Every finding on record at Corning Therapy and Living Center

Based on record review, interviews, and facility policy review, it was determined that the facility failed to ensure a Care Plan meeting was held every three months for one (Resident #4) of one resident reviewed. The findings include: A review of Resident #4's admission Record indicated the facility admitted Resident #4 on 04/01/2024 with diagnoses which included type two diabetes mellitus and mild cognitive impairment related to a history of stroke. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 10/28/2025, revealed Resident #4 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. Review of Resident #4's Care Plan, revised 07/25/2025, revealed the resident had impaired cognitive function or impaired thought processes due to memory problems, delusions, and intermittent awareness of time. The Care Plan also included interventions, initiated 04/16/2024, to engage in conversations about a pleasant topic before initiating care. Review of Resident #4's Care Plan meeting invitations and multidisciplinary care conferences on 12/17/2025 at 2:46 PM, revealed Resident #4 had a Care Plan meeting invitation sent on 03/25/2025, 08/06/2025, and 10/01/2025 and a multidisciplinary care conference completed on 04/15/2025 and 08/28/2025. During an interview on 12/15/2025 at 12:28 PM, Resident #4 revealed they have not had a Care Plan meeting that they knew of. During an interview on 12/17/2025 at 4:01 PM, the Director of Nursing (DON) revealed that the Social Director sends out the invitations to the families about the Care Plan meetings. She explained Care Plan meetings are held quarterly, every three months. She confirmed all staff were responsible for Care Planning meetings. She revealed that she was aware that Resident #4 did not have a Care Plan meeting prior to March of 2025. During an interview on 12/18/2025 at 9:40 AM, the Administrator revealed that Care Plan meetings are held when the MDS' are completed. She confirmed the Care Plan meetings were held every three months. She reported that she became the Administrator in March of 2025 and was aware of the Care Plan meetings not being completed prior to March. Review of a facility policy titled, Care Planning, revised March 2022, indicated, Care plan meetings are scheduled at the best time of the day for the resident and family when possible. The resident, the resident's family and/or resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Resident care plans are developed according to the timeframes and criteria established by 483.21.

50682 Based on record review, document review, observations, interviews, and facility policy review, the facility failed to ensure adequate supervision was provided to prevent an elopement, as evidenced by failure to ensure increased supervision was provided during periods of increased exit-seeking behaviors for 1 (Resident # 240) sampled resident. The failed practice resulted in past noncompliance at the level of immediate jeopardy (IJ), which caused, or could have caused serious harm, injury or death to Resident # 240 who was at high risk for elopement. Resident # 240 eloped from the facility and was found approximately 300 feet from the facility on 7/30/2023 at 5:45 PM after the facility received a call from a passerby stating they drove by facility and saw elderly [gender of Resident] sitting by the road. A visitor leaving the facility pulled their vehicle between the resident and the highway and remained with the resident until staff reached the resident. The Administrator and Nurse Consultant were notified of the past immediate jeopardy on 8/08/2024 at 1:12 PM. The findings are: A review of a Medical Diagnosis Record indicated the facility admitted Resident # 240 with a medical diagnosis (dx) of Dementia, with agitation. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/05/2023 revealed Resident # 240 scored 06 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS), exhibited wandering behavior in section E0900, and in section E1100 change of behavior or other symptoms was revealed current behavior or wandering was worse compared to prior assessment. Review of Resident # 240's Care Plan, initiated 11/05/2020, revealed the resident was an elopement risk/wanderer r/t (related to) Dementia. Resident # 240 was disoriented to place, had impaired safety awareness and a history of attempts to leave facility unattended. Resident wandered aimlessly and interventions included distract resident from wandering by offering diversions, structured activities, food, conversation, television or books. The care plan did not address Resident # 240's preferences. A review of a nursing Progress Note Type: Alert Note dated 7/24/2023 at 8:11 AM revealed Resident # 240 was wandering and unable to redirect. A review of a nursing Progress Note Type: Hot Rack Charting dated 7/24/2023 at 7:05 PM revealed Resident # 240 had increased anxiety that medication had minimal effect, that resident was exit seeking and wandered around the facility yelling Grandpa let us out and was unable to be reoriented or redirected. A review of a nursing Progress Note Type: Hot Rack Charting dated 7/25/2023 at 4:15 PM revealed Resident # 240 wandered around the facility and into other resident rooms having to be redirected. A review of a nursing Progress Note Type: General Note dated 7/28/2023 at 7:13 PM revealed Resident # 240 rolled up and down corridor in wheelchair stating, God, please help us! and disturbing other residents and was unable to be redirected. A review of a nursing Progress Note Type: Hot Rack Charting dated 7/29/2023 at 6:49 PM revealed Resident # 240 had been up and about the facility wandering to each exit stating let me out requiring frequent supervision from staff required for safety. The Resident was observed to become easily agitated with staff at times and was redirected. The past noncompliance began on 7/30/2023 at 5:45 PM, when the facility received a call from a passerby who stated, Hey I just drove by your facility and saw elderly [gender of resident] sitting by the road and wanted to let you know! Resident # 240 was observed sitting by the highway in a wheelchair (w/c). A visitor leaving the facility pulled their vehicle between the resident and the highway and remained with the resident until staff reached the resident. Resident # 240 was returned to the facility and placed on the secured unit. The Resident's family member and on-call physician were notified. A review of a nursing Progress Note Type: Nursing I & A (incident & accident) dated 7/30/2023 at 7:25 PM written by Registered Nurse (RN) # 8 indicated a call to the Nurse Practitioner at 7:58 PM and family contact at 7:55 PM revealed that Resident # 240 exited the facility via the front door and was at the end of the driveway. Immediate intervention upon Resident return to the facility was Resident # 240 was placed on the secured unit for safety due to exit seeking and wandering. A review of a nursing Progress Note Type: Nursing I & A follow up dated 07/30/2023 at 8:25 PM written by the Director of Nurses (DON) indicated the facility received a call from a passerby who stated, Hey I just drove by your facility and saw elderly [gender] sitting by the road and wanted to let you know! Resident # 240 was observed sitting by the highway in a wheelchair (w/c). A visitor leaving the facility pulled their vehicle between the resident and the highway and remained with the resident until staff came. Resident # 240 was returned to the facility and placed on the secured unit. Resident # 240's family member and the on-call physician notified with orders received and processed. The Long-Term Intervention: Resident placed on secure dementia unit and intervention was added to the care plan. Review of Resident # 240's Care Plan initiated 11/22/2023 revealed resident needed secured/special care neighborhood due to behaviors, wondering and exit seeking. Interventions included walking with or redirecting resident, to engage in diversionary activity such as towel folding, music, or coloring and to have supplies and activity resources readily available and scheduled in the neighborhood. During an interview on 8/07/2024 at 4:45 PM, Certified Nurses Aid (CNA) # 5 said it happened during a night shift that she wasn't working. She was told someone called the facility, and the staff didn't know for sure how resident got out or how long resident was outside, but they thought [gender] followed someone outside. CNA # 5 said Resident # 240 had a history of wandering around the facility and going in/out of other resident's rooms, going to the doors and looking out. The CNA said she did not remember having an in-service or training related to (r/t) elopement afterwards. During an interview on 8/07/2024 at 4:55 PM, CNA # 6 said, she was told about the elopement the next morning during report, that Resident # 240 got out without staff knowing and was only discovered after someone called the facility to report it. She didn't know if Resident # 240 was wandering that night but had previously seen resident wandering and exit seeking. As far as she could remember, they did not a training related to elopement after the incident. During a telephone interview on 8/07/2024 at 5:40 PM, CNA # 7 said that she didn't know the exact time, maybe between 5:00 PM and 6:00 PM, but remembered Resident # 240 was seated in w/c out in the front foyer. CNA # 7 said that staff didn't know the resident was gone until the facility received a phone call from someone driving down the road saying that there was someone in a w/c out by the road. None of the staff working that night knew how the resident got out but assumed that Resident # 240 went out the front door when a visitor left. CNA # 7 said Registered Nurse (RN) # 8 and CNA # 5 went outside to get the resident. Resident # 240 was crying, screaming and yelling at RN # 8 while the RN was trying to assess resident for heat related injury because it was hot outside. CNA # 7 recalled seeing Resident # 240 wandering around the facility, going to the entrance and exit doors and looking outside, but did not observe resident wandering or at the door that evening, but remembered resident seated in the front foyer. CNA # 7 said she couldn't remember if an in-service was done after the elopement or in the last year. During a telephone interview on 8/08/2024 at 8:55 AM, the DON said she was called by RN # 8 and was told about Resident # 240 leaving the building. She came to the facility to follow protocol and fill out an I&A note. She was told that Resident # 240 must have left through the front door with a visitor and was found on the side of the highway by a passerby who called the facility. RN # 8 assessed the resident for possible heat stroke or other injuries. The DON said she thought it was warm that day since it was in July. The DON said that RN # 8 called the resident's family member, herself, the APN (Advanced Practice Nurse) and [name] the Administrator, who would have a done a reportable and call the police. She said she couldn't remember if an in-service on elopement was done but she was pretty sure the facility did. During an interview on 8/08/2024 at 10:44 AM, the Administrator said the facility did not have cameras but the best they could tell, a visitor went out the front door and Resident # 240 went out with the visitor. An internal investigation was conducted with the Action Plan completion date of 7/30/2023 on the same day resident eloped. The Action Plan included: An elopement assessment upon admission, quarterly and PRN, residents identified as high risk for elopement care planned with appropriate interventions, resident that demonstrate new exit seeking/elopement behaviors have an updated assessment. Elopement Drill conducted 7/31/23 at 3:15 PM, Elopement Drill conducted 8/9/23 at 4:35 PM, Elopement Drill conducted 10/03/23 at 11:20 AM, Weekly Exit Door Inspections for the months of August 2023, September 2023, October 2023, November 2023, December 2023, January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, July 2024 and the first week of August 2024. The Administrator said, I did not report to the OLTC (Office of Long-Term Care) because Resident # 240 did not leave the premises, so it was not considered an elopement and necessary to report. Review of facility policy titled Elopements with a revision date of December 2007 indicated Staff shall investigate and report all cases of missing residents to the administrator. Elopement is a resident missing from the facility without staff knowledge. On 8/08/2024 at 11:30 AM an elopement in-service completed on 7/30/2023 with fifty-two staff signatures was provided by the Administrator. Out of fifty-two, twenty-seven were still employed at the facility. At 11:35 AM Licensed Practical Nurse (LPN) # 2 said I can't remember an elopement in-service or an elopement drill. At 11:42 AM CNA # 9 said I can't honestly say if there had been an elopement in-service or drill. At 11:48 AM Housekeeping # 10 said I remember an elopement drill and I'm pretty sure there was an in-service sometime last year. At 11:49 AM Maintenance said we had elopement drills, in-services and an action plan to prevent further incidents. During an observation an In-service education notebook at the nurse's station on 8/08/2024 at 12:07 PM did not have copies of an Elopement in-service inside it. At 12:10 PM LPN # 11 returned a phone call after a message was left from surveyor. LPN said, I don't remember signing an in-service on elopement or having a drill. During a telephone interview on 08/08/2024 at 12:20 PM, RN # 8 said she remembered the night of the elopement. She assumed Resident # 240 went out the front door with a visitor, but she didn't think the visitor realized it was a resident trying to leave. RN # 8 said the resident used a wheelchair and was 1 person transfer assist but could get around good in the chair. Resident # 240 was found outside close to the road and was quickly assessed outside, then a full assessment done upon entry. RN # 8 said the resident was monitored for behaviors and had a history of wandering. She couldn't remember having an elopement in service in the last 6 months but was pretty sure the facility had one after the elopement. On 8/08/2024 at 12:52 PM, guidance from the State office indicated to provide facility with Immediate Jeopardy (IJ)Template. At 1:12 PM, Immediate Jeopardy (IJ) template was signed by Administrator and Nurse Consultant.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure that activities were provided for all 42 residents that reside in the building. The findings included: On 8/5/24 at 2:33 PM, the Surveyor did not observe activities upon entry of the secure unit. On 8/6/24 at 8:57 AM, the Surveyor observed no activities occurring on the secure unit. On 8/6/24 at 10:08 AM, the Surveyor observed staff offering the residents a snack. No activities observed this morning on the secured unit. On 8/6/24 at 2:01 PM, the Surveyor observed no activities on the secure unit. On 8/7/24 at 8:52 AM, the Surveyor observed no activities on the secure unit. One Certified Nursing Assistant (CNA) observed sitting at desk in day room with residents that were watching television. On 8/7/24 at 9:46 AM, the Surveyor observed no activities being provided on the secure unit. One CNA observed sitting at desk in day room with residents that are watching television. On 8/7/24 at 10:04 AM, the Surveyor observed staff offering snacks to the residents. No activities observed this morning on the secure unit. On 8/7/24 at 11:14 AM, the Surveyor observed no activities being provided on the secure unit. One CNA observed sitting at desk in day room with residents that are watching television. On 8/7/24 at 12:04 PM, the Surveyor observed no activities being provided on the secure unit. On 8/7/24 at 1:15 PM, the Surveyor observed no activities being provided on the secured unit. One CNA observed sitting at desk in day room with residents that are watching television. On 8/7/24 at 2:02 PM, the Surveyor observed no activities being provided on the secured unit. One CNA observed sitting at desk in day room with residents that are watching television. During an interview on 8/7/24 at 1:53 PM, Resident #28's family member stated activities are not performed on the secure unit. During an interview on 8/7/24 at 2:42 PM, the Activities Director stated activities should be performed on the secure unit daily. She confirmed activities had not been performed daily for the past 30 days During an interview on 8/7/24 at 3:09 PM, CNA #4 stated activities should be performed every day on the secure unit. During an interview on 8/8/2024 at 9:19 AM, the Administrator stated activities should be offered every day for those residents that were willing to participate, that activities provided daily were a resident's right, and each activity should be documented in the resident's electronic health record when they occur. The Administrator stated the benefits of activities included socialization, decreased depression, and an overall better quality of life. The Administrator stated lack of activities could lead to depression and a decline in the residents' health. The Administrator stated the Social Service Activity Director was in charge of the activities for the facility, except the secured unit, which was completed by a neighborhood coordinator/CNA who also provided direct care to the residents on the secured unit. The facility provided a policy titled, Activity Program with a revision date of June 2018 revealed activity programs are designed to meet the needs and interests of and support the physical, mental, and psychosocial well-being of each resident. Policy Interpretation and Implementation noted the activities program is ongoing and is to enhance the resident's sense of well-being and to promote or enhance physical, cognitive or emotional health. Activities are scheduled seven days a week. Resident activity participation is to be documented in the resident's medical record.

Based on observation, interviews, and record review, it was determined the facility failed to ensure interventions that were implemented in the care plan to promote safety while smoking for one (Resident #17) of one sampled resident. Findings include: Review of facility policy titled Smoking Policy-Residents dated 2001 (revised July 2017) indicated This facility shall establish and maintain safe resident smoking practices. A review of an Admission Record indicated the facility admitted Resident # 17 on 2/01/2024 with diagnoses that included Nontraumatic Ischemic Infarction of Muscle of left lower leg, persistent Atrial Fibrillation and behavioral disturbance. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/08/2024, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident was moderately impaired for their daily decision making. Review of Resident #17's Care Plan revised 2/19/2024 revealed the resident is a smoker and requires supervision while smoking. Interventions included The resident requires a smoking apron while smoking. Date Initiated: 02/19/2024. On 8/07/2024 at 11:30 AM, Resident #17 was observed smoking and Resident #17 did not have a smoking apron on. During an interview with Certified Nursing Assistant (CNA) #1 at 11:35 AM, was asked if Resident #17 should have on a smoking apron. CNA#1 said the resident should have a smoking apron on to protect himself if he should drop the cigarette. Medication Administration Tech #3 was asked on 8/07/2024 at 11:35 AM to observe Resident #17 while smoking. She was asked if Resident #17 had a smoking apron on and if they should have on one. She stated Resident #17 did not have an apron on but, they should. On 8/07/2024 at 11:40 AM, Licensed Practical Nurse (LPN) #2 was asked if Resident #17 should wear a smoking apron while smoking. She stated all smokers should wear a smoking apron to prevent an accident while smoking. During an interview on 8/07/2024 at 1:00 PM, Nurse Consultant stated the resident should have been wearing a smoking apron to prevent any accidents while smoking.

Based on interview and record review, the facility failed to ensure an antidepressant medication was not prescribed and administered to a resident who did not have a diagnosis of depression for 1 (Resident #32) of 1 (Residents #32) sampled resident who had Physician Order for an antidepressant medication in the facility per a list provided by the Director of Nursing (DON) on 07/27/23 at 10:15 AM. The findings are: 1. A Physician's Order dated 06/28/23 revealed Resident #32 received Duloxetine (an antidepressant) 20 milligrams one time a day for depression. 2. The June 2023 and July 2023 Medication Administration Record (MAR) revealed Resident #32 received Duloxetine 20 milligrams daily beginning on 06/28/23. 3. Resident #32's Medical Diagnosis list did not include a diagnosis of depression. 4. On 07/27/23 at 8:55 AM, the Surveyor asked the Director of Nursing (DON) to identify if there were any psychotropic medications ordered for Resident #32. The DON stated, Yes, they've got an order for Duloxetine. The Surveyor asked what diagnosis the medication was documented to treat. The DON stated, It's for depression. The Surveyor asked if there was a medical diagnosis for depression in Resident #32's chart. The DON stated, No there's not. The Surveyor asked if a medication should be administered if it was not being used to treat a specific condition that had been diagnosed and documented in the resident's clinical record. The DON stated, Oh, no. 5. The facility policy titled, Administering Medications, provided by the Administrator on 07/27/23 at 9:40 AM, did not detail specifics on psychotropic medications. The Surveyor requested additional information on the facility's medication policy. The Nursing Consultant stated that no additional policy information was available.

Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for 1 (Resident #6) of 6 (Residents #5, #6, #9, #10, #13, and #310) residents who required assistance with personal hygiene for cleaning their face of nasal drainage. This failed practice had the potential to affect 8 residents who resided on the 200 Hall and required assistance with wiping their nose per a list provided by the Nurse Consultant on 07/27/23. The findings are: 1. Resident #6 had diagnoses Unspecified Dementia, Peripheral Vascular Disease, and Depressive Disorders. a. On 07/25/23 at 8:20 AM, Resident #6 was sitting in a wheelchair in the Dining Room at a table with another resident. Resident #6 was sitting with her head drooping forward with clear nasal drainage dripping from her left nare approximately 4 inches. A Certified Nursing Assistant (CNA) removed Resident #6's clothing protector. The clear nasal drainage remained dripping from Resident #6's nose approximately 4 to 6 inches. A second CNA assisted Resident #6 to her room and left her up in her wheelchair sitting by the window. The nasal drainage remained dripping from her nose approximately 6 to 8 inches. b. On 07/25/23 at 9:00 AM, during observation of wound care to Resident #6's head wound, Licensed Practical Nurse (LPN) #3 had to hold Resident #6's head in the upright position to perform the wound care. Resident #6 had clear nasal drainage hanging approximately 8 to 10 inches from her left nare. c. On 07/25/23 at 9:30 AM, two CNAs entered Resident #6's room to perform resident care and to assist the resident to the Dayroom. One of the CNAs got a tissue and removed the nasal drainage from the residents left nare. d. On 07/26/23 at 1:34 PM, the Surveyor asked CNA #1, What would you do if you observed a resident sitting in the Dining Room with clear nasal drainage dripping from their nose approximately 6 to 10 inches? CNA #1 stated, I would get some gloves and then get a tissue and clean them up. The Surveyor asked, Should a resident have nasal drainage dripping from their nose for an hour? CNA #1 stated, No, they should not. The Surveyor asked, Would you say that is a dignity issue for a resident? CNA #1 stated, Yes. e. On 07/26/23 at 1:40 PM, the Surveyor asked CNA #2, What would you do if you observed a resident sitting in the Dining Room with clear nasal drainage dripping from their nose approximately 6 to 10 inches? CNA #2 stated, I would clean them up. The Surveyor asked, Should a resident have nasal drainage dripping from their nose for an hour? CNA #2 stated, No. The Surveyor asked, Would you say that is a dignity issue for a resident? CNA #2 stated, Yes ma'am. f. On 07/26/23 at 1:45 PM, the Surveyor asked LPN #1, What would you do if you observed a resident sitting in the Dining Room with clear nasal drainage dripping from their nose approximately 6 to 10 inches? LPN #1 stated, I would get a tissue and clean that up. The Surveyor asked, Should a resident have nasal drainage dripping from their nose for an hour? LPN #1 stated, No, of course not. The Surveyor asked, Would you say that is a dignity issue for a resident? g. On 07/26/23 at 1:50 PM, the Surveyor asked LPN #3, What would you do if you observed a resident sitting in the Dining Room with clear nasal drainage dripping from their nose approximately 6 to 10 inches? LPN #3 stated, I would get some gloves and a tissue and clean them up. I would probably take them to their room to do it. The Surveyor asked, Should a resident have nasal drainage dripping from their nose for an hour? LPN #3 stated, No. The Surveyor asked, Would you say that is a dignity issue for a resident? LPN #3 stated, Yes. The Surveyor asked, When you did the wound care on Resident #6's forehead yesterday, did you see the nasal drainage dripping from her nose approximately 6 to 10 inches? LPN #3 stated, Oh no, I did not. Honestly if I had seen it I would of cleaned it up. h. On 07/27/23 at 8:20 AM, the Surveyor asked the Director of Nursing (DON), Should a resident be allowed to sit in the Dining Room with nasal drainage dripping from their nose approximately 6 to 10 inches if they cannot clean it themselves? She stated, No they should not. The Surveyor asked, Is that a resident dignity issue, or Quality of Care issue to have nasal drainage dripping from their nose for approximately one hour? She stated, that is all of the above. That should not happen. i. The Care Plan with a revision date of 06/26/23 indicated Resident #6 required extensive assistance of one staff for oral care/personal hygiene. j. A facility policy titled, Activities of Daily Living (ADLs), Supporting, provided by the Nurse Consultant on 07/26/23 at 4:05 PM documented, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLS independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) . k. A facility policy titled, Quality of Life-Dignity, provided by the Nurse Consultant on 07/27/23 at 8:35 AM documented, Policy Statement Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1. Residents shall be treated with dignity and respect at all times . 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .

Based on record review and interview, and review of the Centers for Medicare and Medicaid Services Resident Assessment Instrument Manual 3.0, the facility failed to accurately record the assessment for 2 (Residents #24 and #31) of 8 (Residents #13, #17, #20, #24, #31, #33, #34 and #45) sampled residents whose MDS was reviewed. The findings are: 1. Resident #24's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/23/23 documented, under section J1900, the resident had two falls with no injury and one fall with injury. a. Resident #24's Significant Change in Status MDS with an ARD of 05/12/23 documented, under section J1900, the resident had two falls with no injury, one fall with injury and two falls with major injury. b. A Nursing Incident and Accident (I&A) Note dated 03/20/23 documented staff entered Resident #24 ' s room and found him kneeling on his left knee next to the bed with his torso across the bed, his left knee was light red in color. No injuries were noted. c. A Nursing I&A Note dated 03/22/23 documented Resident #24 was found on the floor in the living/lounge area. No injuries were documented. d. A Nursing I&A Note dated 04/30/23 documented Resident #24 was found lying between his bed and the recliner on his left side in the fetal position with a small abrasion to his left knee. No other injuries were noted. e. A Nursing I&A Note dated 07/15/23 documented Resident #24 was found lying on the floor on his right side between the air conditioning unit and the bed with a skin tear to both elbows and the back of his left hand. No other injuries were noted. f. On 07/26/23 at 12:11 PM, the Surveyor asked the Nursing Consultant why Resident #24 had two falls with major injury coded on their MDS. The Nursing Consultant voiced intent to investigate. g. On 07/26/23 at 12:18 PM, the Surveyor asked the Nursing Consultant and Licensed Practical Nurse (LPN) #4 if Resident #24 was coded as having two falls with major injury since the last assessment. LPN #4 stated, Yes, it's showing [Resident #24] has had two. The Surveyor asked if Resident #24 had any major injuries documented in the chart. LPN #4 stated, No, [Resident #24] hasn't had any major injuries. 45065 2. Resident #31's Admission MDS with an ARD of 06/14/23 documented Resident #31 did not receive oxygen therapy while a resident. a. On 07/24/23 at 1:30 PM, Resident #31 was in bed with oxygen on per nasal canula at two liters per minute. b. A Physicians Order dated 06/05/23 indicated Resident #31 received oxygen at 2 liters per minute per nasal cannula as needed for shortness of breath. c. A Care Plan with an initiated and a revision date of 06/08/23 indicated Resident #31 received oxygen therapy at 2 liters per minute via nasal cannula. d. Resident #31's Admission assessment with an effective date 06/06/23 indicated Oxygen Rate 2 (liters) per nasal cannula. e. A Nursing Progress Note dated 06/07/23 time at 6:43 AM documented, .Resident continues on hospice with no complaints voiced. O2 at 2 L [liters] via NC [nasal cannula]. No dyspnea (shortness of breath) noted . f. On 07/26/23 at 2:00 PM, the Administrator and the Nurse Consultant reviewed Resident #31's Admission MDS with an ARD of 06/14/23 and stated, It does not have that he needs it (oxygen), but we would look at the look back date and see if he had used the oxygen and we would answer the question from that. The Surveyor asked the Nurse Consultant, Does the resident have an order for the Oxygen? The Nurse Consultant stated, It looks like he does have an order for PRN [as needed] oxygen dated 06/05/23. But we would not mark it unless he was using it. The Surveyor asked the Nurse Consultant if there was a progress note in the resident file stating Resident #31 was resting with oxygen on per nasal cannula, would the answer to the question be yes then. The Nurse Consultant stated, Yes if it is documented on a progress note during the look back time frame then the MDS should have it documented yes for oxygen as a resident. 3. A facility policy titled, Resident Assessment Instrument, provided by the Nurse Consultant on 07/26/23 at 4:05 PM documented, .4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning .

Based on observation, record review, and interview, the facility failed to ensure incontinent care was provided in a timely manner for 1 (Resident #1) of 4 (Residents #1, #2, #3, #4) on the case mix residents who were had pressure ulcers and were dependent on staff to provide incontinent care The failed practices had the potential to affect 7 residents who had a pressure ulcer and were dependent on staff for care, according to a list provided by the Administrator on 5/24/22 at 09:30 a.m. The findings are: Resident #1 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/24/22 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, was totally dependent on staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing, was always incontinent of bowel and bladder. a. The Plan of Care with a revised date 5/2/17 documented, .The resident requires EXTENSIVE ASSISTANCE OF 1 staff for toileting. CHECK BRIEF PERIODICALLY TO ASSURE RESIDENT IS APPROPRIATELY COVERED AND DIGNITY IS MAINTAINED . b. The Medical Doctor order dated 5/10/22 documented, Cleanse stage IV PU to left trochanter with normal saline pat dry with 4x4 gauze pack with moistened kerlix cover with 4x4 gauze then apply ABD [Abdominal] pad secure with tape daily and prn [as needed] reassess in 14 days every day shift related to PRESSURE ULCER OF LEFT HIP, STAGE 4 AND as needed for dislodgement/soiled . c. A nursing note dated 5/23/22 at 1:59 AM, completed by Registered Nurse (RN) #1, documented, .Tx [treatment] to wounds continue with all dressings clean dry and intact. Resident requires frequent redirection from picking at and removing bandages and contaminating wound bed. All interventions effective at this x [time] with resident resting quietly. incont [incontinent] of b and b [bowel and bladder] with peri-care prn [as needed] and q [every] 2 hours. Turned and repositioned q 2 hours. No s/s [signs/symptoms] pain or discomfort WCTM [will continue to monitor] . d. A Skin & Wound Evaluation dated 5/23/22 documented the pressure ulcer on the resident's left trochanter was In- House acquired.Stage 4: Full-thickness skin and tissue loss . e. On 5/24/22 at 03:34 a.m. surveyor went with Certified Nursing Assistant (CNA) #1 to see if resident needed have her brief changed. Resident #1 was lying in bed sideway with a wet brief on. There was a strong odor that smelled like urine. CNA #1 told the surveyor that the resident was wet and would have to wait on another staff member to come help her change Resident #1's wet brief. f. On 5/24/22 at 03:45 a.m. CNA #1 and #2 were changing R #1. As they were rolling resident from side to side to remove the saturated brief that had a strong odor of urine, the surveyor observed a piece of yellow tinged cloth material fall onto the bed landing in the resident's wet brief. CNA #2 picked up the piece of material and threw it in the trash can with the soiled brief. The dressing was dated 5/23/22 at 3:00 p.m. The dressing was not intact with the skin. The dressing was saturated in a light yellowish urine smelling fluid. The CNA performed peri care, then placed a clean disposable brief on the resident. As the CNA's were securing the brief, CNA #2 flattened out the dressing and pulled the brief over to hold the dressing in place. CNA #2 was asked if she could show the surveyor what fell out of the dressing. CNA #2 pulled out a gauze 4x4 that had a piece of cord like material with a light pink color on top of the 4x4, which was wet with a foul odor of urine and stated, We can't do anything with the dressing, we will have to tell the nurse and she will come down and look at it. g. On 5/24/22 at 3:55 a.m., CNA #1, When did this resident have her brief changed prior to this change? CNA #1 stated, about 2 hours ago. The CNA was asked, Is it normal for the resident to be this wet every 2 hours? CNA #1 stated, Sometimes but not all of the time. h. On 5/24/22 at 4:33 a.m. Licensed Practical Nurse (LPN) #1 and RN #1 were changing the dressing on the resident's left buttock after removing the saturated dressing. RN #1 was asked, Can you describe what you saw on the ABD bandage that you removed from the resident's left buttock? She stated, It was wet with the smell of urine and that is why I went ahead and changed the dressing. The RN was asked, How often are residents rounded on? She stated, Every 2 hours but this resident probably needs to be rounded on more often if she is that wet every 2 hours.

Based on record review and interview, the facility failed to notify resident representatives or Power of Attorneys (POA) in writing of the bed hold policy upon a resident's transfer to the hospital and/ or discharge as required for 2 (Resident #27 and #22) of 6 (Resident #27, #42, #41, #16, #38 and #22) sample residents who were transferred to the hospital in the last five months. The findings are: 1. Resident #27 had a diagnosis [CONDITION(S)] and [CONDITION(S)]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 1/17/2022 documented a score of 11 (8-12 indicates Moderately impaired) on a Brief Interview for Mental Status (BIMS). a. Nurses note dated 12/9/2022 at 9:20 PM, documented, This nurse entered resident's room at med [medication] pass time and observed resident leaning to right side in bed with copious amount of drool draining from mouth onto chest. Resident lethargic . APRN [Advanced Practice Registered Nurse] notified of findings with order obtained to transfer resident to ER [emergency room ] for eval [evaluation] . b. Nurse's Note dated 12/10/2022 at 1:00 PM, documented, [Hospital] contacted facility at this time with update for resident. Resident admitted to [hospital] for dx [diagnosis] of [CONDITION(S)]. Resident's POA [Power of Attorney] was aware of resident's admission. c. There was a Discharge with Return Anticipated MDS dated [DATE] and Entry MDS dated [DATE]. The Notice of Bed Hold Policy and Return documented it was completed on 12/13/2021. d. SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers dated 1/2/2022 at 9:50 AM, documented, . Resident appears more tired than usual, he is having light brown milky appearing urine. Urine is consistent in appearance like his Peg [percutaneous endoscopic gastrostomy] tube feedings . Primary Care Provider responded with the following feedback: . Send to ER for evaluation and treatment . e. The MDS documented a Discharge with Return Anticipated on 1/2/2022 with an Entry on 1/14/2022. The Notice of Bed Hold Policy and Return documented it was completed on 1/4/2022. 2. Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 1/24/2022 documented a score of 14 (13-15 indicates Cognitively intact) on a Brief Interview for Mental Status (BIMS). a. Nurse's Note dated 4/23/2022 at 7:00 AM, documented, .Resident hospitalized at [geri psych facility] . b. The Resident's Census documented 4/22/2022 . Hospital Unpaid Leave . The Notice of Bed Hold Policy and Return documented it was completed on 4/25/2022. c. Nurse's Note dated 3/14/2022 at 8:47 AM, documented, .Reported to this nurse from Physical Therapist, general decline and weakness. Wound Nurse c/o [complained of] slurred speech (sic). APN gave order to send to send to ER for eval and treatment . d. Nurse's Note dated 3/15/2022 at 10:56 AM, documented, admitted to . for [CONDITION(S)] on 3/14/2022. Husband aware and at hospital with resident. e. The MDS documented a Discharge with Return Anticipated on 3/14/2022 with an Entry on 3/15/2022. The Notice of Bed Hold Policy and Return documented it was completed on 3/15/22. f. Nurse's Note dated 3/28/2022 at 12:17 PM documented, . resident admitted with dx of [CONDITION(S)] . g. Nurse's Note dated 12/28/2021 at 6:30 PM documented, . Resident noted to be in severe pain, vomited moderate amount of gray to brown colored emesis. Spoke with resident regarding change of condition with request to go to the hospital, spoke with . APRN with order given to transfer out to ER for evaluation . h. An MDS documented a Discharge with Return Anticipated on 12/28/2021 with an Entry on 1/12/2022. The Notice of Bed Hold Policy and Return documented it was completed on 12/29/2021. 3. On 4/27/2022 At 10:29 AM, the Business Office Manager [BOM] was asked, who is responsible for completing the bed hold and transfer letter? She replied, Me. She was asked, When should the bed hold, and transfer letter be processed? She replied, If they are transferred on Friday, they should be done by Monday. She was asked, what if the resident is transferred during the week? She replied, I get them out within 24. She was asked, For [Resident #27, #41, #16 and #22] that were transferred to the hospital, is there a reason why the resident's bed hold, and transfer letter were not completed on the day of the transfer? She replied, Either I'm not here or I thought I had 24 hours. 4. The Admission Packet was received on 4/27/2022 documented, . Bed-Hold Policy: Except in the case of an emergency, before the facility transfers the patient to a hospital . the Facility will provide written information to the Patient and a family member or Patient Representative that specifies: . For private pay patients, the bed will be held . For Medicaid Patients the bed will be held . If the patient's hospitalization .leave exceeds the bed- hold period, the facility will permit readmission upon the first availability of a bed .

Based on observation, record review, and interview, the facility failed to ensure treatment and care for management of indwelling urinary catheters were provided in accordance with accepted standards of nursing practice, by failing to ensure the urinary catheter tubing was secured to prevent potential pulling or trauma to the urinary meatus/urethra for 1 (Residents #42) of 1(R#42, R#16 and R#7) sample residents with indwelling catheters. The failed practices had the potential to affect 2 residents who had indwelling urinary catheters, according to a list provided by the Administrator on 4/27/22. The findings are: 1. Resident #42 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set with an Assessment Reference Date of 1/27/22 documented the resident scored an 11 (8 -12 indicates moderately impaired) on a Brief Interview for Mental Status and required Assistance of 1-2 staff members for Activities of Daily Living [ADLS]. a. A Care Plan with a review date of 04/14/22 documented, [Resident #42] has an indwelling (18) fr (French) Foley Resident will remain free from catheter -related trauma . The care plan did not address the need to secure the catheter tubing to prevent to potential trauma to the bladder or urinary meatus. b. On 04/25/22 at 01:02 PM, Licensed Practical Nurse (LPN) #1, the Treatment nurse provided peri-care to Resident #42. LPN #1 was asked, Is his catheter secured? LPN #1 stated, No, I'll (I will) get him a stat lock . She was asked, What is a complication of his catheter not being secured? She stated, He could pull it out. c. On 4/28/22 at 08:57 AM, the Director of Nursing (DON) was asked, When should a resident's foley catheter be secured? She stated, At all times. She was asked, How should a Foley Catheter be secured to prevent trauma? She stated, With a stat lock. She was asked, Who is responsible for ensuring the resident's catheter is secured with a stat lock? She stated, Everyone. d. On 4/26/22 A Review of the Policy and Procedure titled, Foley Catheter Insertion, Male Resident documented, .25. Tape catheter to top of thigh or lower abdomen .

Based on observation, record review, and interview, the facility failed to ensure toenails were trimmed to promote good foot care for 1 (Residents #26) of 21 (Resident #39, #46, #15, #6, #34, #45, #23, #3, #42, #2, #26, #9, #16, #24, #38, #27, #12, #10, #21, #22 and #41) sampled residents who were dependent for nail care. The findings are: Resident #26 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The revised Care Plan documented, The resident has Potential for Decline and Complications R/T [Related to] ADL [Activities of Daily Living] self-care performance deficit r/t Dementia . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. b. On 4/25/22 at 11:43 AM, the resident was resting in a low bed. He had a heel protector on the left foot. The resident's toenail was uneven and jagged. c. On 4/27/22 at 9:12 AM, CNA (Certified Nursing Assistant) #1 was asked, Who performs toe care on the residents? She replied, The CNAs. She was asked, when is toenail care completed? She replied, On their shower days and as needed. d. On 4/27/22 at 9:20 AM, the Licensed Practical Nurse (LPN) #2 accompanied the surveyor to the resident's room. The resident was sitting in a Geri-chair with non-skid socks on. The LPN was asked, Who performs toenail care on the residents? She replied, The CNAs on their shower days. The LPN was asked, Are her two big toes uneven and jagged? She replied, Yes, they are, and they need to be filed, they could cause a skin injury. The LPN was asked, Who is responsible to ensure the resident's toenail care are completed? She replied, The floor nurses. e. The Policy on Activities of Daily Living (ADLs), Supporting was received on 4/27/22 documented, . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain . personal .hygiene.Appropriate care and services will be provided for residents, who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene .

Based on observation, record review and interview, the facility failed to ensure information regarding resident's code status was accurately documented and readily available to enable staff to quickly ascertain the resident's wishes in the event of a decline in condition for 1 (Residents #27) of 21 (Residents #22 #24, #26, #9, #27, #16, #41, #46, #12,#39, #3, #42, #2, #34, #23, #10, #45, #6, #38, #21, and #15) sampled residents whose code status was reviewed. The findings are: Resident #27 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) [DATE] documented a score of 11 (,d+[DATE] indicates Moderately impaired) on a Brief Interview for Mental Status (BIMS). a. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [miscellaneous] . b. The face sheet documented, CPR [Cardiopulmonary Resuscitation] FULL CODE - Please see misc. c. The Care Plan dated [DATE] documented, The resident's code status is Full Code . Check to make sure that Full Code is listed as the resident's code status on the resident profile/face sheet . Review code status with the resident/responsible party quarterly or as needed. d. On [DATE] under Document Manager Misc. documented, ' . CODE STATUS-DNR [Do Not Resuscitate] UPDATED [DATE]. The code status was signed by his sister, Resident #27 ' s documented Responsible Party and Emergency Contact in his Profile Page, which was dated [DATE]. e. On [DATE] at 11:20 AM, Licensed Practical Nurse (LPN) was asked, How do you know what the resident's code status is? She replied, It's in the computer, on the resident's profile page. The LPN was asked, What is [Resident #27's] code status? The LPN logged onto the computer, which took approximately a minute to bring up the resident's electronic record then she stated, He's a full code. f. On [DATE] at 11:30 AM, the Director of Nursing (DON) was asked, How do you know what the resident's code status is? She replied, It's on the resident's closet close plan and on their profile page in the computer. A copy of the resident's closet care plan was received from the DON which documented the resident was a Full Code. The DON was asked, Is the resident a Full Code or a DNR (Do Not Resuscitate)? The DON replied, According to the closet care plan and his profile page he is a full code. The DON was asked to review the code status on [DATE] and she stated, He's a DNR, I will check into that and correct his code status.

Based on record review and interview, the facility failed to ensure baths / showers / oral care were regularly and consistently provided, to maintain good personal hygiene and prevent odors for 1 (Residents #9) of 14 (Resident #39, #46, #15, #6, #34, #45, #23, #3, #42, #2, #26, #9, #16, and #41) sampled residents who required assistance from staff for personal hygiene / bathing. The findings are: Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set with an Assessment Reference Date of 1/6/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and required extensive one-person physical assistance for personal hygiene and bathing. a. The revised Care Plan dated 2/4/22 documented, The resident has an ADL [Activity of Daily Living] self-care performance deficit r/t [related to] impaired vision, weakness . BATHING/SHOWERING: extensive X [times] 1 . PERSONAL HYGIENE/ORAL CARE: extensive X1 . The resident exhibits dental/mouth problem as evidenced by several missing teeth . Provide set-up/supervision/hand under hand assistance as needed for mouth/oral care. b. On 4/26/22 at 7:28 AM, the resident was sitting in his recliner. The resident stated, It's been a long time since I've brushed my teeth, I have no mouth wash, and I need help bruising my teeth, they don't offer to help. My last shower was a week ago, Monday. I'm not even getting them once a week. I have to wash myself with a washcloth. I never refuse a shower, they hardly offered to give me one. c. On 4/27/22 at 9:38 AM, the resident was sitting in his recliner. He was asked if he had his teeth brushed or a shower this morning and he stated, No, I need assistance, if they would just put the tooth paste on my toothbrush, I could brush my teeth. d. The facility Activities of Daily Living Flow sheet dated April 2022 documented the following: .Bathing Monday, and Thursday and PRN [as needed]. On Monday the 18th the resident received a shower, on Thursday the 21st and Monday the 25th it was documented the resident received a bed bath. e. On 4/27/22 at 9:12 AM, Certified Nursing Assistant (CNA) #1 was asked, Who performs the resident's showers? She stated, The CNAs. She was asked, how often do the residents receive showers. She stated, Two to three times a week. The CNA was asked, what if they refuse? She replied, I reattempt, inform the nurse and chart it in the kiosk. The CNA was asked, Who brushes the resident's teeth? She replied, The CNAs. She was asked, Do you assist [Resident #26] with brushing his teeth? She replied, No, I have never assisted him with his teeth, I don't always work on this hall, I work on all halls. f. On 4/27/22 at 9:20 AM, Licensed Practical Nurse (LPN) was asked, who performs the resident's showers? The LPN stated, The CNAs. She was asked, how often do the resident receive showers. She stated, Two to three times a week. The LPN was asked, Who brushes the resident's teeth? She replied, The CNAs. The LPN was asked, Who is responsible to ensure the resident's teeth are brushed and showers are completed as scheduled? She stated, The floor nurses. g. The Policy on Activities of Daily Living (ADLs), Supporting was received on 4/27/22 documented, . Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain . personal .hygiene.Appropriate care and services will be provided for residents, who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing .oral care .

Complaint # (AR 143) was substantiated, all or in part, with these findings: Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 7 residents who received pureed diets, as documented on the Diet List provided by the Registered Dietitian on 3/9/2021 at 1:27 p.m. The findings are: 1. On 3/8/2021 at 12:12 p.m., the following observations were made on the steamtable: a. On 3/8/2021 at 12:13 p.m., a pan of pureed noodles was on the steamtable. The consistency of the pureed noodles was not smooth. It was thick and there were pieces of parsley visible in the mixture. b. On 3/8/2021 at 12:14 p.m., a pan of pureed beef stroganoff was on the steamtable. The consistency of the pureed beef stroganoff was not smooth. It was gritty and thick. c. On 3/8/2021 at 12:15 p.m., a pan of pureed bread was on the steamtable. The consistency of the pureed bread was thick. d. On 3/8/2021 at 1:05 p.m., Certified Nursing Assistant #1, who was assisting residents with their meal, was asked to describe the consistency of the pureed food items served to the residents. She stated, The pureed meat was not all the way pureed. The pureed noodles and pureed bread were thick. e. On 3/8/2021 at 1:06 p.m., Certified Nursing Assistant #2, who was assisting residents with their meal, was asked to describe the consistency of the pureed food items served to the residents who received pureed diets. She stated, The pureed noodles were not smooth. It was thick. You can see pieces of parsley. The pureed bread was thick, and the pureed stroganoff was thick. f. On 3/8/2021 at 1:20 p.m., Dietary Employee #2 was asked to describe the consistency of the pureed food items prepared and served to the residents who received a pureed diet. She stated, I should have used a little more milk to puree them. They should have been creamer. g. On 3/9/2021 at 8:30 a.m., the residents who received a pureed diet were served pureed sausage. The consistency of the pureed sausage was not smooth. It was lumpy. There were pieces of meat visible in the mixture and the pureed bread was thick. h. On 3/9/2021 at 8:32 a.m., Certified Nursing Assistant #1, who was assisting residents with their meal in the Dining Room, was asked to describe the consistency of the pureed sausage and the pureed bread served to the residents who received a pureed diet. She stated, The pureed bread was thick. The pureed sausage was not smooth. It was not pureed enough. i. On 3/9/2021 at 8:34 a.m., Licensed Practical Nurse #1 was asked to describe the consistency y of the pureed sausage and the pureed bread served to the residents who received a pureed diet. She stated, The texture of the pureed bread is too thick. It is supposed to be creamer. The pureed sausage was ground texture. j. On 3/9/2021 at 11:53 a.m., Dietary Employee #3 was asked to describe the consistency of the pureed sausage served to the resident at breakfast. She stated, It was still gritty.

Based on observation and interview, the facility failed to ensure dietary employees / staff washed their hands between dirty and clean tasks, before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 49 residents who received meals from the kitchen (Total census: 51), according to the list provided by the Registered Dietician on 3/9/2021 at 1:27 p.m. The findings are: 1. On 3/8/2021 at 11:57 a.m., Dietary Employee #1 walked out of the walk-in refrigerator, picked up a tray of clean glasses, and placed the tray of clean glasses on the counter. She opened the refrigerator door and removed boxes of nectar thickened water and milk and placed them on the counter. Without washing her hands, she picked up glasses by the rims and poured beverages in the glasses to be served to the residents who received thickened liquids for the lunch meal. She covered the glasses with lids. At 11:59 a.m., Dietary Employee #1 removed a marker from her pocket and used it to write the date on the lids. At 12:00 p.m., Dietary Employee #1 removed a bottle of cranberry juice, a carton of nectar milk, and a carton of nectar cranberry juice and placed them on the counter. Without washing her hands, she picked up glasses by the rims and poured beverages in the glasses to be served to the residents for the lunch meal. At 2:10 p.m., Dietary Employee #1 was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 2. On 3/8/2021 a 12:02 p.m., Dietary Employee #2 picked up a potholder and placed it on the counter. She picked up a pan and picked up a 6 ounce ladle spoon from the drawer and scooped 5 servings of beef stroganoff into a pan. Dietary Employee #2 did not wash her hands after picking up the potholder and touching the drawer. She picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who received a pureed diet. At 1:59 p.m., Dietary Employee #2 was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. I forgot to. 3. On 3/9/2021 at 8:40 a.m., Dietary Employee #3 removed a box of oatmeal from the storage room and poured some in a bowl. She added water and placed it in the microwave to cook. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who received a pureed diet. At 11:54 a.m., Dietary Employee #3 was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 4. The facility policy titled Employee Cleanliness and Handwashing Technique provided by the Dietary Supervisor on 3/9/2021 at 2:27 p.m. documented, . 13. Dietary Department Employees are required to wash their hands on the occasions listed below . 23. Any other time deemed necessary . Before picking up clean item or food item .

Based on observation, record review, and interview, the facility failed to ensure facial hair was removed regularly to maintain good grooming for 2 (Residents #18 and #38) of 3 (Residents #3, #18, and #38) sampled residents who were dependent on staff for assistance with care and facial hair removal. This failed practice had the potential to affect 9 residents who were dependent on staff for assistance with care and facial hair removal and resided on the 100 Hall, according to a list provided by the Minimum Data Set (MDS) Coordinator on 3/11/2021. The findings are: 1. Resident #18 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 11/23/2020 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); required supervision and set up help with bed mobility, transfer, dressing, toilet use, and personal hygiene; and required extensive one-person assistance with bathing. a. A Care Plan with a revised date of 7/13/2017 documented, . Focus . The resident has Potential for Complications R/T (related to) ADL (activities of daily living) self-care performance deficit . Interventions . Bathing / Showering . The resident Needs Extensive Assist (Assistance) of 1 . Personal Hygiene / Oral Care . The resident Needs Set-Up and Supervision . Skin Inspection . The resident requires Skin inspection Q (every) Shift during care . Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse . Licensed Nurse to do Body Audit Weekly and PRN (as needed) . b. On 3/8/2021 at 11:34 a.m., Resident #18 was sitting in a wheelchair and had approximately one-fourth inch of white, facial hair growth on her chin. c. On 3/9/2021 at 9:01 a.m., the resident was sitting in a wheelchair watching television and was asked about the facial hair on her chin. Resident #18 stated, They need to shave me, but they have not done it. The resident could not recall last time she had the facial hair removed from her chin. (The Surveyor took a photograph of the resident's chin facial hair at this time.) d. On 3/10/2021 at 2:42 p.m., Certified Nursing Assistant (CNA) #6 was asked, What type of care is provided to resident's during showers or baths? CNA #6 stated, If the resident needs assistance, we do help them wash their body and we shave them, and lotion them, and dry their hair if they want it dried. We do have some residents that are set up and we just monitor them to make sure they don't fall. CNA #6 was asked if (Resident #18) was able to assist with their shower or bath. CNA #6 stated, (Resident #18) needs assistance washing her back, bottom, and legs. CNA #6 was asked, When is the resident's hair removed from their face and legs? CNA #6 stated, We don't have a lot of them that like their legs and underarms shaved, but we try to have all faces shaved by 10:00 a.m. CNA #6 was asked, When was the facial hair last removed from (Resident #18)? CNA #6 stated, Honestly, I don't know the last time (Resident #18) was shaved. CNA #6 was asked, How fast does the resident's hair grow? CNA #6 stated, Really fast. CNA #6 was asked, Do residents have to ask for care? CNA #6 stated, No. It is on a regular schedule. If they ask for shower on a day that is not a regular day, we try to get them in if we can. CNA #6 was shown a photograph of Resident #18's face and was asked how long it had been since the resident had been shaved. CNA #6 stated, About a week. 2. Resident #38 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 1/6/2021 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status); required supervision with set up help with bed mobility, transfer, dressing, toilet use, and personal hygiene; and required extensive one-person physical assistance with bathing. a. On 3/8/2021 at 11:34 a.m., Resident #38 was sitting in a wheelchair to the right of her bed and had approximately one-fourth to one-half inch black, white, and gray hair above her upper lip and on her chin. b. On 3/9/2021 at 8:59 a.m., Resident #38 was asked about the facial hair. Resident #38 stated, I asked to be shaved and they have not done it yet. I guess they will get to it when they can. (The Surveyor took a photograph of the resident's facial hair at this time.) c. A Care Plan with a revised date of 4/20/2020 documented, . Focus . The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) [MEDICAL CONDITION], Abnormal Gait and Mobility, [MEDICAL CONDITIONS] ([MEDICAL CONDITION]) . Interventions . Bathing / Showering . Provide sponge bath when a full bath or shower cannot be tolerated . Bedfast . The resident is bedfast all or most of the time Focus . The resident is at risk for falls r/t (related to) Abnormal Gait and Mobility, [MEDICAL CONDITIONS] . Interventions . Anticipate and meet the resident's needs . d. On 3/10/2021 at 2:31 p.m., Certified Nursing Assistant (CNA) #5 was asked, When are residents shaved or hair removed from their face or legs? CNA #5 stated, The shower and the bath. We can shave them right then. I am not certain on legs, but usually when they ask. CNA #5 was asked if they (residents) have to ask for their face and legs to be shaved or if it is offered. CNA #5 stated, I think they do have to ask for that type of care. e. On 3/10/2021 at 2:42 p.m., CNA #6 was asked, What type of care is provided to resident's during showers or baths? CNA #6 stated, If the resident needs assistance, we do help them wash their body, and we shave them, and lotion them, and dry their hair if they want it dried. We do have some residents that are set up and we just monitor them to make sure they don't fall. CNA #6 was asked if (Resident #38) was able to assist with their shower or bath. CNA #6 stated, (Resident #38) needs assistance washing her back, bottom, and legs. CNA #6 was asked, When is residents' hair removed from their face and legs? CNA #6 stated, We don't have a lot of them that like their legs and underarms shaved, but we try to have all faces shaved by 10:00 a.m. CNA #6 was asked, When was the hair last removed from (Resident #38)? CNA #6 stated, The last time I shaved her was a week ago. CNA #6 was asked if resident have to ask for care. CNA #6 stated, No. It is on a regular schedule. If they ask for a shower on a day that is not a regular day, we try to get them in if we can. CNA #6 was shown a photograph of Resident #38's face and was asked, How long has it been since the resident was shaved? CNA #6 stated, A week, to a week and a half. f. On 3/10/2021 at 2:58 p.m., the Director of Nursing (DON) was asked Who is responsible for removing resident's facial hair? The DON stated, The CNAs when they are in the shower should be making sure that it is removed, and the nurses should be ensuring that, and then I should be ensuring that. The DON was asked if she knew why (Resident #18's) and (Resident #38's) facial hair had not been removed. The DON stated, No. The only thing I can think of is because of the snowstorm and we are trying to get back into a routine. The DON was shown a photograph of Resident #18's chin and Resident #38's mouth and chin and was asked if residents should have to ask to have the hair removed. The DON stated, That has been a while, and they should be offered and not have to ask. g. A facility policy titled Activities of Daily Living (ADLs), Supporting provided by the Minimum Data Set Coordinator on 3/11/2021 documented, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good . grooming and personal hygiene . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs (activities of daily living) independently . including appropriate support and assistance with . a. Hygiene (bathing, dressing, grooming, and oral care) .

Based on observation, record review, and interview, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician, to minimize the potential for [MEDICAL CONDITION] or other respiratory complications for 1 (Resident #38) of 6 (Residents #38, #12, #31 #40, #44, and #51) sampled residents who were receiving oxygen therapy; and, the facility failed to ensure a Physician's Order was obtained for the administration of oxygen therapy for 1 (Resident #12) of 6 (Residents #12, #31 #38, #40, #44, and #51) sampled residents who had oxygen in use. These failed practices had the potential to affect 10 residents who were receiving oxygen therapy, according to a list provided by the Minimum Data Set (MDS) Coordinator on 3/11/2021. The findings are: 1. Resident #38 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 1/6/2021 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status); required set up and supervision for bed mobility, transfer, and toilet use; did not have shortness of breath; and received oxygen therapy. a. A Care Plan dated 2/15/2020 documented, . Focus . The resident has altered respiratory status / difficulty breathing r/t (related to) [MEDICAL CONDITIONS] . Intervention . Administer medication / puffers as ordered . Resident With O2 (oxygen) at 2 L (liters) Via N.C. (nasal cannula) . Change Oxygen Tubing Every Sunday and PRN (as needed) . b. A Physician's Order dated 5/26/2020 documented, .Change and date oxygen tubing every Sunday and prn (as needed) every night shift every Sun (Sunday) for SOB (shortness of breath) . oxygen (at) 2 L (Liters) (per) NC (nasal cannula) via NC continuous and PRN (as needed) for SOB . c. On 3/8/2021 at 11:30 a.m., Resident #38 was sitting in a wheelchair to the right of the bed with a nasal cannula in her nares which was attached to a humidifier and oxygen concentrator. The oxygen flow rate on the concentrator was set at 4 liters per minute (LPM). The nasal cannula and humidifier were dated 3/1/2021. d. On 3/9/2021 at 9:02 a.m., Resident #38 was sitting in a wheelchair to the right of the bed with a nasal cannula in her nares. The nasal cannula was attached to a humidifier and oxygen concentrator. The oxygen flow rate on the concentrator was set at 4 liters per minute. The nasal cannula and humidifier were dated 3/8/2021. e. On 3/10/2021 at 2:58 p.m., the Director of Nursing (DON) was asked, How often are oxygen tubing and humidifiers changed? The DON stated, Once a week. The DON was asked, Should Physician's Orders be followed? The DON stated, Yes. f. On 3/11/2021 at 11:21 a.m., the Director of Nursing (DON) accompanied the Surveyor to the resident's room. The DON was asked, What rate is the oxygen the resident is receiving set at? The DON looked at the oxygen concentrator and stated, 4 liters. The DON was asked, Is that the rate ordered by the Physician? The DON stated, It is supposed to be on 2. The DON was asked, If the Physician's Order for oxygen is to run at a specific rate, should it be followed? The DON stated, Yes. The DON was asked, Why should oxygen orders be followed? The DON stated, It is like a medication and should be followed exactly as written. 2. Resident #12 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/22/2021 documented the resident scored 3 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); required extensive two-person assistance with transfers, bed mobility, and toilet use; required extensive one-person assistance with personal hygiene; did not have shortness of breath; and did not require oxygen therapy. a. A Physician's Order dated 7/13/2020 documented, .ProAir HFA Aerosol Solution 108 (90 Base) MCG/ACT (micrograms per actuation) ([MEDICATION NAME] HFA) 2 puffs inhale orally every 4 hours as needed for cough and SOB (shortness of breath) . A Physician's Order dated 3/3/2021 documented, .Contact / Droplet isolation . As of 3/8/2021 at 12:30 p.m., the Physician's Orders contained no documentation related to oxygen administration. b. A Care Plan dated 10/10/2020 documented, .The resident has altered respiratory status / difficulty breathing . Acute [MEDICAL CONDITION] / Pneumonia . Administer medication / puffers as ordered . Monitor for effectiveness and side effects . The Care Plan contained no documentation related to the administration of oxygen. c. On 3/8/2021 at 1:00 p.m., Resident #12 was receiving oxygen with the oxygen flow rate set at 3 liters by nasal cannula. He was on droplet isolation for COVID-19 precautions. His humidifier water bottle was dated 3/1/2021. d. On 3/10/2021 at 10:14 a.m., Resident #12 was lying in bed. The resident was receiving oxygen with the oxygen flow rate set at 3 liters by nasal canula. e. On 3/10/2021 at 11:38 a.m., Licensed Practical Nurse (LPN) #3 was asked, Can you tell me what the Physician's Order reads for (Resident #12's) oxygen? LPN #3 stated, It should be at 2 liters and prn. She was asked, Could you look up his order in the Electronic Record and tell me what it says? She stated, I'm looking and I'm not seeing it. She was asked, If you don't have a Physician's Order, how do you know how much oxygen to administer? She stated, I know he was out here on the floor and he had oxygen before. She was asked, Should you have a Physician's Order before oxygen is administered? She stated, Yes, we should. 3. A facility policy titled Oxygen Administration provided by the Minimum Data Set (MDS) Coordinator on 3/11/2021 documented, .The purpose of this procedure is to provide guidelines for safe oxygen administration . 1. Verify that there is a Physician's Order for this procedure . Review the resident's Care Plan to assess for any special needs of the resident . Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .

Based on observation and interview, the facility failed to ensure expired drugs or biologicals in 1 of 1 Medication Storage Room were removed and disposed of in accordance with the manufacturer's instructions / expiration date and accepted standards of pharmacy practice. This failed practice had the potential to affect 51 residents who resided in the facility, according to the Resident Census and Conditions of Residents form dated 3/8/2021. The findings are: 1. On 3/10/2021 at 10:20 a.m., the Medication Storage Room was checked with the assistance of Licensed Practical Nurse (LPN) #3. There were 11 Health Line Secondary Intravenous (IV) tubing with the expiration date of 1/2/2021 located in a box of assorted IV tubing, starter kits, and saline flushes. 2. On 3/10/2021 at 11:02 a.m., the Director of Nursing was asked, How often is the supply inventory in the Medication Storage Room checked for expired items? She stated, I do not know. I have only been here approximately 3 weeks. She was asked, Are you supposed to use expired tubing? She stated, Absolutely not. She was asked, Does the facility currently have any residents on IV therapy? She stated, No. 3. On 3/10/2021 at 11:11 a.m., Registered Nurse (RN) #4 was asked, How long have you worked here? She stated, It will be a year in April (April 2021). She was asked, How often is the supply inventory in the Medication Storage Room checked for expired items? She stated, The Pharmacy Technician checks stuff every month. The nurses check their carts (Medication Carts) daily or weekly. She was asked, So inventory like IV flushes and tubing is checked daily? She stated, No. That is checked monthly unless we have a resident on IV fluids, then we check it daily or check it before we use it. The IV tubing is changed every 24 hours. She was asked, Are there any residents currently on IV therapy? RN #4 stated No. 4. A facility policy titled Storage of Medications provided by the Minimum Data Set (MDS) Coordinator on 3/11/2021 at 11:20 a.m. documented, .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals . All such drugs shall be returned to the dispensing pharmacy or destroyed .

Based on observation, record review, and interview, the facility failed to ensure a resident's preference to smoke was honored and the resident was provided the opportunity and assistance for scheduled smoke times to convey respect and maintain dignity for 1 (Resident #4) of 3 (Residents #4, #29, and #43) sampled residents who smoked. This failed practice had the potential to affect 3 residents who resided in the facility and chose to smoke, according to a list provided by the Administrator on 3/8/2021. The findings are: Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 10/22/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status); required set up and supervision with bed mobility, transfer, eating, personal hygiene, and toilet use; required limited one-person assistance with dressing; and did not contain information on tobacco use. a. A Smoking assessment dated [DATE] documented the resident was able to safely smoke with supervision and with preferences to smoke Morning, Afternoon, Evenings, and Nights. b. A Care Plan dated 11/23/2020 documented, .Focus . The resident is a smoker Intervention . Instruct resident about the facility policy on smoking . locations, times, safety concerns The resident requires Supervision while smoking . Focus . No discharge anticipated . plans are for long term care . Goal . The resident and / or family will receive the support needed for successful transition into long term care . Interventions . Honor the resident's customary routine for . preferred activities, bathing, dressing, snacks, going to bed / getting up in the morning, etc (et cetera / and so on) . c. The Annual Minimum Data Set with an Assessment Reference date of 1/19/2021 documented the resident did not use tobacco. d. On 3/8/2021 at 12:05 p.m., Resident #4 was walking in hallway on the locked Memory Care Unit and requesting to be taken out to smoke. Certified Nursing Assistant (CNA) #2 told the resident she could not go to smoke until after lunch. Licensed Practical Nurse (LPN) #2 was asked if the resident went out during regular smoke times. LPN #2 stated, They take (Resident) when she asks. CNA #2 stated, She is the only one on the Unit who smokes, and we take her out when she asks if we can. LPN #2 stated, We don't take her out during smoke hours. She stopped smoking for a while and now started again so asking is like encouraging her. We are using the power of suggestion of not asking. e. On 3/9/2021 at 9:09 a.m., CNA #3 was asked where the resident was. CNA #3 stated, The resident is outside with the CNA and nurse smoking. Resident #4 was outside smoking with CNA #2 and the Director of Nursing. f. On 3/10/2021 at 2:31 p.m., CNA #5 was asked what the smoking times were for the residents. CNA #5 stated, I believe they are 9:30 a.m., 10:30 a.m., 1:30 p.m., 4:30 p.m., and 7:30 p.m. CNA #5 was asked if there were any smokers on the Memory Unit. CNA #5 stated, (Resident #4) smokes. CNA #5 was asked if the resident is taken out during regular smoke times, or if she has to ask to go out. CNA #5 stated, We ask her if she wants to go out with the nurse to smoke and she tells us if she wants to go out or not. CNA #5 was asked if the resident refuses to go out during regular smoking times. CNA #5 stated, No. She is trying to quit so she is on and off about it. g. On 3/10/2021 at 2:58 p.m., the Director of Nursing (DON) was asked what the smoking times are for residents. The DON stated, (Resident #4) is the first smoker back there. That is the question I was wondering yesterday, or if it is different back there, and I am not sure. The DON was asked if staff should wait for a resident to ask to go out to smoke or be taken out during the scheduled smoking times. The DON stated, They should be taken out when they know it is smoke time. They should be offering that resident to go out to smoke. The DON was asked if staff should refuse to take a resident out to smoke when a resident asked, and they have not been taken out during a scheduled smoke break. The DON stated, No. h. A list of the resident smoking times provided by the Administrator on 3/12/2021 documented the scheduled smoking times as follows: 9:30 a.m. through 9:45 a.m.; 11:30 a.m. through 11:45 a.m.; 2:15 p.m. through 2:30 p.m.; 4:45 p.m. through 5:00 p.m.; 6:45 p.m. through 7:00 p.m.; and 9:00 p.m. through 9:15 p.m. i. A facility policy titled Smoking Policy - Residents provided by the Minimum Data Set Coordinator on 3/11/2020 documented, .1 .Residents shall be informed of the smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences .

Based on observation, record review, and interview the facility failed to ensure call lights were kept within residents' reach and were accessible to allow residents to summon assistance to accommodate their individual care needs for 1 (Resident #52) of 23 (Residents #52, #38, #18, #5, #33, #19, #3, #32, #9, #23, #34, #13, #4, #16, #11, #47, #104, #37, #29, #12, #36, #51, and #31) sampled residents who were dependent on staff assistance and were capable of utilizing the call light system. This failed practice had the potential to affect 39 residents who were dependent on staff assistance and capable of utilizing the call light system, according to the list provided by the Administrator on 3/12/2021. The findings are: Resident #52 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/23/2021 documented the resident scored 12 (8-12 indicates moderately impaired) on a Brief Mental Status (BIMS); was totally dependent with one-person assistance for bathing; required extensive two-person assistance for bed mobility, transfer, dressing and toilet use; required extensive one-person assistance for locomotion and personal hygiene; was always incontinent of bladder; and was continent of bowel with an ostomy. a. The Care Plan with a revised date of 7/10/2020 documented, .The resident is (Specify High, Moderate, Low) risk for falls r/t (related to) . Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . The resident needs prompt response to all requests for assistance . The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to)[MEDICAL CONDITION], Heart Failure, Kidney Failure, Hx (History of) [MEDICAL CONDITION], Weakness, Unsteady Gait . Encourage the resident to use bell to call for assistance . The resident has an alteration in musculoskeletal status (Specify) r/t (related to) . Anticipate and meet needs . Be sure call light is within reach and respond promptly to all requests for assistance . c. On 3/9/2021 at 9:33 a.m., Resident #52 was lying in bed with the call light clipped to the top left of the bedsheet. (The Surveyor took a photograph of the call light at this time.) While the Surveyor was talking to the resident, he was not moving his left arm. The resident was asked if he could move his left arm. The resident stated, I can, but not very well. The resident was asked if he could reach his call light. The resident reached across his body with his right arm and stated, I don't even know where it is, but no, I can't reach it. d. On 3/10/2021 at 9:35 a.m., Resident #52 was lying in bed. The resident was asked, Can you reach your call light? The resident stated, I'm not even sure where it is. He looked down under his cover and stated, Oh, here it is. The resident was asked, Can you reach it to call if you need help? The resident stated, Yes. e. On 3/10/2021 at 2:05 p.m., Certified Nursing Assistant (CNA) #4 was asked, How does (Resident #52) let someone know when he needs assistance? CNA #4 stated, He uses his call light; or he hollers. f. On 3/10/2021 at 10:43 a.m., Licensed Practical Nurse (LPN) #3 was asked, Should the call lights be within a resident's reach? She stated, Yes. g. On 3/12/2021 at 8:35 a.m., the Director of Nursing ((DON) was asked, How important is it for the residents to be able to reach their call lights? She stated, Oh my gosh! Very important. The DON was asked, Why is it so important? The DON stated, So they can get help. The DON was asked, Should the residents be reminded where the call light is and to use it when they need help? She stated, Yes. h. A facility policy titled Admitting the Resident: Role of the Nursing Assistant provided by the Nurse Consultant On 3/10/2021 at 2:37 p.m., documented, .Steps in the Procedure . 7. Demonstrate the use of the nurses' call signal . Place the call light within easy reach of the resident .

Complaint # (AR 476) was substantiated, all or in part, in these findings: Based on observation, record review and interview, the facility failed to ensure the transport van's wheelchair restraints were securely and properly applied to a resident's wheelchair prior to transport in the van, which resulted in the resident tipping over backward in his wheelchair and hitting his head, for 1 (Resident #1) of 5 (Residents #1 through #5) case mix residents who required wheelchairs for transport in the facility van. This failed practice resulted in past non-compliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Resident #1, who suffered an intraventricular hemorrhage as a result of the van incident, and had the potential to cause more than minimal harm to 24 residents who required wheelchair transport, as documented on a list provided by the Administrator on 9/13/17 at 10:32 a.m. The Administrator was informed of the past immediate jeopardy condition on 9/13/17 at 9:40 a.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) with an assessment reference date of 8/23/17 documented the resident scored 12 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required limited assistance of 1 person for transfers, had functional limitation in range of motion of both lower extremities, did not ambulate, and used a wheelchair for mobility. a. An Incident and Accident Report dated 9/5/17 at 3:24 p.m. documented, .On 9/5/17 at approximately 3:24 p.m., CNA (Certified Nursing Assistant #1) was transporting (Resident #1) from a doctor's appointment when she pulled out of the parking lot of the clinic onto the highway, (Resident #1's) wheelchair tipped backward causing him to hit his head on the van floor. CNA called 911 and resident was transported to the emergency room at (Hospital #1) by EMS (Emergency Medical Services) . Conclusion: Based on the investigation it was determined that the Q'Straints and the tracks were in proper working condition and (CNA #1) failed to ensure that the two front securing devices were completely taut . Per (CNA#1's) witness statement: 'I put (Resident #1) in the van after his doctor's appointment. I locked the wheelchair and put the front straps on his chair, then I put the seatbelt on him and then I went to the back and put the lock straps on the back of his chair . Actions taken: (CNA #1) was suspended pending investigation . Transport van was taken out of commission until it could be inspected by (Mobility Company) . (CNA #1) was terminated on 9/11/17, due to failure to ensure that the two front securing devices were not securely taut. Based on the Q'Straint manufacturer's instructions at paragraph f. 6). below, all 4 tie-down straps were to be secured to the wheelchair prior to applying the seat belt and shoulder belt to secure the resident in the wheelchair. CNA #1's statement also did not address whether the shoulder belt was applied on the date of the incident. b. A Radiology Report dated 9/5/17 at 4:44 p.m. documented, .CT (Computed Tomography) Head without contrast . CT Brain . This is an 81 y/o (year old) patient was in a transport van and the wheelchair flipped backwards and he hit his head inside the vehicle . 5 mm (millimeter) Axial imaging was obtained from the base of the skull to the vertex without contrast and with bone windows . OPINION: Large intraventricular and parenchymal hemorrhage right cerebral hemisphere with 8 mm right to left shift . c. Hospital records from Hospital #2 documented the resident was transferred to that hospital and placed on life-sustaining support, then on 9/8/17, the resident was removed from life-sustaining support, as per the family members' wishes and was pronounced dead on 9/8/17 at 4:39 p.m. d. On 9/12/17, the facility's training of van transport staff was reviewed, with the following findings: 1.) A letter dated 6/27/17, from the Q'Straint Representative to the facility, documented, An in-service training was conducted on this date. The following attendees were trained in the proper use and operation of the wheelchair lift and tie-down restraints: (Administrator), (Maintenance) and (CNA #1). The letter was signed by the Q'Straint Representative. 2.) A Van Transport In-service form dated 7/10/17 documented, Watched video. This form was signed by 4 employees assigned to transport duty. CNA #1's signature was not documented on this form. 3.) On 9/12/17 at 3:51 p.m., the Maintenance Supervisor was asked about the facility's van restraint training that was conducted prior to the 9/5/17 incident involving Resident #1 and stated, .When I started last year, (previous transport aide) was the one transporting then, and she showed me (how to apply the van's wheelchair restraints), and we had these in-services; we would go to the van and strap each other into the straps. We did that every six months. He was asked, So every time you did an in-service, there was visual verification of staff competency? He stated, Yeah . e. On 9/13/17 at 8:35 a.m., Q'Straint Representative #1 was asked, If the transport aide performed all of the (van wheelchair restraint application) steps correctly, is there any way that a wheelchair could have tipped backward? He stated, In this case, the 2 front points would have had to fail at the same time for the wheelchair to fall backward, which is unheard of and highly unlikely. More often than not, I hate to say this, but it is operator error. He was asked, Are you familiar with (CNA #1)? He stated, I cannot picture her face, but let me look her up. Yes, she was trained on 6/27/17 in (city name). It was a very thorough training, and she was competent to use the equipment, based on this training she received that day. The actual van was brought from the facility, and the training was performed on that equipment; it was in good repair and functioning properly at that time. f. The facility removed the immediate jeopardy and corrected the failed practices on 9/6/17, prior to the survey, as evidenced by the following: 1.) The facility's written corrective action plan dated 9/6/17 documented the following corrective actions, which were confirmed by the surveyor as completed: All staff members who will be driving the facility van will have a valid driver's license and approved driving record. All staff members who will be driving the facility van or assisting during transport will be trained per manufacturer's guidelines/operator training video and facility checklist. The facility will maintain employee competency check-offs for van drivers and assistants. The facility will maintain a current list of employees who have been trained to drive the facility van and to assist the transportation. The transportation aide will perform a pre-transport documented inspection daily, per facility checklist, prior to first transport x (times) 14 days . After 14 days daily check-off, transport aide will perform a pre-transport visual inspection daily. The inspection check list will be signed after completion of inspection daily and given to the Maintenance Supervisor to maintain for record of inspection x 14 days. Maintenance will perform a quarterly inspection of the facility van for safety and proper functioning of all equipment and prn (as needed). All incidents/accidents will immediately be reported to the Administrator and Director of Nursing. Incidents/accidents will be investigated and an incident report completed and a Red Alert will be sent to the risk management team. All staff members who will be participating in transports will be trained per manufacturer's guidelines on safety restraint system. 2.) A Van Transport in-service form dated 9/7/17 documented the 4 current van transport employees were retrained on the van's safety devices. 3.) A 6-month vehicle wheelchair lift maintenance inspection form dated 9/7/17 documented a van inspection was conducted by the licensed mobility equipment company and, Found all seat belt and tie down plates retractors to be in satisfactory condition. 4.) On 9/12/17 at 3:51 p.m., the Maintenance Supervisor was asked, What kind of routine monitoring is in place, now? He stated, Since the incident, all staff that are approved to drive were educated with return demonstration on 9/7/17, and they had to watch the training video and do return demonstrations. He was asked, How often are the return demonstrations going to be conducted? He stated the return demonstrations would be conducted daily for 14 days, then every 6 months thereafter. 5.) Resident Council Minutes, Grievance Logs and Incident / Accident information dated June 2017 through September 2017 were reviewed. There was no documentation of any other incidents or resident injuries related to van transports for Residents #2 through #5, or any other resident in the facility. 6.) The Q'Straint manufacturer's instruction sheet documented, A. Secure wheelchair. 1. Place wheelchair facing forward in securement area; apply wheel locks . 2. Attach the four tie-downs into floor anchorages and ensure they are locked in. 3. Attach the four tie-down hooks to solid frame members or weldments, near seat level. Ensure tie-downs are fixed at approximately 45 degrees, and are within angles shown in (Figure 2). Do not attach hooks to wheels, plastic, or removable parts of wheelchair . Warning: Do not allow webbing to get twisted inside retractors . Wheelchair accessories and equipment should be properly secured or removed from wheelchair and secured in the vehicle during transportation . Whenever possible, items attached to wheelchair in front of the passenger should be removed and secured separately during transportation . B. Secure passenger. 1. Attach lap belts - Use integrated stiffeners to feed belts through openings between seat backs and bottoms, and / or armrests to ensure proper belt fit around occupant . i.) On 9/12/17 at 4:53 p.m., the facility van returned from transport. The non-case mix resident currently being transported had the wheelchair locked with all 4 points of the anchoring system in place and correctly applied, per the manufacturer's instructions. ii.) On 9/12/17 at 5:00 p.m., the Maintenance Supervisor and CNA #2 (the only transport staff available at this time) performed a simulation of loading a resident in a wheelchair into the van and securing the wheelchair. Both staff members correctly applied and secured the restraints, per the manufacturer's instructions.

Complaint # was substantiated (all or in part) with these findings Based on record review and interview, the facility failed to ensure necessary care and services were provided for Resident #1 to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The facility failed to ensure a thorough assessment and frequent monitoring was provided and documented after identification of a change in mental and physical status and a significant decrease in fluid intake and that the physician was immediately consulted to determine if further services were needed to prevent a delay in [DIAGNOSES REDACTED]. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who was admitted to the hospital with [REDACTED]. The facility was informed of the Immediate Jeopardy on 2/14/13 at 1:19 p.m. The findings are: 1. The facility's policy titled "Condition Change, of the Resident (Observing, Recording and Reporting)" procedure received from the DON 2/15/13 at 9:46 a.m. documented the following: a. Purpose: To observe, record and report any condition change to the attending physician so proper treatment will be implemented. b. Procedure: 1. After all resident falls, injuries or changes in physical or mental function, monitor the following: ...f. Observe for alterations in consciousness, g. Observe for incontinence,...h. Observe for sensory weakness, i. Observe for general weakness, ...j. observe for gait, posture or balance disorder,...m. Observe for proper reflexes (response to painful stimuli), n. Take vital signs and include temperature, ...r. Observe for dyspnea or variations in respirations (irregular)... 2. Have someone stay with the resident while the nurse is calling the attending physician, if necessary... 5. Monitor the resident's condition frequently until stable. 2. Resident #1 was admitted [DATE], with Diabetes Mellitus Type II, Hypertension, [MEDICAL CONDITIONS] Joint Disease, Dementia, Depression and Anxiety. An Admission Minimum Data Set (MDS) with an assessment reference date of 6/29/12 documented the resident scored 4 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS); scored 9 (5-9 indicates mild depression) on the resident mood interview; required extensive assistance in bed mobility, transfers, locomotion, toilet use, and bathing; required limited assistance in dressing and personal hygiene; required supervision for eating, was occasionally incontinent of urine and continent of bowel; had a swallowing disorder; and required a therapeutic diet. The Quarterly MDS with an assessment reference date of 11/6/12, documented the resident scored 3 (0-7 indicates severely impaired) on the BIMS; scored 9 (5-9 indicates mild depression) on the resident mood interview; was totally dependent on staff for bed mobility, transfers, locomotion, dressing, toilet use, bathing, required extensive assistance for eating, and was frequently incontinent of bowel and bladder; had a swallowing disorder; and required a mechanically altered therapeutic diet. a. The January 2013 Intake sheet documented the resident drank a total of 600 cubic centimeters (cc) on the 23rd and 900cc on the 22nd of January. b. A Nurses Note dated 1/24/13 at 12:55 p.m. documented, "V/S (vital signs) - (Temperature)100.0 - P (pulse) 98- R (respiration)48- (blood pressure) 50/40. Resp (Respiration) even but labored. SOB (Shortness of Breath) noted. O2 Sat (Oxygen Saturation) @ (at) 83%. Applied O2 at 2L (liters) per NC (Nasal Cannula). Resident keeping left eye closed, right eye barely open, pupil fixated. Resident has not voided last night or this shift. Resident not eating or drinking, was able to get meds down after multiple attempts. (Advance Practice Nurse Name) was here making rounds, let him know what was going on. Said to transfer to ER (emergency room ) for mental status change. Resident left facility at 12:50 p.m. There was no documented assessments of the residents condition in the Nurses Notes prior to 1/24/13. The Nurses Notes prior to this one was dated 1/17/13 at 1:35 p.m. A physician progress notes [REDACTED]. Patient lethargic, pocketing food. Patient acutely ill status not stable transporting to ER." c. Nurses Notes dated 1/24/13 at 6:00 p.m., documented the resident was admitted to hospital ICU (Intensive Care Unit) with a [DIAGNOSES REDACTED]." The Hospital History and Physical dated 1/24/13 (no time) documented the resident was transferred to the ER for decreased mental status which was a fairly acute onset within the last day or two, had no urine output and would not open his eyes according to the nursing home. d. The Advanced Practice Nurse and facility staff were interviewed regarding the resident's condition prior to transfer to emergency room : 1). On 2/14/13 at 9:51 a.m., Licensed Practical Nurse #1 (LPN#1) was interviewed and asked what happened with (Resident #1) the day resident was sent to hospital (1/24/13). LPN #1 stated, "I came on that morning. It took a lot of encouragement to get him to take medication. I crushed them and put them in pudding and got some down. Noon med pass there was a noticeable difference in appearance, right side of face was drooping any fluid put in mouth just dribbled out, audible wheezing. Doctor was here making rounds and I went and got him and told him how resident was and he said to send to ER for mental status change. The LPN was asked if the Certified Nurse Assistant (CNA) let her know that he had not drank or ate that morning. LPN #1 stated, Yes, she did and that the day before (1/23/13) that he wasn't eating either that they had reported it the day before. The LPN was asked who informed her that the resident had not voided on day shift. The LPN stated, "I think (CNA #1) and (CNA #2) said the resident hadn't as well on their shift the day before." The LPN stated that they (indicating the CNA staff) had mentioned it to the nurse on the day before on day shift. The LPN stated that they, indicating the LPN staff, worked 12 hour shifts. The LPN also stated that they (indicating the CNA staff) had reported it to the day nurse that the resident was not right and the resident had not voided. At 10:50 a.m., LPN #1 was asked, "When you knew you had difficulty with the medications and knew that the resident had not voided, why did you not call the physician." LPN #1 stated, "I knew he was going to be here at facility at 9:00 a.m. or so." The LPN was asked, "When did you talk to the doctor." The LPN stated, "It was about 11:00 a.m. after I gave morning medications." The LPN was asked what if the physician was not making rounds. LPN #1 stated, "I would have called him that morning after trying to give (resident) the medicine but, I knew he would be in; in a couple of hours." The LPN was asked how she found out the resident had not voided on the night shift. LPN #1 stated, "The day NA (Nurse Assistant) mentioned to me that she had heard he had not voided on night shift. The LPN was asked, "Is it the facility practice to wait if doctor is making rounds." LPN #1 stated, "No, that's not the facility practice. If he had been in distress or B/P (Blood Pressure) had dropped I would have called. That morning he was drooping on left side of mouth and at noon it was worse." 2) On 2/14/13 at 8:48 a.m., CNA #1was asked if she took care of (Resident #1) on 1/24/13. CNA #1 stated, "Yes, I worked the day the resident went to the hospital." CNA #1 was asked what occurred the morning the resident went to the hospital. The CNA stated, "Couldn't get (resident) to eat or drink anything, waited a little, offered again would not take anything, went back again and he still refused to eat or drink. The nurse was passing meds and I reported it to her that he refused to eat or drink. I took him over to the day room." The CNA was asked if the resident responded to her. The CNA stated, "Yeah, told me no when I tried to give him food or fluids. Later he had a weird gurgle like sound in his throat. I reported it to the nurse and she said to get (resident's) vital signs. I had another nurse recheck his blood pressure because it was so low, she checked his pulse ox it was low, they got oxygen and shipped him out." On 2/15/13 at 9:30 a.m., CNA #1 was asked if she told LPN #1 that the resident had not voided on night shift. CNA #1 stated, "Yes, they (indicating told me he had not voided that night." The CNA was asked when she told LPN #1. CNA #1 stated, "When she was counting medications at shift change that morning. The CNA was asked, "Did the LPN give you any instructions." CNA #1 stated, "No." 3) On 2/14/13 at 11:34 a.m., CNA #3 was asked what she remembered about the resident the day the resident went to the hospital on [DATE]. CNA #3 stated, "(Resident #1) was acting funny that day, different from his normal self and I reported that. (Resident #1) drank the 10:00 a.m. snack just fine but (Resident #1) would not drink that morning. At lunch he was spitting food out and not drinking. Told the nurse, it was either during or after lunch. I told the nurse he was not acting like himself more than earlier. Then he was sent out." The CNA was asked if the resident was different than normal that morning. CNA #3 stated, "(Resident #1) was different from when I saw him last, I had 2 days off." 4) On 2/14/13 at 1:45 p.m., LPN # 2 was asked, "Did the day nurse come to you and tell you about (Resident #1) on the 24th of January. LPN #2 stated, "No." LPN #2 was asked, "When did you find out anything about (Resident #1) on the 24th." The LPN stated, "We (Advanced Practice Nurse) finishing up on rounds and (LPN #1) stopped by with her medication cart at the desk (nursing station) and said 'you know I think there is something going on with (Resident's #1), he is different.' The APN said 'mental status change?' She (LPN #1) said 'yeah.' (APN) said 'send him to the hospital now.' She (LPN #1) said 'you mean I can send him on mental status change.' (APN) told her that 'you better send anybody with a mental status change to the hospital.' The residents were eating lunch I don't know exact time. I helped her get papers together and we transferred him from the Broda chair to the gurney at the nursing station." LPN #2 was asked when were the vital signs obtained. LPN #2 stated, "The CNAs got the vitals signs while we got the papers together." LPN #2 was asked did anyone assess the resident. The LPN stated, "Yeah, me and (DON) were looking at him after she got the order to transport him. That was the first we knew anything." LPN #2 was asked, "When you and the DON looked at the resident what did you find." The LPN #2 stated, "(Resident) wasn't breathing well, like he might be taking his last breath any moment. (Resident) was cold, eyes were shut, we put O2 on him. (Resident) was a grayish color." 5) On 2/14/13 at 11:12 a.m. the APN was asked, "Who was here at facility making rounds on Thursday the 24th." The APN stated, "I can assure you that it was me. This is (Physician) month and we do not come on the same day." The APN was asked how often she came to the facility. The APN stated, "Once a week every Thursday." The APN was asked when she was informed about (Resident #1). The APN stated, "It was toward the end of my rounds about 11:30 or 12:00." The APN was asked what he was told concerning (Resident #1) on the 24th. The APN stated, "(LPN #1) said (resident) was lethargic, pocketing food, just didn't seem like his normal self-leaning to one side I think that is also what they said." The APN was asked, "Did they talk to you about resident prior to this." The APN stated, "No." 6) On 2/13/13 at 3:21 p.m., the DON was asked if there was any documentation concerning the resident for 1/22/13 or 1/23/13. The DON stated, "No, even on the 24 hour report sheets there was nothing documented leading up to transfer to hospital." On 2/14/13 at 10:47 a.m., the DON stated, "To know (the resident) face was drooping and he had not voided (the nurse) should have been on the phone calling the doctor. On 2/15/13 at 11:41 a.m., the DON was asked, "What did you observe the morning of the 24th on (Resident #1)." The DON stated, "Lethargic, Short of Breath, mottling to feet, pulse ox was low, non-responsive, and eyes closed. By the time I was notified of his change we were getting him transferred." 3. The Immediate Jeopardy was removed on 2/14/13 at 4:40 p.m. and scope and severity to an "E" when the facility implemented the following Plan of Removal: a. Upon discovery of new information on 2/14/13 at approximately 11:00 a.m., the facility Administrator, (name), completed DHS (Department of Human Services) -7734 forms and faxed to OLTC (Office of Long Term Care) to report neglect. Administrator discovered that a facility LPN had self-reported, via telephone conversation to OLTC surveyor, that she had noticed facial drooping on a male resident and did not notify the attending physician. Upon discovery, this LPN (name), was terminated. b. On 2/14/13 at approximately 11:00 a.m., Facility Director of Nursing, or Designee, began to inservice all staff, currently in the facility, with special emphasis to licensed nursing employees, to immediately report any resident change of condition to physician and Director of Nursing. Staff inservice included that licensed nurses are to also do an assessment and continue monitoring of residents change of condition. c. Director of Nursing or Designee, will also inservice all other employees, on this same information before starting to work on their shift. d. Director of Nursing or Designee will continue this process, for each oncoming shift until all employees are inserviced on this matter. e. On 2/14/13 at approximately 2:00 p.m., the Director of Nursing, LPN charge nurses and Nurse Consultant began assessing all residents with the potential to be at risk for this failed practice. Any resident identified to be at risk will be assessed for any changes and reported to the physician immediately for appropriate intervention. f. Director of Nursing or Designee will conduct observation rounds on residents daily for four weeks, then five times a week for three weeks to monitor and to identify any resident noted to have a change of condition. Any identified residents will be assessed for any changes and reported to the physician immediately for appropriate intervention.

Complaint # was substantiated (all or in part) with these findings Based on record review and interview, the facility failed to ensure the physician was immediately consulted to prevent a delay in [DIAGNOSES REDACTED].#1) of 1 case mix resident who had significant changes in condition. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who was admitted to the hospital with [REDACTED]. The facility was informed of the Immediate Jeopardy on 2/14/13 at 1:19 p.m. The findings are: 1. The facility's policy titled "Condition Change, of the Resident (Observing, Recording and Reporting)" procedure received from the DON 2/15/13 at 9:46 a.m. documented the following: a. Purpose: To observe, record and report any condition change to the attending physician so proper treatment will be implemented. b. Procedure: 1. After all resident falls, injuries or changes in physical or mental function, monitor the following: ...f. Observe for alterations in consciousness, g. Observe for incontinence,...h. Observe for sensory weakness, i. Observe for general weakness, ...j. observe for gait, posture or balance disorder,...m. Observe for proper reflexes (response to painful stimuli), n. Take vital signs and include temperature, ...r. Observe for dyspnea or variations in respirations (irregular)... 2. Have someone stay with the resident while the nurse is calling the attending physician, if necessary... 5. Monitor the resident's condition frequently until stable. 2. Resident #1 was admitted [DATE], with Diabetes Mellitus Type II, Hypertension, [MEDICAL CONDITIONS] Joint Disease, Dementia, Depression and Anxiety. An Admission Minimum Data Set (MDS) with an assessment reference date of 6/29/12 documented the resident scored 4 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS); scored 9 (5-9 indicates mild depression) on the resident mood interview; required extensive assistance in bed mobility, transfers, locomotion, toilet use, and bathing; required limited assistance in dressing and personal hygiene; required supervision for eating, was occasionally incontinent of urine and continent of bowel; had a swallowing disorder; and required a therapeutic diet. The Quarterly MDS with an assessment reference date of 11/6/12, documented the resident scored 3 (0-7 indicates severely impaired) on the BIMS; scored 9 (5-9 indicates mild depression) on the resident mood interview; was totally dependent on staff for bed mobility, transfers, locomotion, dressing, toilet use, bathing, required extensive assistance for eating, and was frequently incontinent of bowel and bladder; had a swallowing disorder; and required a mechanically altered therapeutic diet. a. The January 2013 Intake sheet documented the resident drank a total of 600 cubic centimeters (cc) on the 23rd and 900cc on the 22nd of January. b. A Nurses Note dated 1/24/13 at 12:55 p.m. documented, "V/S (vital signs) - (Temperature)100.0 - P (pulse) 98- R (respiration)48- (blood pressure) 50/40. Resp (Respiration) even but labored. SOB (Shortness of Breath) noted. O2 Sat (Oxygen Saturation) @ (at) 83%. Applied O2 at 2L (liters) per NC (Nasal Cannula). Resident keeping left eye closed, right eye barely open, pupil fixated. Resident has not voided last night or this shift. Resident not eating or drinking, was able to get meds down after multiple attempts. (Advance Practice Nurse Name) was here making rounds, let him know what was going on. Said to transfer to ER (emergency room ) for mental status change. Resident left facility at 12:50 p.m. A physician progress notes [REDACTED]. Patient lethargic, pocketing food. Patient acutely ill status not stable transporting to ER." c. Nurses Notes dated 1/24/13 at 6:00 p.m., documented the resident was admitted to hospital ICU (Intensive Care Unit) with a [DIAGNOSES REDACTED]." The Hospital History and Physical dated 1/24/13 (no time) documented the resident was transferred to the ER for decreased mental status which was a fairly acute onset within the last day or two, had no urine output and would not open his eyes according to the nursing home. d. The Advanced Practice Nurse and facility staff were interviewed regarding the resident's condition prior to transfer to emergency room : 1) On 2/14/13 at 9:51 a.m., Licensed Practical Nurse #1 (LPN#1) was interviewed and asked what happened with (Resident #1) the day resident was sent to hospital (1/24/13). LPN #1 stated, "I came on that morning. It took a lot of encouragement to get him to take medication. I crushed them and put them in pudding and got some down. Noon med pass there was a noticeable difference in appearance, right side of face was drooping any fluid put in mouth just dribbled out, audible wheezing. Doctor was here making rounds and I went and got him and told him how resident was and he said to send to ER for mental status change. The LPN was asked if the Certified Nurse Assistant (CNA) let her know that he had not drank or ate that morning. LPN #1 stated, Yes, she did and that the day before (1/23/13) that he wasn't eating either that they had reported it the day before. The LPN was asked who informed her that the resident had not voided on day shift. The LPN stated, "I think (CNA #1) and (CNA #2) said the resident hadn't as well on their shift the day before." The LPN stated that they (indicating the CNA staff) had mentioned it to the nurse on the day before on day shift. The LPN stated that they, indicating the LPN staff, worked 12 hour shifts. The LPN also stated that they (indicating the CNA staff) had reported it to the day nurse that the resident was not right and the resident had not voided. At 10:50 a.m., LPN #1 was asked, "When you knew you had difficulty with the medications and knew that the resident had not voided, why did you not call the physician." LPN #1 stated, "I knew he was going to be here at facility at 9:00 a.m. or so." The LPN was asked, "When did you talk to the doctor." The LPN stated, "It was about 11:00 a.m. after I gave morning medications." The LPN was asked what if the physician was not making rounds. LPN #1 stated, "I would have called him that morning after trying to give (resident) the medicine but, I knew he would be in; in a couple of hours." The LPN was asked how she found out the resident had not voided on the night shift. LPN #1 stated, "The day NA (Nurse Assistant) mentioned to me that she had heard he had not voided on night shift. The LPN was asked, "Is it the facility practice to wait if doctor is making rounds." LPN #1 stated, "No, that's not the facility practice. If he had been in distress or B/P (Blood Pressure) had dropped I would have called. That morning he was drooping on left side of mouth and at noon it was worse." 2) On 2/14/13 at 8:48 a.m., CNA #1was asked if she took care of (Resident #1) on 1/24/13. CNA #1 stated, "Yes, I worked the day the resident went to the hospital." CNA #1 was asked what occurred the morning the resident went to the hospital. The CNA stated, "Couldn't get (resident) to eat or drink anything, waited a little, offered again would not take anything, went back again and he still refused to eat or drink. The nurse was passing meds and I reported it to her that he refused to eat or drink. I took him over to the day room." The CNA was asked if the resident responded to her. The CNA stated, "Yeah, told me no when I tried to give him food or fluids. Later he had a weird gurgle like sound in his throat. I reported it to the nurse and she said to get (resident's) vital signs. I had another nurse recheck his blood pressure because it was so low, she checked his pulse ox it was low, they got oxygen and shipped him out." On 2/15/13 at 9:30 a.m., CNA #1 was asked if she told LPN #1 that the resident had not voided on night shift. CNA #1 stated, "Yes, they (indicating the previous shift, night shift, CNA's) told me he had not voided that night." The CNA was asked when she told LPN #1. CNA #1 stated, "When she was counting medications at shift change that morning. The CNA was asked, "Did the LPN give you any instructions." CNA #1 stated, "No." 3) On 2/14/13 at 11:34 a.m., CNA #3 was asked what she remembered about the resident the day the resident went to the hospital on [DATE]. CNA #3 stated, "(Resident #1) was acting funny that day, different from his normal self and I reported that. (Resident #1) drank the 10:00 a.m. snack just fine but (Resident #1) would not drink that morning. At lunch he was spitting food out and not drinking. Told the nurse, it was either during or after lunch. I told the nurse he was not acting like himself more than earlier. Then he was sent out." The CNA was asked if the resident was different than normal that morning. CNA #3 stated, "(Resident #1) was different from when I saw him last, I had 2 days off." 4) On 2/14/13 at 1:45 p.m., LPN # 2 was asked, "Did the day nurse come to you and tell you about (Resident #1) on the 24th of January. LPN #2 stated, "No." LPN #2 was asked, "When did you find out anything about (Resident #1) on the 24th." LPN #2 stated, "We (Advance Practice Nurse) were finishing up on rounds and (LPN #1) stopped by with her medication cart at the desk (nursing station) and said 'you know I think there is something going on with (Resident's #1), he is different.' The APN said 'mental status change?' She (LPN #1) said 'yeah.' (APN) said 'send him to the hospital now.' She (LPN #1) said 'you mean I can send him on mental status change.' (APN) told her that 'you better send anybody with a mental status change to the hospital.' The residents were eating lunch I don't know exact time. I helped her get papers together and we transferred him from the Broda chair to the gurney at the nursing station." LPN #2 was asked when were the vital signs obtained. LPN #2 stated, "The CNAs got the vitals signs while we got the papers together." LPN #2 was asked did anyone assess the resident. The LPN stated, "Yeah, me and (DON) were looking at him after she got the order to transport him. That was the first we knew anything." LPN #2 was asked, "When you and the DON looked at the resident what did you find." The LPN #2 stated, "(Resident) wasn't breathing well, like he might be taking his last breath any moment. (Resident) was cold, eyes were shut, we put O2 on him. (Resident) was a grayish color." 5) On 2/14/13 at 11:12 a.m. the APN was asked, "Who was here at facility making rounds on Thursday the 24th." The APN stated, "I can assure you that it was me. This is (Physician) month and we do not come on the same day." The APN was asked how often she came to the facility. The APN stated, "Once a week every Thursday." The APN was asked when she was informed about (Resident #1). The APN stated, "It was toward the end of my rounds about 11:30 or 12:00." The APN was asked what he was told concerning (Resident #1) on the 24th. The APN stated, "(LPN #1) said (resident) was lethargic, pocketing food, just didn't seem like his normal self-leaning to one side I think that is also what they said." The APN was asked, "Did they talk to you about resident prior to this." The APN stated, "No." 6) On 2/14/13 at 10:47 a.m., the DON stated, "To know (the resident) face was drooping and he had not voided (the nurse) should have been on the phone calling the doctor. On 2/15/13 at 11:41 a.m., the DON was asked, "What did you observe the morning of the 24th on (Resident #1)." The DON stated, "Lethargic, Short of Breath, mottling to feet, pulse ox was low, non-responsive, and eyes closed. By the time I was notified of his change we were getting him transferred." 3. The Immediate Jeopardy was removed on 2/14/13 at 4:40 p.m. and scope and severity to an "E" when the facility implemented the following Plan of Removal: a. Upon discovery of new information on 2/14/13 at approximately 11:00 a.m., the facility Administrator, (name), completed DHS (Department of Human Services) -7734 forms and faxed to OLTC (Office of Long Term Care) to report neglect. Administrator discovered that a facility LPN had self-reported, via telephone conversation to OLTC surveyor, that she had noticed facial drooping on a male resident and did not notify the attending physician. Upon discovery, this LPN (name), was terminated. b. On 2/14/13 at approximately 11:00 a.m., Facility Director of Nursing, or Designee, began to inservice all staff, currently in the facility, with special emphasis to licensed nursing employees, to immediately report any resident change of condition to physician and Director of Nursing. Staff inservice included that licensed nurses are to also do an assessment and continue monitoring of residents change of condition. c. Director of Nursing or Designee, will also inservice all other employees, on this same information before starting to work on their shift. d. Director of Nursing or Designee will continue this process, for each oncoming shift until all employees are inserviced on this matter. e. On 2/14/13 at approximately 2:00 p.m., the Director of Nursing, LPN charge nurses and Nurse Consultant began assessing all residents with the potential to be at risk for this failed practice. Any resident identified to be at risk will be assessed for any changes and reported to the physician immediately for appropriate intervention. f. Director of Nursing or Designee will conduct observation rounds on residents daily for four weeks, then five times a week for three weeks to monitor and to identify any resident noted to have a change of condition. Any identified residents will be assessed for any changes and reported to the physician immediately for appropriate intervention.

Complaint # was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure two-person transfer assistance was provided in accordance with the plan of care to reduce the risk of accident/injury for 1 (Resident #2) of 2 (Resident #1 and #2) case mix residents who required two-person physical assistance for transfers. This failed practice resulted in actual harm to Resident #2 who sustained bilateral tibial plateau fractures and a right hip fracture at a previous repair site during an inappropriate transfer. The facility also failed to ensure all members of nursing staff were included in transfer-related training/inservices and that the competency of direct care staff with resident transfers was monitored after the incident occurred, to reduce the risk of further transfer-related injuries. The failed practices had the potential to cause more than minimal harm to 11 residents who required two-person assistance for transfers, according to a list provided by the Director of Nursing on 5/10/12 at 4:35 p.m. The findings are: Resident #2 had a [DIAGNOSES REDACTED]. The MDS also documented transfers did not occur in the 7 days preceding the assessment. a. The Plan of Care dated 12/5/11 documented, "Resident has ADL (Activities of Daily Living) Self-Care Deficit Needs assistance with (specify Self Performance) ...ext (extensive) (assistance) x (times) 2" for transfers ... " b. QA (Quality Assurance) Visual Symbols System received from the Administrator on 5/9/12 at 3:55 p.m. documented, "two person transfers with lift." b. The Falls Investigation Worksheet dated 5/3/12 documented, " ...activity at time of fall - assist to BR (bathroom) ... did resident require supervision with - yes, CNA (Certified Nursing Assistant #1) present... record of statement - Called to R (resident) bathroom; R (resident) lying in floor with CNA at side. R c/o (complained of) R (right) knee pain, guarding R (right) knee. States she 'can't move it.' Unable to determine ROM (range of motion). MD (Medical Doctor) notified. T.O. (telephone order) send to ER (emergency room ) to eval (evaluate) and tx (treat)... recommendations/interventions - Do not take R into BR (bathroom) until gait belt is in place and 2nd (second) CNA is in place to help her." 1.) On 5/10/12 at 9:15 a.m., CNA #1 stated, "On 5/3/12 around 4:45 a.m., I got (Resident #2) out of bed by myself using a gait belt because she was to leave at 5:30 a.m. for an eye doctor's appointment. I pushed her in her wheelchair to the nurse's station. Around 5:00 a.m., the transport aide arrived. The transport aide brought (Resident #2) to her room because the aide said (Resident #2) had to go to the bathroom. I took (Resident #2) to the bathroom by myself. I put the gait belt around her. I cleaned the toilet seat. I sat her on the toilet seat and I was going to talk to (Resident #2) and push the emergency light for someone to come and help me. About the time I went to hit the call light (Resident #2) grabbed the bar and stood up. I grabbed the gait belt which was around her and stood up. Within seconds her knees buckled. She was pinned between me, the bar and the wheelchair. Her knees were against the wall when she buckled. I shoved the wheelchair out of the way. I got behind her and my left knee was under her butt. She was kinda sitting on it. I let go of the gait belt and was holding her by her hips. Her knees were still against the wall. I slowly started stepping backwards and eased her to the floor. I went to the door and called for help. (Licensed Practical Nurse (LPN) #1) came." CNA #1 was asked "What type of assistance did (Resident #2) require?" CNA #1 stated, "Two assistants as far as I know." CNA #1 was asked, "Tell me your rationale for a one person assist out of bed." CNA #1 stated, "I was the only one on the hall." CNA #1 was asked, "If you were the only one on the hall, how did you expect assistance in the bathroom?" CNA #1 stated, "I was hoping either a nurse or aide would come." The Daily Staffing log received from the Director of Nursing on 5/10/12 was reviewed from 5/2/12 for all three shifts for 6:00 a.m. through 7:00 a.m. without negative findings. 2.) On 5/10/12 at 11:10 a.m., CNA #2 was asked about Resident#2's assistance with transfers. The CNA stated, "I took care of (Resident #2). She required assistance with transfers. She was a two-person assist with a gait belt. She could bear some weight. She could help pivot. She could take two steps at the best." 3.) On 5/10/12 at 11:15 a.m., CNA #3 was asked about Resident#2's assistance with transfers. The CNA stated, "I did take care of (Resident #2). She needed assistance with transfer. She needed two people with a gait belt. She could bear very little weight. She could only take a couple of steps with us bearing 25% or more of her weight. We had to assist her from bed to wheelchair, wheelchair to bed and wheelchair to commode. We always used a gait belt and there were two of us at all times. I could not have transferred her by myself for her safety, plus mine. c. The local hospital's Radiology Report dated 5/3/12 for the right knee documented, "There is soft tissue swelling with joint effusion of the suprapatellar bursa. Diffuse osteopenia, which lowers the sensitivity of this exam. Linear lucency at the proximal tibia, better visualized in the lateral view, which may represent non-displaced fracture. There is callous formation and also orthopedic hardware seen at visualized portions of the distal femur. In the frontal view, there is questionable linear lucency in the proximal fibula, which may represent a non-displaced fracture. Recommend follow up with CT or bone scan for further evaluation. (Attending Physician) was notified with the results on 5/3/12 at 8:50 a.m." 1.) The local hospital's Radiology Report dated 5/3/12 for the left knee documented, "There is a linear lucency in the proximal fibula, which may represent a non-displaced fracture. There is also disruption of the trabecular pattern at the tibial eminence, which may represent a non-displaced fracture. There is soft tissue swelling with joint effusion. There is a fluid level within the suprapatellar bursa. Diffuse osteopenia. There is metallic hardware identified at the visualized portion of the distal femur. (Attending Physician) was notified with the results on 5/3/12 at 9:50 a.m." 2.) The Nurse's Notes dated 5/3/12 at 9:30 a.m. documented, "R arrived back from (local hospital) ER via facility van. No new orders from ER. Fx (Fracture) noted to left tibia/fibula. No surgery needed per (Attending Physician's) orders and ER MD (Medical Doctor. Appt (Appointment) made with (Orthopedic Surgeon) for 5/9/12 at 1345 (1:45 p.m.) R and family aware. PRN (as needed) pain medication given per R request. O2 (Oxygen) at 3 liters per nc (nasal cannula). No s/s (signs or symptoms) of acute distress noted. CLWR (call light within reach). Will monitor." 3.) The Nurse ' s Notes dated 5/3/12 at 9:30 p.m. documented, "...No s/s (signs or symptoms) acute distress... Will cont (continue) to monitor." 4.) The Nurse's Notes dated 5/4/12 at 10:00 a.m. documented, "R c/o (complained of) pain LLE (left lower extremity), pain med (medicine) per orders at 9:00 a.m. No c/o at present..." 5.) The Nurse's Notes dated 5/4/12 at 3:00 p.m. documented, "RLE (right lower extremity) noted with edema, red and warm to touch. BP (blood pressure) 88/58, SPO2 (oxygen saturation) at 87% on 3 lpm (liters per minute) O2 via nc. Notified APN (Advanced Practice Nurse). Family at bedside and requests R be sent to (hospital). Rcvd (received) order to send to (hospital) ER. Ambulance notified." 6.) The hospital History and Physical dated 5/4/12 (not timed) documented, "...Apparently yesterday she fell in the nursing home and hurt her left leg. She was complaining of pain at that time so they took her to the emergency room and had x-rays done. Apparently was initially told there was no fracture. However, later in the day she began complaining of pain in her other leg and she started having increased swelling and redness in her right leg. She came to the emergency room this evening and had repeat studies and was found to have bilateral tibial plateau fractures and a right hip fracture at a previous repair site." The Assessment and plan documented, "1. Fall with multiple fractures. Consult Orthopedic surgery. 2. Provide pain control and keep her NPO (nothing by mouth) until they have evaluated her..." 7.) The Imagines Services Report dated 5/4/12 (not timed) of the three view x-ray of the bilateral knees documented, "Suspicion of an oblique fracture through the medial tibial plateau and a V-shaped fracture through the fibular head. Fat fluid level in the lateral projection. The fracture is further discussed in the CT (computed tomography) scan interpretation. The images of the left knee show osteoporosis. No evidence of acute fracture. Suspect tibial and fibular fractures, right." 8.) The Imagins Services Report dated 5/4/12 (not timed) of the CT of the right knee documented a conclusion of, "Inverted V-shaped fracture of the tibial plateau and tibial condyle of the right knee with slight depression of a fragment from the posterior medial aspect. Note also made of an inverted V-shaped fracture of the fibular head. 9.) The Imagins Services Report dated 5/4/12 (not timed) of the bilateral hips documented a conclusion of, "Previous internal fixation of femoral fracture, right." 10.) The Orthopedic Consultation dated 5/4/12 documented an impression of, "1. Mildly displaced bicondylar right tibial plateau fracture. 2. Old healed multiple right femoral fracture treated by (Orthopedic Surgeon) in the past." d. The facility's Inservice Record, provided by the Director of Nursing on 5/9/1, documented the following inservices were provided to staff after the incident involving Resident #2: 1) The 5/3/12 inservice record documented, "If a resident needs 2 assist for toileting, make sure both staff members are present and ready to help before taking the resident into the bathroom." The employee sign-in sheet for this inservice was not signed by CNA #1 to indicate she attended. The facility had a total of 52 Nursing Staff members, according to the attached sign in roster. A total of 30 Nursing Staff members signed the inservice sign-in sheet. 2.) The 5/8/12 inservice record documented, "Q.A. (Quality Assurance) visuals are located on the over bed lights of residents. They are to serve as reminders for the staff in providing the appropriate care and precautions for residents. There is a 'closet care plan' and a list of the Q.A. visuals inside each resident's closet. Staff must pay attention to closet care plans and Q.A. visuals as these will change at times due to changes in the resident's condition and needs." Twenty-seven of the facility's 52 Nursing Staff members signed the inservice log on this date. e. The Employee Timecard Report documented that CNA #1 worked 5/3/12 from 9:49 p.m. until 5/4/12 at 6:19 a.m. The Employee Termination Record documented CNA #1 was terminated on 5/8/12. The reason for termination was documented as, "Violated established company rule, broke policy and procedure and transferred a 2 person assist by yourself." f. On 5/10/12 at 2:18 p.m., CNA #4, who had been employed by the facility for approximately six months and has worked all three shifts, was asked, "Does anyone randomly monitor your transfers of residents?" CNA #4 stated, "No, I have not noticed anyone doing that." g. On 5/10/12 at 2:35 p.m., CNA #5, who had been employed by the facility approximately nine months and worked the 2:00 p.m. to 10:00 p.m. shift, was asked, "Does anyone randomly monitor your transfer of residents?" CNA #5 stated, "No, not the RN (Registered Nurse) or LPN (Licensed Practical Nurse)... not the Lead CNA." h. On 5/10/12 at 4:12p.m., the Director of Nursing was asked, "Does any management person randomly watch and compare transfers of residents related to their Minimum Data Set, Plan of Care and diagnoses?" The Director of Nursing stated, "No, not that I could say."