observation on 8/10/16 at 7:10 a.m., revealed the exit doors located in the Inpatient B entrance near the inpatient Transitional Care Unit (TCU), was unlocked and not alarmed, and the information desk left unattended. A sign located above the doors identified the doors as an exit door. On 8/11/16 at 7:03 a.m., observation revealed the B entrance/exit doors unlocked and not alarmed, and the information desk left unattended. At 7:30 a.m., observation revealed the information desk left unattended, and the B entrance/exit doors opened as the surveyor walked by the doorway. At 7:38 a.m., a person stopped by the information desk, turned on the lights, and sat down by the desk. On 8/11/16 at 11:00 a.m., Staff D, TCU unit care coordinator, and Staff F, Continuous Care Unit (CCU) coordinator identified a total of 4 residents at the facility as cognitively impaired and independently mobile. In an interview on 8/11/16 at 11:15 a.m., the Administrator stated he/she had not realized the doors had opened before 7:30 a.m., as they should have been locked until that time. The Administrator reported he/she would follow up with maintenance personnel about the doors. During findings 8/11/16 at 1:15 p.m., Staff G, CCU Team Leader, stated the doors had been set to unlock at 6:30 a.m., before school buses arrived. The B entrance doors had not been reset to a later time during the summer months. Staff G verified the desk was unattended during that time, but they had multiple staff who loaded residents on the buses. At 1:20 p.m., the Administrator reported he/she spoke with Maintenance and the person who managed the computerized system, and found the doors had been set to unlock at 6:30 a.m. The Administrator the door system was set to unlock at 7:30 a.m. after having spoken to the surveyor that morning. An interview on 8/8/16 at 9:30 a.m. with the Environmental Services Manager revealed a receptionist monitored Entrance B until 6:00 p.m., and the door is locked after he/she left for the day. 2. An observation in the continuing care unit (CCU) on 8/8/16 at 4:05 p.m., revealed medications for Resident #16 left unattended on the top of a medication cart parked outside Room 450. The medications were as follows: a bubble pack that contained Baclofen (muscle relaxant) 20 mg (29 pills remaining), a bottle of Glycopyrrolate (anticholinergic) liquid 0.5 mg/ml (20 ml remaining), and bottle of liquid fish oil with 5.5 ounces left in the bottle. Staff E, LPN came out of the bathroom down the hall and walked up to the cart. During an interview on 8/8/16 at 4:07 p.m. with Staff E stated he/she explained she spilled gotten fish oil on his/her hands and had to wash them. Staff E stated he/she usually did not leave medications on the cart unattended. During an interview on 8/9/16 at 3:25 p.m., Staff F RN/Unit Supervisor reported he/she expected staff not to leave medication unattended at any time.

Based on observation, facility records and policies, and staff interview, the facility failed to maintain sanitary conditions in the kitchen food preparation area for 8 of 54 residents the facility reported as their current census. Findings include: An observation of meal preparation on 8/8/16 at 10:30 a.m. revealed an accumulation of a fuzzy black substance on the 2 feet x 4 foot fluorescent light fixtures and vents located on the ceiling above the food preparation counter near the stove/oven and fryer, and above the dishwasher where clean dishes exited after being washed/rinsed. The black fuzzy substance stuck to the fixtures and the vents moved as they circulated the air. The 1/26/12 Cleaning Schedule directed staff the light fixtures and vents should be cleaned monthly, with the Dietary Manager designated to check the cleanliness of the kitchen. An email from the Dietary Manager dated 7/19/16 had informed the recipient the kitchen's vents contained a lot of dust and needed to be cleaned. An interview on 8/8/16 at 11:40 a.m. with the Dietary Manager revealed that maintenance had been designated to clean the vents and lights, and she had submitted a work order on 7/19/16 regarding the same. The Dietary Manager verified the vents and lights had not been cleaned since that correspondence.

Based on resident record review, observation, and interviews, the facility failed ensure residents received adequate supervision during transfers for two of two residents (Resident #1 and Resident #8). The facility reported a resident census of 51 at the time of the survey. The facility also failed to ensure potential hazards were secured at all times. The facility reported a resident census of 51 at the time of the survey. Findings include: 1. A quarterly MDS ( Minimum Data Set Assessment Tool) dated 8/24/12 identified Resident #1 with the following [DIAGNOSES REDACTED]. The MDS revealed Resident #1 had both short and long term memory impairment and severely impaired cognitive function related to daily decision making skills. The MDS identified the resident as rarely to never understanding communication or being able to make own needs or wants known. The assessment indicated the resident as totally dependent upon the staff for all activities of daily living and required 2 or more staff for all transfers. The assessment revealed the resident with both upper and lower extremity impairment of range of motion. A care plan dated 9/30/12 under mobility/safety problem directed staff to follow recommendations for all lifting and transfer activities (including bathing) per lifting/transfer sheet kept at the bedside. The lifting/transfer sheet posted at the bedside last reviewed on 1/4/11 by the physical therapy department, directed the staff perform a 3 person lift or use the mechanical lift with the assist of 2 staff members. An observation made on 10/30/12 at 8:40 a.m. revealed Staff A, LPN ( Licensed Practical Nurse, Staff B, LPN, and Staff C, RN ( Registered Nurse), performed a 3 person log lift from the bed to the wheelchair. The resident's left leg casted from the toes to just below the left groin area with slight knee flexion present. Nursing note documentation dated 9/30/12 at 1:05 p.m. indicated the resident appeared to have discomfort during the night when repositioned but the CNA did not notice any specific area(s) of redness, tenderness, or swelling during an assessment performed at 7:00 a.m.. At this time the resident appeared to be sleeping without any facial grimacing or crying out as if experiencing any pain or discomfort. The documentation identified the left knee possibly slightly swollen. Documentation revealed at 12:30 p.m., the nurse again summoned to the resident room by the CNA as the left leg is now noticeably swollen from the mid-thigh area to the toes, is warm to touch, and though the resident didn't cry out during the assessment, opened eyes when the leg touched. The nurse documented a call placed to the resident's physician to update on the resident's current condition. The physician returned the call with the following new orders received: 1. Apply cold pack to Left knee x 30 minutes as needed for swelling, keep left leg elevated. 2. Splint left leg until further notice. 3. Portable x-ray of the left leg. 4. Hydrocodone/APAP 7.5/500 mg/ 15 ml, give 15 ml every 4-6 hours as needed for pain control. Nursing note documentation dated 9/30/12 at 3:00 p.m. revealed the physical therapist at the facility at 2:30 p.m. and applied a splint to the left leg at which time the resident cried and shook during the splint application. The documentation revealed all staff talked to on duty through the past 36 hours and no one recalled anything unusual occurring to cause a possible injury to the leg. The portable x-ray obtained on 9/30/12 revealed three views of the resident ' s left knee. The x-ray showed an acute oblique fracture of the distal femoral shaft with mild angulation and overriding of the ends of the fracture. The fracture line extends inferiorly to the distal metadiaphyseal junction. There is mild bowing of the proximal tibial metadiaphyseal junction which appears to be chronic. Nursing note documentation dated 9/30/12 at 6 p.m., identified a " late entry for 9/30/12 at 6 a.m. " The note revealed a CMA (Certified Medication Administration Aide) reported at 4:00 a.m. of Resident #1 was acting differently. The nurse documented she assessed the resident ' s legs and there was no redness, swelling or bruising, and his/her legs were cool to touch with no visible marks or issues. The resident then rested quietly once he/she had been repositioned. An Adverse Event Report initiated on 9/30/12 by Staff H, LPN, identified a fracture of unknown origin occurred. A History and Physical dated 10/4/12 by the resident's primary physician identified a fractured left distal femoral shaft with angulation. During the actual exam documented the left leg in the femoral area is extremely swollen and tender to touch. There is a bruise noted over the medial aspect of the patella and the patella is also warm to touch. The swelling at this point in time is mainly near the patellar area where the fracture is - one appreciating a significant decrease in the swelling over that area. Plan for realignment of the fractured area while under anesthesia with casting of the leg. The nursing notes dated 10/5/12 at 3:00 p.m. revealed the resident transported to the local hospital for the casting procedure and returned to the facility at 6:00 p.m.. An interview conducted on 10/31/12 at 2:00 p.m. with Staff C, CCU Unit Manager, revealed Staff H, LPN, team lead for the weekend, phoned Staff C to report the resident's left leg swollen and the physician ordered a portable X-ray to be done. Staff C stated she made sure Staff H contacted the resident's family and to make sure the resident received pain medication for comfort. Staff C stated she then called the facility DON ( Director of Nursing) to inform him of the event. Staff C stated she was surprised to hear this happened to Resident #1 and questioned Staff H how this happened. Staff C stated upon her arrival to work the following day she checked all documentation and began obtaining statements from the shift who worked the weekend this happened. Staff C stated the resident had not been transferred with the Hoyer lift with 2 assist or 3 person lifted but in fact 2 staff members transferred the resident and stated this was not the correct way for this particular resident. An interview conducted on 10/31/12 at 3:00 p.m. with Staff F, CMA (Certified Medication Administration Aide), revealed she did not work with Resident #1 at all on 9/29/12 but worked with the resident on 9/30/12 as she assisted with cares. Staff F stated she assisted in dressing the resident the morning of 9/30/12 and assisted Staff T, CMA transfer the resident via the Hoyer lift into the wheelchair. Staff F stated neither one of them noticed anything unusual with the resident at this time. Staff F stated at around 10:45 a.m. Staff T checked on the resident and noticed the resident's heart rate in the upper 120 range and explained this was high for this resident. Staff F stated the resident wet through clothing and they changed the wet clothes. Staff F stated at this time they noticed the left leg to be swollen around the knee area and Staff T summoned the nurse Staff H, LPN, to come and assess the resident. Staff F stated to her knowledge nothing unusual occurred with the resident and stated the resident did not ever move on own. Staff F stated there is a binder at the head of each resident's bed that tells you about the care of the resident including the proper way to transfer or lift the resident and how people are required. Staff F stated it is each staff member's responsibility to look at the binder and do the cares correctly. An interview conducted on 10/31/12 at 4:05 p.m. with Staff H, LPN, revealed on 9/30/12 the night CNA approached her at 6:00 a.m. and stated she thought something unusual was going on with the resident. Staff H state she went to the resident's room and undressed the resident at this time and did not find anything unusual. Staff H stated she did not observe the resident ' s legs bare at this time. Staff H stated she talked with Staff F and Staff T as they were the resident's caregivers for the day shift and told them to keep an eye on the resident. Staff H stated later in the morning, Staff F approached her again requesting she look at the resident. Staff H stated upon entering the resident's room, Staff F pulled the resident's pants up to the thigh and she noticed immediately the left leg quite swollen by the left knee and the thigh above the knee appeared to be somewhat bowed. Staff H stated she called the resident's physician who ordered a portable x-ray which showed the left leg broken close to the center of the Femur bone. She explained the resident clearly appeared uncomfortable with any movement of the left leg and appeared 75% more comfortable after the physical therapist applied the splint and immobilized the leg. She stated she kept the resident in bed for the rest of her shift with the leg elevated for comfort. Staff H stated there is a binder on the wall above each resident' bed with a yellow cover identifying how to transfer the resident and how many people are required to assist. She explained it is the staff ' s responsibility to know how to safely transfer these residents. An interview conducted on 11/1/12 at 8:20 a.m. with the DON (Director of Nursing) revealed during the facility investigation of the fracture, no specific event or time could be determined as to when the fracture could have occurred as the resident did not become symptomatic immediately. The DON stated through his interviews with staff after the event, at least 2 staff transferred the resident incorrectly prior to the fracture. The DON reported because he takes these injuries quite seriously, he decided to suspend the identified staff members and explained they are required to take additional training related to transfers and lifting techniques. The DON stated he conversed with the resident's primary physician regarding the injury. The DON stated the physician believed that probably something minor happened to the resident's leg during the course of the normal routine and because the resident did not display symptoms of injury immediately, it is likely it continued to be aggravated until the symptoms finally became to appear. An interview conducted on 11/1/12 at 9:42 a.m. with the resident's primary physician revealed he/she believed something did probably happen to the resident's leg to cause the fracture. He/she explained the resident is fed via a feeding tube but the bones are probably quite brittle. The physician explained the initial injury more than likely continued to be aggravated by the resident' normal routine due to the fact the symptoms did not appear immediately. An interview conducted on 10/31/12 at 3:45 p.m. with Staff D, CNA (Certified Nursing Assistant) revealed on 9/29/12 on the day shift, Staff D stated she incorrectly transferred Resident #1 using only a 2 person lift instead of the required 3. Staff D stated she and another staff member 2 person lifted Resident #1 from the bath gurney into the wheelchair. Staff D stated she knew the correct method to transfer the resident as the information is posted at the head of the resident's bed. She stated staff could either use the mechanical lift with 2 assist or do a transfer using 3 people. An interview conducted on 10/31/12 at 3:15 p.m. with Staff E, LPN, revealed on 9/29/12 on the evening shift, Staff E assisted Staff D transfer Resident #1 from the wheelchair into bed just the 2 of them. Staff E stated she knew the correct method to transfer Resident #1 involved the use of the mechanical lift and 2 staff or a 3 person transfer lift but just went ahead and did a 2 person transfer to assist Staff D at the time. An interview conducted on 10/31/12 at 4:00 p.m. with Staff G, LPN, revealed on 9/29/12 on the day shift, she assisted Staff D, CNA, transfer Resident #1 from the bath gurney into the wheelchair using just the 2 of them instead of the recommended 3 person lift. Staff G stated at the time of the transfer she knew the correct method to transfer the resident required either a 3 person lift or the use of the mechanical lift and 2 people present during the transfer. The facility lifting policy dated 7/17/12 identified under section 4.0 - C. " Staff will adhere to the transfer/lifting plan designed for each individual child. " Under section 7.1 Procedures: D. " To ensure the safety of staff and children, staff are encouraged and expected to alert other staff members when observing other staff using unsafe lifting techniques to promote mutual accountability. In addition, staff are encouraged and expected to notify their supervisor of staff member using unsafe techniques. Under section 7.4 Skilled Care Services Procedures: A. " All residents will be assessed upon admission and periodically thereafter by a physical or occupational therapist or nurse trained in lifting assessment to determine the best way to lift and transfer the patient." C. " As a result of the child specific assessment, individualized lifting protocols will be incorporated into each child's care plan, including : the number of personnel needed for safe lift, the use of necessary mechanical lifting devices and other patient handling aides as identified by the care team." 2. According to the Minimum Data Set MDS dated [DATE], Resident #8 had [DIAGNOSES REDACTED]. The assessment identified a Brief Interview for Mental Status (BIMS) summary score of zero (00). (A BIMS score of 13 to 15 identified the resident demonstrated intact cognition.) The assessment identified the resident as unable to complete the interview. The MDS documented the resident totally dependent on one staff for transfers, dressing, using the bathroom and personal hygiene. A physician progress notes [REDACTED]. The Transition Care Unit Team Meeting not dated and the physician progress notes [REDACTED]. The Multidisciplinary Care Plan dated 10/17/12, directed staff to provide the resident with safe transfers with every transfer. Observation on 10/30/12 at 10:18 a.m. Staff M, Registered Nurse and Staff N, Certified Nurses Aide, transferred the resident from the wheelchair to the bathroom without a gait belt. During an interview on 11/1/12, at 3:40 p.m. revealed Staff U, Transition Care Unit, Service Manager, showed a gait belt located in the resident's room. Staff U revealed the gait belt was used for ambulation with the resident, which included ambulation to the bathroom. Staff U stated the gait belt was to be used no matter the distance. 3. Observation revealed on 10/30/12, at 3:15 p.m. the secured door to room 424 was proped open from 3:15 p.m. to 3:25 p.m. The room 424 door sign designated the room as the Enternal Solution Room(a room where the feeding formulas are mixed and dispensed to the residents' plastic bin for a 24 hr. duration). The observation revealed no staff present with view of the opened door. On environmental tour with Staff W, the facility Environment Service Manager, 11/1/12 at 9:05 a.m. observation of the secured door to room 424 revealed the door as closed. The Evironment Service Manger stated coded doors are to closed/locked and secure. Observation on 11/1/12, at 9:40 a.m. revealed Staff V Licensed Professional Nurse, in room 424 with the door opened. Staff V stated any door with a code to enter should be locked and never to be left open without staff present.

Based on observation, record review and staff interview, it was determined the facility failed to provide appropriate nursing supervision to prevent accidents for 1 of 4 residents reviewed (Resident #1). A staff member failed to remove Resident #1's shoes prior to entering and utilizing the inflatable slide per the safety instructions indicated by the rental agency. This resulted in Resident #1's shoes hitting the rubber platform at the base of the slide resulting in a sudden stop that fractured the child's right and left distal tibia and distal fibula. The facility identified a census of 45 residents. Findings include: According to the Record of Admission sheet, Resident #1 had [DIAGNOSES REDACTED]. The Quarterly assessment dated [DATE] documented Resident #1 as non ambulatory and dependent on staff for all cares. The Care Plan dated 4/17/12 directed staff to provide the child community activities as they arise and revealed he/she required a one person lift for transfers. The Nurse's Notes dated 5/12/12, 4:20 PM documented Resident #1 in bed playing at 7 AM, smiling and mouthing fingers, up for the Run for Kids activities at 9:30 AM and left at 9:40 AM with Staff A for outdoor activities. Resident #1 returned at 11:15 AM accompanied by Staff B, with Resident #1 crying inconsolable with both legs drawn up. Staff C removed Resident #1's clothes in bed and attempted to assess for injuries. Staff B reported Resident #1 was with her on an inflatable slide outside, when she reached the bottom of the slide with Resident #1 on her lap the Resident's shoes stuck on the slide and both feet made a stop suddenly and the Resident cried immediately, there had been no crying prior to this activity. Orders were received to transport Resident #1 to the emergency room . The hospital radiology transcription report dated 5/12/12 documented Resident #1 had an impacted fracture of the right and left distal tibia metaphysis and a subtle non displaced fracture of the distal fibular metaphysis. When interviewed on 5/23/12, at 9:30 AM Staff A reported at approximately 10:30 AM on 5/12/12, he had Resident #1 with him outside at the Fun Run at which time Staff B came up and asked, "Can I take Resident #1 down the inflatable slide? and I said, "Of course." Staff A stated that at that point Staff B and I got Resident #1 out of his/her wheel chair and Staff B began to take Resident #1 up the inflatable stairs. I did not see a sign that said, Please take off your shoes prior to entering the slide. Staff A reported Resident #1 was extremely happy when he/she reached the top of the slide with Staff B. Resident #1 and Staff B slid down the slide and I came around the slide to see Resident #1 and Staff B at the bottom. Resident #1 was crying at that time. Staff B and I took Resident #1 back to his/her wheel chair and I assessed him/her. Resident #1 did not appear to tolerate range of motion. We took Resident #1, back to his/her room where the nurse and physical therapist assessed him/her. Staff A stated, the facility did not provide training on the use of the inflatable slide prior to using it. No rules were provided for determining safety for the children prior to its use. When interviewed on 5/22/12, at 2 PM Staff B reported she helped with the "Run for the kids" on 5/12/12, the day was winding down and she went outside to get her children who were volunteering and I saw Resident #1 with Staff A and I asked if I could take Resident #1 down the inflatable slide. Staff B reported she took Resident #1 from his/her wheel chair and Staff A held Resident #1 while she took off her shoes and waited for her turn. Staff B stated she got on the platform of the inflatable slide and Staff A handed Resident #1 to her. Staff B reported she carried Resident #1 upright over her shoulder and went up the ladder, when she reached the top she sat down with Resident #1 on her lap with Resident #1's back against her chest and his/her feet out front. Staff B reported his/her feet were straddling her legs, one foot on either side. We went down the slide much quicker than she expected. When we reached the bottom there was an inflated platform, I felt Resident #1's feet hit the platform and he/she still had his/her shoes on. Staff B stated, I believe the tread against the rubber platform made his/her feet grab and stop instantly. Staff A waited at the bottom of the slide for us and he pointed to Resident #1 and I turned him/her to look at his/her face and he/she was crying with is/her knees pulled to his/her chest. Staff B reported she saw other people had taken their shoes off, so she took her shoes off as well. Staff B stated she didn't take Resident #1's shoes off because he/she was on her lap when going down the inflatable slide. Staff B reported the facility did not provide training on the inflatable slide and did not receive any training prior to the event. When interviewed on 5/22/12, at 3 PM Staff C stated, while providing physical therapy services to another resident during the Childserve Fun Run activities she an a resident came to the slide area and noticed shoes on the ground at the slides entrance. Staff C reported she took her shoes off and helped her resident take off his/her shoes. A volunteer set at the slide entrance monitoring when the next person could enter the slide. We went down the slide, landed on the bottom platform and then climbed off to the left. We retrieved our shoes and returned to the building. Staff C reported she did not receive or participate in training for inflatable rides at Childserve. When interviewed on 5/23/12, Staff D reported on 5/9/12, she contacted the representative of the inflatable slide in order to get a copy of the rules for the inflatables to give to the volunteers on the day of the event. The representative emailed a copy of the rules. On 5/12/12, the inflatable employees came to set up the inflatable's and a copy of the safety rules were shared and Staff D signed the waiver. Staff D reported she greeted the volunteers and gave an orientation including their job description and safety guidelines. Rules For Safe Operation Of Inflatables provided to the volunteers included the following safety instructions: Supervision is required at all times by an adult who has read and understands this contract and all rules. Children should not use this if they have any existing medical conditions such as, but not limited to: neck, back or joint injuries, heart, asthma, bronchitis, circulatory problems or other health conditions. Remove shoes, eye glasses, jewelry, and anything in pockets before entering inflatable. When interviewed on 5/23/12, at 11:25 AM, the Administrator reviewed the inflatable safety instructions provided per the Internet and stated she was not aware of the safety rules for the inflatables. Staff E reported the facility did not educate staff on the use and safety rules of the inflatable rides prior to the 5/12/12, Fun Run community activity. The facility failed to properly train the staff prior to the event to establish a standard of case in order for staff to properly supervise the children under their care to prevent accidents.