Every finding on record at Courtyard Rehabilitation and Health Center, LLC

Based on observation, interview, and record review, the facility failed to ensure food, including raw meat, was thawed, stored, and sealed properly to prevent a potential foodborne illness; to ensure expired food items were promptly removed from stock to reduce the risk of food-borne illness; to ensure prepared foods in the refrigerator were covered to prevent a potential foodborne illness; to ensure dietary staff washed their hands upon completion of a task and before starting another task; to ensure the meat slicer was cleaned after use; to ensure utensils placed in the clean utensil drawer and ready for use were clean and free of particles. These failed practices had the potential to affect 73 residents who received meals from 1 of 1 kitchen as documented on a list provided by the Administrator on [DATE]. The findings are: On [DATE] at 6:10 PM, during the initial tour of the kitchen the surveyor observed a plastic lock bag of raw chicken sitting on a shelf in the walk-in refrigerator that was not closed. The surveyor asked [NAME] #4 if the plastic lock k bag was closed securely. [NAME] #4 stated it was not sealed. The surveyor observed two boxes of thickened tea had expired on [DATE] sitting on a shelf in the walk-in refrigerator. One box had an open date of [DATE] and the second box had not been opened. The surveyor observed a stainless-steel container of white gravy sitting on a rack in the walk-in was not covered. [NAME] #4 stated the gravy was for breakfast the following morning and it should have been covered. On [DATE] at 6:20 PM, the surveyor observed a bag of frozen cookies and a bag of blueberry muffins not sealed in the walk-in freezer. [NAME] #4 sealed the cookies bag and placed the blueberry muffins in a plastic lock bag. On [DATE] at 6:40 PM, the surveyor asked [NAME] #4 who cleans the ice machine. [NAME] #4 stated any dietary staff could clean it. [NAME] #4 opened the ice machine and wiped the inside and the drop shield without washing hands or putting on a pair of gloves before performing the task. The surveyor asked [NAME] #4 what she should have done prior to getting into the ice machine. [NAME] #4 stated that she should have washed her hands. A review of the facility policy: Food and Nutrition Services, undated, showed Item IV Personal Hygiene - 1. Directs staff to wash hands carefully with soap and water .after handling . dirty dishes. The policy was given to the Survey Team, by the Nurse Consultant on [DATE] at 12:55 PM. A review of facility policy: Handwashing and Glove Usage in Food Service: undated showed Introduction: According to the Center for Disease Control and Prevention (DDC) hand washing is the single most important way to stop the spread of infection. Correct hand washing procedure must be continually monitored by Food Service managers. The policy also indicates when food handlers must wash their hands; Bullet point 13 - After touching anything else such as dirty equipment, work surfaces or cloths. and gloves should be changed before beginning a different task. The policy was given to the Survey Team by the Administrator on [DATE] at 9:49 AM. On [DATE] at 6:50 PM, the surveyor observed a small piece of pinkish substance lying on a meat slicer. The surveyor asked [NAME] #4 if the meat slicer had been used during the evening meal. [NAME] #4 stated it was not used for the evening meal but had been used to slicing ham at lunch. The surveyor asked [NAME] #4 what the pinkish substance was. [NAME] #4 thought it looked like ham. A review of the policy: Food and Nutrition Services, undated, showed VI: Proper food handling, item S. All food grinders, choppers, mixers, etc. should be cleaned, sanitized, dried, and reassembled after each use. The policy was given to the Survey Team, by the Nurse Consultant on [DATE] at 12:55 PM. On [DATE] at 6:55 PM, the surveyor observed a white particle lying inside a ladle in the utensil drawer, ready for use. On [DATE] at 7:00 PM, the surveyor observed the dishwasher being loaded and noticed the temperature log sheet did not have any temps logged for the lunch or dinner meals. Dietary Aide (DA) #5 and [NAME] #6 were rinsing dishes and loading them into the dish racks. The surveyor asked how you know the dishes were being sanitized. [NAME] #6 said they check it by running a dish cycle then we check the temperature and the strip Part Per Million (PPM). Then we log it on the log. She said they had run the dishwasher, and it was 140 degrees, and the strip was green. The surveyor asked DA#5 and [NAME] #6 to check the PPM on the dishwasher. [NAME] #6 proceeded to run the machine and placed the strip in the water holding in the bottom of the dishwasher. The strip did not change colors. [NAME] #6 checked two strips from the bottle sitting on top of the top of the dishwasher and then retrieved a third strip from a bottle in the manager's office. All 3 strips remained white. The Administrator was notified, and informed the surveyor that he would contact the facility chemical representative to be at the facility the next morning. The Administrator informed the surveyor the dishwasher would not be used until the problem was resolved and the staff would use the three compartments sink to wash the dishes. On [DATE] at 7:23 AM, the chemical representative was at the facility to work on the dishwasher. The chemical representative showed the surveyor the problem. The sanitizer hose was not placed in the sanitizer bucket correctly. He informed the surveyor that this was a low-temp machine and the temp had to be at 120 degrees with the sanitizer to sanitize the dishes. On [DATE] at 6:11 AM, the surveyor observed food had been placed on the steam table at 6:15 AM. The food on the steam table was not covered until 6:44 AM. The surveyor interviewed staff DA#7 and asked why it is important to cover food on the steam table. DA#7 stated, to keep flies off. On [DATE] at 6:30 AM, the surveyor observed two rolls of frozen ground beef sitting on a rolling cart in the kitchen. At 6:53 AM, [NAME] #8 placed the two rolls of ground beef in a sink and turned on the water and left the water running over the meat. At 7:00 AM, the surveyor observed the water that had been running over the two rolls of ground beef had been turned off. At 7:22 AM, DA #7 is observed turning the water on and leaving it running over the ground beef. The meat appeared to be frozen. A review of policy Food and Nutrition Services undated showed section V item F:Frozen foods must be thawed at refrigeration temperatures of 40 degrees or below or quick-thawed as part of the cooking process. The policy was given to the Survey Team, by the Nurse Consultant on [DATE] at 12:55 PM. On [DATE] at 7:07 AM, [NAME] #9 was observed holding the plate with her thumb on the food surface of the plates. [NAME] #9 positioned the plate on the serving tray and then placed food on the food surface of the plate. [NAME] #9 picked up two more plates in this manner. The surveyor brought this to the attention of [NAME] #8. At 7:13 AM, [NAME] #9 was observed picking up a divided plate by putting three fingers in one of the divided slots on the food surface of the plate and grasping the plate. A review of policy, Food and Nutrition Services, undated, showed VI Proper Food Handling, item N. Utensils cups, glasses and dishes must be handled in such a way as to avoid touching surfaces with which food or drink will come in contact . The policy was given to the Survey Team, by the Nurse Consultant on [DATE] at 12:55 PM. On [DATE] at 10:38 AM, Surveyor observed [NAME] #9 prepare pureed spaghetti with meat sauce. Upon [NAME] #9 completing the process, the surveyor observed the pureed spaghetti with meat sauce and noted it was gritty in appearance. The surveyor asked [NAME] #9 how the pureed spaghetti looked to her. [NAME] #9 poured the pureed spaghetti into a serving container and stated, It looks good. The surveyor then asked [NAME] #8 how the pureed spaghetti appeared to her. [NAME] #8 said it looks gritty and lumpy. [NAME] #8 instructed [NAME] #9 to puree the spaghetti again. [NAME] #9 pureed the spaghetti a second time and then poured it into the serving container. [NAME] #9 asked [NAME] #8 how it looked. [NAME] #8 told her to do it again and explained to [NAME] #9 that it had to be smooth like baby food. [NAME] #9 pureed the spaghetti a third time. On [DATE] at 10:50 AM, [NAME] #9 was observed going from preparing the pureed spaghetti to the storage drawer that contained clean tongs and other utensils. [NAME] #9 did not wash her hands between pureeing the spaghetti and putting her hand in the drawer of clean utensil drawer and retrieving a set of tongs.

Based on observations, interviews, record reviews and facility policy review, the facility failed to ensure that staff used appropriate infection control measures and donned the proper Personal Protective Equipment (PPE) during high-contact care for 1 (Resident #8) sampled resident. The finding include: According to Quarterly Minimum Data Set with the Assessment Reference date of 8/12/2024, Resident #8 had severely impaired cognition. Resident #8 was incontinent of bowel and bladder and had a feeding tube. A Care Plan (revision date 06/19/2024) revealed Resident #8 required Enhanced Barrier Precautions (AEB) related to percutaneous endoscopic gastrostomy (PEG) tube. On 08/26/24 at 7:00 PM, the Surveyor observed Certified Nursing Assistant (CNA) #1 and #2 provide incontinence care to Resident #8. The Surveyor observed CNA #1 and #2 put on gloves but did not put on a gown to provide care. The Surveyor observed CNA #1 touch clean items and items commonly used by staff and/or the resident with gloved hands that had been used to wipe urine and feces. On 08/26/24 at 7:15 PM, CNA #2 stated Resident #8 had a PEG tube and was on BP. CNA #2 stated gown and gloves should be worn when care is provided to Resident #8. Both CNA #1 and #2 confirmed the bed control remote, clean wipes, clean brief, call light, and bed side table were touched with dirty gloved hands. On 08/29/24 at 08:43 AM, the Director of Nursing (DON) stated a resident with a PEG tube would be on BP and staff should don gown and gloves when providing high-contact care to prevent an immunocompromised resident from getting an infection from another resident. The DON confirmed if staff touched bed control remote, clean wipes, clean brief, call light, and bed side table were touched with dirty gloved hands it was an infection control issue. A policy titled Enhanced Barrier Precautions dated 2022 noted Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents know to be colonized or infected with a [ Multi-Drug Resistant Organism] MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 4. High-contact resident care activities include: a. dressing b. bathing c. transferring d. providing hygiene e. changing linens f. changing brief or assisting with toileting g. device care or use: central lines, urinary catheter, feeding tubes, tracheostomy/ventilator tubes h. wound care: any skin opening requiring a dressing.

Based on observations, interviews and record reviews, the facility failed to ensure the call device was within reach for 2 (Resident #8 and #63) sampled residents. The findings include: 1. According to Quarterly Minimum Data Set with the Assessment Reference Date 8/12/2024 Resident #8 had memory problems. Resident #8 had impairment on one side. A Care Plan (revision date 11/22/2021) revealed Resident #8 was at risk for falls due to non-ambulatory and mechanical lift. Approach/task documented keep call light within reach On 08/26/24 at 6:34 PM, the Surveyor observed Resident #8 lying in bed and the call device on floor out of the resident's reach. On 08/26/24 at 7:12 PM, the Surveyor observed Resident #8 lying in bed and the call device on floor out of the resident's reach. On 08/28/24 at 7:50 AM, the Surveyor observed Resident #8 lying in bed and the call device wrapped around the feeding pump out of the resident's reach. On 08/28/24 at 11:11 AM, the Surveyor observed Resident #8 lying in bed and the call device wrapped around the feeding pump out of reach the resident's reach. On 08/28/24 at 1:22 PM, the Surveyor observed Resident #8 lying in bed and the call device wrapped around the feeding pump out of reach the resident's reach. 2. According to Quarterly Minimum Data Set with the Assessment Reference Date 5/28/2024 Resident #63 had memory problems. Resident #63 did not have upper or lower extremities impairment. A Care Plan (revision date 8/27/2024) revealed Resident #63 was at risk for falls related to immobility and a history of falls. \On 08/26/24 at 7:42 PM, the Surveyor observed Resident #63 lying in bed and the call device clipped to the outlet on the wall out of the resident's reach. On 08/26/24 at 8:52 PM, the Surveyor observed Resident #63 lying in bed and the call device clipped to the outlet out of the resident's reach. On 08/26/24 at 8:52 PM, the Director of Nursing (DON) stated the call device was not within reach of resident #63. On 08/28/24 at 2:27 PM, Licensed Practical Nurse #3 stated that the call device was not within reach of the Resident #8. On 08/29/24 at 8:32 AM, the DON stated the call device should be within reach of the resident in case the resident needs anything they can notify the staff. The DON voiced the call device not being within reach of the resident could contribute to falls and behaviors.

Based on record review, interviews and the facility failed to provide notice of discharge to 1 (Resident #76) sampled resident or the resident representative. The findings include: According to a Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) 05/15/2024, Resident #76 had a Brief Interview of Mental Status score of 15, indicating cognitively intact and was a Medicaid recipient. A Care Plan (cancelled Date: 6/17/2024) revealed the Preadmission Screening and Resident Review identified that Resident #76 needed specialized services due to intellectual disability (ID). The specialized services would help achieve optimal functioning and recovery. A Nursing Note (dated 6/13/2024 at 12:53) noted the author spoke with the Director at behavioral facility and was able to get Resident #6 an appointment at 11. The facility notified the behavioral facility of the resident's behaviors at the facility. The behavior facility contacted a hospital and got the resident accepted there for his behaviors, and the resident was admitted . Review of the MDS with ARD of 6/13/2024 entry/discharge reporting showed discharge assessment-return not anticipated. On 08/28/24 at 12:08 PM, the Director of Nursing stated Resident #76 was threatening staff and residents, and the facility could not care for him. The DON stated the resident or resident representative was not provided with a notice of discharge.

Based on record review and interview, the facility failed to ensure an Annual Minimum Data Set (MDS) assessment was coded correctly to document a resident had a serious mental illness and or intellectual disability or related condition requiring level II PASARR (Preadmission Screening and Resident Review) to ensure continuity of care for 1 (Resident #9) sampled residents with a diagnosis of serious mental illness. The findings are: 1. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/2023 indicated Resident #9 had diagnoses of depression, bipolar depression, and seizure disorder and scored 11(8 - 12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS). a. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/2023 indicated, A1500 Preadmission Screening and Resident Review .Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition? 0. No . b. The Care Plan with a revision date of 07/11/2024 indicated Resident #9 uses antidepressant medication related to major depression and bipolar disorder. c. On 8/27/2024 at 3:10 PM, the Surveyor requested a copy of the residents complete PASARR (Preadmission Assessment Screening and Resident Review) packet from the Director of Nursing (DON). d. On 08/27/2024 at 3:20 PM, the Surveyor received the complete PASSAR packet dated May 3rd, 2013, from the Nurse Consultant that contained a letter dated May 3, 2013, from (name of state designated authority for PASARR determination) that indicated Resident #9 did not require specialized services for their mental illness beyond the capabilities of a nursing facility. e. On 08/28/24 at 09:15 AM, during an interview the MDS Coordinator stated Resident #9 had serious mental health diagnoses requiring a level II PASARR to be completed prior to the resident's admission to the facility and the Annual MDS dated [DATE] had been coded incorrectly. f. On 08/29/24 at 08:35 AM, the DON was asked if she had a policy on accuracy of MDS Assessments. g. On 08/29/24 at 09:20 AM, the policy titled Resident/Elder Assessment and Comprehensive Care Plan Procedure indicated, .Resident/Elder assessment. It is the policy of this nursing facility to conduct and document, initially and periodically, comprehensive assessments on all Residents/Elders admitted to the nursing facility. Comprehensive assessments of Residents/Elders functional capacity are accurate, and standardized. Comprehensive assessments describe the Resident/Elder's capability to perform daily living functions and significant impairment in functional capacity to provide the nursing facility with the information necessary to develop a care plan and to provide appropriate care and services for each Resident/Elder .

Based on observations, interviews and record review, the facility failed to ensure that staff did not lower the head of the bed while 1 sampled (Resident #8) was receiving continuous enteral feeding. The finding include: According to Quarterly Minimum Data Set with the Assessment Reference date of 8/12/2024 Resident #8 had severely impaired cognition. Resident #8 had a feeding tube. A Care Plan (revision date 06/19/2024) revealed Resident #8 required Enhanced Barrier Precautions related to percutaneous endoscopic gastrostomy (PEG) tube. On 08/26/24 at 7:00 PM, the Surveyor observed Certified Nursing Assistant (CNA) #1 lower Resident #8's head of bed and both CNA #1 and #2 turn the resident from side to side while the enteral feeding was running. On 08/26/24 at 7:15 PM, CNA #2 confirmed the head of the bed was lowered while Resident #8's enteral feed pump was running. On 08/29/24 at 8:37 AM, the Director of Nursing (DON) stated staff should not lower the head of the bed when a resident is receiving eternal feeding They know better than that. The DON confirmed that turning a resident side to side while receiving eternal feeding could potentially cause aspiration. Review of policy titled Accident Hazards Prevention, undated, noted the facility is responsible for providing care to residents in a manner that helps promote quality of life.

Based on observations, interviews, and record reviews, the facility failed to ensure that incontinence care was provided in a manner to promote cleanliness for 1 (Resident #8) sampled resident. The findings include: According to a Quarterly Minimum Data Set with the Assessment Reference date of 8/12/2024 Resident #8 had severely impaired cognition. Resident #8 was always incontinent of bowel and bladder. A Care Plan (revision date 8/19/2021) revealed Resident #8 was incontinent of bowel and bladder related to (r/t) impaired mobility, diagnosis of chronic renal failure, and requires total care for Activities of Daily Living (ADLS). On 08/26/24 at 7:00 PM, the Surveyor observed Certified Nursing Assistant (CNA) #1 and #2 provide incontinence care to Resident #8, who had been incontinent of bowel and bladder. The Surveyor observed CNA #1 not clean the genital area or buttock correctly. On 08/26/24 at 7:15 PM, CNA #1 stated a portion of the genital area was not cleaned because the resident was too contracted. CNA #1 stated not cleaning the genital area properly could cause a urinary tract infection or there could be stool remaining on the resident. Both CNA #1 and #2 stated that incontinence care was not provided correctly. On 08/29/24 at 8:43 AM, the Director of Nursing (DON) confirmed incontinence care was not provided correctly if the genital area or buttock was not cleaned properly.

Based on observations, interviews, and facility policy review, the facility failed to ensure medications and/or biologicals were securely locked away. The findings include: On 08/26/24 at 6:05 PM, the Surveyor observed an unattended and unlocked cart with medications and cleaning solution used for treatments. On 08/28/24 at 6:21 PM, Licensed Practical Nurse #3 stated the cart should be locked. On 08/29/24 at 8:34 AM, the Director of Nursing (DON) stated she left the treatment cart unlocked and the cart should not have been unlocked. The DON stated a resident could have gotten in the treatment cart and got stuff out of there that could have been potentially harmful. A policy titled Pharmaceutical Services Policy noted Storage of drugs. All drugs and biologicals are stored in locked compartment under proper temperature controls.

Based on observation, interview and record review, the facility failed to ensure the facility ' s 1 of 1 ice machine was maintained in clean condition; foods stored in the storage area, refrigerator, and freezer were sealed, labeled, and dated; the kitchen equipment and air vents were maintained in clean condition; expired food items were promptly removed from stock and discarded; and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 77 residents who received meals from the kitchen. The findings included: During observation on [DATE] at 10:41 AM, the panel of the ice machine in the kitchen was covered with a wet black /pink residue. During interview on [DATE] at 10:41 AM, the Dietary Supervisor said the panel of the ice machine has a pink and black residue, and she cleans it once a month. The Surveyor asked the Dietary Supervisor, Who uses the ice from the ice machine and how often do you clean it? She stated, That's the ice the CNAs (Certified Nursing Assistants) use for the water pitchers in the residents' rooms and to fill beverages served to the residents' at the mealtimes. On [DATE] at 10:43 AM, the following observations were made on the food preparation counter. a. Two undated opened bags of bread. b. Rust on the legs of the counter. Three drawers facing where the drawers were missing had an accumulation of black stains. The facing of the drawers had an accumulation of caked on grease with black stains. c. Grease and dust were on the air vent above the tea and beverage makers. d. Grease and dust were on the air vent above the area by the steam table where the plate warmer was kept. On [DATE] at 10:44 AM, the following spices were observed on a shelf above the food preparation sink undated. a. Two containers of Garlic powder. b. One container of light chili powder. c. One container of ground mustard. d. One container of ground cinnamon. e. One container of ground cloves. f. One container of paprika. g. One container of nutmeg. h. One container of ground thyme. i. One bottle of pure vanilla extract. j. One container of Mediterranean style seasoning. k. One container of ground white pepper. l. One container of ground cumin. m. One bottle of pure lemon extract. n. One container of ground lemon pepper. o. One container of onion powder. During observation on [DATE] at 10:47 AM, an opened bag of coffee filters with coffee ground was below the food preparation counter, and an opened box of filters was on a shelf below the tea, coffee, and beverage counter. During observation on [DATE] at 10:54 AM, Dietary Employee (DE) #1 opened the walk-in refrigerator, took out a bottle of grape jelly and a container of chicken salad and placed them on the counter, removed gloves from the glove box, placed them on her hands. She picked up a peanut butter container, 2 bags of bread from a rack in the storage room and placed them on the counter. She untied the bags of bread with the same gloved hands, she removed slices of bread from the bag and placed them on a paper liner on the counter. She scooped a serving of chicken salad on the slices of bread and topped each slice with another slice of bread to be served to the residents. On [DATE] at 10:56 AM, the following observations were made on a rack in the kitchen. a. An opened unsealed box of wafers. b. A box of cheddar style deluxe cheese sauce with an expiration date of [DATE]. c. A box of gluten free double chocolate brownie mix with an expiration date of [DATE]. d. An opened bag of gluten free baking flavor beef with an expiration date of [DATE]. On [DATE] at 11:08 AM, the following observations were made on a shelf in the walk-in refrigerator: a. Two opened, uncovered, and unsealed boxes of sausage. b. An opened, uncovered, and undated pan of bologna c. An opened, uncovered, and unsealed box of bacon. On [DATE] at 11:15 AM the following observations were made on a shelf in the walk-in freezer. a. An opened, uncovered, and unsealed box of hamburger patties. b. An opened, uncovered, and unsealed box of garlic bread. c. An opened, uncovered, and unsealed box of turkey patties. d. An opened and unsealed bag of hot dogs. e. An opened, unsealed, and uncovered box of corn on the cob. f. An opened, unsealed, and uncovered box of dinner rolls. g. A partially opened ,d+[DATE]-gallon container of discolored vanilla ice cream. The Dietary Supervisor said the ice cream appeared to have thawed and refrozen. During observation on [DATE] at 12:11 PM, Dietary Employee (DE) #3 pushed a cart of clean plates towards the steam table. She picked up tray cards and placed them on the trays. Without washing her hands, she picked up the plates to be used to serve residents lunch and placed them on the trays with her fingers inside the plates. During observation on [DATE] at 3:32 PM Dietary Employee (DE) #3 picked up two pans of hot dogs from the stove and placed them on the counter. Without washing her hands, she picked a clean blade and attached it to the base of the blender to be used in pureeing food items. During observation on [DATE] at 3:40 PM, Dietary Employee (DE) #3 used a rag to wipe off splashes of foods on the blender motor. Without washing her hands, she picked up a clean blade and attached it to the base of a blender. She picked up biscuits with her hands and placed them into the blender added milk and pureed. She poured the pureed biscuits in a pan covered with foil and placed them in the oven. During interview on [DATE] at 12:58 PM, Dietary Employee (DE) #3 said she should wash her hands after touching dirty objects and before handling equipment. Review of facility's policy titled, When food handlers must wash their hands, provided by the Dietary Supervisor on [DATE] at 1:27 PM showed handwashing should occur before starting work, after leaving and returning to the kitchen/prep area, and after touching anything else such as dirty equipment or engaging in other activities that contaminates the hands.

Based on observation and interview, the facility failed to ensure meals were served in a method that maintained the appearance of a cold product and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. The findings included: On 09/18/2023 at 11:38 AM, the surveyor asked Resident #24 how are the meals? She stated, The food is usually cold. On 09/18/2023 at 03:41 PM, the surveyor asked resident #23 how are the meals? If it was cold during breakfast, lunch, and dinner. It is cold occasionally during all meals. On 09/19/2023 at 12:03 PM an unheated food cart that contained 22 trays for lunch was delivered to 200 Hall. At 12:24 PM, immediately after the last resident was served in their room on 200 hall, temperatures of the food items on the tray used as test trays were taken and read by the Dietary Supervisor with the following results: a. Potato salad 46 degrees Fahrenheit. b. Barbeque chicken 108 degrees Fahrenheit. c. Baked beans 109 degrees Fahrenheit. On 09/19/2023 at 12:26 PM, an unheated food cart that contained 34 trays for lunch was delivered to 300 hall. At 12:33 PM immediately after the last resident was served in their room on 300 hall, temperature of the food items on the tray used as test trays were taken and read by the Dietary Employee with the following results: a. Milk 52 degrees Fahrenheit. b. Potato salad 46 degrees Fahrenheit. c. Ground barbeque chicken with sauce 109 degrees Fahrenheit. d. Baked beans 111 degrees Fahrenheit. e. Barbeque chicken115.7 degrees Fahrenheit.

Based on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 6 residents who received pureed diets. The findings included: The following observations were made on 09/18/2023: a. At 11:39 AM, the consistency of a pan of pureed tortilla was thick and not smooth. b. Dietary Employee (DE) #3 at 3:30 PM added water to 8 servings of hot dog meat and 8 buns and blended the food. She poured the mixture into a pan covered the pan with foil and placed it on the steam table. The consistency of the pureed hot dog meat and buns was liquified and not formed. c. DE #3 at 4:48 PM, poured pureed macaroni and cheese into a pan. She covered it with foil and placed it on the steam. The consistency of the pureed macaroni and cheese was not smooth with pieces of noodles in the mixture. During interview on 09/18/2023 at 4:40 PM, Certified Nursing Assistant #1 said the consistency of the pureed hot dog with buns was too runny. Certified Nursing Assistant #2 at 4:41 PM said the consistency of the pureed hot dog with buns was liquidly. During observation on 09/19/2023 at 7:34 AM, the pureed eggs served to the residents who received pureed diets were gritty and not smooth. The pureed sausage was runny, gritty, and not smooth. The pureed bread was thick and lumpy. During interview on 09/19/2023 7:40 AM, Dietary Employee (DE) #2 said the consistency of the pureed eggs were gritty and not smooth. The pureed bread was thick and lumpy. The pureed sausage was runny and not smooth.

Based on observation, record review and interview, the facility failed to ensure that meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. The facility failed to meet the nutritional needs of residents by including a disliked food on the meal tray for 1 Resident (Resident #78) and failed to provide a standing order for ice cream for 1 Resident (Resident #54) to ensure their nutritional needs are meet. The findings included: Review of the facility's menu for Spring/Summer 2023 for lunch showed residents on pureed diets were to receive 2 #8 scoop (1 Cup) of a pureed soft taco, 1/2 cup of vegetable juice, and a #16 scoop (1/4 Cup) of pureed tortilla. Residents on mechanical soft and regular diets were to receive 2 soft tacos each. During observation on 09/18/2023 at 12:02 PM, Dietary Employee (DE) #2 served one soft taco each to the residents on regular and mechanical soft diets instead of two each per the facility's written menu. During observation on 09/18/2023 at12:09 PM, Dietary Employee (DE) #2 served pureed meat, flour tortilla, cream corn, and cake to the residents on pureed diets. There was no vegetable juice served to the residents on pureed diets for lunch as specified on the facility ' s written menu. On 09/18/2023 at 12:19 PM, the following observations were made during the noon meal service in the main dining room. a. Dietary Employee (DE) #3 served one soft taco to the residents on a regular and mechanical soft diet instead of two soft tacos each. b. Dietary Employee (DE) #3 served pureed meat, flour tortilla, cream corn, and cake to the residents on pureed diets. There was no vegetable juice served to the residents on pureed diets for lunch as specified on facility's written menu. On 09/19/23 at 7:44 AM Dietary Employee (DE) #2 said she forgot the menu said to give 2 #8 scoops of a pureed soft taco. Vegetable juice was prepared but forgot to bring them out. Review of Resident #54's meal slip dated 09/18/2023 showed a standing order for chocolate ice cream. During observation on 09/18/2023 Resident #54 did not have ice cream on the noon meal tray. During interview on 09/18/2023 at 1:15 PM, Certified Nursing Assistant (CNA) #3 said Resident #54 was not served chocolate ice cream as ordered. Review of Resident #78's meal slip dated 09/18/2023 showed corn as a food the Resident dislikes. During observation on 09/18/2023 at 12:45 PM, Resident #78 was served corn on the lunch meal tray. CNA #5 confirmed Resident #78 disliked corn.

Based on observation and interview, the facility failed to ensure that refrigerated scheduled II-V controlled medications were maintained within a separately locked permanently affixed compartment in 1 (Hall 300) of 2 Halls (Hall 200 and 300) medication storage rooms. The findings included: On 09/19/2023 at 1:40 PM during a tour of the medication storage room on Hall 300 with LPN #3, a small plastic box with a red plastic lock numbered 83210 was discovered in the refrigerator on an open shelf. The plastic box containing two vials of Lorazepam 2.5ml (milliliters) with an expiration date of 01/2024, was not in the permanently affixed locked box located in the refrigerator. On 09/19/2023 at 1:45PM, the Surveyor asked LPN #3, how many locks are narcotics supposed to be stored under? LPN #3, said she was not sure, and the box doesn't fit inside the refrigerator lock box when there are other medicine in there. The Surveyor observed that there were no other medications in the refrigerator lock box. During interview on 09/19/2023 at 2:48 PM the DON (Director of Nursing), confirmed narcotics should be locked in a permanent lock box in the refrigerator in the medication storage room, and the portable plastic box with Lorazepam should be locked inside the refrigerator locked box. Review of facility policy provided by the DON on 09/19/2023 titled Pharmaceutical Services showed, all drugs and biologicals are stored in compartments that are locked under proper temperature controls. The separately locked and permanently affixed compartments are provided for storage of controlled Schedule II drugs.

Based on observation, interview and record review, the facility failed to ensure that a residents hand roll was placed in the hand nightly as care planned. This failed practice affected 1 Resident (Resident #62) of 5 Residents with hand roll orders. The findings included: Review of Resident #62's Medical Diagnosis form dated 01/27/2023 showed a diagnosis of cerebral infarction with paralysis affecting the left side. During an interview on 09/19/2023 at 10:50 AM, Resident #62 said his hand roll has been missing for months. The surveyor observed a sign above Resident #62's bed stating, Please put hand roll in patient's left hand at bedtime. Review of Resident #62's care plan with a revision date of 02/01/2023 showed palm roll to left hand at night. During interview on 09/20/2023 at 2:10 PM, CNA #2 said she did not know Resident #62's hand roll was missing, and it should be in his room. During interview on 09/20/2023 at 3:25 PM, the Director of Nursing (DON) said the CNA's and nurses are responsible for making sure residents wear their hand rolls and document daily on the card index. The DON said she could show this documentation on the card index but was unable to provide Resident #62's card index.

Based on observation, record review and interview, the facility failed to ensure fingernails were regularly trimmed and cleaned to promote good personal hygiene and grooming for 2 (Residents #19 and #36) residents out of 11 (Residents #11, #19, #21, #35, #36, #37, #54, #57, #64, #78, and #133) sample mixed residents who required assistance or were dependent for nail care. The findings included: Review of Resident #19's physician's Order Summary Report dated 09/19/2023 showed diagnoses of muscle weakness (generalized) and rheumatoid arthritis Review of Resident #19's care plan with an initiated date of 08/16/2023 showed risk for impaired skin integrity. Keep nails trimmed / filed to minimize jagged edges to reduce risk for skin impairment. During observation on 09/18/2023 at 1:37 PM, Resident #19's fingernails were approximately 1/2 inch beyond the nailbed with black matter underneath the nail. During observation on 09/19/2203 at 9:05 AM, Resident #19's fingernails were approximately 1/2 inch beyond the nail bed with black matter underneath the nail. During observation of the lunch meal on 09/20/2023 Resident #19 was using fingers to pick up food from the plate. During observation on 09/20/2023 at 2:45 PM, Resident #19's fingernails were approximately 1/2 inch beyond nail bed with black matter underneath the nail. During interview on 09/20/2023 at 2:47 PM, Certified Nursing (CNA) #4, said Resident #19's fingernails are dirty and long. During interview on 09/20/2023 at 2:54 PM, Licensed Practical Nurse (LPN) #2 said Resident #19's fingernails are long and dirty. Review of Resident #36's physician's Order Summary Report showed diagnoses of dementia, agitation, disorientation, and muscle wasting. Review of Resident # 36's care plan with an initiated date of 01/31/2023 showed requires total assistance of 1 staff member with personal hygiene care. Review of Resident #36's quarterly Minimum Date Set Resident Assessment and Care Screening dated 08/09/2023 showed 1 person assistance for personal hygiene. During observation on 09/18/2023 at 1:35 PM, Resident #36's fingernails were approximately 1/2-inch past the nailbed with some jagged edges and dark matter beneath the nail. During observation on 09/19/2023 at 9:07 AM, Resident #36's fingernails were approximately 1/2-inch past the nailbed with jagged edges and dark matter underneath the nail. During observation on 09/20/2023 at 10:42 AM, Resident #36's fingernails were approximately 1/2-inch past the nailbed with some jagged edges and dark matter underneath the nail. During interview on 09/20/2023 at 10:29 AM, CNA #4, said Resident # 39's fingernails are dirty and long. During interview on 09/20/2023 at 10:36 AM, LPN #2 said Resident #19 's fingernails are dirty, long, and some nails are slanted with sharp corners, and some look dirty like dirt is underneath the nail.

Based on observation and interview, the facility failed to ensure food items were dated; expired food items were promptly removed /discarded on or before the expiration or use by dates; dietary staff washed their hands before handling clean equipment or food items to prevent the potential for cross contamination; and failed to ensure meat items stored in the refrigerator were covered or sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 68 residents who received meals from 1 of 1 kitchen (Total Census: 70), according to the lists provided by the Dietary Supervisor dated [DATE] at 1:02 PM The findings are: 1. On [DATE] at 9:40 AM, during the initial tour of the kitchen with the Dietary Manager, in the refrigerator there was a plastic container with strawberries that had been opened and in the dry storage room there was a bag of yellow cake mix that had been opened. There was not a date on either of them indicating when they had been opened. The Dietary Manager was asked, Should food products have a date placed on the container or bag showing when that item was opened? The Dietary Manager stated, Yes. The Dietary Manager was asked, How do you know when food should be discarded if there is not a date indicating when it had been opened? The Dietary Manager stated, There's no way to tell when it should be thrown away. 2. On [DATE] at 10:30 AM, in the pantry refrigerator located on the 200 Hall, there was 7 half pint cartons of 2% milk that had an expiration date of [DATE]. The Dietary Manager was asked, Who is responsible for ensuring that expired milk is discarded? The Dietary Manager stated, The hydration CNA [Certified Nursing Assistant], but she is out on sick leave so I guess that would be the dietary department. The Dietary Manager was asked, What could be the possible outcome if a resident had drunk the expired milk? The Dietary Manager stated, The residents could get sick. 3. On [DATE] at 10:45 AM, CNA #1 was asked, Have you given a resident any beverages from the refrigerator located in the pantry on the 200 Hall? CNA #1 stated, No sir, not in a while. We only use that if a resident request extra milk. CNA #1 was asked, Who is responsible for checking the beverages in the 200 Hall pantry? CNA #1 stated, The dietary department. CNA #1 was asked, What should be done if you get a carton of milk out of the 200 Hall pantry for a resident? CNA #1 stated, Look at the expiration date on the milk. CNA #1 was asked, What could happen if a resident drank expired milk? CNA #1 stated, The residents could get sick. 4. On [DATE] at 11:00 AM, CNA #2 was asked, Have you given a resident any beverage from the refrigerator located in the pantry on the 200 Hall? CNA #2 stated, No sir. CNA #2 was asked, Who is responsible for checking the beverages in the 200 Hall pantry? CNA #2 stated, The dietary department. CNA #2 was asked, What should be done if you get a carton of milk out of the 200 Hall pantry for a resident? CNA #2 stated, See if it's expired. CNA #2 was asked, What could happen if a resident drank expired milk? CNA #2 stated, The residents could get sick to their stomach. 5. On [DATE] at 11:15 AM, CNA #3 was asked, Have you given a resident any beverages from the refrigerator located in the pantry on the 200 Hall? CNA #3 stated, No sir; the hydration CNA does that. CNA #3 was asked, Who is responsible for checking the beverages in the 200 Hall pantry? CNA #3 stated, Dietary stocks the pantry with drinks and snacks. CNA #3 was asked, What should be done if you get a carton of milk out of the 200 Hall pantry for a resident? CNA #3 stated, I don't get anything out of there. I get everything from the kitchen. CNA #3 was asked, What could happen if a resident drank expired milk? CNA #3 stated, I haven't seen anyone drink expired milk, but I guess it could cause an upset stomach. 6. On [DATE] at 2:34 PM, the following observations were made in the walk-in refrigerator: a. A box of twelve 32 fluid ounce boxes of heavy whipping cream was stored on a shelf. The box had an expiration date of [DATE]. b. A box of nine 32 fluid ounce boxes of half and half was stored on a shelf. The box had an expiration date of [DATE]. c. A bag of gluten free bread was stored on a shelf. The bag had an expiration date of [DATE]. d. A box of sausage was stored on shelf. The box was not covered. 7. A bag of raisin cinnamon bread was stored on the bread rack in the storage room. The bag had an expiration date of [DATE]. 8. On [DATE] at 3:51 PM, Dietary Employee #1 was wearing gloves on her hands when she turned on the food preparation sink and rinsed a spatula. She turned off the faucet with her gloved hand and without changing gloves and washing her hands, she picked up the 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 pureed diets for the supper meal. At 3:53 PM, she placed 4 servings of yellow cake in the blender, added milk and pureed. She picked 4 bowls and placed them on the counter with her gloved fingers touching the interior surfaces of the bowls. At 5:04 PM, Dietary Employee #1 was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have changed gloves and washed my hands. 9. On [DATE] at 4:01 PM, Dietary Employee #2 turned on the hand washing sink and washed her hands. After washing her hands, she turned off the faucet with her bare hands and without washing her hands, she picked a clean blade and attached it at the base of the blender to be used in pureeing food items to be served to the residents who received pureed diets. At 4:59 PM, Dietary Employee #2 was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 10. On [DATE] At 4:06 PM, Dietary Employee #1 was wearing gloves on her hands when she turned on the food preparation sink faucet and rinsed a rubber spatula. She then turned off the sink faucet. Without changing gloves and washing her hands, she used her gloved hand to pick up slices of yellow cake from a metal spatula and placed them in individual bowls to be served to the residents at the supper meal. 11. On [DATE] At 4:30 PM, Dietary Employee #3 turned on the hand washing sink and washed her hands. After washing her hands, she used her bare hands to turn of the sink. She then dried her hands with tissue papers. She removed gloves from the box and placed them on her hands contaminating the gloves. She picked up one bag of bread from the bread rack and placed it on the counter. She took out one container of bologna from the refrigerator and placed it on the counter and turned on the stove. She did not change gloves and wash her hands after turning on the stove. She untied the bread bag, removed slices of bologna from the container and placed them on a saucepan on the stove. She then removed slices of bread from the bag and prepared grilled bologna sandwiches for the residents who requested bologna sandwich with their supper meal. At 5:01 PM, Dietary Employee #3 was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have changed gloves and washed my hands. 12. On [DATE] at 9:54 AM, a carton of ice cream was on a shelf in the freezer. The ice cream was discolored and had icicles on it. There was no date to indicate when it was opened or received or who it belonged to. The Dietary Supervisor stated, I am throwing it away. It has no date or name on it. At 11:12 AM, the Dietary Supervisor was asked to describe the appearance of the ice cream in the freezer. She stated, It has icicles and was old. 13. The facility's police titled, Proper Hand Washing Procedure, provided by the Dietary Manager on [DATE] at 1:02 PM documented, .Considerer using a paper towel to create a barrier between hands and surfaces touched after hand washing (faucet and door handles) .

Based on observation, record review and interview, the facility failed to ensure enteral feedings and water flushes had a label on the formula bottle with the documented time they were hung for 1 (Resident #56) of 2 (Residents #50 and #56) sampled residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #56 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set with an Assessment Reference Date of 05/17/2022 documented the resident had modified independence in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and received 51% (percent) or more total calories through a feeding tube. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. On 06/21/22 at 12:45 PM, Resident #56 was lying in bed with a tube feeding of [MEDICATION(S)] 1.5 infusing at 65 ml/hr (milliliters per hour) and a water flush at 50 ml/hr. The [MEDICATION(S)] and the water flush did not have the time they were hung on the label. c. On 06/22/22 at 9:23 AM, Resident #56 was lying in bed. A continuous feeding of [MEDICATION(S)] 1.5 was infusing at 65ml/hr and a water flush at 50 ml/hr. The [MEDICATION(S)] and the water flush did not have the time they were hung on the label. d. On 06/22/22 at 2:52 PM, Licensed Practical Nurse (LPN) #2 accompanied the Surveyor into Resident #56's room. LPN #2 was asked what time the formula and water flush were hung. She stated, It is not on there. She was asked, Should it be on there? She stated, Yes, it usually is, we have to put the time hung on there. This one was hung on night shift maybe around 7:00 PM or 9:00 PM yesterday.

Based on record review and interview, the facility failed to notify the resident/representative of the reason for transfer/discharge to the hospital in writing in a language they understand for 2 (Residents #31 and #45) of 7 (Residents #50, #52, #45, #30, #13, #74 and #13) sampled residents who transferred to the hospital in the last 120 days as documented on a list provided by the Admissions Registered Nurse on 6/22/22 at 1:57 PM. The findings are: 1. Resident #31 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/21/22 documented the resident had modified independence in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS). a. The Discharge Return Anticipated MDS with an ARD of 4/12/22 documented discharged to acute hospital. b. The Progress Note dated 4/12/22 documented, .Resident has been refusing meals and medications . [Medical Doctor #1] says to send resident to ER [emergency room ] . c. The Notice of Transfer Discharge/LOA (leave of absence) with Bed Hold Policy dated 4/12/22 did not document the reason for transfer in writing. The form documented, .The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . 2. Resident #45 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Discharge Return Anticipated MDS with an ARD of 5/3/22 documented discharged to acute hospital. b. The Progress Note dated 5/3/22 documented, .Situation: .Diarrhea Nausea/Vomiting . Primary Care Provider responded with the following feedback: .send to ER . c. The Notice of Transfer Discharge/LOA (leave of absence) with Bed Hold Policy dated 5/13/22 did not document the reason for transfer in writing. The form documented, .The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . 3. On 06/22/22 at 9:30 AM, the Administrator was asked, Who is responsible for notifying the representative of the reason for transfer to the hospital? He answered, I do that. He provided a binder that contained copies of Notices of Transfer Discharge/LOA forms that included copies of the envelopes in which the notices were mailed to the representatives. He was asked, Please show me on the forms the reason for transfer in writing? He reviewed the forms and answered, I don't guess that's on there. I just do it to help the nurses. I have never read the forms. The Nurse Consultant entered the room and stated, We call the representatives, and we document the reason for transfer in the Nurses Notes. She was asked, Do you send a copy of the Nurses Notes to the representatives? She answered, No. She was asked, Where on the form does it document the reason for discharge in writing? She answered, I have never heard of this. I am going to contact our attorney. 4. The facility policy titled, Discharge/Transfer of the Resident, provided by the Nurse Consultant on 6/22/22 at 3:10 PM documented, .Explain transfer and reason to the resident and/or representative and give copy of signed transfer or discharge notice to the resident and/or representative or person responsible for care .

Based on observation, record review and interview, the facility failed to ensure fingernails were regularly trimmed and cleaned to promote good personal hygiene and grooming for 1 (Resident #3) of 24 (Residents #3, #5, #9, #19, #13, #14, #16, #22, #23, #26, #27, #30, #31, #35, #38, #42, #45, #47, #48, #50, #52, #56, #71 and #73) sampled residents who required assistance or were dependent for nail care as documented on a list provided by the Administrator on 6/22/22 at 3:05 PM. The findings are: Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 03/17/22 documented the resident had modified independence in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and was totally dependent of one person physical assistance with personal hygiene and bathing. a. The Plan of Care with a revision date of 06/16/22 documented, .Resident has an ADL [activity of daily living] self-care performance deficit . will be clean and well groomed daily . Nail care Weekly and PRN [as needed] . Personal Hygiene: The resident requires extensive assistance with personal hygiene . a. 06/21/22 at 11:55 AM, Resident #3 was lying in bed. The fingernails on his left hand had a black substance underneath them. b. On 6/22/2022 at 11:41 am, Licensed Practical Nurse (LPN) #1 accompanied the Surveyor to Resident #3's room and was asked to look at the resident's fingernails. LPN #1 was asked what was wrong with the resident's fingernails. She stated, The ones on the left hand need cleaning, and the ones on the right hand need cutting. c. On 06/22/2022 at 2:10 PM, Certified Nursing Assistant (CNA) #5 was asked, Who is responsible for trimming the resident's nails? She stated, The CNA's unless they are diabetic, then the nurses do it. She was asked, When are nails trimmed? She stated, On bath days and when needed. d. On 06/22/22 at 2:20 PM, CNA #6 was asked, Who is responsible for trimming the resident's nails? She stated, I'm really don't know. I have only been here 3 weeks. She was asked, Did they talk to you about nail care in orientation? She stated, No they didn't go over that in training. e. On 06/22/22 at 2:25 PM, CNA #4 was asked, Who is responsible for trimming the resident's nails? She stated, If they're not diabetic, the CNA's trim their nails. She was asked, When are nails trimmed? She stated, On bath days and when needed. f. On 06/22/22 at 2:30 PM, LPN #1 was asked, Who is responsible for trimming the resident's nails? She stated, The CNA's unless they are diabetic, then the nurse or the treatment nurse does it when she does her weekly skin audit. She was asked, When are nails trimmed? She stated, On bath days and when needed.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator and freezer were covered and sealed, expired food was promptly removed from stock and the refrigerator on the 200 Hall were, kitchen equipment was maintained in clean condition, and glasses and pans were allowed to air dry before stored to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 58 residents who received meals from the kitchen (total census: 60), as documented on a list provided by the Dietary Manager on [DATE]. The findings are: 1. On [DATE] at 10:02 A.M., a 3.5 pound package of open stuffing mix was on a shelf in the pantry. The package was not sealed. The Dietary Manager (DM) was asked, Should the stuffing mix be sealed? The DM stated, Yes, it should be inside a 3-gallon freezer bag and sealed. The DM was asked, Why should the stuffing mix be sealed? The DM stated, Because it can be contaminated, and insects can get in. 2. On [DATE] at 8:31 A.M., the following observations were made in the kitchen: a. There was a blue dish rack containing plastic glasses. Several glasses were stacked on top of each other wet. The Dietary Manager was asked to describe what she saw. She replied, Cups stacked wet on top of each other. She was asked how they should be stored. She replied, In a single layer so they can air dry or the moisture will set up in them and mildew. She was asked if stacking the glasses wet could potentially cause food-borne illness. She replied, Yes. (Photo taken.) 3. In the walk-in refrigerator the following food items were not covered, labeled, dated, or discarded by the expiration date: a. A bag labeled cornbread with a date of [DATE] and a use by date of [DATE] had small clear droplets on the inside of the bag. The Dietary Manager was asked to describe what she saw. She replied, Moisture. She was asked how the droplets got inside of the bag. She replied, I don't know. b. A container of a cream colored smooth texture item with no lid, date, or label. The Dietary Manager was asked to identify the item. The Dietary Manager replied, It's puree eggs left from breakfast. She was asked if the puree eggs were stored correctly. She replied, No. I guess she was in a rush. c. There was one fourth of a container of a five pound tub of opened tuna salad with a receive by date of [DATE] and a use by date of [DATE] with no open date. The Dietary Manager replied, I am getting rid of this. d. There were two full five pound containers of unopened sour cream with a receive date of [DATE] and a use by date of [DATE]. e. There was a half of a five pound tub of opened sour cream with a receive date of [DATE], no open date, and a use by date of [DATE]. 4. In the walk-in freezer the following opened items were not re-sealed securely. a. One box of Kielbasa sausages was open with an opened bag with no open date. The Dietary Manager was asked if the sausages were stored properly. She replied, No. She was asked how the sausages should be stored. She replied, Sealed in a zipped locked bag and labeled, then put back in the box. Looks like frost bitten so I'm going to throw them out. b. A second box of Kielbasa sausages was closed. The Dietary Manager opened the box and inside was an opened bag of sausages. The sausages were exposed to air and glistening splotches were seen on the sausages. (Photo taken.) c. A previously opened bag of breaded chicken tenders was not securely re-sealed after opening. d. A portion of an angel food cake, with no date or label. 5. A sticky yellowish substance was on the inside of the underside of the juice dispenser spouts. The Dietary Manager was asked, How often is the juice machine cleaned? She replied, It' supposed to be daily. She was asked if the machine had been cleaned daily routinely. She replied, No, that is a lot of buildup of juice splashes. (Photo taken.) 6. On the clean side of the dish room there were two baking sheet pans stacked together with water droplets on them. The Dietary Manager was asked to raise the top pan, there was water between the two pans. (Photo taken.) 7. On [DATE] at 3:00 P.M., a fan covered with a fussy brownish substance was blowing toward the clean meal trays. (Photo taken.) 8. On [DATE] at 2:10 P.M., Dietary Aid (DA) #1 was asked, If a food item is open and, on a shelf, should it be sealed? DA #1 stated, Yes, it should be sealed and dated and kept for the next three days. After then it should be thrown away. DA #1 was asked, What can happen if it is not sealed? DA #1 stated, It could get contaminated. 9. On [DATE] at 2:14 P.M., DA #2 was asked, If a food item is open and, on a shelf, should it be sealed? DA#2 stated, Yes, it should be sealed and the date it was opened written on it and it should be inside a freezer bag. DA #2 was asked, What can happen if it is not sealed? DA#2 stated, Anything can get inside like insects. It could get contaminated too. 10. On [DATE] at 10:49 A.M., 7 cartons of milk with an expiration date of [DATE] were in the pantry refrigerator on the 200 Hall. The Housekeeping Supervisor was asked, What is the expiration date on this milk? She stated, It's expired by 2 days. Dietary is supposed to check the refrigerators every day.

[NAME] Based on observation, record review and interview, the facility failed to ensure a resident with oxygen in use received adequate supervision to prevent the resident from being in close proximity to other residents, staff or visitors who were smoking and failed to ensure staff were aware of the need to monitor and encourage compliance with oxygen safety measures to prevent potential serious injury for 1 (Resident #63) of 5 (Residents #21, 54, 63, 66, and 73) residents who had a physician's orders [REDACTED]. This failed practice resulted in immediate jeopardy, which could have caused serious harm, injury or death to Resident #63, who was receiving oxygen while sitting in close proximity to another resident and a visitor who were both smoking, and had the potential to cause more than minimal harm to 5 residents who received oxygen therapy and were independently mobile, as documented on a list provided by the Director of Nursing (DON) on 10/08/2019, and 8 residents who smoked in the smoking area frequented by Resident #63, as documented on a list provided by the Administrator on 10/7/19. The Administrator was informed of the Immediate Jeopardy condition on 10/08/2019 at 1:40 p.m. The findings are: 1. Resident #63 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/15/19 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), required limited assistance with transfers, required limited assistance with locomotion on and off the unit, used a wheelchair for mobility and received oxygen therapy while a resident. a. A physician's orders [REDACTED]. b. On 10/8/19 at 11:26 a.m., Resident #63 was sitting in a wheelchair in the courtyard gazebo, with oxygen therapy in use via a nasal canula. The oxygen tank was attached to the back of the wheelchair. There was a visitor sitting next to the resident and holding a lit cigarette down by her right side, which was approximately 24 to 30 inches from Resident #63's left side. There was also another resident, approximately 4 feet away, who was smoking a cigarette while Resident #63's oxygen was in use. The surveyor took a photograph of the residents and visitor at this time. c. On 10/8/19 at 11:56 a.m., Resident #63 was asked, Do you normally go outside with oxygen on to the area where others are smoking? She stated, I go where people are; their habits are their habits. She was asked, Can you physically get out the door to the courtyard by yourself without any help? She stated, Yes. She was asked, Has the facility educated you about the risk of having oxygen in use and being around others who are smoking? She stated, No, but I am cognizant of what smoking and oxygen are, but no, they have never said anything directly to me. d. On 10/8/19 at 12:08 p.m., the Assistant Director of Nursing (ADON) was asked, Is (Resident #63) able to get outside to the courtyard by herself? She stated, Yes. She was asked, Does (Resident #63) normally go to the area where others are smoking? She stated, It depends on where her friends are at. It really depends - it changes every day - she's a roamer. She was asked, What education has the facility provided to (Resident #63) regarding her oxygen being in use and others smoking around her? She stated, She knows . don't know if its documented, but she knows that oxygen is flammable . while in the process of smoking, she doesn't need to be out there. She was asked, Are you aware that (Resident #63) is going outside to the courtyard with oxygen on and where others are smoking? She stated, No, not myself (sic). e. On 10/8/19 at 12:14 p.m., Certified Nursing Assistant (CNA) #1 was asked, Are you familiar with (Resident #63)? She stated, Yes, somewhat. She was asked, Is (Resident #63) able to get out to the courtyard by herself? She stated, Yes, ma'am. She was asked, Can (Resident #63) propel herself outside? She stated, Yes, ma'am. She was asked, Do you know where (Resident #63) goes outside? She stated, To the flowerbeds; if other residents are out there, she will talk to them. She was asked, What education has the facility provided to you about smoking and oxygen use? She stated, They let us know if they (residents who smoke) need an apron or can be outside by themselves. She was asked, Do you know the dangers of oxygen use and smoking? She stated, It can blow up. She was asked, What if you have visitors or staff that are smoking outside; how would you monitor a resident outside with oxygen in use? She stated, They would have to move. She was asked, Does (Resident #63) come up to visitors and staff if they are outside smoking? She stated, (Resident #63) will come up to you but, doesn't come that close. She was asked, Can you tell me how close (Resident #63) gets to staff who are smoking? She stated, About 3 feet . She was asked, Has the facility provided education to you about the risks of smoking and residents with oxygen on? She stated, No, ma'am. f. On 10/8/19 at 12:23 p.m., the Minimum Data Set (MDS) Coordinator was asked, Are you familiar with (Resident #63)? She stated, Yes. She was asked, Can (Resident #63) get outside to the courtyard by herself? She stated, Yes. She was asked, What education has (Resident #63) been given about having oxygen in use and going around others who are smoking? She stated, We have a policy; they are given on admission and explained the rules. She was asked, Have you talked to (Resident #63) about the risk of being outside with oxygen on and smoking? She stated, I haven't. She was asked, Are you aware (Resident #63) propels herself outside with oxygen on and is around other visitors, staff and other residents smoking? She stated, No. g. On 10/8/19 at 12:37 p.m., Licensed Practical Nurse (LPN) #1 was asked, Are you familiar with (Resident #63)? She stated, Yes. She was asked, Does she use oxygen? She stated, Routine. She was asked, Can she get out to the courtyard by herself? She stated, She can. She was asked, What type of training has the facility provided to you about residents who have oxygen in use and being near other residents, visitors and staff who smoke? She stated, I started in August; none to my knowledge. She was asked, Do you think it is a good practice to allow a resident using oxygen around residents, visitors and staff who are smoking? She stated, No, not a good practice. h. On 10/8/19 at 12:45 p.m., the facility's Resident Smoking Policy was provided by the MDS Coordinator. It documented, RESPONSIBILITY: It is the responsibility of all employees to follow the smoking safety and assessment policies, to monitor smoking safety practices of residents and to intervene appropriately to keep residents safe. POLICY: It is the policy of this facility to have a smoking policy that protects the rights of individual residents while providing the safest possible environment for all residents .L[NAME]ATION OF SMOKING AREA: The approved designated smoking area(s) in the facility: COURTYARD DESIGNATED AREA . STAFF TRAINING. The facility smoking policy will be covered during the orientation of all new employees and annually thereafter. ENVIRONMENTAL CONSIDERATIONS. The following environmental issues were evaluated in support of the facility smoking policy: .A method for observation / supervision by facility associates . The location of the designated smoking and provisions to assure resident with the need for supplemental oxygen do not access the area while smoking is taking place. The storage of any hazardous material i.e. (such as) oxygen, medical gas, combustible or inflammable materials is not located near the approved smoking area . i. The facility's, Smoking Location (and) Smoking Times information, provided by the Administrator on 10/7/19 at 8:54 a.m., documented, SMOKING L[NAME]ATION: PATIO IN FRONT OF DINING ROOM, SMOKING TIMES: 8:30 AM, 10:30 AM, 1:30 PM, 3:30 PM, 6:30 PM, 8:30 PM. j. On 10/10/19 at 11:00 a.m., Resident #63 was observed lying in bed with oxygen therapy via nasal cannula and was asked, Do you go outside with oxygen on where others are smoking? She stated, Yeah, yeah. She was asked, Has the facility educated you about oxygen use and smoking? She stated, No, but the staff will normally cup their hands. (Resident #63 demonstrated by cupping her hands in front of her). She was asked, How far do you get from staff who are smoking when you are outside? She stated, A little closer than you are to me, maybe 3 feet. The surveyor was sitting approximately 1 to 2 feet from the foot of the bed and approximately 3 to 4 feet from the head of the bed. She was asked, How far do you get from residents who are smoking when you are outside? She stated, I really don't know any residents that smoke now; may have known 1 or 2 that's (sic) not here. She was asked, Do you go outside around staff and visitors who are smoking with your oxygen in use? She stated, Yes. k. On 10/10/19 at 11:43 a.m., the DON was asked to identify the resident who was smoking near Resident #63 on 10/8/19. She stated, I believe (Resident #17), after you showed me the picture. She was asked, Does (Resident #17) smoke? She stated, Yes. She was asked, Does (Resident #63) have a Physicians Order for oxygen therapy at 2.5 liters per minute? She stated, Yes. She was asked, Does the use of oxygen near lit cigarettes or open flames from lighters and matches have the potential to cause combustion, fire, serious injury or death? She stated, Yes. She was asked about monitoring of the resident to prevent her from being in proximity to smokers while her oxygen was in use. She stated, We weren't aware she was around smoking at that time. l. On 10/10/19 at 12:22 p.m., the Assistant DON (ADON) was asked What education has the facility provided to (Resident #63) about her oxygen use and going outside where others are smoking? She stated, On admission, they do a form. She was asked, Have you provided education to the resident about the risks of oxygen use and smoking? She stated, Not me personally, until after the incident (immediate jeopardy notification on 10/8/19). She was asked, Does the use of oxygen near lit cigarettes or open flames from lighters or matches have the potential to cause combustion, fire, serious injury or death? She stated, As far as I know. 2. Resident #17 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/18/19 documented the resident scored 10 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS) and required extensive assistance with transfers. On 10/10/19 at 10:53 a.m., Resident #17 was lying in bed. She was asked, Do you smoke? She stated, I do and nodded her head to indicate yes. She was asked, Did you have visitors on 10/8/19 that sat with you outside underneath a gazebo? She stated, Grandson (name) and wife. She was asked, Did (Resident #63), who had oxygen on, sit outside with you and your visitors on 10/8/2019? She stated, Yes, and boom! The resident emphasized the word boom loudly. She was asked, Is it normal for (Resident #63) to have her oxygen on and go outside where others are smoking? She stated, Yes. Boom! and nodded her head. 3. On 10/8/19 at 3:43 p.m., the Immediate Jeopardy was removed, and the scope and severity decreased to [NAME] when the facility implemented the following Plan of Removal: 1.) The courtyard area at the facility is now a non-smoking area. 2.) The designated smoking area in the facility is out the side door of the 300-wing door, outside. 3.) All staff will be in-serviced concerning the changes to the smoking area. The in-service will include the dangers of smoking near oxygen. No resident on oxygen is to be closer than 10 feet from an open flame or cigarettes. 4.) The facility will monitor Resident #63 to ensure she does not enter the new smoking area. 5.) 'No smoking' signs will be placed on all doors leading to the courtyard. 6.) The facility will monitor the courtyard area daily for 3 weeks or until compliance with the Office of Long-Term Care to ensure residents, staff, and visitor smoke in the designated area. Any negative findings will be corrected immediately. B. Based on observation, record review and interview, the facility failed to ensure the water in the whirlpool bath was maintained at a safe temperature to prevent potential injury for residents who took whirlpool baths on 1 (300 Hall) of 2 (200 and 300) halls. This failed practice had the potential to affect 16 residents who used the whirlpool on the 300 Hall, according to a list provided by the Director of Nursing (DON) on 10/10/19. The findings are: 1. Resident #66's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/21/19 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). On 10/06/19 at 6:02 p.m., Resident #66 stated, The whirlpool bath on the 300 Hall is either too cold or too hot, so everyone uses the shower and it runs out of hot water, and when afternoon comes, it's too cold to bathe in. She was asked, Has it been reported? She stated, Oh, yes. There are 2 maintenance men here. She was asked, How long has it been this way? She stated, Three weeks to a month, and I am ready for my whirlpool baths again. 2. On 10/6/19 at 6:58 p.m., Resident #19, whose MDS with an ARD of 7/19/19 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, stated, .For 2 years, we have been trying to get someone to fix the tub. The thing that regulates the temperature of the water is what's wrong with it. The other day, Saturday, the temp started at 84, went down to 76 and then went up to 119 degrees. The aides have even complained; the Administrator said he fixed it one time and he don't know how to fix it . 3. On 10/6/19 at 7:56 p.m., the Director of Nursing (DON) was asked to provide the incident and accident (I/A) logs from (MONTH) 2019 to the current date. 4. On 10/6/19 at 8:10 p.m., Certified Nursing Assistant (CNA) #3 was asked about the whirlpool (w/p) and shower. She stated, Yes they use the whirlpool and shower on this side. (the 300 side) She was asked, Does the whirlpool work pretty good? She stated, Yes, I think the shower works pretty good, too, She was asked, Does the water ever get too hot in the whirlpool tub? She stated, Well yes, it does, but you can adjust it. You just have to watch closely and if the water temp is going up, don't use it. She was asked, Has there been a problem with the water temp going up? She stated, No, at one time it was too cold, 93-95 to 109. She was asked, Have there ever been [MEDICAL CONDITION] hot water? She stated, No. 5. On 10/6/19 at 8:15 p.m., the DON was asked for the maintenance temp logs. She stated, I don't have them but will call him (maintenance). 6. On Monday, 10/7/19 at 8:25 a.m., CNA #4 was asked about the water temperatures and stated, We don't give baths on Sunday nights. Sometimes the water temp was up to 105 then it goes down to 95. We don't give baths on Sunday, so the temp might be higher today. She was asked, [MEDICAL CONDITION] hot water temps? She stated, No. At 8:30 a.m., Resident #53 was asked about baths/showers and water temps and he stated, I take showers; the water is warm, but they can adjust it. At 8:40 a.m., CNA 5 was asked about the bath/shower days and water temps and stated, Yes, we give baths on evenings but not on Sundays. We use the whirlpool and showers. She was asked, Any problems with the whirlpool? She stated, It gets cool sometimes, I guess you can say water temperature fluctuates. She was asked, Water temperature ever too hot? She stated, Two weeks ago, it did get up to 120 degrees; some say it was too hot, and others said it was okay. She was asked, Was the resident in the tub when the water was 120 degrees? She stated, No, the resident was not in the tub yet. I let the resident feel of the water. 7. On 10/7/19 at 10:27 a.m., Maintenance Director #1 was asked if there were any problems with the whirlpool tub on the 300 Hall. He stated, I just checked the tub and adjusted the water. He was asked, Was the water too hot? He stated, No it was cold. He was asked, Are you having problems with the mixing valve? He stated, No, they put one in the first of this year. He was asked, Who put it in? He stated, (Company name). He was asked, Can I see the invoice? He stated, (Company name) has the invoice. 8. On 10/7/19 at 11:05 a.m., several staff were interviewed and asked about the w/p and water temperatures. CNA #6 was asked, Have there been any problems with the whirlpool tub? She stated, Yes. She was asked, How long? She stated, About a month, they just fixed it this morning. She was asked, Was the water temp getting hot? She stated, Yes, scalding hot. She was asked, How hot? She stated, It has gotten up to 129 degrees. We would not put the residents in the whirlpool. She was asked, Did they know there were problems with the whirlpool temperatures? She stated, Yes. She was asked, Was the water in the reservoir hot too? She stated, Yes, it was also hot. She was asked, Were there any incidents of residents being burned? She stated, Oh, no ma'am, we knew to watch the temperatures. At 11:30 a.m., Licensed Practical Nurse (LPN) #2 was asked, Are there problems with the water temperatures for the whirlpool tub on 300 hall? She stated, Yes, there were but they just fixed it. She was asked, What was the problem with the tub? She stated, It was too cold, then he worked on it, and it was too hot. This morning, they did not use it. He worked on it, then they were able to use it. She was asked, It is working now? She stated, It was 107 degrees at 9:30 a.m.; they also worked on it last week. She was asked, Have there been any incidents/burns from the temperature going up? She stated, No. She was asked, Does the temperature in the shower get too hot? She stated, No, the shower works perfectly. 9. On 10/7/19 at 11:49 a.m., the temperature of the whirlpool was checked by the Maintenance Director and was 112 degrees. 10. On 10/8/19 at 11:10 a.m., the water temperature of the w/p was checked by the Maintenance Director and was read as 105 degrees, and then the temp went down to 83 degrees within 8 minutes. 11. On 10/11/19 at 9:30 a.m., the water temperature of the w/p was checked by the Maintenance Director and was read as 103 degrees, and then the temp went down to 82 degrees within 8 minutes. 12. The Manufacturing Guidelines for the whirlpool tub, provided by the DON on 10/10/19, documented, .Failure to heed these precautions could result in injury to the operator or resident. Perform the following safety checks daily for the (brand name) tub. 1. High temperature limit . Test the fill and shower water temperature to ensure that it reaches no more than 115 degrees Fahrenheit (lower if required by local regulations) .

Complaint # was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to prevent injury to Resident #1 during staff assisted transfers. The facility failed to ensure staff competency in the use of the mechanical lift was assessed and monitored for 1 (Resident #1) of 5 (Residents #1-5) case mix residents who required the use of the mechanical lifts for transfers. This failed practice resulted in an Immediate Jeopardy which caused or could have caused serious harm, injury or death for Resident #1 who fell from the mechanical lift while being transferred sustaining a laceration to the back of the head, and had the potential to affect 20 residents who required transfers using a mechanical lift according to the list provided by the Administrator on 1/24/14. The Immediate Jeopardy was removed by the facility on 1/7/14 prior to entrance date of survey, however the underlying deficient practices were not fully corrected. The facility was notified of the Immediate Jeopardy removed on 1/23/14 at 5:40 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 11/8/13 documented the resident had severely impaired cognitive skills for daily decision making per a staff assessment for mental status, was totally dependent on staff for transfers with two person to physical assist. a. A Nurses dated 1/7/14 at 10:00 a.m. documented, "Summoned to resident room per CNA (Certified Nursing Assistant). Upon arrival to room observed resident lying on floor on abd (abdomen) and resident's arm. CNA stated, ' the lift tilted ' , resident was being transferred from Geri-Chair to bed with use of mechanical lift. 2 CNA's in room, resident responded verbally upon evaluation. ' I'm okay ' , grips bilaterally equal. Neuro checks initiated, WNL (within normal limits). Noted superficial laceration to back of head. Area cleansed. Ambulance notified of transfer to ER (emergency room ) for treatment as indicated, family notified. 1315 (2:15 p.m.) resident returned to facility via ambulance in stable condition. " b. An Incident/ Accident Reported dated 1/7/14 at 10:00 a.m. documented, "Summoned to resident room per CNA. Upon arrival to room observed resident lying on floor on abd (abdomen) and resident's arm. CNA stated, ' the lift tilted ' , resident was being transferred from Geri-Chair to bed with use of mechanical lift. 2 CNA's in room, resident responded verbally upon evaluation. ' I'm okay ' , grips bilaterally equal. Neuro checks initiated, WNL (within normal limits). Noted superficial laceration to back of head. Area cleansed. Ambulance notified of transfer to ER (emergency room ) for treatment as indicated, family notified. Physician Notified at 10:00 a.m. on 1/7/14. Family notified at 10:15 a.m. on 1/7/14. Injury: superficial laceration. Follow-Up: Resident sent to ER for evaluation. Staff re-educated on (use) mechanical lift/return demonstration. Neuro checks initiated. " 1) On 1/22/14 at 2:40 p.m., CNA #2 was asked about the resident's fall on 1/7/14. She stated, "I've worked here for [AGE] years, I was on my way to the shower with another resident and (CNA #3) came to the resident's (Residents #1) door and told me to come in and help her. When I walked in, she had already hooked the resident up to the lift and she started lifting him, she had the wheels locked before putting him up, she weighed him, the next thing I know he hit the floor. The lift tilted over, it happened so fast." The CNA was asked did the resident get hurt. She stated, "Yes, he fell on his back, his head hit the corner of the dresser and he had a cut to his head. They took him straight to the ER for the cut on his head. They questioned us and sent me home." The CNA was asked did the other CNA (CNA #3) go home. She stated, "Well, after the incident the other CNA went on the van route with the residents. I don't know if she came back here or not." The CNA was asked where was the resident being moved from? She stated, "The bed." The CNA was asked if the other CNA (CNA#3) attempted to transfer the resident alone. She stated, "Well when I came into the room, she already had him hooked up to the lift." The CNA was asked if the lift sling was too large or small. She stated, "No, he had the right size sling, his was purple." 2) On 1/23/14 at 10:50 a.m. CNA #3 was asked if she was the one who did the weights? She stated, "Yes." She was asked if she was alone when she weighed Resident #1. The CNA stated, "No, (CNA #2) was with me." The CNA was asked what happened to cause the resident to fall. She stated, "(CNA #2) was just standing on the opposite side of the geri-chair. I was just lifting to weigh him and letting him back down when it happened. I don't know what happened." The CNA was asked did the resident get hurt. She stated, "They said he had a scratch on the head. There was some bleeding. When the resident fell another CNA (CNA#4) heard the commotion and ran in and (CNA #2) went to get a nurse." The CNA was asked if the resident was being lifted from the bed or the geri-chair. She stated, "From the geri-chair." The CNA was asked if the lift was malfunctioning on that day the resident fell . She stated, "No, it was working like it is now." The CNA was asked who does the training for mechanical lift transfers. She stated, "I did it the last two times with the ADON (Assistant Director of Nursing). Either the ADON or supervisors does it." The CNA was asked, " Were you sent home the day of the incident. " CNA #3 stated, "No, I left the building to go with the residents. I was gone the rest of the day." c. An ER Report dated 1/7/14 at 10:47 a.m. documented, "Resident presented to the ER by EMS (emergency medical service). Chief Complaint: Fall, Injury/Pain. Patient was being transferred from a chair to the bed at the nursing home. The lift went forward and the patient hit his head. Onset of symptoms was immediately prior to arrival in the ER department. Additional review of symptoms unobtainable due to patient's impaired ability to communicate. Clinical Impression: Fall, Minor head injury." A CT (Computerized Tomography) Report dated 1/7/14 documented, "admitting [DIAGNOSES REDACTED]. No evidence of subdural or epidural fluid collection or mass effect." d. On 1/21/14 at 1:53 p.m., the resident was observed lying in bed. An audit of the resident's head was done with the assistance of Licensed Practical Nurse (LPN) #1. There was a small indented healed area at the back of the residents head. No suture scars or lines visible. There was, no redness or swelling was observed. e. On 1/23/14 at 9:50 a.m., LPN #2 was asked about the slings for the lifts and how the CNA's know what size to use for each resident? She stated, "The size that each resident uses is on the CNA care plan and also in the ADL (activities of daily living) book." The LPN was asked who weighs the resident? She stated, "The restorative CNA's, there is only one working right now because the other one is off." The LPN was asked if the resident was already being transferred by CNA #3. She stated, "According to (CNA #2), yes, she was already in the process of transferring the resident. (CNA #2) told me that she was not the one operating the lift (CNA #3) was." The LPN was asked how are the CNA's trained to use the lift. The LPN stated, "There used to be an orientation where the new CNA's were trained at the time of hire; before they hit the floor, they were checked off for lift transfers. They would see the supervisor, then go to therapy to be trained in transfers using the gait belt, but that was stopped a long time ago." The LPN was asked how long ago. The LPN stated, "Over a year ago. The ADON (Assistant Director Of Nursing) is suppose to be doing the training now." The LPN was asked if the CNA's who were hired over a year ago or within the past 6 months were trained in using the lift and demonstrated knowledge of using the mechanical lift. She stated, "No, I can't say that they were." f. On 1/23/14 at 11:25 a.m., CNA #4 was asked about the resident's fall. She stated, "(CNA #2) was not in the room, she was called in by (CNA #3) because this CNA was in the room alone with the resident and she was trying to get the resident's weight." The CNA also stated, "(CNA #2) was sent home but (CNA 3) was not because she was gone out on the van the rest of the evening to take the residents to the dentist." g. On 1/23/14 3 CNA staff workers with hire dates within the past 2-., 9 months were interviewed and asked about training during orientation or since employment for the use of the mechanical lift. The responses were as follows: 1) At 10:20 a.m., CNA #1 stated, "I've worked here for 8-9 months. I was not here the day that the resident fell . " When asked if she had training to use the mechanical lift, she stated: " ...No (indicating no training during orientation or since employment), but we had training this month on using the lift." 2) At 11:25 a.m., CNA #4 was asked how long she had worked in the facility? She stated, "Four months, I started on nights." The CNA was asked if she was shown how to use the mechanical lift. She stated, "No one showed me here, honest. The only training that I had for using the lift was after the resident fell from the lift. When asked who normally does the training. She stated, "The DON did it that day. I don't know who usually does it, because I never had the training using the lift until this month." 3) At 12:00 p.m., CNA #5 was asked how long she had worked here and stated, "Three months." The CNA was asked if she was shown how to use the mechanical lift when she was hired? She stated, "I orientated on the 200 hall 2 days and on the 300 hall 2 days with two different people." The CNA was asked again if she had been trained to use the mechanical lift since here at the facility. She stated, No, not until this month." The CNA was asked did you receive this training after the resident's fall. She stated, "Yes." h. On 1/23/14 at 3:40 p.m., the Director of Nursing (DON) was asked how often training was done for mechanical lift transfers. She stated, "They're given on orientation, as needed and when there is a new lift. " The DON was asked how are they checked off as having demonstrated correct use of the lift. She stated, "We have check off sheets in their personnel files. " The DON was asked about CNA #2 most current training. She stated, "I can't tell you about hers. When I looked in the file to do the reportable, I couldn't find it." The DON was asked what happened to cause the lift to tilt. She stated, "I couldn't tell if it (lift) was locked or not." The DON was asked who does the lift instruction. She stated, "(LPN #2)." On 1/23/14 at 5:30 p.m., LPN #2 was asked when was the last time that she trained new orientees or Current CNA's to use the mechanical lift? She stated, "It has been a long time." The LPN was asked, "How long." She stated, "It's been about a year. ...I helped to train a few of the CNA's using the lift after the resident's fall." The LPN was asked if orientees were being trained now, before working on the floor. She stated, "I can't state that when they come now, they were checked off using the lift. I see the new hires on my hall, and a lot of times, I don't know when the new hires are coming to my hall until they show up." i. On 1/23/14 at 5:40 p.m., while talking with the DON and the Administrator about the incident with (Resident #1) the Administrator stated, "The lift tilted because the wheels were locked." The DON was asked at this time what had been put in place to prevent recurrence of residents falling when being transferred from mechanical lifts. She stated, "We immediately did a reportable and sent it in to OLTC (Office of Long Term Care) and had an inservice training for all staff with return demonstration. They were checked off for passing the training. They also watched the Invacare video for proper procedure using the lift." The DON was asked for documentation of how they were monitoring mechanical lift transfers to ensure they were currently being done correctly? She stated, "I don't have the monitoring documented, but I have been checking mechanical lift transfers daily." j. On 1/24/14 at 10:00 a.m., employee files were randomly reviewed for training using the mechanical lift. CNA #1 had documentation of Orientation Video check list dated 8/7/13 with no skills check-off for demonstrating use of mechanical lift prior to 1/7/14. CNA #2 had no previous documentation for training using the mechanical lift prior to 1/7/14. CNA #3 ' s most current documentation prior to 1/7/14 was dated 8/17/11for training using the Marissa lift. CNA #4 and CNA #5 had no documentation of skills check off demonstration using the mechanical lift prior to 1/7/14. k. The facility removed the Immediate Jeopardy and reduced the scope /severity to E on 1/7/14 , prior to the survey entrance date when the following actions were taken. On 1/7/14 the facility identified the issue and initiated corrective actions as follows: Incident and Accident Report completed, Investigation, to see what caused the resident to fall from the lift, Suspension of staff involved, Inservice initiated on 1/7/14 training on use of mechanical lift with return demonstration and check off after completion.

Complaint # substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure the facility's Abuse Protocol was implemented as evidenced by the facility's failure to ensure an incident between a staff member and resident that was suspicious of abuse was immediately reported to the Administrator/Designee, an investigation initiated and protection provided to prevent the potential for further abuse for 1 of 1 case mix resident (Resident #1) who sustained an injury during a staff member's attempt to provide care. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, impairment or death for Resident #1 who sustained an injury suspicious of abuse during care and had the potential to affect all 56 residents as documented on the facility's Roster/Matrix dated 11/30/11. The facility removed the immediate jeopardy prior to the survey but did not fully correct the underlying failed practices. On 12/1/11 at 3:20 p.m., the Administrator was informed of the Immediate Jeopardy removed. The findings are: 1. The facility's Abuse and Neglect Acknowledgement Policy and Procedure (no effective date given) documented, "...An internal investigation will be initiated immediately in every case of alleged resident ...abuse, mistreatment... The identification of the investigation process will include interviews with appropriate persons, including ...the resident..." 2. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 9/15/11 documented the resident had a score of 8 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), did not have any verbal or physical behavioral symptoms, required total assistance of 2 staff for transfers, limited assistance of 1 with eating, and extensive assistance of 1 with personal hygiene and toileting. a. The care plan documented, "...9/15/11 - Behavior Problem related to Confusion/Alzheimer's, Approaches: ... Provide non-confrontational environment for care, ...Monitor behavior episodes and attempt to determine under lying-cause. Consider ...person involved, etc..." b. The nurses' notes dated 4/6/11 through 11/29/11 documented the resident had a history of [REDACTED]. There was no documentation the resident was physically abusive to himself or others. c. According to the personnel file, CNA #1 had been employed by the facility since 11/9/11. On 12/1/11 at 12:07 p.m., CNA #1 was asked if the facility had inserviced him on how to intervene with combative, aggressive residents. CNA #1 stated, "Yes, ...I would try to calm them down, get the charge nurse. If you can't calm them, bring someone else to be witness with you." The Surveyor stated, "I understand the night (11/24/11) before the (11/25/11) incident you had asked to be reassigned. Tell me about that." CNA #1 stated, "When I first got here I did my room checks. It was around 3:25 p.m., I asked (Resident #1) if I could clean him up and he said no [***] , you can not. I asked him what was going on and he said all you M-----F-----s are no good. Get out. So I told (LPN #1), I refuse to go back in his room because I didn't want it to escalate. I thought that was the end of it. But I came back on Friday (11/25/11) and she assigned me to him again. She said just give it a try again. You do what the charge nurse says so I said Lord be with me. I went in and (Resident #1) was fine at the first of the shift..." d. The Nurses' Notes dated 11/25/11 at 7:00 p.m. and signed by LPN #1 documented, "CNA (CNA #1) came to this nurse and reported that resident was cursing at him when he was trying to give resident some water. Resident grabbed water pitcher out of CNA's hand and started swinging pitcher at CNA and cursing him. Resident was swinging water at CNA and Resident hit himself in the face and caused a S/T (skin tear) to Rt (right) side of nose. CNA finally got water pitcher from resident before he could injury himself further. ...Resident refused to let this nurse administer care to S/T... CNA scrubs was soaked with water from water pitcher when he reported incident to this nurse. CNA c/o (complained of) resident hit him in the face with water pitcher before CNA could get pitcher from resident... This nurse did not observe red area on CNA's face." The Incident and Accident (I/A) Report dated 11/25/11 at 7:00 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "CNA (CNA #1) came to this nurse and reported that R (resident) was cursing at him when he was trying to give R some water. R grabbed water pitcher out of CNA's hand and started swinging it at CNA and cursing at him. R hit his self in the face with water pitcher and there is a small cut on Rt (right) side of nose. CNA finally got water pitcher from R before he could injury himself further..." d. Nurses notes dated 11/25/11 at 10:00 p.m. documented, "(Resident) finally let this nurse cleanse S/T to right side of nose but would not let nurse apply Band-Aid or observe for any other injuries. All the time this nurse was trying to do care on S/T, resident was cursing calling CNA and this nurse, 'M----- F----- You want some of this' swinging his fist at staff." 1) An I/A report dated 11/25/11 at 11:25 p.m. and signed by LPN #1 documented, "CNA (CNA #1) came to this nurse and was visibly upset and c/o (complained of) (Resident #1) had got mad at him because he "CNA" was not giving him water out of the pitcher fast enough started cursing CNA and grabbed the water pitcher from CNA and started swinging it at CNA. CNA got water pitcher from (Resident #1) before resident could further hurt himself. CNA was soaked in water from water pitcher and c/o (Resident #1) hitting "CNA" in face with pitcher. (Resident #1) hit himself in the face with water pitcher and CNA finally got water pitcher from resident before resident could injure himself any more." 2) On 11/30/11 at 2:55 p.m., LPN #1 was asked if she ever had a problem with staff and residents not getting along? LPN #1 stated, "When I do I reassign the CNA." After reviewing the documentation of the incident, LPN #1 was asked if she had interviewed Resident #1 that night (11/25/11) to find out what had happened? LPN #1 stated, "Yes, He said he's trying to beat me up, you know, and stuff like that." She was asked, "He? Who is he? Are you referring to (CNA #1)?" LPN #1 stated, "Yes, he (Resident #1) said, "Get him (CNA #1) out of here." The Surveyor stated, "So the resident told you this the evening of the incident?" LPN #1 stated, "Honestly, it's all a blur and I can't remember. He was cursing me and wouldn't let me look at his nose. Let me take that (statement) back." The Surveyor stated, "If you questioned the resident that evening, why didn't you put that on your statement because all you documented was the interview with (CNA #1)?" LPN #1 stated, "Well, he was just cussing me." She was asked why she thought the resident was so upset. LPN #1 stated, "He's upset most of the time. I had to take another CNA out of there the other day." She was asked when she went in the resident's room that evening (3:00 p.m. - 11:00 p.m. shift - 11/25/11) after the incident, what did she see. LPN #1 stated, "All that was visible was the S/T on the side of the nose. He wouldn't let me touch him. Finally about 10:00 p.m. he let me clean it with normal saline." She was asked if at any point when the CNA reported this, and she saw the resident, did she feel that the CNA possibly might've done something to him (resident)? LPN #1 stated, "I did not, because later he let (CNA #1) change him. He had calmed down." She was asked if she attempted to talk to the resident at that point. LPN #1 stated, "When I started trying to talk to him be became violent again, so I left." She was asked did she feel a need to protect the resident. LPN #1 stated, "I didn't feel like (CNA #1) was a threat to that resident because I work with (CNA #1- hired 11/9/11) and I know his personality." The surveyor stated, "You said earlier that if there's a conflict between a resident and a CNA, you would reassign. Did you not feel the need to reassign CNA #1 that evening after the incident?" LPN #1 stated, "When (CNA #1) went into change (Resident #1) later, I went in the room right after him so I was in there with him." She was asked if on the previous night (11/24/11), CNA #1 had asked to be reassigned away from this resident and why. LPN #1 stated, "(Resident #1) was cussing him. (Resident #1) cusses me everyday. I just don't take it personal. I reassigned (CNA #1) the previous night and put (CNA #3) in there." She was asked why she reassigned CNA #1 to go back into Resident #1's room the next night. LPN #1 stated, "(CNA #1) is assigned to all the men but he didn't say anything that next evening about not wanting to go in there." She was asked, "Did you not feel there was a reason to keep those 2 (Resident #1 and CNA #1) apart since CNA #1 had asked to be reassigned away from Resident #1 the previous evening?" LPN #1 stated, "Like I said, he cusses me everyday and I just go about my business." She was asked, "Why was he cussing CNA #1?" LPN #1 stated, "Because he wasn't getting him water fast enough." When Resident #1 calmed down did you attempt to get someone else to go in and talk to the resident about the incident. LPN #1 stated, "No." She was asked if she told the Director of Nursing the evening before that CNA #1 had asked to stay away from Resident #1. LPN #1 stated, "No." 3) On 12/1/11 at 12:07 p.m., CNA #1 stated, "...After supper I went in to clean him (Resident #1) up again and he said [***] give me some water. I told him to calm down and he was upset because he said someone had messed with his bed. I gave him the pitcher and he said M-----F----- [***] ain't[***]and whacked me in the face with the pitcher. I fell back. I looked up and he was swinging the pitcher and hitting himself in the face. I was yelling, Help! Help! No one came so I grabbed the pitcher and ran out the room." The surveyor asked, "What do you mean by 'he was swinging the pitcher'?" CNA #1 stated, "He was swinging the pitcher trying to hit me. I didn't know he had that much strength." The Surveyors stated, "You stated you have been trained to back off when residents are combative or agitated. Why didn't you do that with Resident #1?" CNA #1 stated, "Because they say if the residents could hurt themselves then do what you can do. I probably was wrong by not stopping, but I feel like it would've been wrong not to try to stop him from hurting himself more." CNA #1 was asked, "If the resident sustained [REDACTED].?" CNA #1 stated, "When I left out of the room, I didn't see anything because I didn't really focus on that. When I went back in the room with (LPN #1) I saw the knot on his head and the S/T on his nose. I don't really know when the injuries occurred." CNA #1 was asked how he took the pitcher from the resident. CNA #1 demonstrated that he grabbed and held Resident #1's left wrist down and pulled the pitcher out of his left hand. CNA #1 was asked if he was told to take someone in the room with him when providing care to Resident #1. CNA #1 stated, "No." CNA #1 was asked, "After the incident that evening, do you know why the nurse didn't reassign you for the rest of the shift on 11/25/11?" CNA #1 stated, "I said I didn't want to go back in there. I don't know why she didn't. If I had been reassigned to begin with, I wouldn't be in this predicament. Always, even since the 90's (1990's), if I feel uncomfortable in a situation, I've been reassigned." CNA #1 was asked if he provided care to Resident #1 the rest of the shift? CNA #1 stated, "I didn't go back in by myself. I did go back in to change him, but (LPN #1) was in there." CNA #1 was asked why he asked to be reassigned on 11/24/11. CNA #1 stated, "Because he (Resident #1) was aggressive and I was worried something would happen, not that I would lose my temper. I was scared of him. I feel like it could have been avoided. This is something serious. It all goes back to the assignments. I would never hit someone, even if they hit me." 4) On 11/30/11 at 4:00 p.m., CNA #3 was asked what the facility instructed her to do if a resident becomes aggressive or combative. CNA #3 stated, "...walk away, leave about 5 - 10 minutes, tell the nurse, try to get someone else to go and take care of them." CNA #3 stated, "I worked 11/24/11 (Thursday) and heard (CNA #1) tell the nurse (LPN #1) that (Resident #1) was cursing him and he wanted to be reassigned. So I was asked to switch with (CNA #1) and I did. I didn't have any problems with (Resident #1). The next night, I over heard (CNA #1) telling the nurse about the situation on 11/25/11. I didn't witness anything that went on in the room. I've never known (Resident #1) to hit himself. He has a history of swinging at me, but never hit me." 5) On 12/1/11 at 8:20 a.m., the DON was asked what she inserviced her staff to do when a resident becomes combative or aggressive? The DON stated, "...Make sure the resident is safe, give them time to cool off, report to the nurse, let them assess the resident then go back later." She was asked when she became aware that CNA #1 had requested to be reassigned on 11/24/11, prior to the incident. The DON stated, "On 11/30/11 (4 days later)." She was asked what did LPN #1 report to her when she called and left a voice message on 11/25/11. The DON stated, "(Resident #1) was showing out. He's cussing (CNA #1). (CNA #1) wasn't getting his water fast enough and something about a straw." e. The Nurses' Notes dated 11/26/11 at 9:45 a.m. and signed by LPN #2 documented, "Summoned to room by CNA. Resident presents with quarter sized bump to right forehead, scratch approx. (approximately) 1/2 inch long below right eye and some bruising and 6 inch scratch across abdomen. Resident states, 'that long brown girl whooped me down.' Reported to (Weekend RN)." The Nurses' Notes dated 11/26/11 at 9:50 a.m. and signed by Registered Nurse (RN #1) documented, "Resident resting in supine position with HOB (head of the bed) elevated slightly. Bump on right side of head approx. 2.0 cm (centimeters) in diameter noted and 2 scratches under right eye on lateral part of nose. Also scratch on abd (abdomen)/lower chest at center line of chest across left part of abd (abdomen), when asked what happened resident replied 'that tall skinny brown skinned girl who's been taking care of me the past 3 or 4 days came in here yesterday evening, she was mad, and started hitting on me down in this bed.' Asked resident if she said anything as to why and he replied, 'No, I don't know why she's been kind of smart with me and I just didn't talk to her. Now I have this bump on my head and that lady that passes the pills, she cleaned up the blood on my face where these scratches are.' Resident again states, 'that black girl was all over me down in this bed.' ...Director of Nursing (DON) notified of above information. DON to notify Administrator." f. The DMS-7734 documented, "...On 11/26/11 at approximately 9:45 a.m. (Resident #1) reported to (CNA #2) and (LPN #2) that 'a tall skinny brown skinned girl who's been taking care of me the past 3 or 4 days came in here yesterday evening and she was mad and started hitting on me down in this bed.' Resident stated he didn't know why but she's been 'kinda smart' with him so he just didn't talk to her." 1) Nurses Notes dated 11/26/11 at 1:00 p.m. documented, "(Police) Officer at facility to take report... (Officer asked) Well sir, can how did you got that knot in your head? Resident states, 'That tall skinny brown girl who been helping me lately came in here last night and started whooping me down in this bed.' Officer asked resident if he knew what may have caused the attack? Resident stated, 'I don't know, she been kind of having a bad attitude with me lately.' Officer asked resident if he knew who it was? Resident states, 'I don't know her name, but if I saw her I'd tell ya.' 2) The police report documented, "...On 11/26/11 at 1320 (1:20 p.m.) hours I was dispatched to (nursing home) in reference to a battery report. ...(RN #1) is the in-charge registered nurse on duty at the (nursing home) and (RN #1) stated she received information that a resident (Resident #1) had possibly been abused by (CNA #1). (RN #1) performed a preliminary investigation and took a statement from (Resident #1) ...(Resident #1) stated he requested some water from (CNA #1). (CNA #1) came into the room with a pitcher of water and started beating (Resident #1) with the pitcher. (Resident #1) had several cuts and abrasions on his face and a large knot on the right side of his forehead just over his right eye. (Resident #1) also had an approximate 4 inch scratch across his abdomen. I then spoke with the suspect (CNA #1), states he has been assigned to (Resident #1) for the last three nights. The second day (11/24/11) to work with (Resident #1), he attacked (CNA #1) verbally. (CNA #1) asked the charge nurse to remove (Resident #1) from his care and assign him (CNA #1) someone else. The charge nurse still placed (Resident #1) in (CNA #1's) care. On the third day (11/25/11) at approx. 1900 (7:00 p.m.) hours (CNA #1) entered (Resident #1's) room to carry him some water. (CNA #1) states (Resident #1) snatched the pitcher out of his hands and hit (CNA #1) with the pitcher. (Resident #1) continued swinging the pitcher wildly eventually striking himself in the head and face with the pitcher. To keep (Resident #1) from further hurting himself, (CNA #1) ran in and took the pitcher away from (Resident #1) and ran down the hallway to tell his supervisor." g The DMS-7734 witness statements: 1) The witness statement signed by CNA #1 documented, "I, CNA #1, first went in the resident's room and asked him could I clean him up. He said yes and I did that and he was good. But when I went back in the room... the resident said "[***] give me some water". And he said that [***] came in here and did something to my bed and I said, "Calm down (Resident #1) and when I went on and gave him the pitcher of water he grabbed it from me and said that "You [***] es are not up to no good" and started to swing that pitcher out of control and he hit me in the face so I fell back and water was in my face and so he said that, "M-----f----- and about s--- and he was swing that pitcher out of control and he was hitting himself in the face with the water pitcher. And I was scream out help me, no one came and so I got the water pitcher out of his hand and run out on the hallway and found the nurse and told her what happen and she said that ok. And she went in there and look at him. And he told her 'yea [***] I hit that m-----f----- and I will do the same to you.' My uniform was soaking wet with water and my face was red ...the nurse didn't ask me to write a statement or anything. And the day before (11/24/11) the resident went off calling me names and I said that I don't want to go back in that room and I told the nurse and (CNA #3) had to. And so I came back the same next day into something much bigger and crazyer. So I think that I did that right things. But its seem that I was wrong but I know what I do I have been doing this cont. 98s (1998) so I know what to do. But she (LPN #1) still didn't take me out that room. After I said that I did not want to go back in the room." 2) The witness statement signed by LPN #1 documented, "CNA (CNA #1) came to this nurse with scrubs all wet and water pitcher in his hand. CNA c/o R grabbing water pitcher out of CNA's hand when he was try to give R some water. CNA c/o R hitting him in the face with water pitcher. CNA was able to get water pitcher away from R before R injured himself or CNA any more. This nurse entered R room and observed R had S/T to Rt (right) side of nose with small amount of blood. R was cursing CNA and this nurse. R refused treatment to face from this nurse. At 10:00 p.m. R finally let this nurse cleanse S/T to Rt side of nose but refused Band-Aid. ...R was cursing CNA calling him a M-----F-----. cursing this nurse calling her a Nappy Headed N----- and M-----F-----. This nurse replied, 'thank you (Resident #1) and walked out of the R room." h. On 11/30/11 at 8:30 a.m., the resident was in bed. He had bluish discoloration/bruise under right eye with slight swelling noted. He had a scratch approximately 2 centimeters on his upper forehead. He was asked what happened. The resident stated, "Some man woman hit me, or whatever she is and she ain't been back in here neither." The resident was asked if he hit himself and he said, "No." i. On 12/1/11 at at 1:55 p.m., the DON was asked what the facility had done to prevent this incident from happening again. The DON stated, "We did an inservice on abuse on 11/27/11, nothing on behaviors yet and we did dignity on 12/1/11." At 3:50 p.m., the DON stated she spoke with (RN #1) (weekend supervisor) and asked her if she read CNA #1's statement she received on 11/26/11 and RN #1 told her she did not read it. The RN did not report to her that CNA #1 had made a request not to provide care to Resident #1 on 11/24/11. RN #1 did not report that LPN #1 assigned CNA #1 again to Resident #1 on 11/25/11 as documented on CNA #1's statement. i. The facility removed the Immediate Jeopardy and reduced the scope/severity to "G" by taking the following corrective actions prior to the survey entrance date: 1) CNA #1 was suspended on 11/26/11 pending investigation 2) Staff were inserviced regarding "Nursing Home Abuse" on 11/27/11 3) LPN #1 was verbally counseled on 11/28/11 (not documented until 12/1/11) regarding reassignment of CNAs who have issues with resident behaviors, immediate removal of involved staff when an incident between resident/staff occurs, and immediate investigations of suspicious incidents/injuries. (LPN #1 was suspended pending investigation on 12/1/11)

Complaint # substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure an incident between a staff member and resident that was suspicious of abuse was immediately reported to the Administrator/Designee, an investigation initiated and protection provided to prevent the potential for further abuse for 1 of 1 case mix resident (Resident #1) who sustained an injury during a staff member's attempt to provide care. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, impairment or death for Resident #1 who sustained an injury suspicious of abuse during care and had the potential to affect all 56 residents as documented on the facility's Roster/Matrix dated 11/30/11. The facility removed the immediate jeopardy prior to the survey but did not fully correct the underlying failed practices. On 12/1/11 at 3:20 p.m., the Administrator was informed of the Immediate Jeopardy removed. The findings are: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 9/15/11 documented the resident had a score of 8 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), did not have any verbal or physical behavioral symptoms, required total assistance of 2 staff for transfers, limited assistance of 1 with eating, and extensive assistance of 1 with personal hygiene and toileting. a. The care plan documented, "...9/15/11 - Behavior Problem related to Confusion/Alzheimer's, Approaches: ... Provide non-confrontational environment for care, ...Monitor behavior episodes and attempt to determine under lying-cause. Consider ...person involved, etc..." b. The nurses' notes dated 4/6/11 through 11/29/11 documented the resident had a history of [REDACTED]. There was no documentation the resident was physically abusive to himself or others. c. According to the personnel file, CNA #1 had been employed by the facility since 11/9/11. On 12/1/11 at 12:07 p.m., CNA #1 was asked if the facility had inserviced him on how to intervene with combative, aggressive residents. CNA #1 stated, "Yes, ...I would try to calm them down, get the charge nurse. If you can't calm them, bring someone else to be witness with you." The Surveyor stated, "I understand the night (11/24/11) before the (11/25/11) incident you had asked to be reassigned. Tell me about that." CNA #1 stated, "When I first got here I did my room checks. It was around 3:25 p.m., I asked (Resident #1) if I could clean him up and he said no [***] , you can not. I asked him what was going on and he said all you M-----F-----s are no good. Get out. So I told (LPN #1), I refuse to go back in his room because I didn't want it to escalate. I thought that was the end of it. But I came back on Friday (11/25/11) and she assigned me to him again. She said just give it a try again. You do what the charge nurse says so I said Lord be with me. I went in and (Resident #1) was fine at the first of the shift..." d. The Nurses' Notes dated 11/25/11 at 7:00 p.m. and signed by LPN #1 documented, "CNA (CNA #1) came to this nurse and reported that resident was cursing at him when he was trying to give resident some water. Resident grabbed water pitcher out of CNA's hand and started swinging pitcher at CNA and cursing him. Resident was swinging water at CNA and Resident hit himself in the face and caused a S/T (skin tear) to Rt (right) side of nose. CNA finally got water pitcher from resident before he could injury himself further. ...Resident refused to let this nurse administer care to S/T... CNA scrubs was soaked with water from water pitcher when he reported incident to this nurse. CNA c/o (complained of) resident hit him in the face with water pitcher before CNA could get pitcher from resident... This nurse did not observe red area on CNA's face." The Incident and Accident (I/A) Report dated 11/25/11 at 7:00 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "CNA (CNA #1) came to this nurse and reported that R (resident) was cursing at him when he was trying to give R some water. R grabbed water pitcher out of CNA's hand and started swinging it at CNA and cursing at him. R hit his self in the face with water pitcher and there is a small cut on Rt (right) side of nose. CNA finally got water pitcher from R before he could injury himself further..." d. Nurses notes dated 11/25/11 at 10:00 p.m. documented, "(Resident) finally let this nurse cleanse S/T to right side of nose but would not let nurse apply Band-Aid or observe for any other injuries. All the time this nurse was trying to do care on S/T, resident was cursing calling CNA and this nurse, 'M----- F----- You want some of this' swinging his fist at staff." 1) An I/A report dated 11/25/11 at 11:25 p.m. and signed by LPN #1 documented, "CNA (CNA #1) came to this nurse and was visibly upset and c/o (complained of) (Resident #1) had got mad at him because he "CNA" was not giving him water out of the pitcher fast enough started cursing CNA and grabbed the water pitcher from CNA and started swinging it at CNA. CNA got water pitcher from (Resident #1) before resident could further hurt himself. CNA was soaked in water from water pitcher and c/o (Resident #1) hitting "CNA" in face with pitcher. (Resident #1) hit himself in the face with water pitcher and CNA finally got water pitcher from resident before resident could injure himself any more." 2) On 11/30/11 at 2:55 p.m., LPN #1 was asked if she ever had a problem with staff and residents not getting along? LPN #1 stated, "When I do I reassign the CNA." After reviewing the documentation of the incident, LPN #1 was asked if she had interviewed Resident #1 that night (11/25/11) to find out what had happened? LPN #1 stated, "Yes, He said he's trying to beat me up, you know, and stuff like that." She was asked, "He? Who is he? Are you referring to (CNA #1)?" LPN #1 stated, "Yes, he (Resident #1) said, "Get him (CNA #1) out of here." The Surveyor stated, "So the resident told you this the evening of the incident?" LPN #1 stated, "Honestly, it's all a blur and I can't remember. He was cursing me and wouldn't let me look at his nose. Let me take that (statement) back." The Surveyor stated, "If you questioned the resident that evening, why didn't you put that on your statement because all you documented was the interview with (CNA #1)?" LPN #1 stated, "Well, he was just cussing me." She was asked why she thought the resident was so upset. LPN #1 stated, "He's upset most of the time. I had to take another CNA out of there the other day." She was asked when she went in the resident's room that evening (3:00 p.m. - 11:00 p.m. shift - 11/25/11) after the incident, what did she see. LPN #1 stated, "All that was visible was the S/T on the side of the nose. He wouldn't let me touch him. Finally about 10:00 p.m. he let me clean it with normal saline." She was asked if at any point when the CNA reported this, and she saw the resident, did she feel that the CNA possibly might've done something to him (resident)? LPN #1 stated, "I did not, because later he let (CNA #1) change him. He had calmed down." She was asked if she attempted to talk to the resident at that point. LPN #1 stated, "When I started trying to talk to him be became violent again, so I left." She was asked did she feel a need to protect the resident. LPN #1 stated, "I didn't feel like (CNA #1) was a threat to that resident because I work with (CNA #1- hired 11/9/11) and I know his personality." The surveyor stated, "You said earlier that if there's a conflict between a resident and a CNA, you would reassign. Did you not feel the need to reassign CNA #1 that evening after the incident?" LPN #1 stated, "When (CNA #1) went into change (Resident #1) later, I went in the room right after him so I was in there with him." She was asked if on the previous night (11/24/11), CNA #1 had asked to be reassigned away from this resident and why. LPN #1 stated, "(Resident #1) was cussing him. (Resident #1) cusses me everyday. I just don't take it personal. I reassigned (CNA #1) the previous night and put (CNA #3) in there." She was asked why she reassigned CNA #1 to go back into Resident #1's room the next night. LPN #1 stated, "(CNA #1) is assigned to all the men but he didn't say anything that next evening about not wanting to go in there." She was asked, "Did you not feel there was a reason to keep those 2 (Resident #1 and CNA #1) apart since CNA #1 had asked to be reassigned away from Resident #1 the previous evening?" LPN #1 stated, "Like I said, he cusses me everyday and I just go about my business." She was asked, "Why was he cussing CNA #1?" LPN #1 stated, "Because he wasn't getting him water fast enough." When Resident #1 calmed down did you attempt to get someone else to go in and talk to the resident about the incident. LPN #1 stated, "No." She was asked if she told the Director of Nursing the evening before that CNA #1 had asked to stay away from Resident #1. LPN #1 stated, "No." 3) On 12/1/11 at 12:07 p.m., CNA #1 stated, "...After supper I went in to clean him (Resident #1) up again and he said [***] give me some water. I told him to calm down and he was upset because he said someone had messed with his bed. I gave him the pitcher and he said M-----F----- [***] ain't[***]and whacked me in the face with the pitcher. I fell back. I looked up and he was swinging the pitcher and hitting himself in the face. I was yelling, Help! Help! No one came so I grabbed the pitcher and ran out the room." The surveyor asked, "What do you mean by 'he was swinging the pitcher'?" CNA #1 stated, "He was swinging the pitcher trying to hit me. I didn't know he had that much strength." The Surveyors stated, "You stated you have been trained to back off when residents are combative or agitated. Why didn't you do that with Resident #1?" CNA #1 stated, "Because they say if the residents could hurt themselves then do what you can do. I probably was wrong by not stopping, but I feel like it would've been wrong not to try to stop him from hurting himself more." CNA #1 was asked, "If the resident sustained [REDACTED].?" CNA #1 stated, "When I left out of the room, I didn't see anything because I didn't really focus on that. When I went back in the room with (LPN #1) I saw the knot on his head and the S/T on his nose. I don't really know when the injuries occurred." CNA #1 was asked how he took the pitcher from the resident. CNA #1 demonstrated that he grabbed and held Resident #1's left wrist down and pulled the pitcher out of his left hand. CNA #1 was asked if he was told to take someone in the room with him when providing care to Resident #1. CNA #1 stated, "No." CNA #1 was asked, "After the incident that evening, do you know why the nurse didn't reassign you for the rest of the shift on 11/25/11?" CNA #1 stated, "I said I didn't want to go back in there. I don't know why she didn't. If I had been reassigned to begin with, I wouldn't be in this predicament. Always, even since the 90's (1990's), if I feel uncomfortable in a situation, I've been reassigned." CNA #1 was asked if he provided care to Resident #1 the rest of the shift? CNA #1 stated, "I didn't go back in by myself. I did go back in to change him, but (LPN #1) was in there." CNA #1 was asked why he asked to be reassigned on 11/24/11. CNA #1 stated, "Because he (Resident #1) was aggressive and I was worried something would happen, not that I would lose my temper. I was scared of him. I feel like it could have been avoided. This is something serious. It all goes back to the assignments. I would never hit someone, even if they hit me." 4) On 11/30/11 at 4:00 p.m., CNA #3 was asked what the facility instructed her to do if a resident becomes aggressive or combative. CNA #3 stated, "...walk away, leave about 5 - 10 minutes, tell the nurse, try to get someone else to go and take care of them." CNA #3 stated, "I worked 11/24/11 (Thursday) and heard (CNA #1) tell the nurse (LPN #1) that (Resident #1) was cursing him and he wanted to be reassigned. So I was asked to switch with (CNA #1) and I did. I didn't have any problems with (Resident #1). The next night, I over heard (CNA #1) telling the nurse about the situation on 11/25/11. I didn't witness anything that went on in the room. I've never known (Resident #1) to hit himself. He has a history of swinging at me, but never hit me." 5) On 12/1/11 at 8:20 a.m., the DON was asked what she inserviced her staff to do when a resident becomes combative or aggressive? The DON stated, "...Make sure the resident is safe, give them time to cool off, report to the nurse, let them assess the resident then go back later." She was asked when she became aware that CNA #1 had requested to be reassigned on 11/24/11, prior to the incident. The DON stated, "On 11/30/11 (4 days later)." She was asked what did LPN #1 report to her when she called and left a voice message on 11/25/11. The DON stated, "(Resident #1) was showing out. He's cussing (CNA #1). (CNA #1) wasn't getting his water fast enough and something about a straw." e. The Nurses' Notes dated 11/26/11 at 9:45 a.m. and signed by LPN #2 documented, "Summoned to room by CNA. Resident presents with quarter sized bump to right forehead, scratch approx. (approximately) 1/2 inch long below right eye and some bruising and 6 inch scratch across abdomen. Resident states, 'that long brown girl whooped me down.' Reported to (Weekend RN)." The Nurses' Notes dated 11/26/11 at 9:50 a.m. and signed by Registered Nurse (RN #1) documented, "Resident resting in supine position with HOB (head of the bed) elevated slightly. Bump on right side of head approx. 2.0 cm (centimeters) in diameter noted and 2 scratches under right eye on lateral part of nose. Also scratch on abd (abdomen)/lower chest at center line of chest across left part of abd (abdomen), when asked what happened resident replied 'that tall skinny brown skinned girl who's been taking care of me the past 3 or 4 days came in here yesterday evening, she was mad, and started hitting on me down in this bed.' Asked resident if she said anything as to why and he replied, 'No, I don't know why she's been kind of smart with me and I just didn't talk to her. Now I have this bump on my head and that lady that passes the pills, she cleaned up the blood on my face where these scratches are.' Resident again states, 'that black girl was all over me down in this bed.' ...Director of Nursing (DON) notified of above information. DON to notify Administrator." f. The DMS-7734 documented, "...On 11/26/11 at approximately 9:45 a.m. (Resident #1) reported to (CNA #2) and (LPN #2) that 'a tall skinny brown skinned girl who's been taking care of me the past 3 or 4 days came in here yesterday evening and she was mad and started hitting on me down in this bed.' Resident stated he didn't know why but she's been 'kinda smart' with him so he just didn't talk to her." 1) Nurses Notes dated 11/26/11 at 1:00 p.m. documented, "(Police) Officer at facility to take report... (Officer asked) Well sir, can how did you got that knot in your head? Resident states, 'That tall skinny brown girl who been helping me lately came in here last night and started whooping me down in this bed.' Officer asked resident if he knew what may have caused the attack? Resident stated, 'I don't know, she been kind of having a bad attitude with me lately.' Officer asked resident if he knew who it was? Resident states, 'I don't know her name, but if I saw her I'd tell ya." 2) The police report documented, "...On 11/26/11 at 1320 (1:20 p.m.) hours I was dispatched to (nursing home) in reference to a battery report. ...(RN #1) is the in-charge registered nurse on duty at the (nursing home) and (RN #1) stated she received information that a resident (Resident #1) had possibly been abused by (CNA #1). (RN #1) performed a preliminary investigation and took a statement from (Resident #1) ...(Resident #1) stated he requested some water from (CNA #1). (CNA #1) came into the room with a pitcher of water and started beating (Resident #1) with the pitcher. (Resident #1) had several cuts and abrasions on his face and a large knot on the right side of his forehead just over his right eye. (Resident #1) also had an approximate 4 inch scratch across his abdomen. I then spoke with the suspect (CNA #1), states he has been assigned to (Resident #1) for the last three nights. The second day (11/24/11) to work with (Resident #1), he attacked (CNA #1) verbally. (CNA #1) asked the charge nurse to remove (Resident #1) from his care and assign him (CNA #1) someone else. The charge nurse still placed (Resident #1) in (CNA #1's) care. On the third day (11/25/11) at approx. 1900 (7:00 p.m.) hours (CNA #1) entered (Resident #1's) room to carry him some water. (CNA #1) states (Resident #1) snatched the pitcher out of his hands and hit (CNA #1) with the pitcher. (Resident #1) continued swinging the pitcher wildly eventually striking himself in the head and face with the pitcher. To keep (Resident #1) from further hurting himself, (CNA #1) ran in and took the pitcher away from (Resident #1) and ran down the hallway to tell his supervisor." g The DMS-7734 witness statements: 1) The witness statement signed by CNA #1 documented, "I, CNA #1, first went in the resident's room and asked him could I clean him up. He said yes and I did that and he was good. But when I went back in the room... the resident said "[***] give me some water". And he said that [***] came in here and did something to my bed and I said, "Calm down (Resident #1) and when I went on and gave him the pitcher of water he grabbed it from me and said that "You [***] es are not up to no good" and started to swing that pitcher out of control and he hit me in the face so I fell back and water was in my face and so he said that, "M-----f----- and about s--- and he was swing that pitcher out of control and he was hitting himself in the face with the water pitcher. And I was scream out help me, no one came and so I got the water pitcher out of his hand and run out on the hallway and found the nurse and told her what happen and she said that ok. And she went in there and look at him. And he told her 'yea [***] I hit that m-----f----- and I will do the same to you.' My uniform was soaking wet with water and my face was red ...the nurse didn't ask me to write a statement or anything. And the day before (11/24/11) the resident went off calling me names and I said that I don't want to go back in that room and I told the nurse and (CNA #3) had to. And so I came back the same next day into something much bigger and crazyer. So I think that I did that right things. But its seem that I was wrong but I know what I do I have been doing this cont. 98s (1998) so I know what to do. But she (LPN #1) still didn't take me out that room. After I said that I did not want to go back in the room." 2) The witness statement signed by LPN #1 documented, "CNA (CNA #1) came to this nurse with scrubs all wet and water pitcher in his hand. CNA c/o R grabbing water pitcher out of CNA's hand when he was try to give R some water. CNA c/o R hitting him in the face with water pitcher. CNA was able to get water pitcher away from R before R injured himself or CNA any more. This nurse entered R room and observed R had S/T to Rt (right) side of nose with small amount of blood. R was cursing CNA and this nurse. R refused treatment to face from this nurse. At 10:00 p.m. R finally let this nurse cleanse S/T to Rt side of nose but refused Band-Aid. ...R was cursing CNA calling him a M-----F-----. cursing this nurse calling her a Nappy Headed N----- and M-----F-----. This nurse replied, 'thank you (Resident #1) and walked out of the R room." h. On 11/30/11 at 8:30 a.m., the resident was in bed. He had bluish discoloration/bruise under right eye with slight swelling noted. He had a scratch approximately 2 centimeters on his upper forehead. He was asked what happened. The resident stated, "Some man woman hit me, or whatever she is and she ain't been back in here neither." The resident was asked if he hit himself and he said, "No." i. On 12/1/11 at at 1:55 p.m., the DON was asked what the facility had done to prevent this incident from happening again. The DON stated, "We did an inservice on abuse on 11/27/11, nothing on behaviors yet and we did dignity on 12/1/11." At 3:50 p.m., the DON stated she spoke with (RN #1) (weekend supervisor) and asked her if she read CNA #1's statement she received on 11/26/11 and RN #1 told her she did not read it. The RN did not report to her that CNA #1 had made a request not to provide care to Resident #1 on 11/24/11. RN #1 did not report that LPN #1 assigned CNA #1 again to Resident #1 on 11/25/11 as documented on CNA #1's statement. i. The facility removed the Immediate Jeopardy and reduced the scope/severity to "G" by taking the following corrective actions prior to the survey entrance date: 1) CNA #1 was suspended on 11/26/11 pending investigation 2) Staff were inserviced regarding "Nursing Home Abuse" on 11/27/11 3) LPN #1 was verbally counseled on 11/28/11 (not documented until 12/1/11) regarding reassignment of CNAs who have issues with resident behaviors, immediate removal of involved staff when an incident between resident/staff occurs, and immediate investigations of suspicious incidents/injuries. (LPN #1 was suspended pending investigation on 12/1/11)

Complaint # was substantiated all or in part in these findings. A. Based on observation, record review, and interview, the facility failed to ensure staff responded promptly and appropriately to significant changes in resident condition as evidenced by the facility failures to ensure: Significant changes in resident condition were immediately identified, assessed, and documented upon returns from emergency room ; [MEDICAL CONDITION] precautions were taken after the [DIAGNOSES REDACTED].#16) of 4 (Residents #1, #8, #1 and #16) case mix residents who had [MEDICAL CONDITION] or significant changes in condition. The facility also failed to ensure that diagnostic brain scans were obtained as ordered following a head injury for 1 (Resident #16) of 1 (Resident #16) case mix residents who had brain scans ordered following a head injury. Neurological assessments were performed after the first 24 hours post fall to monitor for complications from a head injury ; and potentially significant changes in resident condition post fall were promptly identified, assessed, and physician consulted for 1 of 1 (Resident #17) case mix residents who sustained a head injury secondary to a fall. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, impairment or death to Resident #16 and Resident #17 and had the potential to cause more than minimal harm to 3 residents who could potentially experience a change of condition, as identified by the MDS/Nurse Consultant on 9/3/10 at 10:00 p.m.; 9 residents who had [MEDICAL CONDITION] as identified by the Licensed Practical Nursing (LPN) Consultant on 9/3/10 at 10:00 p.m.; and 6 residents who were at risk for injury from falls, as identified by the Nurse Consultant on 9/3/10 at 10:00 p.m. The facility was informed of the Immediate Jeopardy on 9/3/10 at 3:20 p.m. The findings are: 1. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Nurses Notes dated 8/28/10 at 12:20 a.m. documented, "This nurse was summon to room (number) where R (resident) was found by CNA (certified nursing assistant) on the floor wrapped in a sheet snoring loudly. (Resident) was between bed (and) nightstand when she was rolled over blood was coming from her mouth several attempts were made to arouse her. Emergency Transport called vitals were BP (blood pressure) 130/80, (pulse) 106 (respirations)16. (Physician) family and DON (Director of Nursing) notified." The Initial Assessment Form from the emergency room dated 8/28/10 and time noted as 1:05 a.m. documented: " ...Chief Complaint Mouth Injury (Mod (moderate)-Severe) ...According to Nsg (Nursing) Home personnel patient was found lying on the floor with her blankets - it was unclear if patient ...could have fallen or had a [MEDICAL CONDITION] - lacerations are noted on both sides of tongue ... " The Physician Documentation form documented: " ...Review of Systems: positive confusion, positive [MEDICAL CONDITION] ...Patient discharged to Nursing Home Condition: Stable, satisfactory ...Patient ' s condition non-emergent. Disposition ...08/28/2010 01:23 (1:23 a.m.). Discussed care with Nurse. Explained findings, diagnosis, and need for follow-up care ..." The Patient Disposition Page dated 8/28/10 at 1:55 a.m. documented: " ...Discharge Diagnoses: [REDACTED]. b. Nurses Notes dated 8/28/10 at 2:15 a.m. documented, "(Resident) just returned from ER (emergency room ) paper work from hospital behind physician's orders [REDACTED]. 128/74, 66, 20, 97.3." There was no documentation in the Nurses Notes that [MEDICAL CONDITION] precautions were taken upon the resident ' s return to the nursing home. c. Nurses Notes dated 8/28/10 at 3:15 a.m. documented, "This nurse summons to room (number) resident found having [MEDICAL CONDITION] activities per CNA stepped in hall (and) called for nurse. side rails (down) resident fell on floor continuing in [MEDICAL CONDITION] activities. phoned 911 to respond." On 9/3/10 at 2:00 p.m., the Director of Nursing (DON) was asked if an investigation was completed on the 8/28/10 incidents about what was done regarding the CNA (certified nursing assistant) that stepped away from the resident's bed with the side rails down prior to the second fall. The DON stated, "Yes there was an investigation. Not a written investigation or action taken. We just talked to her. I don't know who the CNA was." d. The hospital initial assessment form dated 8/28/10 at 3:40 a.m. documented, "Semi-emergent Chief complaint Head Injury (mod-severe)." The hospital history and physical form dated 8/28/10 at 3:58 a.m. documented, "...Chief Complaint--Head Injury (Mod-Severe) ...Onset of symptoms was immediately prior to arrival in the Emergency Department. Symptoms came on suddenly. Injury occurred in nursing home. Patient sustained injury as a result of fall. fell from standing position. Mechanism of injury unknown. Patient found unresponsive. On EMS (emergency medical services) arrival to NH (nursing home) pt confused and on what look like postictal (pertaining to the period following a [MEDICAL CONDITION] or convulsion), pt was just d/c (discharged ) from the ED (emergency department) with a DX (diagnosis) of [MEDICAL CONDITION] Symptoms located in the left frontal area of the head. Associated signs and symptoms:...positive laceration, ...Neurological: positive confusion, positive [MEDICAL CONDITION].Physical Examination ...Skin: Laceration: Simple, Length-2 cm (centimeters), location: Forehead, linear, extending incompletely through dermis, margins sharp, clean, no active bleeding ...Neurologic: ...Disoriented to place, time. ...Clinical Impression: 8/28/10 6:02 a.m. 1. Contusion Head 2. Simple Laceration: Forehead 3. [MEDICAL CONDITION]. ...Patient's condition was emergent...Laceration that is jagged, to the Left Forehead, bleeding is controlled, approximately 4 centimeters long. ...Neurological: [MEDICAL CONDITION] observed while in ED....Neurological: Witness [MEDICAL CONDITION] while still in collar and spinal immobilization. Blood noted from mouth. Pt with snoring respirations and tonic movements noted...Disposition: 8/28/10 7:12 a.m. Admit: Patient's disposition is: Admit-IMCU (intensive medical care unit)[MEDICAL CONDITION] observed while in ED. [MEDICAL CONDITION] have occurred multiple times within 24 hours..." A hospital history and physical dated 8/28/10 documented, "...She apparently was found on the floor in the nursing home. There was a question of her having a [MEDICAL CONDITION]. ...She has been admitted for further evaluation and for institution of anticonvulsant therapy...." A hospital consultation report dated 8/28/10 documented, "Reason for consultation: Evaluation of new-onset [MEDICAL CONDITION]. ...CT scans of the head and neck were ordered, but the scanner broke down in the middle of her brain scan. ...I contacted the nursing home and the nurse who was on duty told me that (resident) was "fairly new to us", having been admitted there only in the last couple of weeks. She says her admission information indicates a history of hypertension, dementia, [MEDICAL CONDITION], and diabetes, although no hypoglycemic medications were ordered and no blood sugars were ordered. No history and physical is on the chart at the nursing home as yet. Nursing assessment stated the patient was alert and had impaired memory, although the nursing assessment also says "alert and oriented X 3" (the nurse who spoke indicates they have an automated medical record and suggested that this record or orientation was not accurate.)...I note from records in the computer that as far back as 2002, the patient was stated to have had a "[MEDICAL CONDITION] disorder,"...5. I would get a CT scan of the brain since she has had some recent falls, to make sure she does not have a subdural hematoma. I do not think that brain imaging is urgent enough to warrant getting an MRI because of the fact the CT scanner is "down", but I would simply wait for the CT scanner to become available again and then do a brain CT." e. A hospital Patient Discharge Instructions dated 8/30/10 at 2:30 p.m. documented, "...Principal [DIAGNOSES REDACTED]." f. There was no entry in the Nurses Notes that documented the date and time the resident had returned to the facility. Nurses Notes dated 8/31/10 at 1:50 a.m. documented, "Resident resting quietly in bed (with) eyes closed. Resp even (and) unlabored. No S/S (signs and symptoms) of distress or discomfort noted. Resident encouraged to use call light for help (with) ambulation. Will continue to monitor." There was no documentation in the Nurses Notes that [MEDICAL CONDITION] precautions were taken upon the resident ' s return to the nursing home or that the resident was frequently observed for [MEDICAL CONDITION] activity. g. Nurses Notes dated 9/1/10 with no time entry documented, "(resident) found sitting on floor during rounds (resident) states ' I missed the chair ' -denies pain or discomfort Full ROM (range of motion) UE (upper extremities) to LE (lower extremities)-no bruising or ST (skin tear) noted to coccyx/hips or back." An Incident/Accident Investigation Report dated 9/1/10 at 6:45 p.m., documented, "Making rounds on 300 Hall and (resident) found sitting on floor by chair-(resident) states she missed the chair-(resident) denies pain or discomfort. states she did not hurt herself! Inspected coccyx ROM bilateral hips denies pain-No bruising or open wounds No ST's VS (vital signs stable ...Will monitor CB (call button) in reach..." h. As of 9/3/10 at 11:00 a.m., there was no documentation in the Nurses Notes to indicate that the resident had returned to the hospital for the scheduled CT of the brain on 9/2/10. The facility's van transportation log for September 2010 received from the Administrator on 9/3/10 at 1:47 p.m. had no documentation to indicate that the resident was scheduled or taken for any outpatient tests for September 2010. On 9/3/10 at 2:00 p.m., the Director of Nursing (DON) was asked what was done about the CT brain scan scheduled for the resident on 9/2/10 and the DON stated, "Let me look and I'll get right back to you." i. As of 9/3/10 at 2:30 p.m., there was no documentation in the Nurses Notes or the Care Plan that the resident was frequently monitored for [MEDICAL CONDITION] activity and that [MEDICAL CONDITION] precautions were taken after the 8/28/10 incident of [MEDICAL CONDITION] activity. j. The facility's procedure entitled Nursing Management of [MEDICAL CONDITION] received from the Nursing Consultant on 9/3/10 5:25 p.m. documented: "Basic Responsibility: Licensed Nurse Purpose 1. To prevent injury to the resident. 2. To maintain patent airway. 3. To implement emergency care and prevent complications. ...Procedure 1. Stay with the resident. 2. Summon help through use of resident call light or emergency light in bathroom. ...4. Note time [MEDICAL CONDITION] started. Note any sounds or movements that precede the [MEDICAL CONDITION]. 5. Support resident and protect from injury by padding side rails and head of bed. 6. If resident is in bed, remove pillow from under resident's head and gently hyperextend head to maintain airway patency. Position on side, if possible, to facilitate drainage of mucus and decrease possibility of aspiration of secretions. 7. If resident is not in bed, a small pillow may be placed under head if injury could be sustained. ...14. Observe entire body, type and progression of body movements (tonic or clonic) and specific areas of the body involved. 15. Monitor vital signs as indicated. 16. Notify physician of resident's condition. 17. When [MEDICAL CONDITION] subsides, observe resident at frequent intervals until condition is stable. 18. Assess change in mental and/or physical function after [MEDICAL CONDITION] subsides. ...General Resident Care Plan Documentation Guidelines Problem Identify problem of [MEDICAL CONDITION] and underlying cause if known. Goal Establish a measurable goal for [MEDICAL CONDITION] control. Approaches Medication as ordered. Provide calm environment. Avoid stimuli that cause [MEDICAL CONDITION]. Airway or bite stick at bedside. Observe at frequent intervals. Pad side rails and head of bed. Monitor blood level of medication, if indicated." 2. Resident # 17 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented the resident had modified independence in cognitive skills for daily decision making, required limited assistance with transfers, locomotion, dressing, personal hygiene, extensive assistance with hygiene, and had symptoms of pain less than daily with moderate intensity. a. The Resident Care Plan dated 8/23/10 documented, "...Pain: Complaints of pain related to Lumbar/Lumbarsacral Intervertebral Disc Degeneration, Spinal Stenosis-Lumbar. As evidenced by: Crying/moaning, facial grimace, guarding... Goal: Resident will not experience a decline in overall function related to pain...Approaches: Signs and symptoms of pain, monitor and report to nurse: Worsening of pain, report changes in pain location/type, frequency/intensity to physician, provide comfort measures ... " b. The Incident/Accident (I&A) Investigation Report dated 8/27/10 at 12:20 (a.m./p.m. not designated) documented, "Resident was in her chair with CNAs in the room. She tried to stand and fell over to the floor. R (Resident) has a bump to the forehead and abrasion with bruising to the right knee, "L" (left) has an abrasion as well ... Pupils checked, grasps firm, no other signs of injury..." The "Neurological Assessment" documented: " Neurological Assessment requires documentation ... Q (every shift) for the remaining 72 hours and until stable ... " The last documented neurological assessment for the resident was the day shift on 8/28/10 (36 hours after the resident ' s fall). The facility's policy titled "Incident and Accident Investigation" received from Administrator on 8/31/10 documented, "...Nurses Notes: Document all information in the nurses notes including a full description of the incident/accident and the time each of the following measures was taken...Head injuries require a follow-up note by a Licensed Nurse in the nurses notes is required at least once a shift for at least 72 hours if the resident received a head injury. Head Injuries also require the documentation of neuro checks on the Neurological Assessment...for 72 hours at the following intervals: Q (every) 15 minutes for the first hour, Q 30 minutes x 2, Q Hr (hour) x 2, Q 4 Hr x 2, Q shift for the remaining 72 hours and until stable..." c. Nurses Notes dated 8/29/10 at 2200 (10 p.m.) documented the resident complained of dizziness and that [MEDICATION NAME] (prn order since 8/18/10 per August 2010 Physician order [REDACTED]. Nurses Notes on 8/31/10 at 3:30 a.m. documented the resident was medicated for a headache. There was no documented neurological assessment and there no documentation the physician was consulted. d. On 9/3/10 at 10:50 a.m., the resident was lying in bed with a cloth covering her eyes with the left side rail down. The bed was not in "Low" position. The resident was asked by the surveyor if she needed both side rails up? The resident stated, "Yes, I probably do because, I'll try to get up too fast and then I get dizzy...I have to keep my eyes closed because my head hurts so bad." e. On 9/3/10 at 12:20 p.m., the resident was lying in bed with a cloth covering her eyes. There was a blue-green resolving bruising noted to the left forehead and around the left eye. The resident stated, "I have to keep a cloth over my eyes and my eyes closed because I get dizzy, sick at my stomach and my head hurts so bad. I told the nurse that my head hurt real bad about 30 minutes ago." f. On 9/3/10 at 12:25 p.m., LPN # 4 was asked, "Did the resident tell you she needed something for pain and nausea?" LPN # 4 stated, "No, she told me she needed something for pain and nausea about 10:50 a.m. I called the doctor (named) and left a message with the nurse...I told her the resident was just nauseated." g. The Nurse's Notes dated 9/3/10 at 12:40 p.m. documented, "Call placed to doctor's (named) nurse x 2 regarding resident's c/o (complaint) nausea, left message, also spoke with receptionist who stated ' His (physician) nurse was at lunch and would return @ (at) 1:00 p.m., and would be calling me back as soon as she receives the message ' ." h. On 9/3/10 at 12:55 p.m., the resident stated, "I have been dizzy and had a headache since my fall. The problem is that when I need to ' tee-tee ' (urinate) and they (staff) sit me up on the side of the bed I get real sick and dizzy." i. On 9/3/10 at 1:40 p.m., LPN # 4 was asked if the physician was notified of the resident's condition. LPN # 4 stated, "I called the office at 12:40 p.m. and left another message. Receptionist stated that she would tell them to call back as soon as possible, that they (physician/nurse) would be back around 1:00 p.m." LPN # 4 was asked if she had taken the resident's vital signs or performed neuro checks. LPN # 4 stated, "No, I have not done any vital signs, resident was just complaining of a headache..." j. On 9/3/10 at 1:45 p.m., the surveyor asked the resident how she was feeling. The resident stated, "I am dizzy, sleepy and kind of sick at my stomach. This is a terrible headache and I don't know why I am so sleepy." 3. The Immediate Jeopardy was removed and scope/severity was lowered to a "H" on 9/3/10 at 10:45 p.m. when the facility implemented the following Plan of Removal: a. Immediately (9/3/10 at 2:45 p.m.) begin assessment of affected Resident to determine current neuro status and stability while assessments are being made for CT evaluation and medical assessment. Vital Signs every 30 minutes, Neuro Checks every 1 hour by RN. Facility Medical Director notified to assist in coordinating assessments. RN received telephone order from the Medical Director at 5:30 p.m. for outpatient CT and ED evaluation for head injury. Resident was transported by ambulance to hospital at 5:50 p.m. b. Immediately (9/3/10 at 3:35 p.m.) arrangements made for stat CT for follow-up as previously ordered and medical assessment of Resident. Facility Medical Director notified to assist in coordinating assessments. Order received for ED evaluation. Resident transported by ambulance to hospital at 4:04 p.m. c. All Residents at risk for [MEDICAL CONDITION], falls or those with a change of condition were identified and assessed as of 6:00 p.m. 9/3/10. d. Direct care staff on all three shifts beginning with the evening shift on 9/3/10 will be in-serviced by 9/4/10 at 8:00 a.m. on the following topics: Nursing Management of [MEDICAL CONDITION] Resident Change of Condition (Observing, Recording and Reporting) This in-service topic includes: Falls, Fall Assessment, Reporting Requirements, appropriate interventions and documentation of those interventions. e. [MEDICAL CONDITION] precautions and fall prevention interventions will be implemented based on individualized care planning following Resident assessment. f. No staff member will be allowed to work in a direct care role until after completing the above in-services. g. The DON or Designee will review all I&A's every shift following the incident for the appropriateness of interventions and follow-up care planning. These actions will be reviewed with the Administrator following the nursing reviews as part of the I&A review process. This monitoring will take place five days a week for the next six weeks. h. The DON, ADON or RN Designee will assess all Resident's with a Change of Condition daily, documenting the assessment in the Resident Nurses, until Resident is determined to be stable and all signs and symptoms related to the Change of Condition are resolved. i. Beginning immediately, all licensed nursing staff will conduct a face to face report at shift change with all participating signing the report. j. For the next week, the DON, ADON or designee will attend every shift to shift report to assess the quality of information exchanged. Thereafter, for the next four weeks, the DON, ADON or RN designee will attend at least 1 shift report daily, then at least once a week per shift for four additional weeks. k. A copy of the signed shift to shift report will be provided to the Administrator for all observed reports". B. Based on record review and interview, the facility failed to ensure that residents that received [MEDICAL TREATMENT] had their overall condition assessed and monitored for complications that included observation of the vascular access site after the resident's return from [MEDICAL TREATMENT] treatment for [REDACTED]. This failed practice had the potential to affect 5 residents in the facility who received [MEDICAL TREATMENT] as documented on the Resident Census and Condition of Residents form dated 8/30/10. The findings are: 1. Resident #11 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident was independent in cognitive skills for daily decision making and had special care treatments and procedures of [MEDICAL TREATMENT]. a. A physician's orders [REDACTED]." b. The Resident Plan of Care dated 8/9/10 documented, "At risk for complicating factors, related to [MEDICAL TREATMENT]...Observe shunt and palpate/auscultate for thrill/bruit. Document observations. Notify physician if no bruit is palpated. ...Monitor site for signs of infection, redness, swelling, malodorous or purulent drainage. Report abnormal findings promptly to physician. " c. As of 9/2/10 at 3:00p.m., there was no documentation on the September 2010 Medication Record to indicate that the [MEDICAL TREATMENT] was assessed every shift. d. On 9/2/10 at 3:02 p.m., Licensed Practical Nurse (LPN) #2 reviewed the September 2010 Medication Record and was asked if the assessment of the [MEDICAL TREATMENT] shunt site was documented and the LPN stated, "No." 2. The facility's procedure guidelines entitled Care of Resident Receiving [MEDICAL TREATMENT] received on 9/2/10 at 3:15 p.m. from the Director of Nursing documented, "1. To monitor residents receiving [MEDICAL TREATMENT] for infection or complications of the disease process. 2. To monitor the shunt for complications. ...Procedure...5. Check shunt site every shift for patency (bruit and thrill), bleeding, swelling, redness. To check thrill and bruit, feel over the access area. A thrill is the vibration you feel over the [MEDICAL TREATMENT] access. A bruit is the swish you hear with a stethoscope over the [MEDICAL TREATMENT] access. If a thrill can not be felt or cannot hear bruit, notify physician. ...General Documentation Guidelines ...Daily observation of shunt site. ..Note frequency of [MEDICAL TREATMENT], shunt sites, ...etc. in nursing summary charting. ...".

Complaint # was substantiated all or in part in these findings. A. Based on observation, record review, and interview, the facility failed to ensure interventions were developed and implemented for prevention of further falls, accidents/falls were investigated, post fall assessments were completed, and care plans updated to prevent the potential for injury for 2 (Residents #16 & #17) of 8 (Residents #2, #3, #4, #7, #8, #16, #17, and #18) case mix residents who sustained falls or were at risk for falls. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, impairment or death, for Resident #16 who had seizures and fell sustaining a head injury and Resident #17 who fell and then experienced a significant change in condition and had the potential to cause more than minimal harm to 6 residents who could potentially experience a fall or were at risk for a fall, as identified by the Nurse Consultant on 9/3/10 at 10:00 p.m. The facility was informed of the Immediate Jeopardy conditions on 9/3/10 at 3:20 p.m. The findings are: 1. Resident #16 had [DIAGNOSES REDACTED]. a. The Resident Plan of Care dated 8/4/10 documented, "Risk for falls or injury related to history of falls and unsteady gait, Review medications for therapeutic or nontherapeutic effects. Provide a safe, uncluttered environment. ...Instruct staff on safety to ensure no resident injuries. Observe closely to ensure resident's safety. Observe skin closely for tears, bruising or breakdown. Monitor and encourage wearing of skid proof shoes. 7/26/10 Instructed to use CL (call light) for all needs and wants." b. An Incident/Accident Investigation Report dated 7/26/10 documented, "R (resident) found upon rounds sitting on floor, full ROM (range of motion)-no noted bruising to coccyx, back or hips. R denies pain or discomfort. Assisted back to bed-SR (side rails) (up)-instructed (resident) to use call light for all needs-verbalized understanding alert to self only." c. A nurses note dated 8/20/10 at 11:29 a.m. documented, "ID (interdisciplinary team) met to discuss (Resident) fall on 7/26/10. (Resident) [DIAGNOSES REDACTED]. (Resident) fell in room no injuries noted (at) time of fall. Post fall assessment done. Family & physician notified. Fall investigation complete. Care plan updated Intervention to instruct (Resident) to use C/L (call light) for all needs in place." d. A facility nurses note dated 8/28/10 at 12:20 a.m. documented, "This nurse was summon to room 302 A where R (resident) was found by CNA (certified nursing assistant) on the floor wrapped in a sheet snoring loudly. (Resident) was between bed (and) nightstand when she was rolled over blood was coming from her mouth several attempts were made to arouse her Emergency Transport called vitals were BP (blood pressure) 130/80, (pulse) 106 (respirations)16. (Physician) family and DON (Director of Nursing) notified." The Initial Assessment Form from the emergency room dated 8/28/10 and time noted as 1:05 a.m. documented: " ...Chief Complaint Mouth Injury (Mod (moderate)-Severe) ...According to Nsg (Nursing) Home personnel patient was found lying on the floor with her blankets - it was unclear if patient ...could have fallen or had a seizure - lacerations are noted on both sides of tongue ... " The Physician Documentation form documented: " ...Review of Systems: positive confusion, positive seizures ...Patient discharged to Nursing Home Condition: Stable, satisfactory ...Patient ' s condition non-emergent. Disposition ...08/28/2010 01:23 (1:23 a.m.). Discussed care with Nurse. Explained findings, diagnosis, and need for follow-up care ..." The Patient Disposition Page dated 8/28/10 at 1:55 a.m. documented: " ...Discharge Diagnoses: [REDACTED]. e. Nurses Notes dated 8/28/10 at 2:15 a.m. documented, "(Resident) just returned from ER (emergency room ) paper work from hospital behind physician's orders [REDACTED]. 128/74, 66, 20, 97.3." f. Nurses Notes dated 8/28/10 at 3:15 a.m. documented, "This nurse summons to room (number) resident found having seizure activities per CNA stepped in hall (and) called for nurse. side rails (down) resident fell on floor continuing in seizure activities. phoned 911 to respond." On 9/3/10 at 2:00 p.m., the Director of Nursing (DON) was asked if an investigation was completed on the 8/28/10 incidents about what was done regarding the CNA (certified nursing assistant) that stepped away from the resident's bed with the side rails down prior to the second fall. The DON stated, "Yes there was an investigation. Not a written investigation or action taken. We just talked to her. I don't know who the CNA was." g. The hospital initial assessment form dated 8/28/10 at 3:40 a.m. documented, "Semi-emergent Chief complaint Head Injury (mod-severe)." The hospital history and physical form dated 8/28/10 at 3:58 a.m. documented, "...Chief Complaint--Head Injury (Mod-Severe) ...Onset of symptoms was immediately prior to arrival in the Emergency Department. Symptoms came on suddenly. Injury occurred in nursing home. Patient sustained injury as a result of fall. fell from standing position. Mechanism of injury unknown. Patient found unresponsive. On EMS (emergency medical services) arrival to NH (nursing home) pt confused and on what look like postictal (pertaining to the period following a seizure or convulsion), pt was just d/c (discharged ) from the ED (emergency department) with a DX (diagnosis) of seizures Symptoms located in the left frontal area of the head. Associated signs and symptoms:...positive laceration, ...Neurological: positive confusion, positive seizures....Physical Examination ...Skin: Laceration: Simple, Length-2 cm (centimeters), location: Forehead, linear, extending incompletely through dermis, margins sharp, clean, no active bleeding ...Neurologic: ...Disoriented to place, time. ...Clinical Impression: 8/28/10 6:02 a.m. 1. Contusion Head 2. Simple Laceration: Forehead 3. Seizure. ...Patient's condition was emergent...Laceration that is jagged, to the Left Forehead, bleeding is controlled, approximately 4 centimeters long. ...Neurological: Seizures observed while in ED....Neurological: Witness seizure while still in collar and spinal immobilization. Blood noted from mouth. Pt with snoring respirations and tonic movements noted...Disposition: 8/28/10 7:12 a.m. Admit: Patient's disposition is: Admit-IMCU (intensive medical care unit)...Seizures observed while in ED. Seizures have occurred multiple times within 24 hours..." A hospital history and physical dated 8/28/10 documented, "...She apparently was found on the floor in the nursing home. There was a question of her having a seizure. ...She has been admitted for further evaluation and for institution of anticonvulsant therapy...." A hospital consultation report dated 8/28/10 documented, "Reason for consultation: Evaluation of new-onset seizures. ...CT scans of the head and neck were ordered, but the scanner broke down in the middle of her brain scan. ...I contacted the nursing home and the nurse who was on duty told me that (resident) was "fairly new to us", having been admitted there only in the last couple of weeks. She says her admission information indicates a history of hypertension, dementia, osteoarthritis, and diabetes, although no hypoglycemic medications were ordered and no blood sugars were ordered. No history and physical is on the chart at the nursing home as yet. Nursing assessment stated the patient was alert and had impaired memory, although the nursing assessment also says "alert and oriented X 3" (the nurse who spoke indicates they have an automated medical record and suggested that this record or orientation was not accurate.)...I note from records in the computer that as far back as 2002, the patient was stated to have had a "seizure disorder,"...5. I would get a CT scan of the brain since she has had some recent falls, to make sure she does not have a subdural hematoma. I do not think that brain imaging is urgent enough to warrant getting an MRI because of the fact the CT scanner is "down", but I would simply wait for the CT scanner to become available again and then do a brain CT." h. Nurses Notes dated 8/28/10 at 6:00 a.m. documented, "Follow-up with ER (emergency room ) (resident) had another seizure while waiting for CT (computerized topography) scan on hold status due to broken machine." i. A hospital Fall Risk Assessment Scoring Tool form dated 8/28/10 and 8/29/10 documented, "Total at Risk To Fall Score: 8/28/10 22 8/29/10 22... At Risk patients (score 10 or greater) should have all categories of nursing interventions addressed..." j. There was no entry in the Nurses Notes that documented the date and time the resident had returned to the facility. Nurses Notes dated 8/31/10 at 1:50 a.m. documented, "Resident resting quietly in bed (with) eyes closed. Resp even (and) unlabored. No S/S (signs and symptoms) of distress or discomfort noted. Resident encouraged to use call light for help (with) ambulation. Will continue to monitor." k. The facility's Fall Risk Assessment and Post Fall Assessment documented, "7/22/10 Total Score 8; 7/26/10 Total Score 8; 8/30/10 Total Score 10. ...If the total is 12 or greater, the resident is considered to be at high risk for falls..." l. A nurses note dated 9/1/10 with no time entry documented "(Resident) found sitting on floor during rounds (Resident) states 'I missed the chair' -denies pain or discomfort Full ROM (range of motion) UE (upper extremities) to LE (lower extremities)-no bruising or ST (skin tear) noted to coccyx/hips or back." An Incident/Accident Investigation Report dated 9/1/10 at 6:45 p.m. documented, "Making rounds on 300 Hall and (Resident) found sitting on floor by chair-(Resident) states she missed the chair-(Resident) denies pain or discomfort. 'states she did not hurt herself!' Inspected coccyx ROM bilateral hips denies pain-No bruising or open wounds No ST's VS (vital signs) stable ...Will monitor CB (call button) in reach..." As of 9/3/10 at 2:30 p.m. , there were no new interventions documented to prevent further falls on the I&A Investigations or on the care plan. m. On 9/3/10 at 9:55 a.m. , the Director of Nursing (DON) was asked who was responsible for fall assessments and the DON stated, "The charge nurse should do the assessment at the time of the fall then the RN (registered nurse) reviews it within 24 hours." The DON was asked who was responsible to ensure the RN does the assessment and the DON stated, " I am...After you determine that a resident is at risk for falls." The DON was asked when this was done and the DON stated, "Admission assessment and at the time of a fall. If at risk on falling star program. Supervisor or charge nurse." The DON was asked who was on the interdisciplinary team that was documented in the resident's 8/20/10 nurses notes and the DON stated, "MDS (minimum data set), DON, Social, Activities, and Dietary. We try to make it a team decision." The DON was asked who was responsible to ensure that charge nurses were assessing resident's and the DON stated, "I am. The charge nurse should do the assessment at the time of the fall and then the RN reviews them within 24 hours. " 2. Resident # 17 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented the resident had modified independence in cognitive skills for daily decision making, required limited assistance with transfers, locomotion, dressing, personal hygiene, extensive assistance with hygiene. " The Fall Risk Asessment signed and dated 8/10/10 documented the resident ' s score as 9 with the form documenting that a total score of 12 or greater was considered to be a high risk for falls. a. The Care Plan dated 8/23/10 for the problem/need of " At risk for fall related injury " documented: " Use fall risk screen to identify risk factors, ...Call light within reach, area free of clutter Wheelchair, Remind resident and reinforce safety awareness: appropriate footwear. " b. The Incident/Accident (I&A) Investigation Report dated 8/27/10 at 12:20 (a.m./p.m. not designated) documented, "Resident was in her chair with CNAs in the room. She tried to stand and fell over to the floor. R (Resident) has a bump to the forehead and abrasion with bruising to the right knee, "L" (left) has an abrasion as well ... Pupils checked, grasps firm, no other signs of injury..." As of 9/3/10 at 1:45 p.m., the Fall Risk Assessment Form had not been updated post fall and the care plan did not address any new interventions to prevent further falls. c. Nurses Notes dated 8/29/10 at 2200 (10 p.m.) documented the resident complained of dizziness and that Meclizine (prn order since 8/18/10 per August 2010 Physician order [REDACTED]. Nurses Notes on 8/31/10 at 3:30 a.m. documented the resident was medicated for a headache. d. On 9/3/10 at 10:50 a.m., the resident was lying in bed with a cloth covering her eyes with the left side rail down. The bed was not in "Low" position. The resident was asked by the surveyor if she needed both side rails up? The resident stated, "Yes, I probably do because, I'll try to get up too fast and then I get dizzy...I have to keep my eyes closed because my head hurts so bad." e. On 9/3/10 at 10:55 p.m., CNA # 9 (Restorative Aide) entered the room and was asked if the resident needed both side rails up? CNA # 9 stated, "Both side rails need to be up at all times." f. On 9/3/10 at 11:03 p.m., LPN # 4 was asked if the resident's side rails were supposed to be up when in the bed? LPN # 4 stated, "Yes." LPN # 4 was asked how were the CNAs supposed to know if a resident was a fall risk or need the side rails up? LPN # 4 stated, "CNAs are supposed to ask the Charge Nurse if the resident is a fall risk. If the resident is a fall risk, the side rails are supposed to be pulled up when the resident is in bed." There is a Falling Star symbol that is placed outside of the resident's door and another is to be over the resident's head of the bed on the wall. This resident (Resident #17) has fallen before and is a fall risk." LPN was asked to observe the resident. LPN stated, "There is no "Star" (symbol) on the name plate (outside the resident's room) or above the bed to indicate the resident is a fall risk and the side rails are supposed to be up when the resident is in bed." g. On 9/3/10 at 12:20 p.m., the resident was lying in bed with a cloth covering her eyes. There was a blue-green resolving bruising noted to the left forehead and around the left eye. The resident stated, "I have to keep a cloth over my eyes and my eyes closed because I get dizzy, sick at my stomach and my head hurts so bad. I told the nurse that my head hurt real bad about 30 minutes ago." h. On 9/3/10 at 12:25 p.m., LPN # 4 was asked, "Did the resident tell you she needed something for pain and nausea?" LPN # 4 stated, "No, she told me she needed something for pain and nausea about 10:50 a.m. I called the doctor (named) and left a message with the nurse...I told her the resident was just nauseated." i. The Nurse's Notes dated 9/3/10 at 12:40 p.m. documented, "Call placed to doctor's (named) nurse x 2 regarding resident's c/o (complaint) nausea, left message, also spoke with receptionist who stated ' His (physician) nurse was at lunch and would return @ (at) 1:00 p.m., and would be calling me back as soon as she receives the message ' ." j. On 9/3/10 at 12:55 p.m., the resident stated, "I have been dizzy and had a headache since my fall. The problem is that when I need to 'tee-tee' (urinate) and they (staff) sit me up on the side of the bed I get real sick and dizzy." k. On 9/3/10 at 1:40 p.m., LPN # 4 was asked if the physician was notified of the resident's condition. LPN # 4 stated, "I called the office at 12:40 p.m. and left another message. Receptionist stated that she would tell them to call back as soon as possible, that they (physician/nurse) would be back around 1:00 p.m." l. On 9/3/10 at 1:45 p.m., the surveyor asked the resident how she was feeling. The resident stated, "I am dizzy, sleepy and kind of sick at my stomach. This is a terrible headache and I don't know why I am so sleepy." 3. The Immediate Jeopardy was removed and scope/severity was lowered to a "H" on 9/3/10 at 10:45 p.m. when the facility implemented the following Plan of Removal: a. Immediately (9/3/10 at 2:45 p.m.) begin assessment of affected Resident to determine current neuro status and stability while assessments are being made for CT evaluation and medical assessment. Vital Signs every 30 minutes, Neuro Checks every 1 hour by RN. Facility Medical Director notified to assist in coordinating assessments. RN received telephone order from the Medical Director at 5:30 p.m. for outpatient CT and ED evaluation for head injury. Resident was transported by ambulance to hospital at 5:50 p.m. b. Immediately (9/3/10 at 3:35 p.m.) arrangements made for stat CT for follow-up as previously ordered and medical assessment of Resident. Facility Medical Director notified to assist in coordinating assessments. Order received for ED evaluation. Resident transported by ambulance to hospital at 4:04 p.m. c. All Residents at risk for seizures, falls or those with a change of condition were identified and assessed as of 6:00 p.m. 9/3/10. d. Direct care staff on all three shifts beginning with the evening shift on 9/3/10 will be in-serviced by 9/4/10 at 8:00 a.m. on the following topics: Nursing Management of Seizure Resident Change of Condition (Observing, Recording and Reporting) This in-service topic includes: Falls, Fall Assessment, Reporting Requirements, appropriate interventions and documentation of those interventions. e. Seizure precautions and fall prevention interventions will be implemented based on individualized care planning following Resident assessment. f. No staff member will be allowed to work in a direct care role until after completing the above in-services. g. The DON or Designee will review all I&A's every shift following the incident for the appropriateness of interventions and follow-up care planning. These actions will be reviewed with the Administrator following the nursing reviews as part of the I&A review process. This monitoring will take place five days a week for the next six weeks. h. The DON, ADON or RN Designee will assess all Resident's with a Change of Condition daily, documenting the assessment in the Resident Nurses, until Resident is determined to be stable and all signs and symptoms related to the Change of Condition are resolved. i. Beginning immediately, all licensed nursing staff will conduct a face to face report at shift change with all participating signing the report. j. For the next week, the DON, ADON or designee will attend every shift to shift report to assess the quality of information exchanged. Thereafter, for the next four weeks, the DON, ADON or RN designee will attend at least 1 shift report daily, then at least once a week per shift for four additional weeks. k. A copy of the signed shift to shift report will be provided to the Administrator for all observed reports". l. On 9/3/10 at 10:50 a.m. resident was lying in bed with a cloth covering her eyes with the left side rail left down. The bed was not in "Low" position. B. Based on observation, record review, and interview, the facility failed to ensure that the environment was free from potential hazards by not ensuring hazardous chemicals and sharp objects were securely stored and the storage room, mechanical room, and shower room were kept locked. This failed practice had the potential to affect 15 cognitively impaired self mobile residents in the facility as identified by the Director of Nursing on 9/2/10. The facility failed to ensure that the mechanical lift sling was intact and not torn for 1 (Resident #5) of 4 (Residents #1, #5, #11, and #12) case mix residents who were transferred with a mechanical lift. This failed practice had the potential to affect 16 residents who used the mechanical lift as identified by the DON on 9/2/10 at 12:30 p.m. T The findings are: 1. On 8/30/10 at 2:37 p.m., room 321 was unlocked and used as storage with the following environmental hazards: One 8 oz bottle of "Nightingale No Rinse Formula Periwash" with the Material Safety Data Set (MSDS) that documented, "...First Aid Measures: Eye Contact: Do not rub eyes. Flush eyes thoroughly with water for 15 minutes. If condition worsens or irritation persists, contact physician...Ingestion: Do not induce vomiting. Contact a physician or Poison Control Center..." 2. On 8/30/10 at 2:45 p.m., the Mechanical Room door on the 300 Hall and the Dining Room was unlocked with the following hazards on the floor by inside door: a. One 1 gallon bottle of Tilex Mildew Removal with the MSDS documented hazards, "Eye Contact: Remove any contact lenses, and flush eyes thoroughly with water for 15 minutes. If irritation persists, call a physician, Skin Contact: Remove contaminated clothing; wash affected skin with water, If breathing is affected: Get fresh air immediately and If swallowed: Drink a glass of water. Call a physician. " b. Two buckets of Sheet Rock All Purpose Joint Compound with the lid of the top bucket c. One 1 gallon of Spectracide Bug Stop Spray bottle with the documented hazard, "Skin Contact: Harmful if absorbed through skin. Avoid contact with skin, eyes or clothing. Wash hands thoroughly with soap and water after handling and before eating, drinking, chewing gum or using tobacco. First Aid: Take off contaminated clothing. Rinse skin immediately with plenty of water for 15-20 minutes. Call a Poison Control Center or doctor for treatment advice. Special Notes: Have the product label with you when calling a Poison Control Center or doctor." d. Twenty 2 1/2 inch screws e. Thirty-five 1 inch metal screws f. A 12 oz soda bottle with red liquid approximately 100 cc was on the floor by the door., g. Lying on top of the air conditioner unit: tools, 1 box cutter with blade out, one 10 inch metal tool "L" shape with screw driver on the end, 1 Cressant Wrench, Maxwell House Coffee Can with 2.5 oz identified as paint, with the documented hazard, "Prolong overexposure to hazard...can cause chronic effects to the following organs or systems: the liver, the urinary tract.. " 3. The Administrator was asked if the mechanical room was supposed to be locked? The Administrator stated, "That would be the Maintenance Director (named), I have no idea what he's got in there". 4. On 9/1/10 at 3:25 p.m., the tile in the bathroom in room 300 was torn, uneven and had a hole 35 centimeters (cm) x 3 cm. 5. On 9/1/10 at 4:55 p.m. ,the "Tub/Shower Room" on the 300 Hall was left unlocked by the facility's staff with the following hazards: a. Five 14 ounce (oz) tubes of Zinc Oxide with the Material Safety Data Set (MSDS) that documented, "...First-Aid Procedures: Ingestion - Do not induce vomiting. Seek medical attention immediately...Eye Contact - Flush with water for a least 15 minutes. Seek medical attention immediately." b. One 1 gallon jug of Aloe Vesta 2-n-1 Body Wash and Shampoo with the MSDS that documented, "Health Hazard Data - Effects of Overexposure (Medical) Conditions Aggravated/Target Organ Effects. A. Acute (Primary Route of Exposure) Eyes: Detergents in product will cause mild irritation to eyes. Skin: Prolonged contact without rinsing may produce irritation to the skin. Indigestion: Overexposure may result in cramps and diarrhea...Eyes: If splashed into eyes, flush with flowing water. Ingestion: Drink large amounts of water and contact a physician..." c. Six Nail Clippers d. Fourteen Orange sticks e. Five 8 oz bottles "Aloe Vista Protective Ointment " with the MSDS that documented, "...First Aid Measures...Eyes: Flush eyes under (or with) running water. Get medical assistance if irritation develops...Ingestion: Do not induce vomiting, call a physician or a poison control center..." f. Seven 3 oz bottles of "Mennen Afta Shave Lotion" with the MSDS that documented, "...Hazards...Eye Contact: May cause eye irritation on direct contact. Skin Contact: May cause skin irritation on prolonged or repeated contact. Ingestion: May be harmful is swallowed in large quantities. Inhalation: Overexposure may cause respiratory tract irritation. First Aid Measures Eye Contact: Flush eyes with large amounts of water for 15 minutes. Get medical attention if irritation persists. Skin Contact: Rinse area with plenty of water. Get medical attention if irritation persists. Ingestion: Drink 1-2 glasses of water. Get medical attention. Inhalation: Remove victim to fresh air. Get medical attention if symptoms persist" g. One 4 oz bottle of "DermaCen Lotionized Hand Sanitizer" with a MSDS that documented, "...Health hazards: Can be harmful if swallowed. Ingestion may cause diarrhea, distention and/or vomiting. Signs and Symptoms of Exposure: If in eyes: burning, watering, redness. If swallowed: Possible gastrointestinal irritation or disturbance. If vapors are inhaled: Possible giddiness or loss of consciousness...First Aid Measures If in eyes: Flush with water for 15 minutes. If swallowed: If patent is conscious and alert, dilute by drinking large quantities of water. Allow vomiting to occur, then get medical attention. If inhaled: Remove to fresh air. Always get medical attention when product is swallowed or when symptoms ar significant or persist..." h. One 12 oz spray bottle of "QD-64" Germicidal with the MSDS that documented, "...Emergency and First Aid Procedures: Inhalation: Remove to fresh air. Ingestion: Give large quantities of water and see physician. Eyes: Flush with water thoroughly and see a physician if irritation persists. Skin: Wash with soap and water..." and i. One 8 oz bottle of "Nightingale No Rinse Formula Periwash" with the MSDS that documented, "...First Aid Measures: Eye Contact: Do not rub eyes. Flush eyes thoroughly with water for 15 minutes. If condition worsens or irritation persists, contact physician...Ingestion: Do not induce vomiting. Contact a physician or Poison Control Center..." 6. Resident # 5 had [DIAGNOSES REDACTED]. The Annual Minimum (MDS) data set [DATE] documented the resident had moderately impaired cognitive skills for daily decision making, was totally dependent on staff for bed mobility, transfers, locomotion, personal hygiene and was incontinent of urine and stool. a. On 5/31/10 at 5:00 a.m., Certified Nurse Assistant (CNA) # 2 and CNA # 3 placed a Marisa mechanical lift sling with an approximately 6 inch hole in the upper left area under the resident to transfer him into a geri chair. After the lift sling was attached to the lift's balance bar and the resident was lifted approximately 6 inches off the mattress of the bed the transfer was stopped by the surveyor. b. CNA # 2 and # 3 were asked if the resident was supposed to be transferred with a sling that was torn and had a hole in it. CNA # 1 stated, "Technically no. It is dangerous. It could tear and the resident could fall out." CNA # 3 stated, "I wouldn't do it...each resident has his own sling, evidently he (the resident) has been transferred with his sling before." c. On 5/31/10 at 6:15 a.m., Licensed Practical Nurse (LPN) # 1 was asked to describe the lift sling that the CNAs were going to use to transfer the resident. LPN # 1 stated, "There is a hole at the top of the sling approximately the size of a fist." LPN # 1 measured the hole in the sling to be 9.5 cm in length and 4.5 cm in width. LPN # 1 stated, "I don't really know about slings, but from an outside point of view, I don't think it would be safe. As Charge Nurse, I would not want my CNAs to use that sling to transfer a resident." d. On 5/31/10 at 6:25 a.m., the Director of Nurses (DON) was shown the sling and asked if it should be used to transfer a resident. The DON stated, "No, the sling should not have been used and it will be thrown away and I will get a replacement." The DON threw the sling in the trash hamper located in the hall.