Every finding on record at Christian Health Center

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the comprehensive person-centered care plan was implemented for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 4 sampled residents, Resident (R)37.On 04/09/2025, Certified Nursing Assistant (CNA) 10 failed to implement the Comprehensive Care Plan intervention added 02/25/2025, requiring a total lift with green sling and assistance of two staff for transfers. CNA10 transferred the resident independently without the mechanical lift resulting in a laceration to R37's right lower leg. R37 was transferred to the local hospital for sutures. The findings include:Review of the facility's policy titled, Care Planning, revised 03/27/2024, revealed it was the policy of the facility to develop and implement a baseline and comprehensive person-centered care plan for each resident that reflected the resident's medical, nursing, mental, and psychosocial needs.Review of R37's Face Sheet revealed the facility admitted the resident on 09/18/2024 with diagnoses including unspecified dementia, scoliosis, and overactive bladder.Review of R37's Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/10/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. Further review revealed the resident was dependent on staff for chair/bed to chair transfer.Review of R37's Comprehensive Care Plan, dated 09/20/2024, revealed R37 had a self-care deficit related to needing assistance with activities of daily living (ADL) and was at risk for decline related to impaired mobility. The interventions included: provide assistance with ADLS, assistance of two (2) staff, encourage resident to be as independent with ADLs as possible, and assess resident for needed equipment or assistive devices to maximize independence. Additional review revealed on 02/25/2025, a new intervention was added indicating R37 required a total lift with green sling and assistance of two staff for transfers. Review of the Comprehensive Device Assessment, dated 02/25/2025, revealed R37's assistive devices included a wheelchair, a total lift with a green sling, and also side rails for positioning. Additionally, R37 was to use the green sling during transfer to the tub.Review of R37's current Assignment Sheet, revealed the resident required a lift with 2 person assist with the green sling.Review of R37's Progress Note, dated 04/09/2025 at 3:39 PM, written by Registered Nurse (RN)5, revealed, at 2:30 PM the resident was being transferred from wheelchair to bed by CNA10 when she sustained a vertical cut to her right lower extremity that extended full thickness to the bone. Continued review revealed bleeding was controlled, and the physician, Unit Manager, Director of Nursing (DON) and the resident's son was made aware. R37 was transported to the hospital by ambulance.Review of R37's Patient Health Summary, dated 04/09/2025, from the local hospital, revealed the resident's encounter diagnosis was laceration of leg. The discharge care plan revealed the resident sustained a right leg laceration and her condition was stable. The instructions included: warm soapy washes daily and apply a light coating of antibiotic ointment. Elevate it once or twice a day if it starts to swell. Can place a light ace wrap or compression hose over it because you do not really want any swelling. Recheck in 2-3 days. Sutures should be removed in 10 days by family doctor. Observation and concurrent interview with R 37, on 01/14/2026 at 4:00 PM, revealed there was a lift sling in R37's wheelchair. The State Survey Agency (SSA) Representative asked R37 if staff used a lift to transfer her out of the bed, and she stated yes. She then stated she received a big cut on her leg when an aide tried to move her without the lift. R37 stated she could not remember everything about it but she did remember that much. Telephone interview attempts with CNA10 were unsuccessful on 01/14/2026 at 2:18 PM; and on 01/15/2026 at 11:56 AM and 3:15 PM. In an interview with Registered Nurse (RN)5, on 01/15/2025 at 3:10 PM, she stated she was the nurse on the 300 hall on 04/09/2025 when CNA10 informed her R37 was bleeding. Further, CNA10 informed her she had transferred R37 to the bed from the wheelchair. RN5 stated she went to the resident's room and observed a large cut to R37's lower right leg from the iron bed frame. During additional interview on 01/15/2025 at 3:10 PM, RN5 stated she called the Unit Manager and the DON. She further stated the DON had her call the physician, and she also called emergency medical services (EMS) to transport R37 to the hospital emergency room. RN5 stated R37 required the use of a total body lift (mechanical lift) and assistance of two staff for transfers, and CNA10 was aware. RN5 further stated the CNAs received an assignment sheet at the beginning of the shift, and the information showing type of transfer required was on the assignment sheet. In an interview with CNA2 on 01/15/206 at 3:46 PM, she stated she had been at the facility for about 2 years. She stated she worked all units in the facility and had provided care for R37 before. CNA2 stated R37 required a lift for transfers and assistance of two (2) people. She stated she received an assignment sheet at the beginning of her shift. CNA2 stated if a resident required a lift, it would be on the assignment sheet. She further stated the color of the sling a resident used would be on there as well. Additionally, she stated when using a mechanical lift, two people were required when transferring a resident. CNA2 further stated she could also review care plans on the computerIn an interview with CNA4, on 01/15/2026 at 4:22 PM, she stated she worked all units in the facility, and all units used the same assignment sheets. She stated CNAs were to keep their assignment sheets in their pockets and review them if they were not familiar with a resident. She further stated if a resident used a mechanical lift, it would be on the assignment sheet and would be marked two (2) assist and the color of the sling to use would be noted. She stated she could also access the care guide on the computer (electronic health record).In an interview with the MDS Nurse, on 01/15/2026 at 4:11 PM, he stated he had been completing MDS Assessments for about 18 months. He stated the unit managers assisted him with completing the comprehensive care plans. He further stated staff nurses could add to the care plans, but he and the unit managers completed most of the updates. The MDS nurse stated the purpose of the care plan was to ensure the staff were following standards of care based on a resident's specific needs. He stated we would expect staff to follow interventions that were in place on the plan of care. In an interview with the Director of Nursing (DON), on 01/15/2026 at 5:14 PM, she stated it was her expectation staff follow the interventions on the care plan. She stated the facility had a skills check off with education provided in March 2025 which included use of the total lift.The DON further stated CNA10 was aware R37 required a lift (mechanical lift) and two (2) assist for transfers but transferred her anyway, resulting in an injury.In an interview with the Interim Executive Director (ED), on 01/15/2026 at 6:39 PM, she stated CNA10 transferred R37 by herself because she thought she could do it without using the lift. The ED stated she expected staff to follow resident care plans.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 sampled residents, Resident (R) 37.On 04/09/2025, Certified Nursing Assistant (CNA) 10 transferred R37 by herself and without the use of a total lift (mechanical lift). However, the resident was assessed and care planned to be transferred by a total lift with 2 staff members. R37 sustained a laceration to her right lower leg requiring transfer to the hospital emergency room for sutures. The findings include:Review of the facility's policy titled, Accidents and Supervision, dated 04/2025, revealed the residents' environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This included implementing interventions to reduce hazards and risks, monitoring for effectiveness, and modifying interventions when necessary. Continued review revealed implementing interventions meant using specific interventions to try to reduce a resident's risks from hazards in the environment.During an interview with the Interim Executive Director on 01/14/2025, she stated the facility did not have a policy on the use of mechanical lifts. (A mechanical lift is a device, often battery or electrically powered to safely move individuals with limited mobility). Review of Resident (R)37's Face Sheet, revealed the facility admitted the resident on 09/18/2024 with diagnoses including unspecified dementia, scoliosis, and overactive bladder.Review of R37's Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/10/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. Further review revealed the resident was dependent for chair/bed-to-chair transfer and utilized a wheelchair.Review of R37's Comprehensive Care Plan dated 09/20/2024, revealed the resident was care planned as having a self-care deficit related to needing assistance with activities of daily living (ADL) and at risk for decline related to impaired mobility. The interventions included: provide assistance with ADLS, assistance of two (2) staff, encourage resident to be as independent with ADLs as possible, and assess resident for needed equipment or assistive devices to maximize independence. Additional review revealed on 02/25/2025, a new intervention was added indicating R37 required a total lift with green sling and assistance of two staff for transfers.Review of the Comprehensive Device Assessment, dated 02/25/2025, revealed R37's assistive devices included a wheelchair, a total lift with a green sling, and side rails for positioning. Further, R37 was to use the green sling during transfer to the tub.Review of R37's current Assignment Sheet, revealed the resident required a lift with 2 persons assist and a green sling.Concurrent observation and interview with R37 on 01/14/2026 at 4:00 PM, revealed a lift sling in R37's wheelchair. R37 was questioned if staff used a mechanical lift to get her out of bed, and she stated yes. R37 further stated she got a big cut on her leg when an aide tried to move her without the lift. She stated she couldn't remember everything about it, but she did remember that much.Review of R37's Progress Note, dated 04/09/2025 at 3:39 PM, signed by Registered Nurse (RN)5, revealed at 2:30 PM, resident was being transferred from the wheelchair to bed by CNA10 when she sustained a vertical cut to her right lower extremity that extended full thickness to the bone. Bleeding was controlled, and the physician, Unit Manager, Director of Nursing (DON), and R37's son were made aware. Resident was transported to the hospital by ambulance.Review of R37's Patient Health Summary, dated 04/09/2025, from the local hospital, revealed the encounter diagnosis was laceration of the leg. The discharge care plan stated: right leg laceration and condition stable. Additional instructions included: warm soapy washes daily and apply a light coating of antibiotic ointment. Elevate it once or twice a day if it starts to swell. Can place a light ace wrap or compression hose over it because you do not want any swelling. Recheck in 2-3 days, sutures should be removed in 10 days by family doctor. Tylenol as needed for pain. There is no fracture or any other abnormality on the x-ray except the bones are thin with osteoporosis.Review of the facility's Final Report/5 Day Follow-Up, dated 04/16/2025, revealed after a thorough investigation, it was determined despite documented and verified recent training on use of Hoyer lift (mechanical lift) on 03/27/2025, CNA10 did not use the mechanical lift as care planned. As a result, R37 sustained a laceration to her right leg.Review of CNA10's Employee File, revealed a hire date of 03/13/2025. Continued review revealed all required checks were completed on 03/13/2025.Review of the document titled, Counseling/Discipline Record, revealed the Director of Nursing (DON) issued a final written warning to CNA10 on 04/11/2025. Per the document, the investigation revealed, on 04/09/2025, CNA10 transferred R37 from her bed without using the required Hoyer lift. CNA10 admitted to transferring the resident without using safety equipment. R37 received an injury while in the process of being moved.During an interview with Registered Nurse (RN)5, on 01/15/2025 at 3:10 PM, she stated she was the nurse on the 300 hall on 04/09/2025. She stated CNA10 informed her R37 was bleeding after she transferred the resident to the bed from the wheelchair. RN5 stated she went to the resident's room and observed R37 had a large cut to the right lower leg from the iron bed frame.During further interview with RN5, on 01/15/2025 at 3:10 PM, she stated she called the Unit Manager and the DON. She further stated the DON had her call the physician, and she also called emergency medical services (EMS) to transport R37 to the emergency room. RN5 stated R37 required the use of a total body lift and assistance of two staff for transfers, and CNA 10 was aware. RN 5 stated the CNAs received an assignment sheet at the beginning of the shift, and instructions on how to transfer the resident were on the assignment sheet.Telephone interview attempts with CNA 10, who transferred R37 on 04/09/2025 were attempted, but were unsuccessful on 01/14/2026 at 2:18 PM; and on 01/15/2026 at 11:56 AM and 3:15 PM.In an interview with CNA3, on 01/15/2026 at 3:57 PM, she stated she worked as needed (PRN) and worked in all areas of the facility. She stated she was familiar with R37 and knew the resident required a total lift for transfers. She stated the amount of assistance a resident required (one or two people) was noted on the assignment sheets for all units. She further stated if a resident used a lift, the sling color would also be on the sheets.During an interview with the Director of Nursing (DON), on 01/15/2026 at 5:14 PM, she stated she had been at the facility for 21 years. She further stated she was made aware of R37's incident immediately by RN5. The DON stated she went upstairs to R37's room and saw CNA10 holding pressure to R37's leg. She stated she asked RN5 what happened, and RN5 stated CNA10 attempted to transfer R37 by herself without using the lift. The DON stated she told RN5 to call the physician and send her to the hospital Emergency Department (ED) because the cut was pretty bad.During continued interview with the DON, on 01/15/2026 at 5:14 PM, she stated she had a discussion with CNA10 and she was suspended. She stated CNA10 did not give a reason for transferring R37 by herself without a lift and informed her she had done it before. She stated CNA10 was aware R37 required a lift and two (2) assist for transfers but transferred her without the lift anyway. The DON further stated CNA10 did not have her assignment sheet on her at the time which would have shown the resident was to be transferred with a lift and two staff members.During an interview with the Interim Executive Director (ED), on 01/15/2026 at 6:39 PM, she stated she was in the facility when R37's incident occurred and was notified immediately. She stated she was the Assistant Executive Director at that time. She stated CNA10 transferred R37 by herself because she thought she could do it without using the lift. She further stated CNA10 was suspended following the incident. In continued interview, the Interim Executive Director (ED) stated she expected staff to follow resident care plans. She stated the facility had zero tolerance and had terminated staff for not following the plan of care.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure all drugs and biologicals were kept under lock when not attended. In addition, medications/solutions were not dated when opened (to indicate an expiration date) and/or disposed of when expired. This failure affected one of two medication carts and one of three medication rooms that were audited. The findings include: Review of an undated facility policy, titled, Medication Storage in the Facility, revealed medications and biologicals are to be stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Further review revealed outdated, contaminated, or deteriorated medications are to be immediately removed from stock and disposed of according to procedures for medication disposal. 1. Observation upon entrance to the facility on [DATE] at 10:38 AM, revealed Registered Nurse (RN) 1 administering medications to residents sitting in the common living room area on the 100 Hall. RN1 walked away from the medication cart and left the cart (which contained multiple medications) unlocked and unattended for approximately five minutes while she entered the medication supply storage room to gather additional supplies. In an interview with RN 1 on 08/20/2024 at 2:30 PM, she stated that medication carts should be locked at all times if the staff was not getting into them to get something out. In addition, per RN1, the medication cart should be locked after staff get medications out, before walking away to give them to a resident. She further stated that she did not realize that she had walked away from the cart and left it unlocked. She stated that she knows better and had no explanation as to why she walked away and did not lock her cart. She stated it is dangerous to leave a medication cart unlocked because wandering residents and others could get into them and may take things, especially if the cart is left in an accessible area. 2. During an observation of medication administration on 08/21/2024 at 8:27 AM, Certified Medication Technician (CMT) 2 walked away from the medication cart to administer medications to Resident (R) 13 and did not lock the cart. The unlocked medication cart was left in the hallway, while CMT2 was in the resident's room. In addition, CMT2 did not secure a controlled medication (one capsule of Gabapentin) that was to be wasted. The controlled medication was left sitting on top of the unlocked, unattended medication cart. In an interview with CMT 2 on 08/21/2024 at 9:34 AM, she stated that she forgot to lock her cart and secure the controlled medication before going to administer medications to the resident. She further stated she forgot the controlled medication was still sitting on top of the medication cart, as she was waiting for a nurse to become available and witness the waste of the medication with her. She stated a resident, or anyone else, could get into her cart and take some medications if it was left unlocked and unattended. 3. Observation of Medication Storage room [ROOM NUMBER] on 08/21/2024 at 4:00 PM, revealed one vial of Tubersol Solution, with an expiration date of 05/01/2027, that was stored in the medication refrigerator. The vial was opened but not dated. In addition, observation revealed three vials of glucose control level 2 solutions with expiration dates of 01/17/2023, 11/14/2023, and 08/15/2024. In an interview with Licensed Practical Nurse (LPN) 1 on 08/21/2024 at 3:20 PM, she stated that all nurses were responsible for checking the supply storage rooms on a monthly basis. LPN1 stated that they just overlooked the expired solutions when performing their last check. LPN1 confirmed that nursing is ultimately responsible for checking the rooms and making sure everything is up to date and stored correctly. In an interview with the 300 Hall Unit Manager on 08/21/2024 at 4:00 PM, she stated the room was used to store the overflow medications and supplies and did not know if the nursing staff was using the supplies out of the Medication Room on the 300 Hall. Further interview with the Unit Manager revealed that they were ultimately responsible for the storage rooms. In an interview with the Director of Nursing (DON) on 08/23/2024 at 8:46 AM, she stated she expects proper storage of medications, with staff keeping them safe and secure. The DON stated that anyone could come through and retrieve medications if they were to walk by an unlocked cart. She also stated her expectation was that staff keep stock up to date, adding that nurses are trained to look at expiration dates. The DON stated staff are aware of the need to check dates on items because things can expire quickly. She added that they try not to keep expired things in their medication rooms, but staff should look at dates and make sure that they do not use those items. In an interview with the Administrator on 08/23/2024 at 8:32 AM, he stated anything that is getting close to being expired should be used or discarded. He further stated his expectations is for staff to be accurate at all times, and not have expired medications on the floor or in a supply room.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions. Review of the facility Census and Condition, dated 05/30/17, revealed thirty-six (36) of thirty-six (36) residents received their meals from the kitchen. Observations on 05/30/18 revealed the range hood had a build up of black grease all over it and the meat slicer had a large build up of brown and yellow material all over it. In addition, observations on 05/31/18 revealed kitchen staff were observed drying cups with visibly soiled hand towels. The findings include: 1. Review of the facility policy titled, Cleaning Dishes/Dish Machine, not dated, revealed staff are to allow dishes to dry on racks and are not to dry with towels. Observation during a follow up visit of the kitchen, on 05/31/18 at 9:49 AM, revealed Dietary Aide #1 and #2 were drying cups by hand, with visibly soiled hand towels that had a brown stained color, after the cups had been run through the dishwasher. Interview with the Dietary Manager on 05/30/18 at 9:53 AM, revealed all dishes need to be air dried and it was unacceptable to towel dry any dishes. 2. Review of the facility policy titled, Cleaning Slicers, not dated, revealed the slicer will be cleaned and sanitized after each use. Observation during the initial tour of the kitchen, on 05/30/18 at 1:30 PM, revealed the slicer had a massive build up of dried/crusted brown and yellow material all over it. 3. Review of facility policy titled, Cleaning Hoods and Filters, not dated, revealed the stove hoods and filters will be cleaned at least monthly. Observation during the initial tour of the kitchen, on 05/30/18 at 1:27 PM, revealed the stove hood had a massive build up of black greasy material all over it. Interview with the Dietary Manager on 05/30/18 at 1:44 PM, revealed she expected the meat slicer to be clean and taken apart and cleaned after each use. She stated she did not have a meat slicer cleaning schedule in place. She revealed she expected the range hood to be cleaned and when it has buildup she stated she would expect to be notified by the kitchen staff so maintenance can be notified so they can clean it in between contract cleanings. She revealed she did not have a cleaning log in place. Interview with facility Registered Dietician on 05/31/18 at 10:03 AM, revealed she expected the meat slicer to be cleaned after each use. She stated the range hood needs to be monitored and kept clean. She revealed she also expected the dishes to be air dried and towel drying is not appropriate. She further stated she expected the kitchen to be clean and sanitary.

Based on observation, interview, record review, facility policy review, and review of the Kentucky Board of Nursing (KBN), Advisory Opinion Statement (AOS) #14, it was determined the facility failed to ensure the services provided or arranged by the facility, met professional standards of quality for one (1) unsampled resident (Resident A) not in the select sample of ten (10) residents. Observation of a medication pass, on 04/05/17 at 8:20 AM, revealed Registered Nurse (RN) #1, handed Unsampled Resident A a [MEDICATION NAME] ([MEDICATION NAME]) inhaler. The resident was observed to self-administer the medication, one spray to each nostril. However, review of the physician order revealed the resident should have received two (2) sprays to each nostril and there was no order for the resident to self-administer the medication. The findings include: Review of the KBN, AOS #14 Patient Care Orders, last revised October 2011, revealed licensed nurses are responsible for the administration of medication and treatment as prescribed by a Physician or Advance Practice Nurse Practitioner (ARNP) which includes preparing and giving medication in the prescribed dosage, route and frequency. Review of the facility policy titled, Self Administration of Medication and/or Treatments, not dated, revealed the resident was to have signed a form indicating they desired to administer their own medications and/or treatments. The resident was then to have been assessed for their Brief Interview for Mental Status (BIMS,) to determine their long and short term memory status and cognitive skills for decision making. Additionally, the resident was to have been directly observed in their ability to prepare, safely administer and read the pharmacy label on all medications, including inhalant or mist medications, reliably and safely and educated on any side effects or interactions. The staff were to have completed this assessment, education and the evaluation of the resident's compliance with the medication regimen and obtained a physician order, prior to the self-administration of any medications. Record review revealed the facility admitted Unsampled Resident A on 03/06/17, with [DIAGNOSES REDACTED]. Review of the facility Interviewable Residents List, dated 04/04/17, revealed the resident had a BIMS score of 13-15, which indicated the resident was cognitively intact and independent in decision making skills. Review of Unsampled Resident A's April 2017 Physician's Orders revealed an order for [REDACTED].#1 handed Unsampled Resident A a [MEDICATION NAME] inhaler, after the RN had administered the rest of the resident's medications, and observed the resident to administer one (1) spray to each nostril. The RN failed to remind the resident of the need to administer two (2) sprays. Further review of the April 2017 Physician Orders revealed there was no order for Unsampled Resident A to self-administer his/her medications. Interview with RN #1, on 04/05/17 at 2:50 PM and 3:10 PM, revealed the nurse had reviewed the physician order, prior to handing the resident the [MEDICATION NAME]. She stated she just missed the dose, and stated residents were able to administer his/her medications, if their BIMS score was above eight (8). Further interview revealed this was the only requirement needed to self-administer an inhalant. Interview with RN #2, on 04/05/17 at 3:15 PM, revealed the resident's ability to self-administer medications was determined by the BIMS score and also stated if the resident's score was above eight (8,) they were allowed to self-administer. When asked about an assessment for the resident's ability to safely administer medications, the RN checked the resident's medical records and stated normally the Director of Nursing (DON) completes this assessment, and stated the DON was out of the facility this week. RN #2 was unable to find any evidence the assessment had been completed. Interview with the Administrator, on 04/06/17 at 3:42 PM, revealed residents should have been asked if they were interested in self-administering their own medications on the Initial Nursing Assessment, done on admission. The DON was to have been made aware of this need and she would have completed the Self Administration Assessment. If the assessment was acceptable, an order was to have been received from the physician and this should have been placed on the MAR, to alert the nurses administering the medications. The Administrator stated the nurse should have administered the medication herself, if there was no order and ensured the correct dosage was given.

Based on observation, interview and review of facility's policy and procedure, it was determinied the facility failed to ensure food was stored, prepared and served under sanitary conditions for twenty-one (21) of twenty-one (21) residents. Observations during kitchen tour, on 03/15/16 at 6:55 AM, revealed opened non-dated foods in dry storage, brooms sitting directly on the floor in the utility room, and staff not wearing hair net when entering the kitchen area. The findings include: 1. Review of the facility policy and procedure titled, Food Labeling Policy, not dated, revealed the items will be labeled and dated with the correct date and items not properly labeled will be discarded. Review of the facility's policy and procedure titled, Kitchen Cleaning Tools Policy, not dated, revealed mops and brooms will be stored off of the floor. Observation during the Kitchen Tour, on 03/15/16 at 6:55 AM, revealed there was a loaf of white bread and a box of white cake mix, opened and not dated when opened. Further observation revealed one (1) mop, (1) broom and (1) dust pan on the floor in the utility room. 2. Review of the facility's policy and procedure titled, Employee Sanitary Practices, not dated, revealed all employees shall wear hair restraints and clean clothes. Observation during a second Kitchen Tour, on 03/15/16 at 12:30 PM, revealed Dietary Aide #1 walked into the kitchen not wearing a hair net, opened the refrigerator and took out a food item, then walked out of the kitchen. Interview with Dietary Aide #1 on 03/17/16 at 8:30 AM, revealed he was in a hurry and quickly went into the kitchen to get a dessert out of the refrigerator for a staff member and usually always wore a hair net, but got busy and forgot. Interview with Dietary Manager, on 03/15/16 at 7:10 AM and 12:45 PM, revealed when food items are opened, and they are to be used again, staff should label and date with the opening date. She stated all mops, brooms and dustpans are to be up off the floor and secured on the wall. Further interview revealed she would expect all staff entering the kitchen area to have on a hair net. Interview with the facility's Registered Dietitian Consultant, on 03/16/17 at 3:00 PM, revealed she would expect all staff entering the kitchen to have a hair net on, all food items to be labeled and dated when opened, and would expect all brooms, mops and dustpans to be off the floor to help prevent the risk of rodents and infection issues. Interview with Administrator, on 03/17/16 at 2:30 PM, revealed she expected all staff that are in the kitchen to wear a hair net. Further interview revealed she would expect all brooms, mops and dust pans to be off the floor, all foods that have been opened to be labeled and dated and they have already been in contact with the bread company and have a new system in place to label and date bread products.

Based on observations, record reviews, interviews and facility policy, it was determined the facility failed to ensure a safe environment related to care plan interventions not implemented for safety for one resident (Resident #3) in a sample size of ten (10). Resident #3 was observed in bed with the bed not in the low position and the resident's safety alarm not connected. Findings Include: Review of the facility policy entitled, Falls Prevention with effective date of 02/2011, revealed the following: "It is the policy of this facility through assessment and intervention to provide supervision and assistance to residents in an effort to avoid falls and minimize injury that may result from a resident falling. The procedure portion of the policy stated "Residents identified as being at risk for falls will have a falls care plan initiated based on individual risk factors. The charge nurse will complete an Incident/Accident Investigation to determine the root cause of the fall. Based on the findings a new intervention will be added to aid in avoiding future falls. The Director of nursing or designee will review the care plan to ensure it has been updated to reflect the proper intervention initiated". Review of the undated facility policy entitled, Care Plan, revealed "It is the policy of this facility that all residents will have care plans. The resident's care plan provides guidance to all staff caring for the resident and communicates changes in care to all direct care staff. An interdisciplinary approach to identification of problems and developing solutions and goals provides individualization and coordination of resident care". Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE], revealed a the facility had assessed Resident with cognitive impairment and required extensive assistance with activities of daily living. Review of the Certified Nursing Assistant (CNA) care plan dated 05/2013, revealed Resident #3 was to have a bed sensor alarm and the bed in low position. Review of resident #3's Fall care plan, dated 04/25/13, revealed Resident #3 was supposed to have a bed sensor alarm and bed in lowest position. An observation on 05/22/13 at 10:25 AM, revealed the bed alarm cord to be in the floor underneath the bed and not connected to the alarm box and the bed position not in the lowest position. Observation on 05/22/13 at 3:15 PM, with CNAs #1 and #2, revealed after providing incontinent care to Resident #3, the bed alarm cord was underneath the bed and not connected to the alarm box and the bed was not in the lowest position when the CNA #1 and CNA #2 left from Resident #3's room with the resident in the bed. Interview and observation on 05/22/13 at 3:35 PM, with CNAs #1 and CNA #2 revealed they should have made sure the resident's alarm was on and plugged the alarm cord to the alarm box. CNA #1 and CNA #2 looked for the crank for the bed and stated that they couldn't find a way to lower the bed and left Resident #3's room with the resident lying in the bed with the bed not in the lowest positron. An interview on 05/22/13 at 3:40 PM, with Licensed Practical Nurse (LPN) #1 revealed when a resident was in the bed, CNAs should make sure the bed alarm is in place and functioning before leaving the room, and the aides couldn't lower the bed because they were unable to find the crank to the bed. Interview on 05/22/13 at 3:45 PM, with Registered Nurse (RN) #1 revealed he expected CNAs to follow care plans, to check alarms and make sure they are in place, and functioning properly. Observation on 05/22/13 at 3:50 PM, revealed Resident #3's bed was not in the lowest position. Interview on 05/23/13 at 2:50 PM, with the DON revealed she expected interventions to be on resident #3's care plans and to be followed. Interview on 05/24/13 at 10:20 AM, with Staff Development Coordinator/Case Manager (SDC) revealed the CNAs were to go by the CNA care plan at all times and that he updated the care plan when issues arise, such as low beds and bed alarms. The SDC further stated while the resident was in the bed it should be in the lowest position possible. The alarm was to be on at all times except when showering or toileting. The SDC additionally stated the CNAs were inserviced on how to lower beds and if they did not know how to lower the bed they were to go to their immediate supervisor, DON, or come to the SDC. Interview with LPN #3 on 05/24/13 at 8:45 AM, revealed Resident #3's bed was not in the lowest position and should be when the resident was in the bed. LPN #3 further stated that all CNAs were inserviced about the function of the beds. Interview on 05/24/13 at 8:55 AM, with CNA #3 revealed CNAs were inserviced on how to raise and lower the beds and if a resident was care planned for a low bed they needed to make sure it is in the lowest position. CNA #3 further stated they were trained to know if alarms were functioning by testing the alarm for the beep, if it was working, to make sure the light blinks to indicate it was turned on. When the resident was in the bed they were to make sure cord of the alarm was plugged into the alarm box. An interview the the DON on 05/24/13 at 9:05 AM, revealed the bed was not in the lowest position and CNAs were trained to know how to lower the beds. She stated, if a resident was care planned to be on a low bed, the bed should be in the lowest position possible when the resident was in the bed. The DON further stated that if the CNAs did not know how to lower a bed they should get their charge nurse or someone to show them how to lower it, and she expected the interventions on a care plan to be followed. On 05/24/13 at 1:57 PM, an interview with CNA #1 revealed Resident #3 was supposed to be on a low bed, and she couldn't figure out how to lower it. CNA #1 further revealed she should have looked for at the CNA care plan for Resident #3 for guidance, and had someone stay with the resident until she could get the bed adjusted or get someone to fix it. She additionally stated not ensuring the bed was in the lowest position put the resident at risk for injury if there was a fall.

Based on observations, record reviews, interviews, and facility policy it was determined the facility failed to ensure care plan interventions were implemented related to derma sleeves, low bed and a functional alarm for one resident (Resident #3) in the sample size of ten (10). Findings Include: Review of the undated facility policy entitled, Care Plan, revealed; "It is the policy of this facility that all residents will have care plans. The resident's care plan provides guidance to all staff caring for the resident and communicates changes in care to all direct care staff. An interdisciplinary approach to identification of problems and developing solutions and goals provides individualization and coordination of resident care". Review of Facility Policy entitled, Falls Prevention with effective date of 02/2011, revealed "It is the policy of this facility through assessment and intervention to provide supervision and assistance to residents in an effort to avoid falls and minimize injury that may result from a resident falling. Residents identified as being at risk for falls will have a falls care plan initiated based on individual risk factors. The charge nurse will complete an Incident/Accident Investigation to determine the root cause of the fall. Based on the findings a new intervention will be added to aid in avoiding future falls. The Director of Nursing or designee will review the care plan to ensure it has been updated to reflect the proper intervention initiated". Record Review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Review of the Admission Minimum (MDS) data set [DATE], revealed the facility assessed Resident #3 with severe cognitive impairment. Review of Certified Nursing Assistant (CNA) care plan dated 05/2013, revealed that Resident #3 was to have derma sleeves to bilateral upper extremities and bilateral lower extremities, a bed sensor alarm and low bed. Record Review of Fall Care Plan and Potential Pressure Ulcer/Impairment of Skin Integrity Care Plan dated 04/25/13 for Resident #3 revealed he/she was to have a bed sensor alarm, bed in lowest position and bilateral upper and lower derma sleeves. Record Review of physician's orders [REDACTED]. Observation and interview on 05/24/13 at 10:15 AM, revealed the DON verified Resident #3 did not have on derma sleeves. The DON reviewed and verified the Potential Pressure Ulcer/Impairment of skin integrity care plan dated 4/25/13 and the CNA care plan dated 5/13 which stated Resident #3 was to have them on bilaterally. Interview on 05/24/13 at 10:45 AM, with CNA #3 revealed she had forgotten to put the derma sleeves on Resident #3 arms. She did look at the care plan and she had been inserviced to follow the care plan when taking care of the residents. Observation on 05/22/13 at 10:25 AM, revealed the bed alarm cord not connected to the alarm box and the bed was not in the low position. Observation on 05/22/13 at 3:15 PM, with CNA s #1 and #2 revealed after providing incontinent care to Resident #3 the bed alarm cord was not connected to the alarm box and the bed was not in the lowest position when CNA #1 and CNA #2's left Resident #3's room with the resident in the bed. Interview and observation on 05/22/13 at 3:35 PM, with CNAs #1 and #2 revealed they should have made sure the alarm cord was plugged to the alarm box. CNA #1 and CNA #2 looked for the crank for the bed and stated that they couldn't find a way to lower the bed and left Resident #3's room. Interview on 05/22/13 at 3:40, with Licensed Practical Nurse (LPN) #1 revealed when a resident is in bed CNAs should make sure the bed alarm is in place and working before leaving the room and the aides couldn't lower the bed because they couldn't find the crank to the bed. Interview on 05/22/13 at 3:45 PM, with Registered Nurse (RN) #1 revealed he expected the CNAs to follow care plan and to check the alarm to make sure that it is working and in place and functioning properly. Interview on 05/23/13 at 2:50 PM, with the DON revealed she expected interventions to be on the care plan and the interventions followed for Resident #3. Interview on 05/24/13 at 10:20 AM, with the Staff Development Coordinator/Case Manager (SDC) revealed the CDNAs were to go by the CNA care plan at all times. He updated the care plan when an issue was identified, such as low beds and bed alarms. The SDC further stated while the resident was in the bed it should be in the lowest position possible. If residents have alarms, the alarm was to be on at all times except when resident is showering or toileting. The SDC then stated the CNAs were inserviced on how to lower beds, and if they did not know how to lower the bed they were to go to their immediate supervisor, DON, or himself.

Based on observation, interviews and record reviews it was determined the facility failed to ensure medications were administered as per the Physician's Order for one resident (#11), not in the selected sample of ten. Observation of a medication pass on 05/23/13 revealed Resident #11 did not receive a prescribed medication. Findings include: Review of the facility policy, titled "Patient Care Orders, Implementation Of" and dated 12/98, revealed documentation to include "In the receipt and implementation of orders, nurses should follow written approved policies and procedures of the health care facility which are consistent with Karsa Chapter 314". Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. Review of a Physician's Order, dated 05/13/13 at 8:20 AM, revealed [MEDICATION NAME] 100 milligrams (mg) by mouth two times a day for ten days. An observation of a medication pass on 05/23/13 at 8:20 AM, revealed Licensed Practical Nurse (LPN) #2 administering Resident #11's medications. Comparison of the medications administered to Resident #11 and the Resident's Physician's Orders revealed Resident #11 did not receive the last prescribed dose of [MEDICATION NAME] 100 mg. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. An interview with LPN #2 on 05/23/13 at 10:15 AM revealed she read the MAR indicated [REDACTED]. An interview with the Director of Nursing (DON) on 05/23/13 at 2:00 PM, revealed she expected nurses to follow Physician's Orders and administer medications as prescribed.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to promote care in a manner that maintains dignity and privacy during provision of care for one resident (#3), in the selected sample of ten residents. Findings Include: Review of the facility's policy/procedure, Privacy and Dignity, dated 02/2011, revealed "It is the policy of this facility to provide general guidelines for resident rights while caring for the resident. The policy/procedure further revealed "Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including resident dignity and respect. For any procedure that involves direct resident care, follow these steps: Close the room entrance door and provide for the resident's privacy." A record review revealed the facility admitted Resident #3 on 04/11/13 with [DIAGNOSES REDACTED]. A Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of two (2), which indicated the resident was severely cognitively impaired. A review of the care plan "Self-Care Deficit related to inability to complete ADLs safely", dated 04/25/13, revealed the resident was to be provided privacy, and dignity was to be promoted. Observation, on 05/22/13 at 3:15 PM, revealed while providing peri care and incontinent care for Resident #3, Certified Nurse Aide (CNA) #1 and CNA #2 did not close the privacy curtain, and left the door to the hallway open. This left the resident uncovered and exposed as others passed by in the hallway. Interview with CNA #1 and CNA #2, on 05/22/13 at 3:35 PM, revealed they did not pull the curtain while providing care to Resident #3, and they should have covered Resident #3 as much as possible during the provision of care. Interview with CNA #3, on 05/24/13 at 8:55 AM, revealed CNAs were trained to knock before going into a resident's room, to pull the privacy curtains, to pull the window curtains/blinds, and to make sure the resident was covered, and privacy ensured while providing care. Interview with Licensed Practical Nurse (LPN) #1, on 05/22/13 at 3:40 PM, revealed CNAs were suppose to pull the privacy curtain during the provision of care for every resident. Interview with Registered Nurse (RN) #1, on 05/22/13 at 3:45 PM, revealed complete privacy was to be provided during the provision of care, and residents needed to be isolated from windows, doors, hallway and roommates when care was provided. The care plan should be followed and the staff should use an extra blanket to cover him/her up during care. Interview with the Director of Nursing (DON), on 05/23/13 at 2:50 PM, revealed she expected interventions to be on the care plans and followed, such as ensuring privacy/dignity was provided for each resident.

Based on record review and staff interviews, it was determined the facility failed to identify declines in the physical and mental status for one resident (#2), in the selected sample of three, which required a Minimum Data Set (MDS) significant change assessment. The facility failed to complete a significant change MDS assessment when Resident #2 was assessed as having experienced declines in the areas of cognition, behaviors, bed mobility, transfers, ambulation, dressing, toilete use, personal hygiene and continent status. Findings include: A record review revealed the facility admitted Resident #2 on 12/27/11 with [DIAGNOSES REDACTED]. A review of the admission MDS assessment, dated 01/08/12, revealed the facility identified Resident #2 as usually able to make self understood and usually able to understand others, with a Brief Interview for Mental Status (BIMS) score of ten (10). The resident had no behavioral symptoms and had not rejected care. Resident #2 required limited assist of staff with bed mobility, transfer, ambulation in room, locomotion on and off unit, dressing, toilet use and personal hygiene. He/she was occasionally incontinent of urine. A review of the quarterly MDS, dated [DATE], revealed the facility assessed the resident as having experienced declines in the areas of cognition, behaviors, bed mobility, transfers, ambulation, dressing, toilete use, personal hygiene and continent status. Resident was sometimes able to make self understood and sometimes able to understand others. He/she had a BIMS score of one (1). Resident #2 previously had no behavior issues; however, this assessment detailed he/she had physical behavioral symptoms directed towards others which occurred one (1) to three (3) days, other behavioral symptoms not directed toward others occurred four (4) to six (6) days and had rejected care one (1) to three (3) days out of seven. Resident #2 now required extensive assist with bed mobility, transfer, walk in room, locomotion on and off unit, dressing, toilet use and personal hygiene. He/she went from occasionally incontinent of urine to frequently incontinent. An interview with the MDS Coordinator, on 07/06/12 at 10:30 AM, revealed the resident had declines in his/her behaviors and all other areas of activities of daily living (ADL's). She stated a significant change is done when there are declines in two or more care areas. She stated, "I am sure the resident should have had a significant change MDS assessment done." An interview with the Director of Nursing (DON), on 07/06/12 at 10:55 AM, revealed the MDS Coordinator is the person responsible to make the final decision related to a significant change MDS assessment. She stated the MDS Coordinator should have had a significant change assessment completed.

Based on interview and record review, it was determined the Immediate Jeopardy identified during the abbreviated survey, concluded on 05/03/11, had been removed related to providing appropriate supervision and assistance to prevent accidents; however, non-compliance continued to exist at a S/S of an "E" as the facility's Quality Assessment and Assurance Committee had not fully implemented a plan to ensure correction of the deficient practice to prevent non-compliance recurrence. The findings include: Review of the facility's acceptable Allegation of Compliance (AoC), received on 05/23/11, revealed residents requiring the use of a mechanical device for care would first have a Comprehensive Mechanical Device Assessment (CMDA) completed. The process included updating the care plans of all residents related to the findings on the assessment, and the manufacturer's guidelines, to include the amount of assistance required. Per the AoC the Certified Nursing Assistant (CNA) preceptor would do an in-service with all CNAs for proper use of mechanical devices monthly for three months that included a return demonstration that followed recommended guidelines of manufacturer and facility policy for use of mechanical devices. The Director of Nursing would monitor 100% of CNA staff utilizing one of these devices, monthly for three months, to verify that the CNA preceptor's verification and review was correct. Review of the CMDA completed for twenty-five residents revealed use of the shower chair required the assistance of one (1) staff member. However, review of the residents' care plans and the CNA care plans revealed these care plans had not been revised to include the required assistance of one staff member with the use of the shower chair. Interview with the Director of Nursing (DON), on 05/26/11 at 5:28 PM, revealed although the CMDA assessed the use of the shower chair required the assistance of one staff member, the care plans were not revised. She stated the care plans were reviewed with the shower needs for each resident indicated as a whole, and did not specifically include the use of the "powered shower chair", as the resident needed one staff member in the shower at all times. Interview with the Administrator, on 05/26/11 at 5:35 PM, revealed the failure to review and revise the care plans for use of the shower chair was not identified during the Quality Assessment review as these audits were completed by the DON, who did not view this as a problem. Review of the facility's audits revealed the first month review to verify staff utilization of the mechanical devices had not been completed at the time of the revisit. The facility had verified seven out of nineteen CNAs. Interview with the DON, on 05/25/11 at 10:20 AM revealed the audit to verify 100% of the CNAs utilizing the mechanical devices, was due to be completed on 06/03/11. Interview with the Administrator, on 05/26/11 at 5:35 PM, revealed the monitoring was currently being conducted for the first month and this was due to be completed on 06/03/11.

Based on interview and record review, it was determined the Immediate Jeopardy identified during the abbreviated survey, concluded on 05/03/11, had been removed; however, non-compliance continued to exist at a S/S of an "E" as the facility's Quality Assessment and Assurance Committee had not fully implemented a plan to ensure correction of the deficient practice to prevent non-compliance recurrence. The findings include: Review of the facility's acceptable Allegation of Compliance (AoC), received on 05/23/11, revealed residents requiring the use of a mechanical device for care would first have a Comprehensive Mechanical Device Assessment (CMDA) completed. The process included updating the care plans of all residents related to the findings on the assessment, and the manufacturer's guidelines, to include the amount of assistance required. Review of the CMDA assessment tool revealed the shower chair was listed as a mechanical devices. Review of the CMDA assessment tool revealed the shower chair was listed as a mechanical devices. Per the AoC the Director of Nursing would audit all residents' charts monthly for three months for a current CMDA and appropriate care planning of the mechanical devices utilized, with the amount of assistance required. Per the AoC the Certified Nursing Assistant (CNA) preceptor would do an in-service with all CNAs for proper use of mechanical devices monthly for three months that included a return demonstration that followed recommended guidelines of manufacturer and facility policy for use of mechanical devices. The Director of Nursing would monitor 100% of CNA staff utilizing one of these devices, monthly for three months, to verify that the CNA preceptor's verification and review was correct. Review of the Comprehensive Mechanical Device Assessment completed for twenty-five residents revealed use of the shower chair required the assistance of one (1) staff member. However, review of the residents' care plans and the CNA care plans revealed these care plans had not been revised to include the required assistance of one staff member with the use of the shower chair. Interview with the Director of Nursing (DON), on 05/26/11 at 5:28 PM, revealed although the CMDA assessed the use of the shower chair required the assistance of one staff member, the care plans were not revised. She stated the care plans were reviewed with the shower needs for each resident indicated as a whole, and did not specifically include the use of the "powered shower chair", as the resident needed one staff member in the shower at all times. Interview with the Administrator, on 05/26/11 at 5:35 PM, revealed the review and revision of the care plans was not found during the Quality Assessment review as this was done during the audits by the DON, who did not view this as a problem. Review of the facility's audits revealed the first month review to verify staff utilization of the mechanical devices had not been completed at the time of the revisit. The facility had verified seven out of nineteen CNAs. Interview with the DON, on 05/25/11 at 10:20 AM revealed the audit to verify 100% of the CNAs utilizing the mechanical devices, was due to be completed on 06/03/11. Interview with the Administrator, on 05/26/11 at 5:35 PM, revealed the monitoring was currently being conducted for the first month and this was due to be completed on 06/03/11.

Based on observation, interview, record review, policy review, and ArJo manual review it was determined the facility failed to provide appropriate supervision and assistance to prevent accidents, for six residents (#1, #2, #3, #4, #5 and #6) in the selected sample of six using assistive devices. The facility failed to assess the residents to determine whether they were appropriate and safe to use the assistive devices for Residents #1, #2, #3, #4, #5 and #6. (Refer to F272) The facility failed to ensure all staff utilizing assistive devices during care was oriented and educated consistently in accord with facility policy and procedure and manufacturer guidelines. On [DATE], CNA #4 loosened the belt of the whirlpool lift chair during the bathing process for Resident #1 and failed to maintain a hold of the resident while in the assistive device. Resident #1 slid under the abdominal belt and fell to the floor, sustaining a bilateral hematoma and subsequently expired at the hospital. Based on the above findings it was determined the facility failed to ensure residents were provided the appropriate supervision and assistance to prevent accidents which was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], and is ongoing. The findings include: A review of the "Policy and Protocol on Assistive Devices", dated [DATE] and revised [DATE], revealed: 3) Residents will be assessed by the appropriate member of the Interdisciplinary Care Team (ICDT) for the use of assistive devices to promote self performance of ADL's and promote safety and 5) The proper use of the assistive devices will be monitored for correctness and improved self performance by an appropriate member of the IDCT. A review of the "Arjo-Century Whirlpool Century Bathing System Operation/Procedure Manual", (no date), revealed warnings to include: 1) The entire bathing system must be operated by trained personnel only, 2) The seat belt must be securely fastened. Failure to do so could result in injury to the patient, 3) Failure to secure the patient properly with the seat belt could result in injury to the operator or patient and 4) Maintain eye contact during transfer. An observation and demonstration of the whirlpool tub with the mechanical chair lift, on [DATE] at 10:45 AM by CNA #7, revealed there was a bucket seat on a hydraulic lift that enabled the seat to go up and down by accessing the foot pedals which allowed the resident to be raised up, swung around over the tub area, then lowered into the tub. The foot pedals were located behind the chair lift and staff were unable to maintain eye contact with the resident per manufacturer's instructions while operating the lift. An interview conducted with the current MDS Coordinator, on [DATE] at 4:10 PM, revealed she had been responsible for the MDS assessments since February 2011. She had been trained by the DON and had no formal MDS training. She stated she did not assess the residents for use of the whirlpool. She collected the ADL information from the care tracker, nurse's notes and interviews, for a 7-day look back period, and coded the MDS from those findings. She was unaware of who did the assessments for the safe use of the whirlpool. She was unaware of how the determination was made. She was unaware of what residents received a whirlpool bath. There was no formal assessment regarding the whirlpool that the MDS Coordinator completed. An interview with the Director of Nursing (DON), on [DATE] at 1:30 PM, revealed she was responsible for the MDS assessments until February 2011. The assessment for the safe use of the whirlpool was derived from the MDS assessment. If a resident was able to propel themselves in a wheel chair or ambulate and has good sitting posture with no upper torso leaning, the residents were able to get in the whirlpool. Part of the assessment was the cognition to choose which type of bath was preferred. Another section of the MDS utilized was the impairment in the extremities; however' the MDS did not specify what type of impairment it was, only if there was impairment. Observations were not made of the resident utilizing the whirlpool tub during the assessment period. The safe use of the whirlpool had never been addressed with the manufacturer. There was no assessment completed on the residents for the safe use of the whirlpool tub/chair. An interview with CNA #7, on [DATE] at 10:45 AM, revealed he/she was unaware of who assessed the resident or if it was determined which residents were appropriate for a whirlpool bath. The CNA stated the abdominal belt was always to be utilized. She did look at the CNA care plan to see how many staff was required to assist the resident with bathing, but that was all. The CNA had been taught by another CNA during orientation and she had been a preceptor to new CNAs. An orientation check list was utilized and checked off for completion by both the preceptor and new orientee. An interview conducted with CNA #8, on [DATE] at 4:20 PM, revealed she had been oriented to the whirlpool by another CNA. There was a checklist that had to marked off as having learned prior to end of the orientation. The CNA was shown by the preceptor how to transfer a resident to the whirlpool chair, hot and cold water controls, how to secure the seat belt and how to use the pedals. The CNA was told by her preceptor to maintain physical contact with the resident when raising and lowering the whirlpool chair and also when swinging the chair around to position over the whirlpool tub. The CNA did not recall being told about a policy on the whirlpool and did not know if she had been trained according to the manufacturer's guidelines. She has had no other training on the whirlpool. She stated she looked at the CNA care plan. An interview conducted with CNA #5, on [DATE] at 9:50 AM, revealed she was orientated by another CNA. During orientation, she was shown and taught how to use the whirlpool, controls for hot/cold water, foot pedals, seatbelts, soap use and how to clean the tub. She was told by her CNA preceptor to hold onto the whirlpool chair as it is raised or lowered into position. She was checked off on the orientation check list. She stated she watched and assisted in one whirlpool bath and then did the next one by herself. She had oriented other new CNAs by the way she had been taught and checks them off of the orientation check list. She was not aware of any policy on the whirlpool and the manufacturer's guidelines were not mentioned. She had no other inservice/education prior to [DATE]. An interview conducted with CNA #6, on [DATE] at 10:00 AM, revealed she had been a preceptor to new CNAs in orientation. She was taught how to use the whirlpool by another CNA and that was the only time she had any instruction on the use of the whirlpool. CNA #6 stated when she instructed a new CNA about the whirlpool, she would explain the procedure from the first time the resident was taken from their room until the time the resident got to the whirlpool room. She instructed the new orientee regarding transfer to the whirlpool chair, hot/cold water temperature, proper amount of soap and water, securing the seat belt, raising and lowering the resident into the whirlpool tub. She had been taught to keep a physical touch on the resident and/or chair at all times until the resident was secure in the whirlpool tub. An interview with CNA #4, on [DATE] at 9:45 AM, revealed she had been oriented when hired regarding the whirlpool chair lift. She had the orientation check list that was initialed by her preceptor and the orientee. The CNA was not aware of policies or manufacturer's guidelines regarding the whirlpool chair lift assistive device. She was not told to maintain eye contact or physical contact of the resident during the whirlpool bath. An interview conducted with LPN #3, on [DATE] at 4:00 PM, revealed she had oriented new CNAs to the whirlpool. There was an orientation check list that included the whirlpool. Each orientee was to be instructed and/or shown regarding each of the items on the orientation check list, then initialed and dated on completion. She stated she was instructed to maintain physical contact with the resident at all time when the whirlpool chair was moving (raising and lowering). She had not received further education on the whirlpool prior to [DATE]. She knew there was a policy for the use of the whirlpool tub but was unaware of the manufacturer's directions. She stated the licensed staff did not assess the residents for the safe use of the whirlpool. 1. A review of the Incident Investigation, dated [DATE], revealed Resident #1 slid under the seat belt of the whirlpool chair after CNA #4 loosened the seatbelt because the resident was complaining of the seat belt being too tight. Resident #1's head struck the floor, resulting in a laceration to the right side of the head. The resident was transferred to the hospital's Emergency Department (ED). The resident sustained [REDACTED]. An interview conducted with CNA #4, on [DATE] at 10:45 AM, revealed Resident #1 had received a whirlpool bath on the morning of [DATE] at approximately 6:15 AM. The resident had complained throughout the bath that the seat belt was on too tight. The resident was in the process of being lowered to the floor, when the CNA stopped the descent of the chair about two feet from the floor. The CNA loosened the seat belt "about ,[DATE] inch". The CNA then went to the back of the resident to utilize the foot pedals to continue lowering the chair when all she remembered observing was the resident lifted up both arms and the next thing she knew the resident was on the floor and there was blood on the floor. The CNA was not holding onto the resident, nor was she facing the resident. A closed record review revealed Resident #1 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. A review of the Resident Assessment Protocol (RAP) for Activities of Daily Living (ADL)s, dated [DATE], revealed the resident was able to verbalize some needs. The resident needed assistance with ADLs related to hemiparesis resulting from late effects of CVA. The resident had short term memory problems and did not always remember to ask for assistance. A review of the comprehensive device/siderail assessment, dated [DATE], revealed the resident had a history of [REDACTED]. A review of the quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident as moderately cognitively impaired, non-ambulatory, required one staff assistance for transfer and bathing and used a wheel chair. The MDS assessment for Functional Limitation revealed the facility detailed the resident had impairment on one side in both the upper and lower extremities. Balance was not steady, only able to stabilize with human assistance during moving from seated to standing position and surface-to-surface transfer. A record review revealed there was no documented evidence the facility had completed an assessment to determine the resident was appropriate and safe to use the whirlpool lift device. 2. A record review revealed Resident #5 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. Review of the annual MDS assessment, dated [DATE], revealed the facility assessed the resident as moderately cognitively impaired and required physical help in part of bathing activity with one person physical assist. There was no documented evidence the facility had completed an assessment for the safe use of the whirlpool. An interview with Resident #5, on [DATE] at 1:55 PM, revealed the resident used the whirlpool lift chair. 3. A record review revealed Resident #2 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident as requiring extensive assistance of one staff for hygiene/bathing, balance was unsteady and was only able to stabilize with human assistance. The resident had impairment on one side of the upper extremity and impairment on both sides of the lower extremities. Record review revealed there was no documented evidence the facility had completed an assessment for the safe use of the whirlpool. An observation and interview with Resident #2, on [DATE] at 10:07 AM, revealed the resident was alert and verbal. Resident #2 stated he/she utilized the whirlpool for bathing. He/she stated usually there were two staff who assisted him/her with the whirlpool and they utilized the abdomen strap. 4. A record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident to be moderately cognitively impaired. Assessment for balance revealed the resident was not steady, but able to stabilize without human assistance. There was no impairment in the upper and lower extremities. A record review revealed there was no documented evidence the facility had completed an assessment for the safe use of the whirlpool. 5. A record review revealed Resident #4 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident as modified independence (difficulty in decision making when faced with new tasks or situations). A record review revealed there was no documented evidence the facility had completed an assessment for the safe use of the whirlpool. 6. A record review revealed Resident #6 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. The resident was non-interviewable. A review of the admission MDS, dated [DATE], revealed the facility assessed the resident with severe cognitive status. A record review revealed there was no documented evidence the facility had completed an assessment for the safe use of the whirlpool.

Based on interview and record review, it was determined the Immediate Jeopardy identified during the abbreviated survey, concluded on 05/03/11, had been removed related to nurse aide competency in skills and techniques utilizing mechanical and assistive devices; however, non-compliance continued to exist at a S/S of an "E" as the facility's Quality Assessment and Assurance Committee had not fully implemented a plan to ensure correction of the deficient practice to prevent non-compliance recurrence. The findings include: Review of the facility's acceptable Allegation of Compliance (AoC), received on 05/23/11, revealed the Certified Nursing Assistant (CNA) preceptor would provide training of the CNA staff for the use of mechanical devices, with the initial training completed on 05/03/11. This training would utilize the manufacturer provided skills checklist and return demonstration competencies and/or video that were in place in the Lift Manual; which included competency checks for the mechanical lifts utilized by the facility. Per the AoC, the CNA preceptor would do an in-service with all CNAs for proper use of mechanical devices monthly for three months that included a return demonstration that followed recommended guidelines of manufacturer and facility policy for use of mechanical devices. The Director of Nursing would monitor 100% of CNA staff utilizing one of these devices, monthly for three months, to verify that the CNA preceptor's verification and review was correct. Review of the facility's audits revealed the first month review to verify staff utilization of the mechanical devices had not been completed at the time of the revisit. The facility had verified seven out of nineteen CNAs. Interview with the DON, on 05/25/11 at 10:20 AM revealed the audit to verify 100% of the CNAs utilizing the mechanical devices, was due to be completed on 06/03/11. Interview with the Administrator, on 05/26/11 at 5:35 PM, revealed the monitoring was currently being conducted for the first month and this was due to be completed on 06/03/11.

Based on interview and record review, it was determined the Immediate Jeopardy identified during the abbreviated survey, concluded on 05/03/11, had been removed related to assessment of mechanical devices; however, non-compliance continued to exist at a S/S of an "E" as the facility's Quality Assessment and Assurance Committee had not fully implemented a plan to ensure correction of the deficient practice to prevent non-compliance recurrence. The findings include: Review of the facility's acceptable Allegation of Compliance (AoC), received on 05/23/11, revealed residents requiring the use of a mechanical device for care would first have a Comprehensive Mechanical Device Assessment (CMDA) completed. The process included updating the care plans of all residents related to the findings on the assessment, and the manufacturer's guidelines, to include the amount of assistance required. Review of the CMDA assessment tool revealed the shower chair was listed as a mechanical device. Per the AoC the Director of Nursing would audit all residents' charts monthly for three months for a current CMDA and appropriate care planning of the mechanical devices utilized, with the amount of assistance required. Review of the CMDA completed for twenty-five residents revealed use of the shower chair required the assistance of one (1) staff member. However, review of the residents' care plans and the CNA care plans revealed these care plans had not been revised to include the required assistance of one staff member with the use of the shower chair. Interview with the Director of Nursing (DON), on 05/26/11 at 5:28 PM, revealed although the CMDA assessed the use of the shower chair required the assistance of one staff member, the care plans were not revised. She stated the care plans were reviewed with the shower needs for each resident indicated as a whole, and did not specifically include the use of the "powered shower chair", as the resident needed one staff member in the shower at all times. Interview with the Administrator, on 05/26/11 at 5:35 PM, revealed the failure to review and revise the care plans for use of the shower chair was not identified during the Quality Assessment review as these audits were completed by the DON, who did not view this as a problem.

Based on interview, record review, and review of the facility's Incident Investigation report it was determined the facility failed to assess for the safe use of an assistive device for six residents (Residents #1, #2, #3, #4, #5, and #6) in the selected sample of six . The facility identified these six residents as utilizing the whirlpool chair lift as an assistive device when taking a whirlpool bath; however, the facility failed to assess each resident to ensure appropriate and safe use of this lift. On [DATE], the facility staff was using the whirlpool chair lift with Resident #1. After Certified Nursing Assistant (CNA) #4 loosened the belt, the resident slipped from under the belt and fell , sustaining a bilateral hematoma and subsequently expired at the hospital. Based on the above findings it was determined the facility failed to ensure residents were assessed for the safe use of an assistive device which was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], and is ongoing. The findings include: A review of the "Policy and Protocol on Assistive Devices", dated [DATE] and revised [DATE], revealed: 3) Residents will be assessed by the appropriate member of the Interdisciplinary Care Team (ICDT) for the use of assistive devices to promote self performance of ADL's and promote safety and 5) The proper use of the assistive devices will be monitored for correctness and improved self performance by an appropriate member of the IDCT. An interview conducted with the Minimum Data Set (MDS) Coordinator, on [DATE] at 4:10 PM, revealed she did not assess the residents for use of the whirlpool. She collected the ADL information from the care tracker, nurse's notes and interviews, for a 7-day look back period, and coded the MDS from those findings. She was unaware of who did the assessments for the safe use of the whirlpool and was unaware of how the determination was made. Per interview there was no formal assessment regarding the whirlpool that the MDS Coordinator completed. An interview with the Director of Nursing (DON), on [DATE] at 1:30 PM, revealed the safe use of the whirlpool was derived from the MDS assessment. If a resident was able to propel themselves in a wheel chair or ambulate and had good sitting posture with no upper torso leaning, the residents were able to get in the whirlpool. Per interview, cognition was a part of the assessment to determined which type of bath was preferred along with impairment in the extremities. However, the MDS did not specify what type of impairment it was, only if there was impairment. 1. A review of the facility's Incident Investigation, dated [DATE], revealed Resident #1 slid under the seat belt of the whirlpool chair after a CNA loosened the seatbelt because the resident complained that the seat belt was too tight. The CNA was behind the resident adjusting the height of the seat and did not have physical contact with him/her. Resident #1's head struck the floor, resulting in a laceration to the right side of the head. The resident was transferred to the hospital's Emergency Department (ED). The resident sustained [REDACTED]. A closed record review revealed Resident #1 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. A review of the Resident Assessment Protocol (RAP) for Activities of Daily Living (ADL)s, dated [DATE], revealed the resident while able to verbalize some needs, and required assistance with ADLs related to right [MEDICAL CONDITION] from a [MEDICAL CONDITION]. The resident had short term memory problems and did not always remember to ask for assistance. Review of the quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident as moderately cognitively impaired and was non-ambulatory, utilized a wheel chair, and required one staff assistance for transfer and bathing. The MDS assessment for Functional Limitation revealed the resident had impairment on one side in both the upper and lower extremities. The resident's balance "not steady, only able to stabilize with human assistance" during moving from seated to standing position and surface-to-surface transfer. A review of the comprehensive device/side rail assessment, dated [DATE], revealed the resident had a history of [REDACTED]. However, the assessment did not reflect use of the whirlpool chair. Further record review revealed no assessment for the whirlpool use. An interview with the MDS Coordinator, on [DATE] at 4:10 PM, revealed she did not observe Resident #1 in the whirlpool chair lift and did not assess the resident for the safe use of the whirlpool assistive device. 2. A record review revealed Resident #5 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. An interview with Resident #5, on [DATE] at 1:55 PM, revealed the resident used the whirlpool bath. A review of the annual MDS assessment, dated [DATE], revealed the facility assessed the resident to be moderately cognitively impaired. The resident was assessed as requiring physical help in part of bathing activity with one person physical assist. Record review revealed no assessment for the safe use of the whirlpool. An interview with the MDS Coordinator, on [DATE] at 4:10 PM, revealed she did not observe Resident #5 in the whirlpool chair and did not assess the resident for the assistive device. 3. A record review revealed Resident #2 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. An observation and interview with Resident #2, on [DATE] at 10:07 AM, revealed Resident #2 utilized the whirlpool for bathing and stated usually there were two staff who assisted with the abdominal strap. A review of the quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident as requiring extensive assistance of one staff for hygiene/bathing with unsteady balance requiring human assistance to stabilize.. The resident had impairment on one side of the upper extremity and impairment on both sides of the lower extremities. Record review revealed no assessment for the safe use of the whirlpool. An interview with the MDS Coordinator, on [DATE] at 4:10 PM, revealed she did not observe Resident #2 in the whirlpool chair and did not assess the resident for the assistive device. 4. A record review revealed Resident #3 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. An interview with Resident #3, on [DATE] at 2:00 PM, revealed the resident preferred a whirlpool bath rather than a shower. A review of the quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident as moderately cognitively impaired and had an unsteady balance. Record review revealed no assessment for the safe use of the whirlpool. An interview with the MDS Coordinator, on [DATE] at 4:10 PM, revealed she did not observe Resident #3 in the whirlpool chair and did not assess the resident for the assistive device 5. A record review revealed Resident #4 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident as modified independence (difficulty in decision making when faced with new tasks or situations). Record review revealed no assessment for the safe use of the whirlpool. An interview with Resident #4, on [DATE] at 2:02 PM, revealed the resident preferred the whirlpool for bathing. An interview with the MDS Coordinator, on [DATE] at 4:10 PM, revealed she did not observe Resident #4 in the whirlpool chair and did not assess the resident for the assistive device. 6. A record review revealed Resident #6 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. A review of the admission MDS assessment, dated [DATE], revealed the facility assessed the resident with severely impaired cognitive status. Record review revealed no assessment for the safe use of the whirlpool. An interview with the DON, on [DATE] at 1:30 PM, revealed identified Resident #6 received whirlpool baths. An interview with the MDS Coordinator, on [DATE] at 4:10 PM, revealed she did not observe Resident #6 in the whirlpool chair and did not assess the resident for the assistive device. Interviews with LPN #3, on [DATE] at 4:00 PM, and LPN #1 on [DATE] at 10:55 AM revealed she they not assess the residents for the safe use of the whirlpool. LPN #3 stated it was the decision of the CNA if the resident was to get a whirlpool bath. An interview with CNA #10, on [DATE] at 9:25 AM, revealed he/she was unaware of any documentation that specified what residents were to receive a whirlpool. It was his/her understanding that a whirlpool tub bath, shower or bed bath was the choice of the resident. An interview with CNA # 4, on [DATE] at 10:45 AM, revealed the residents could make a choice as to what type of bath they preferred. The CNA had been told by the nurses, if the resident could propel themselves in the wheel chair and sit up straight with no leaning forward, the resident could get in the whirlpool. An interview with CNA #5, on [DATE] at 9:50 AM, revealed he/she was unaware of a list of residents who preferred the whirlpool, the choice was made by the resident. The CNA was unsure of how many residents did prefer the whirlpool. The CNA care plan was referenced for the number of staff assistance the resident required. Per interview with the MDS Coordinator, on [DATE] at 4:10 PM, she had been responsible for the MDS assessments since February 2011 and had no formal MDS training. There was no formal assessment regarding the whirlpool that the MDS Coordinator completed and she was unaware of what residents received a whirlpool bath. Per interview with the Director of Nursing (DON), on [DATE] at 1:30 PM, she was responsible for the MDS assessments until February 2011. She stated observations were not made of the resident utilizing the whirlpool tub during the MDS assessment period and there was no assistive device assessment completed on the residents for the safe use of the whirlpool tub/chair. She stated, "We do not specify whether a resident gets a whirlpool bath, bed bath or shower, they are all baths". The DON stated the CNAs would ask the resident what type of bath they preferred and the CNA made the decision based on what the resident preferred. .

Based on observation and demonstration of the whirlpool tub with the mechanical chair lift, interview, review of facility policy, the Certified Nursing Assistants (CNAs) orientation checklist, and the ArJo manual it was determined the facility failed to ensure CNAs were competent related to the use of the whirlpool lift chair for six (Residents #1,#2, #3, #4, #5 and #6) of six sampled residents. The facility identified these six residents as utilizing the whirlpool chair lift as an assistive device when taking a whirlpool bath. The facility failed to ensure all staff utilizing this assistive device during care was oriented and educated consistently in accordance with facility policy and procedure and manufacturer guidelines. On [DATE], CNA #4 loosened the belt of the whirlpool lift chair during the bathing process for Resident #1 and failed to maintain a hold of the resident while in the assistive device. Resident #1 slid under the abdominal belt and fell to the floor, sustaining a bilateral hematoma and subsequently expired at the hospital (Refer to F323). Based on the above findings it was determined the facility failed to ensure Certified Nursing Assistants (CNAs) were competent related to the use of the whirlpool lift chair which was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], and is ongoing. The findings include: A review of the "Policy and Protocol on Assistive Devices", dated [DATE] and revised [DATE], revealed: 3) Residents will be assessed by the appropriate member of the Interdisciplinary Care Team (ICDT) for the use of assistive devices to promote self performance of ADL's and promote safety and 5) The proper use of the assistive devices will be monitored for correctness and improved self performance by an appropriate member of the IDCT. A review of the "Arjo-Century Whirlpool Century Bathing System Operation/Procedure Manual", (no date), revealed warnings to include: 1) The entire bathing system must be operated by trained personnel only, 2) The seat belt must be securely fastened. Failure to do so could result in injury to the patient, 3) Failure to secure the patient properly with the seat belt could result in injury to the operator or patient and 4) Maintain eye contact during transfer. A review of the facility's orientation checklist revealed the CNA skills were to be checked off by another CNA during the orientation period. Included in the orientation check off list was a listing for the whirlpool. An interview with the Director of Nursing (DON), on [DATE] at 1:30 PM, revealed the new hired CNAs were given an orientation skills check list form that was to be completed during orientation. Each new hired CNA was given a CNA preceptor that would train/teach and mark off completion of each of the skills identified on the orientation skills check list. The whirlpool was identified on the orientation check list which included the use of the whirlpool tub/chair. Per interview, the facility had not provided re-education, inservices, or skills check regarding the use of the whirlpool tub/chair, prior to [DATE]. An observation and demonstration of the whirlpool tub with the mechanical chair lift, on [DATE] at 10:45 AM by CNA #7, revealed there was a bucket seat on a hydraulic lift that enabled the seat to go up and down by accessing the foot pedals which allowed the resident to be raised up, swung around over the tub area, then lowered into the tub. The foot pedals were located behind the chair lift and staff were unable to maintain eye contact with the resident per manufacturer's instructions while operating the lift. An interview with CNA #7, on [DATE] at 10:45 AM, revealed she had been instructed by another CNA during orientation on the use of the whirlpool tub/chair. The CNA stated she had no further inservices or skills review on the whirlpool use. An interview with CNA #4, on [DATE] at 9:45 AM, revealed she had been oriented upon hire regarding the whirlpool chair lift. CNA #4 was not told to maintain eye contact or physical contact of the resident during the whirlpool bath. CNA #4 had no inservice or skills review on the whirlpool tub/chair prior to the incident on [DATE]. An interview with CNA #5, on [DATE] at 9:50 AM, revealed she was orientated by another CNA regarding the use of the whirlpool chair/tub. She was taught by her CNA preceptor to hold onto the whirlpool chair as it was raised or lowered into position. She stated she watched and assisted in one whirlpool bath and then did the next one by herself. She had oriented other new CNAs the same way she had been taught and completed the CNAs' orientation skills check list. CNA #5 had no other inservice/education prior to [DATE]. An interview with CNA #6, on [DATE] at 10:00 AM, revealed she was oriented by another CNA on the use of the whirlpool tub/chair and had been a preceptor to new CNAs in orientation. She was taught to keep physical touch on the resident and/or chair at all times until the resident was secure in the whirlpool tub and instructed the CNAs she oriented to do the same. CNA #6 has had no additional inservice or skills check. An interview with CNA #8, on [DATE] at 4:20 PM, revealed she had been oriented to the whirlpool by another CNA and been instructed with demonstration of the whirlpool tub chair/bath. The CNA was told by the CNA preceptor to maintain physical contact with the resident when raising and lowering the whirlpool chair and also when swinging the chair around to position over the whirlpool tub. CNA #8 had no other inservices or skills instruction regarding the whirlpool chair/tub prior to [DATE]. An interview with LPN #3, on [DATE] at 4:00 PM, revealed she had oriented new CNAs to the whirlpool tub/chair. There was an orientation check list that included the whirlpool. Each orientee was to be instructed and/or shown regarding each of the items on the orientation check list, then initialed and dated on completion. She stated she was instructed to maintain physical contact with the resident at all time when the whirlpool chair was moving (raising and lowering). She had not received further education on the whirlpool prior to [DATE].

Based on interview, record review, policy review and review of ArJo Manufacturer guidelines it was determined the facility failed to be administered in a manner which enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable, physical, mental and psychosocial well-being for six (Residents #1, #2, #3, #4, #5 and #6) in the selected sample of six residents. The facility failed to have a system in place ensure policies and procedures were implemented regarding use assistive devices. The facility failed to assess the residents for the safe use of the whirlpool and to have a comprehensive care plan with individualized interventions for the whirlpool. The facility failed to ensure consistent training of the Certified Nurse Aides (CNA) to ensure its' staff was knowledgeable regarding the safe use of the whirlpool chair/tub. (Refer to F272 and F323) On [DATE], Resident #1 slid under the seat belt of the whirlpool chair, after the seat belt was loosened by a CNA. The resident hit his/her head on the tile floor, resulting in Bilateral Subdural Hematomas. Resident #1 died at the hospital on [DATE]. Additionally, Resident's #2, #3, #4, #5 and #6 were identified by the facility as whirlpool recipients and were not assessed for the whirlpool usage. Based on the above findings it was determined the facility failed to ensure the facility was administered effectively and efficiently which was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], and is ongoing. The findings include: A review of the "Policy and Protocol on Assistive Devices", dated [DATE] and revised [DATE], revealed: 3) Residents will be assessed by the appropriate member of the Interdisciplinary Care Team (ICDT) for the use of assistive devices to promote self performance of ADL's and promote safety and 5) The proper use of the assistive devices will be monitored for correctness and improved self performance by an appropriate member of the IDCT. A review of the policy for the "Whirlpool, Century Bath", dated [DATE], revealed the policy was not specific to the whirlpool chair lift, but to the whole whirlpool bathing system. There were some features of the bathing system that were not being used by the facility. A review of the "Arjo-Century Whirlpool Century Bathing System Operation/Procedure Manual", (no date), revealed warnings to include: 1) The entire bathing system must be operated by trained personnel only, 2) The seat belt must be securely fastened. Failure to do so could result in injury to the patient, 3) Failure to secure the patient properly with the seat belt could result in injury to the operator or patient and 4) Maintain eye contact during transfer. An interview with the Director of Nursing (DON), on [DATE] at 1:30 PM, revealed the assessment for the safe use of the whirlpool was derived from the MDS assessment. If a resident was able to propel themselves in a wheel chair or ambulate and had good sitting posture with no upper torso leaning, the residents were able to get in the whirlpool. Observations were not made of the resident utilizing the whirlpool and the chair lift device. According to the DON, all residents were considered safe for the whirlpool. An interview conducted with the MDS Coordinator, on [DATE] at 4:10 PM, revealed she had been doing the MDS assessments at the facility since February 2011. The MDS Coordinator did not make observations of the resident in the whirlpool chair. The MDS Coordinator did not assess the residents for the use of the whirlpool and was unsure who would be responsible for the assessment. An interview conducted with LPN #3, on [DATE] at 4:00 PM, revealed she had oriented new CNAs to the whirlpool. There was an orientation skills check list that included the whirlpool among numerous other CNA skills. Each orientee was to be instructed and/or shown regarding each of the items listed on the orientation check list, then initialed and dated on completion. She stated she was instructed to maintain physical contact with the resident at all time when the whirlpool chair was moving (raising and lowering). She knew there was a policy in place for the use of the whirlpool tub but was unaware of the manufacturer's directions. She had not received any further education/inservices on the whirlpool prior to [DATE]. Interviews conducted with CNA #4, on [DATE] at 10:45 AM, with CNA #7, on [DATE] at 10:45 AM, with CNA #8, on [DATE] at 4:20 PM, with CNA #5, on [DATE] at 9:50 AM, with CNA #6, on [DATE] at 10:00 AM, with CNA #3, on [DATE] at 10:05 AM, and with CNA #1, on [DATE] at 2:45 PM., revealed all CNAs had been a CNA preceptor in the past, and had been trained by another CNA preceptor during their orientation. Seven of the eight CNAs had not seen a policy on the whirlpool and were unaware of the manufacturers guidelines for the whirlpool. Two of eight CNAs stated they were not taught to keep physical contact with the resident during whirlpool use. Four of the eight CNAs stated they did not always look at the CNA care plan to see what staff assistance the resident required. All eight CNAs stated they had no further training on the whirlpool prior [DATE]. An interview with the DON, on [DATE] at 1:30 PM, revealed she was unaware of the inconsistencies of the CNA preceptor's training/teaching to other orientating CNAs. There was no monitoring or oversight provided by the facility to ensure consistent training was provided by a CNA preceptor to a new hire CNA. An interview with the Administrator, on [DATE] at 12:30 PM, revealed she was unaware of the inconsistencies with the CNA training on the use of the whirlpool and/or chair lift. Additionally, the ADM revealed the residents should have an assessment of the whirlpool chair assistive device completed by a nurse instead of depending on the MDS assessment alone.