Every finding on record at Crestpark Helena, LLC

Number of residents sampled: Number of residents cited: Based on observation, interview and facility policy review, it was determined that the facility failed to provide and maintain a safe and sanitary environment to help prevent the development and transmission of communicable disease and infections for three of three meal services observed. The findings include: Review of a facility policy titled Handwashing/Hand Hygiene revised in April 2010, indicated that the facility considers hand hygiene the primary means to prevent the spread of infections. The policy also indicated that employees must wash hands for at least fifteen seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after eating or handling food; before and after assisting a resident with meals. During an observation of the Lunch Meal served in the dining room on 09/02/2025 at 11:44 AM, Certified Nursing Assistant (CNA)# 5 and CNA #7 did not sanitize their hands before getting meal trays from the facility kitchen serving window and handing trays to the residents. During an observation of the Lunch Meal served in the dining room on 09/03/2025 at 11:40 AM, CNA # 11 and CNA # 9 did not sanitize their hands before getting meal trays from the facility kitchen serving window and handing trays to the resident. CNA # 8 did not sanitize their hands after sitting down to assist a resident with their meal. During an observation of the Lunch Meal served on 200 Hall on 09/03/2025 at 11:47 AM, CNA # 12 did not sanitize their hands before handing trays to residents in rooms or when coming out of rooms after serving trays to the residents. No hand sanitizer dispenser was observed in the rooms or in the hallway. During an observation of the Lunch Meal served on 100 Hall on 09/03/2025 at 11:55 AM, CNA # 5 did not sanitize their hands before handing out trays in rooms. During one observation CNA touched bedside table to move the table closer to the resident then opened items on the tray without sanitizing their hands. No hand sanitizer dispenser was observed in the room or in the hallway. During observation of the Dinner Meal served on 09/03/2025 at 4:35 PM, CNA # 3, CNA # 2 and CNA # 10 did not sanitize their hands before getting meal trays out of the facility kitchen serving window or before opening items on dinner trays. CNA # 9 was observed holding a baked potato with their bare hand while cutting the potato open to put butter on it. During an interview with CNA #5 on 09/05/2025 at 9:42 AM, CNA #5 indicated that their hands were to be sanitized before getting trays out of the serving window. During the setup of trays on halls, their hands were to be sanitized before picking up trays from the cart and before leaving the residents' rooms. If a bedside table was touched, then their hands were to be sanitized before opening items on the tray. CNA #5 also indicated that the outcome of not sanitizing hands was that cross contamination from hands to resident can occur and the resident may get sick. During an interview with Registered Nurse (RN) #6 on 09/03/2025 at 10:21 AM, RN #6 indicated that staff were to sanitize their hands before getting trays out of the serving window, after any care of a resident and before going to the next resident. The resident can get sick, or an infection can occur if hands were not washed or sanitized before serving trays or doing any type of care for a resident. During an interview with Director of Nursing (DON) on 09/05/2025 at 10:54 AM, DON indicated that CNAs are trained on hand washing and hands are to be sanitized before getting trays out of the serving window to give to residents. Hands are to be sanitized before serving trays to residents in their rooms and before the CNA comes out of a resident room. During an interview with the Administrator on 09/05/2025 at 11:35 AM, Administrator indicated that CNAs were to sanitize their hands before getting meal trays out of the kitchen serving window. Administrator also indicated that hand washing in-service was done at least once a year and more if needs are seen. During an interview with the Assistant Director of Nursing (ADON) on 09/05/2025 at 12:26 PM, ADON indicated that CNAs were trained on hand washing after being hired. ADON indicated that spot checks and Hand washing check offs are also done sporadically. ADON also revealed that there have not been any infectious stomach issues with residents per tracking and trending.

Based on observations, interviews and record reviews, it was determined the facility failed to ensure maintenance services were provided for a safe, clean, comfortable and homelike environment, to maintain the quality of life for the residents by reviewing the water temperature for one of three bathroom sinks tested. The findings include: During an observation and concurrent interview on 09/03/2025 at 8:37 AM, the hot water temperature in the bathroom sink that was shared by rooms [ROOM NUMBERS], was obtained by an infrared thermometer, registered 120.9 degrees Fahrenheit. The resident in room [ROOM NUMBER] stated that the water available in the sink was very hot. During an observation with the Administrator (AD) on 09/03/2025 at 10:30 AM, the hot water temperature in the bathroom sink that was shared by rooms [ROOM NUMBERS] registered 122.9 degrees Fahrenheit, the temperature being verified by the Administrator using the facility's thermometer. During an interview with the AD on 09/03/2025 at 10:45 AM, the AD indicated that the maximum temperature of hot water was to be no more than 110 degrees Fahrenheit. During an interview with a Plumber on 09/03/2025 at 11:45 AM, the Plumber stated that it was unknown why the hot water in some rooms was hotter than other rooms and that the temperature of hot water coming from the tank should be the same throughout the building. During an interview with Certified Nursing Assistants (CNA) #5 on 9/05/2025 at 10:54 AM, CNA #5 indicated that water that was too hot could burn a resident that was able to get to and use the water. During an Interview with RN #6 on 09/05/2025 at 11:09 AM, RN#6 indicated that hot water that was not the right temperature could cause burns to a resident's skin. During an Interview with the Director of Nursing (DON) on 09/05/2025 at 11:16 AM, the DON indicated that CNAs are advised to notify Administration if they feel hot water was too hot for a resident. During an interview with the AD on 09/05/2025 at 11:18 AM, the AD indicated that water temperatures were checked once a week and kept in a log. The AD that a Plumber was notified of any issues with water temperatures. AD also stated that the outcome of hot water temperatures being too high was that it could result in a burn to a resident's skin. AD also stated they did not have a facility policy related to water temperatures and review of a policy titled Resident Rights revealed this policy did not include maintaining a safe, clean, comfortable and homelike environment, to maintain the quality of life for the residents.

Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to monitor the continued need for an as needed (PRN) medication order for psychotropic drugs after 14 days, per the regulation, for one (Resident #9) of one resident reviewed for unnecessary drug administration. The findings include: Review of an annual Minimum Data Sheet (MDS) with an Assessment Reference Data of 03/12/2025, indicated Resident #9 had a Brief Interview for Mental Status score of two, which indicated the resident had severe cognitive impairment. The MDS also indicated that the resident had diagnoses which included major depressive disorder; loss of memory, language and reasoning with agitation; loss of memory, language and reasoning with behaviors. Review of a Care Plan indicated Resident #9 was at risk for wandering behaviors and exhibited aggression with staff at times. Interventions included administering medications as prescribed, assessing the effectiveness of the medications given, assess for side effects of medications as ordered. Review of Physician Order's, indicated Resident #9 had a psychotropic medication ordered that was to be used PRN for agitation. Review of a Nurses Note dated 07/09/2025 at 2:30PM, stated Resident #9 cursed at the nurse. A Physician's Order was given to start psychotropic medication every eight hours PRN for agitation. Review of a Medication Record for Resident #9 indicated that a PRN psychotropic medication was ordered for the resident from 07/09/2025 to 09/02/2025. Review of a Medication Regimen Review (MRR) dated 08/11/2025, indicated the MRR was completed without addressing PRN psychotropic drugs, and did not contain a rationale for extending the order for the PRN psychotropic medication past 14 days. During an interview with the Director of Nursing on 09/05/2025 at 9:36 am, the DON indicated PRN medication orders used for behaviors are received from the Physician, and are to be given as the Physician prescribed. During an interview with a Pharmacy Consultant on 09/05/2025 at 9: 49 AM, the Pharmacy Consultant indicated last month's Gradual Dose Reduction did not address the psychotropic drug due to the Pharmacy Consultant being unaware Resident #9 was currently on psychotropic medication. During an interview with the Medical Director (MD) on 09/05/2025 at 12:15 PM, the MD indicated the duration or end date was not indicated on the medication order for the psychotropic medication. The MD also indicated that he was not aware of the regulation requiring PRN psychotropic medications be limited to 14 days. The MD indicated that the Pharmacy Consultant comes out monthly. The MD revealed Pharmacy Consultants review the PRN psychotropic medication order and the Pharmacy Consultant suggests if the medication needs an end date or a decrease in the medication. The MD indicated that the suggestions of the Pharmacy Consultant are followed.

Number of residents sampled: Number of residents cited: Based on record review, interview and facility policy review, it was determined the facility failed to ensure Minimum Data Set (MDS) information was transmitted electronically within 14 days after completion of the assessment for two (Residents #16 and #30) of two resident assessments reviewed. The findings include: Resident #16 Review of Resident #16's Medical Record revealed an admission MDS with an Assessment Reference Date (ARD) of 08/18/2025. Review of a discharge, return not anticipated (DRNA) MDS with an ARD of 06/13/2025 provided by the Administrator on 09/04/2025 at 3:31 PM, indicated that the date of completion of 06/13/2025 was handwritten on the form. Review of an MDS Transmission Form provided by the ADON on 09/05/2025 indicated Resident #16's DRNA MDS with an ARD of 06/13/2025 was transmitted on 07/03/2025, which was six days past the required timeframe of submission of 06/27/025. During an interview on 09/04/2025 at 5:50 PM, the Assistant Director of Nursing (ADON) reviewed Resident #16's DRNA MDS with an ARD of 06/13/2025. ADON acknowledged signing the DRNA MDS when it was completed by the MDS Coordinator and stated the MDS Coordinator inputs the information into the computer system including the date of completion. ADON denied entering MDS data into the computer system. Resident #30 A review of an MDS Transmission Form provided by the ADON on 09/05/2025 indicated Resident #30's quarterly MDS, with an ARD of 06/10/2025, was transmitted on 07/03/2025. A review of Resident #30's quarterly MDS with an ARD of 06/10/2025 indicated the date of completion was 06/11/2025. This MDS should have been transmitted by 06/25/2025 and was transmitted 8 days past this date on 07/03/2025. During a telephone interview with the MDS Coordinator on 09/05/2025 at 10:40 AM, she stated the Resident Assessment Instrument (RAI) manual located in the facility's computer system was used and she did not know the version of the manual. She stated an MDS should be transmitted 2 weeks after completion. She stated [ADON's first name] signs the MDS for completion and she transmit them. She stated she may have worked the floor during the month of June 2025, and this may be the reason several MDS forms were submitted on 07/03/2025. She stated there was no certain date that she submitted the MDS information [in the facility's MDS information system], but she knew the MDS information was supposed to be transmitted within two weeks of completion. Review of a policy titled, Electronic Transmission of the MDS, with a revision date of October 2010, indicated all MDS assessments, such as an admission, annual, significant change, quarterly, discharge and entry records would be completed and electronically put in a coded form into the facility's MDS information system and transmitted to the Centers for Medicare and Medicaid (CMS) system by the current OBRA [Omnibus Budget Reconciliation Act] regulations governing the transmission of MDS data. Review of a policy titled, MDS Completion and Submission Timeframes dated October 2010, indicated the transmission date for a DRNA MDS was the MDS completion date plus (+) 14 calendar days. The transmission date for a quarterly MDS was the MDS completion date + 14 calendar days.

Number of residents sampled: Number of residents cited: Based on observation and interviews, the facility failed to ensure that daily staffing was posted in a prominent place readily accessible to residents, staff, and visitors. The findings include: On 09/03/25 at 2:20 PM, the Daily Staffing Log was observed in a copier room off the main dining area. No signage directing visitors to look in the copier room for staffing assignments was observed. On 09/03/25 at 2:32 PM, Certified Nursing Assistant #1 (CNA#1) indicated that visitors were not allowed to enter the copier room. CNA#1 also stated that visitors would have no reason to go into the copier room. CNA#1 stated the way visitors would know if certain staff members were working would be by the staff telling them. On 09/03/25 at 2:38 PM, CNA#2 indicated that visitors were not allowed to enter the copier room where the Daily Staffing Log was posted. CNA #2 stated if visitors wanted to know if a certain staff member were working they could ask one of the other CNA's and they would direct them to where the staff member was working. On 09/03/25 at 2:43 PM, CNA#3 indicated that visitors were not allowed to enter the copier room where the Daily Staffing Log was posted. CNA#3 stated that visitors could ask staff members who was working. On 09/03/25 at 2:56 PM, Licensed Practical Nurse (LPN #4) indicated that visitors were not allowed to enter the copier room where the Daily Staffing Log was posted. LPN #4 stated that visitors could stop at the front office and ask if certain staff were working if anyone was still in the offices when the visitors came into the facility. LPN #4 stated that she had visitors ask her about who was working, and she would provide the information to them. On 09/03/25 at 3:07 PM, the Director of Nursing (DON) indicated that visitors were not allowed to enter the copier room. The DON stated the facility does not give out information to visitors relating to which staff members were working, or what area they were assigned to. The DON stated that visitors should not be allowed to look at the Daily Staffing Logs. The DON stated that the CNA's schedule was posted at each of the nurse's station if visitors wanted to see that. On 09/03/25 at 3:11 PM, the Assistant Director of Nursing (ADON) indicated that she was responsible for posting the Daily Staffing Log and visitors were not allowed to enter the copier room. The ADON stated that she posts the CNA schedule at each nurse's station and if visitors had a question they could look there. The ADON stated that she was not sure if visitors knew the schedule was posted there. On 09/03/25 at 3:35 PM, the Administrator indicated that visitors were not allowed to enter the copier room where the Daily Staffing Log was posted. The Administrator said that the Daily Staffing Log should be posted in an area that was easily accessible to visitors, but they could ask one of the staff who was working. On 09/03/25 at 3:56 PM, the Daily Staffing log was observed posted at the nurse's station at the end of 100 Hall. The date on the schedule read 08/11/25 through 08/17/25. No nurse's schedule was observed. On 09/03/25 at 4:00 PM, the Daily Staffing log was observed posted behind the nurse's station at the end of 200 Hall. The date on the schedule read 08/18/25 through 08/25/25. No nurse's schedule was observed.

Based on observation and interview, the facility failed to ensure dietary staff performed hand hygiene during the preparation of a meal and during the meal service, and failed to ensure food was properly stored and labeled after it was opened in 1 of 1 kitchen (Census 36). This had the potential to affect 33 residents who received meals from the kitchen. The findings are: 1. On 06/05/2024 at 1:40 PM, the Cook brought a box of frozen dinner roll dough and placed it in on the workstation. Without washing his hands, he donned a pair of clean gloves and a took a can of oil out of the cabinet, removed the top with his left hand and held the can with his right hand and sprayed a metal pan. Without washing his hands or changing gloves, he used the same gloves, and he reached in the box and removed some frozen dinner rolls and placed them on the metal pan. He removed the gloves and took the pan to the counter and pulled some clear plastic wrap over it and then placed the pan on top of the upright oven. He retrieved a second metal pan and without washing his hands, put on a pair of clean gloves, removed the top with his left hand, held the can of oil and sprayed the pan using his right gloved hand. He sat the pan on the counter, discarded the gloves and pulled a piece of clear plastic wrap over the pan and placed it on top of the upright oven. He re-taped the box, and at 1:45 PM he left the kitchen with it. 2. At 1:47 PM, the Cook returned to the kitchen with a bag of frozen vegetables, and a 10 pound box of pulled white turkey. He then retrieved a 49 ounce can of chicken broth. At 1:50 PM, he took a 3rd pan and placed it on the workstation, reached in the upper cabinet and gathered a few plastic bottles of seasonings and sat them on the workstation. With his bare hands, he removed the top and sprayed the pan with oil. He then put on oven mitts and checked the items in the upright oven, removed the oven mitts and without washing his hands, donned a pair of clean gloves and opened a plastic bag of the turkey meat and poured it in a prepared pan. He opened a second bag of turkey meat and poured a small amount into the pan with the other turkey meat. He removed his gloves, took the bag or remaining turkey meat, wrapped it with clear plastic wrap, returned it to the box. 3. At 2:29 PM, the Cook took another metal pan, sprayed it with oil and opened the box of dough sheets using his bare hands. He put on a clean pair of gloves without washing his hands and removed a sheet of the frozen dough and placed it in the pan. He took a second sheet of frozen dough and filled the open areas on the pan. He took a scoop and removed some of the meat and vegetables and layered it over the dough and continued this process of layering with the sheets of dough and then the meat mixture. 4. At 2:34 PM, the Cook changed his gloves without sanitizing his hands and took a sheet of frozen dough and placed it over the meat mixture x 2 sheets. He removed his gloves and placed the prepared turkey pot pie in the over. 5. At 4:38 PM, the first tray was served through the kitchen window. During this observation, the Dietary Helper was assisting with placing utensils, condiments, and other items on the tray before it was passed to the cook with her bare hands. She was asked to retrieve some bread for a resident that received an alternate meal. She left the area and returned to the counter by the sink, holding a bag of bread from the dry storage area. With her bare hands she untied the bag. Without washing her hands, she put a glove on her right hand, and held the bag with her left hand, and reached in the bag with her gloved right hand and removed two slices of bread and placed them on a piece of foil, folded the foil over the bread and passed the foil of bread to the cook. The Surveyor left the kitchen at this time. 6. On 06/06/2024 at 1:08 PM, there were 3 reach in freezers, side by side and the third freezer had a clear plastic bag that was tied off and not properly sealed and there was no date or time noted on the bag. 7. On 06/06/2024 at 1:11 PM, the Cook was asked, Are you familiar with the handwashing policy? The Cook stated, Yes. He was asked, Tell me when should you wash your hands? He stated, Whenever you enter the kitchen, or touch a trash bag. I usually wash my hands after I spray something in the dish or touch items with my bare hands. He confirmed that he should have changed his gloves after he touched a box or can of spray with gloves on. He confirmed on the food that had been opened, it should have been wrapped in [name brand] wrap, put in a [name brand] bag, and labeled with what it was and the date. He added that depending on the items, it might need the expiration date. At 1:15 PM, he was asked to look in the reach in freezer on the right and look at a plastic bag and describe what was in the bag. He looked at the bag and confirmed they were dinner rolls and he confirmed that the bag was not labeled. 8. On 06/06/2024 at 1:18 PM, the Dietary Helper confirmed she should have washed her hands after she touched a non-food item, such as the outer part of a bread sack with her bare hands. She confirmed she should have washed her hands before putting on gloves. She was asked, Before touching the bread with a gloved hand that was used to touch the outer part of a bread sack, what should you do before removing the bread from the inside of the sack? She stated, I should have taken it off and changed my glove. 9. A Handwashing Procedure policy provided by the Dietary Manager on 06/06/2024 contained the procedure when washing the hands but did not contain information regarding when or how often the hands should be washed in the kitchen. A Food Facts sheet by the FDA (United States Food and Drug Administration) revealed, .Clean wash your hands and surfaces often . Wash your hands . before and after handling food . 10. A Storage policy provided by the Dietary Manager on 06/06/2024 revealed, .Correct storage procedures will be followed, and storerooms, refrigerators, and freezers will be kept clean and orderly .Frozen foods are stored at 0 degrees Fahrenheit or below. All foods to be frozen are well wrapped, labeled, and dated before freezing .

Based on record review, interview, and observations, the facility failed to ensure the bedside commode in a resident ' s room was emptied in a timely manner for 1 (Resident #187) of 1 resident with a bedside commode and failed to ensure care plan interventions were followed regarding seizure precautions by installing padded bedrails for 1 (Resident #1) of 1 sample mix resident. The findings are: 1. On 06/03/2024 at 12:21 PM, the Surveyor observed the bedside commode sitting beside Resident #187's bed and in front of the resident who was sitting in the recliner. The commode was lined with a trash bag. The commode had 3 sets of used gloves folded together and tossed in the commode. Solid and liquid waste was observed in the commode. The Surveyor asked when the resident had used the bedside commode. The resident stated, I used the bedside commode at 8:00 AM and again at 10:15 AM. a. On 06/03/2024 at 03:34 PM, the Surveyor observed the bedside commode had three pairs of used gloves and solid/liquid waste inside the trash bag lined bucket. b. On 06/03/2024 at 04:01 PM, the Surveyor observed the bedside commode still contained gloves and solid/liquid waste. The Surveyor asked the resident if the staff had been in and emptied the commode. The resident stated, I don't think so. The Surveyor then asked Resident #187 if the resident had used the toilet since the Surveyor was in last. The resident stated, No, but I'm about to. c. On 06/04/2024 at 08:39 AM, the Surveyor observed the beside commode sitting beside the resident who was receiving therapy. When the therapist left the room, the Surveyor looked inside the toilet which contained a black trash bag with used gloves and liquid waste in the commode bucket. d. On 06/04/2024 at 03:26 PM, the Surveyor observed Resident #187 sitting in the recliner. The bedside commode was sitting beside the resident and contained the same gloves and liquid waste. e. On 06/05/2024 at 08:35 AM, Resident #187 was observed in bed. The bedside commode was observed beside the bed. The bedside commode contained a black trash bag lining the bucket, with liquid waste and gloves tossed inside. The Surveyor asked the resident if she had been up this morning. Resident #187 stated No, I have not been up to toilet this morning. f. On 06/04/2024 at 04:30 PM, Resident #187 was asked about the waste remaining in the bedside commode and stated, Well, one or two pees don't bother me so bad, but when it goes this long, by the end of the day it is embarrassing and nasty. It is unsanitary. It bothers me more that it is not a big deal to the CNAs [Certified Nursing Assistants]. They should want to empty it every time. g. A Facility Policy on Personal Care titled, Bedside Commode, Offering/Removing, provided by the Administrator on 06/05/2024 at 2:05 PM, provided instructions for cleaning the bedside commode once it has been used, .27. Wipe the portable commode clean. Store it in its designated storage area. 28. Discard soiled towels, wash cloth, etc., in the soiled laundry container. 29. Discard disposable items into designated containers. 30. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 31. Clean wash basin and return to designated storage area. 32. Clean the bedside stand. 33. Wash and dry your hands thoroughly. 34. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room . h. Resident #187's Care Plan identified the resident to be incontinent, with a goal to maintain resident's dignity, and that the resident utilizes a bedside commode. 50923 2. Review of Resident #1's Care Plan revealed diagnoses of a seizure disorder, osteoporosis, and fracture of femur. The care plan had a Disease Diagnosis section that indicated the resident was at risk for complications related to possible seizure activity. Approaches included, Keep side rails up and padded to reduce risk of injury. a. On 06/03/2024 at 11:29 AM, the Surveyor observed Resident #1 lying in bed, metal side rails up times two without padding installed, none visualized in room. b. On 06/04/2024 at 9:35 AM, the Surveyor observed Resident #1 lying in bed, metal side rails up times two, no padding noted, none visualized in any location in the resident's room. c. On 06/05/2024 throughout the day starting at 8:35 AM, ending at 5:05 PM, the Surveyor observed Resident #1 lying in bed with metal side rails up times two without padding installed, and none visualized in any location in resident's room. d. On 06/06/2024 at 11:00 AM, the Surveyor interviewed Licensed Practical Nurse (LPN) #1 and asked if she was familiar with Resident #1's care plan and medical diagnoses. LPN #1 stated, Yes. When asked what the policy for seizure precautions regarding bedrails instructs, LPN #1 answered, [Resident #1] should have padded bedrails. The Surveyor walked with LPN #1 to Resident #1's room and asked if the resident had padded bedrails in place. LPN #1 stated, No she doesn't. (None were observed on the bed or in the room). e. On 06/06/2024 at 11:26 AM, the Surveyor interviewed the MDS Coordinator and asked if she was familiar with Resident #1's care plan and medical history. The MDS Coordinator stated, Yes I am familiar. When asked what the policy for seizure precautions regarding bedrails instructs, the MDS Coordinator answered, Padded bedrails. The Surveyor walked with the MDS Coordinator to Resident #1's room and asked if the resident had padded bedrails in place. The MDS Coordinator stated, No. (none were observed on the resident's bed or in the room).

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5 percent (%) during the medication administration observation of 3 (Residents #10, #27 and #32) of 5 (Residents #7, #8, #27, #29 and #32) residents who received medications from 3 Licensed Practical Nurses (LPNs). The findings are: 1. Resident #32 had physician's orders for Lasix 20 milligrams (mg) and Omeprazole 40 mg to be administered at the 8:00 AM medication pass. a. On [DATE] at 8:31 AM, LPN #4 gathered Resident #32's medications and stated she was holding the Lasix because it was to be held if the resident's blood pressure was low. At 8:35 AM, she gave the resident the medications with water, but did not give Lasix 20 mg or Omeprazole 40 mg at this time. b. On [DATE] at 2:38 PM, LPN #4 was asked if she recalled administering Omeprazole to Resident #32 during the 8:00 AM medication pass and she stated, I think I did. She was asked to check the cart to see if the resident had a medication card for the medication in question. LPN #4 checked the medication cart and when she pulled out the resident's cards, there was no card of Omeprazole. She checked the as needed section of the cart, and it was not there. The evening nurse came out of a resident's room and stated the medication was in a packet. She opened the top drawer and removed a clear plastic bag that had foil bubble packets of Omeprazole for this resident. LPN #4 stated, Let me go back to the MAR (medication administration record) and circle that because Resident #32 missed that dose. She was asked if Resident #32 had a physician's order to hold the Lasix because no order was located in the resident's paper chart. She stated she thought she saw an order to hold it if the systolic (top number) blood pressure was less than 110 and the diastolic (bottom number) was less than 60. She was unable to provide an order to hold the Lasix prior to leaving her shift. 2. Resident #27 had physician's order for Potassium Chloride 10 Meq (milliequivalents) and Meloxicam 7.5 mg, both to be given with food. a. On [DATE] at 8:42 AM, LPN #4 gathered Resident #27's 8:00 AM medications and at 8:51 AM, she gave the Resident #27 the scheduled medications, but there was no food on the resident's bedside table, or any applesauce or pudding given with the medications. The facility kitchen served breakfast at 6:45 AM. b. On [DATE] at 2:38 PM, LPN #4 confirmed Resident #27 did not have any food during the morning medication pass. 3. Resident #10 had a physician's order for Eliquis 5 mg to be held times 3 days starting [DATE] at 2:00 PM. There were no further orders to hold the medication past this date, the order was not clarified with the provider to resume the medication after this time. On [DATE] at 8 AM, Resident #10's order to hold the medication had expired. a. On [DATE] at 4:13 PM, LPN #6 stated Resident #10's Eliquis was on hold and she did not administer the medication at the 4:00 PM medication pass. b. On [DATE] at 12:28 PM, the Director of Nursing (DON) confirmed there was no order in the record to continue to hold the Eliquis and stated, She's [the nurse] calling the doctor now. c. An Administering Medications policy provided by the Business Office Manager on [DATE] specified, .Medications shall be administered in a safe and timely manner, and as prescribed .

Based on observation, record review, and interview, the facility failed to ensure the facility remained free of a significant medication error for 1 (Resident #10) of 5 (Residents #7, #8, #10, #27 and #32) residents observed during the medication administration observation. The findings are: Resident #10 had a physician's order for Eliquis 5 milligrams (an anticoagulant medication used to treat and prevent blood clots and strokes) to be held times 3 days starting [DATE] at 2:00 PM. There were no further orders to hold the medication past this date and the order was not clarified with the provider to resume the medication after this time. On [DATE] at 8:00 AM, Resident #10's order to hold the medication had expired. a. On [DATE] at 4:13 PM, Licensed Practical Nurse (LPN) #6 stated Resident #10's Eliquis was on hold, and she did not administer the medication at the 4:00 PM medication pass. b. On [DATE] at 12:28 PM, the Director of Nursing (DON) confirmed there was no order in the record to continue to hold the Eliquis and stated, She's [the nurse] calling the doctor now. c. The [DATE] Medication Administration Record (MAR) reflected the Eliquis was held on [DATE] through [DATE] for the 8:00 AM and 4:00 PM times. The order was written on [DATE] at 2:00 PM to hold Eliquis x (times) 3 days. There was no documentation in the 8:00 AM or 4:00 PM box for [DATE] and [DATE] and the 8:00 AM box for [DATE] was blank. As of [DATE] at 1:00 PM, Resident #10 had missed 8 doses of Eliquis. d. An Administering Medications policy, provided by the Business Office Manager on [DATE] specified, .Medications shall be administered in a safe and timely manner, and as prescribed . The DON confirmed on [DATE] the facility did not have a policy covering significant medication errors.

Based on observations and interviews, the facility failed (1) to ensure the ceiling was in good repair in 1 (Resident #9) resident's room, (2) to ensure the two sofas and a chair in the dayroom were in good repair, free of tears, cracks, and holes, and (3) to ensure the tables, benches, and seating on the patio were in good repair without holes, tears and cracks in the seats. The findings are: 1. On 06/03/2024 at 12:02 PM, the Surveyor observed the ceiling falling/hanging down over Resident #9's dresser. The falling ceiling had 9 nails/screws attempting to hold it in place, with several split areas of ceiling tile hanging down. Resident #9 asked the Surveyor to look at his/her ceiling Resident #9 stated, It has been that way about a month and a half. a. On 06/04/2024 at 3:31 PM, the ceiling over Resident #9's dresser remained damaged. b. On 06/05/2024 at 8:36 AM, the ceiling over Resident #9's dresser remained damaged. c. On 06/06/2024 at 9:15 AM, as the Administrator and Surveyor approached Resident #9's room the Administrator stated, If you are talking about [Resident #9's] ceiling, I have contacted the contractor about it. The Surveyor asked when the contractor was contacted. The Administrator stated, Two weeks ago and then I texted him yesterday. The Administrator was asked if she had proof of the contact made two weeks ago. The Administrator stated, No. The Administrator was asked if she had any work order for the repair. The Administrator stated, No, we just call someone or fix the issue. The Administrator was asked if she had a Repair or Replacement policy. The Administrator stated, No. 2. On 06/03/2024 at 1:25 AM, the Surveyor observed a long sofa and a loveseat in the front day room had multiple tears and cracks in the coverings, a chair was torn from one arm to the other arm across the front of the seat. These areas had the potential to cause skin tears to anyone who might sit in them. a. On 06/06/2024 at 9:15 AM, the Administrator stated the tears in the upholstery could cause a skin tear. 3. On 06/03/2024 at 1:00 PM, the Surveyor observed the resident smoking area had a pink chair with a tear along the front of the chair exposing the foam cushion, cracks in the fabric covering the entire seat of the chair, two blue chairs with holes and cracks in the seats of both chairs, a mauve colored chair with the back broken, a mauve colored chair with cracks and a large split in the fabric exposing the foam cushion, and a wooden bench with a dry cracking wood seat and back. These items have the potential to cause skin tears to residents who smoke or sit outside in this area. a. On 06/04/2023 at 10:00 AM, the damage to the chairs and bench was observed to remain. b. On 06/04/2024 at 3:43 PM, the damage to the chairs and bench was observed to remain. c. On 06/06/2024 at 9:00 AM, the damage to the chairs and bench was observed to remain. d. On 06/06/2024 at 9:15 AM, the Surveyor asked the Administrator to join the Surveyor in the patio area. Upon arriving at the patio area, the Surveyor asked do you have any concerns here. The Administrator stated, Yes, and I hadn't been out here or seen this. The Surveyor asked what could happen if a resident sat at one of the tables or chairs. The Administrator said, They could get a skin tear.

Based on observation, record review, and interview, the facility failed to ensure a comprehensive assessment was completed to provide the resident with the proper type of call light to accommodate the physical limitations of 1 (Resident #1) of 1 sampled resident. This failed practice had the potential to negatively impact resident care and safety due to the inability of the resident to alert staff. The findings are: Resident #1 had severe contractures to both left and right hands with hand contracture pads noted in both hands. Resident #1 is known to be non-verbal per staff and family member. The Minimum Data Set (MDS) with an Assessment Reference Date of 03/18/2024 addresses in section GG the physical limitations of the resident (impairment on both sides, mobility device in use) and bilateral contractures. On 06/03/2024 at 12:32 PM, the Surveyor observed Resident #1 in bed with a standard call light draped across the resident's chest over the blanket. On 06/06/2024 at 11:04 AM, the Surveyor interviewed Licensed Practical Nurse (LPN) #1 regarding the call light for Resident #1. LPN #1 was questioned about her knowledge of the limitations of range of motion and finger dexterity of Resident #1 due to severe contractures to bilateral hands. She confirmed Resident #1 does not have the ability to grip and/or press a standard call light to alert staff of a need, stating No, [Resident #1] couldn't grip it and push the button. The Surveyor asked, what other types of call lights are available? LPN #1 stated, The kind you apply pressure. The Surveyor walked with LPN #1 to Resident #1's room and asked what type of call light was observed in Resident #1's room. LPN #1 answered, The regular one with a button. On 06/06/2024 at 11:32 AM, the Surveyor interviewed the MDS Coordinator regarding the call light for Resident #1. The MDS Coordinator was asked to explain the process of assessing the resident for the proper call light. The MDS Coordinator stated, Can they push the call light, if not, we give them the one they can use. The Surveyor asked the MDS Coordinator about her knowledge of the limitations of range of motion and finger dexterity of Resident #1 due to severe contractures to both hands. She stated, Due to the contractures in [Resident #1's] hands, [the resident] wouldn't have the ability to use the standard call light. The Surveyor walked with the MDS Coordinator to Resident #1's room, and asked what type of call light was observed in Resident #1's room. The MDS Coordinator answered, A standard call light. The Administrator stated they do not have a policy or procedure specific to assessments or the determination of equipment matching the resident ' s needs. On 06/06/2024, the Surveyor discussed the process of assessments and determining the proper equipment for the residents with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON). When asked the process of assessing and determining which equipment would be needed, the Administrator stated, Once the assessments are completed, the nurse decides what is needed based on the assessment. The DON and ADON both agreed this is the facility's process.

Based on observations and interviews, the facility failed to ensure the container used to store controlled substances was permanently affixed in Medication room [ROOM NUMBER]. The findings are: 1. On 06/05/2024 at 2:42 PM, the Surveyor observed the black box used to store controlled substances was not permanently affixed. The box contained 2 vials of 2 mg/ml (milligram/milliliter) of Ativan. The Surveyor asked Licensed Practical Nurse (LPN) #2 if the box was permanently affixed. LPN #2 stated, No, it is not attached to anything. It is locked and the refrigerator is locked but it is not affixed to anything. 2. On 06/05/2024 at 3:45 PM, the Surveyor asked the Director of Nursing (DON) if the black narcotic box in the refrigerator in Medication room [ROOM NUMBER] containing controlled substances should be permanently affixed. The DON stated I don't know about it being permanently affixed we never have it affixed. Is it supposed to be affixed? The Administrator and DON then went to the medication room to look at the box, both stated they did not know it should be affixed but would get it affixed. 3. The facility policy titled Storage of Medications did not contain relevant information.

Based on observation, and interview, the facility failed to ensure the heating system was in good working order for 1 (room [ROOM NUMBER]) failed to ensure a clean, sanitary homelike environment for 5 (Rooms 105,108, 109, 110 and 116) of 15 (Rooms 101, 103, 105, 108, 109, 110, 112, 113, 114, 115, 116, 126, 201, 214 and 217) resident rooms and bathrooms observed. The findings are: a. On 04/10/23 at 11:43 AM, the Resident in Resident room [ROOM NUMBER] stated, It's always so cold in here. My heater broke a week or two ago. b. On 04/11/23 at 2:22 PM, the heater in Resident room [ROOM NUMBER] had vent slats broken and missing on one side of the top of the heater. An attempt was made to turn the heater on. The heater did not turn on and did not produce heat. c. On 04/12/23 at 10:11 AM, the Administrator stated, I have contacted maintenance. I was told yesterday the heater was broken. 2. On 04/10/23 at 11:30 AM, 04/11/23 at 8:15 AM, and 04/11/12 at 2:30 PM, in Resident room [ROOM NUMBER] there were water stains on one ceiling tile and multiple ceiling tiles were sagging. The metal runners between the tiles were brown/rust colored stained. In the bathroom, the paper towel holder was dusty and dirty. 3. On 04/10/23 at 12:16 PM, 04/11/23 at 8:26 AM, and 04/11/23 at 2:32 PM, in Resident room [ROOM NUMBER] the bathroom had a dirty, stained sink. 4. On 04/10/23 at 1:44 PM, 04/11/23 at 8:21 AM, and 04/11/23 at 2:24 PM, in Resident room [ROOM NUMBER]'s bathroom there was a thick, crusty white substance on the bathtub faucets and water handles. There were dark brown stains from the top of the tub, under the faucet and down to the drain, with red rust around the drain. 5. On 04/11/23 at 11:00 AM, and 04/11/23 at 2:49 PM, in Resident room [ROOM NUMBER], the only soap dispenser was broken from the wall and was lying on the edge of the sink, unusable. On 04/11/23 at 2:49 PM, there was a stained ceiling tile above the toilet and a stained ceiling tile above the bathtub. The air conditioning vent, exhaust fan and metal runners for the ceiling tile had a dark brown/rust colored staining. 6. On 04/10/23 at 1:35 PM, 04/11/23 at 8:34 AM, and 04/11/23 at 2:52 PM, in Resident room [ROOM NUMBER], the bathroom sink was dirty, with rust colored discoloration around the drain, the paper towel holder was dusty and dirty looking, and the soap dispenser was dirty. 7. On 04/12/23 at 8:34 AM, Licensed Practical Nurse (LPN) #2 stated, There is no log for staff to document repairs needed. LPN #2 indicated there were two maintenance men who are on call and live nearby and stated, We call the maintenance man. 8. On 04/12/23 at 8:37 AM, LPN #3 stated, If there is something that needs to be fixed, we just call the maintenance man who lives nearby. LPN #3 stated there is no log for them to complete if items need to be repaired. 9. On 04/12/23 at 9:45 AM, the Administrator indicated there were logs on the end of the halls for staff to document maintenance needs and confirmed the facility does not have full-time maintenance staff. The Administrator stated, The staff tell me when there are maintenance needs and I text the maintenance men. They both have other jobs. The Administrator accompanied the Surveyor to Resident Rooms 108, 109, 110, 116 and 105, and confirmed the above observations. The Administrator stated, I can't disagree with what you are saying.

Based on interview, and record review, the facility failed to develop and implement a Quality Assurance Performance Improvement (QAPI) Plan to include identification of problems, implementation of corrective actions, documentation, review, and analyze and tracking of the data. The findings are: 1. On 04/13/23 at 12:12 PM, the Administrator stated, I don't have any sign in sheets for the QAPI meetings. When an issue is identified, we meet, will discuss the issue, and will try something to solve the issue. If it doesn't work, we will try something else. There is no formal process to document what we monitor. 2. On 04/13/23 at 1:20 PM, the Surveyor asked Certified Nursing Assistant (CNA) #3 if she knew what the QAPI goals for 2023 were. CNA #3 stated, No, I don't know. I'm sorry. 3. On 04/13/23 at 1:25 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2 who if she knew what the QAPI goals for 2023 were. LPN #2 stated, I'm trying to figure out what it is. Is that quality control or something? 4. On 04/13/23 at 1:27 PM, the Surveyor asked LPN #1 if she knew what the QAPI goals for 2023 were. LPN #1 stated, No ma'am, I've never heard of it. I don't even know what it is. 5. The facility policy titled, Quality Assurance & [and] Performance Improvement (QAPI) Plan ., provided by the Administrator on 04/11/23 at 1:05 PM documented, .the facility will put in place systems to monitor care and services .; [Facility] uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, it's causes, and implications of a change [Facility] applies a thorough and highly organized/structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered. [Facility ' s] approach comprehensively assesses all involved systems to prevent future events and promote sustained improvement. We also have developed policies and procedures regarding expectations for the use of root cause analysis when problems are identified .

Based on observation, and interview, the facility failed to ensure resident personal care equipment was properly cleaned and stored to prevent potential cross-contamination between residents. The failed practice had the potential to affect all 35 residents who resided in the facility as documented on the Room-Bed List provided by the Administrator on 04/11/23 at 12:00 PM. The findings are: 1. On 04/10/23 at 11:30 AM, 04/11/23 at 8:15 AM, and 04/11/23 at 2:30 PM, in the bathroom in Resident room [ROOM NUMBER] there was a dirty wash basin sitting on the floor under the bathroom sink. The wash basin was not stored in a bag or a storage container. 2. On 04/10/23 at 12:16 PM, 04/11/23 at 8:26 AM and 04/11/23 at 2:32 PM, in the shared bathroom in Resident room [ROOM NUMBER], there was a urinal with dark yellow stains inside of it and a wash basin on the back of the toilet. The wash basin and urinal were not labeled or stored in a bag or storage container. 3. On 04/10/23 at 1:35 PM, and 04/11/23 at 2:42 PM, in the shared bathroom in Resident room [ROOM NUMBER], there was a urinal with yellow stains sitting on the back of the toilet. The urinal was not labeled or stored in a bag or storage container. 4. On 04/11/23 at 10:25 AM, and 04/11/23 at 2:45 PM, in the shared bathroom in Resident room [ROOM NUMBER] there was a dirty urine collection container sitting on the floor under the sink. The urine collection container was not labeled or stored in a bag or storage container. 5. On 04/13/23 at 8:10 AM, the Assistant Director of Nursing, (ADON) indicated the night staff wash and disinfect the personal care equipment, such as the wash basins, then store them in a bag for re-use. The ADON stated, The items are not labeled with the resident's name and are used on other residents. The Surveyor requested to see the products used for cleaning the equipment. 6. The product Data Sheet for the disinfectant used by the facility and obtained from the website by the Surveyor on 04/13/23 at 8:41 AM documented, .Contaminated cleaning materials, blood and other body fluids should be autoclaved and/or disposed of according to local regulations for infections waste disposal . 7. On 04/13/23 at 9:19 AM, the ADON informed the Surveyor there were no audits done to assure personal care equipment is cleaned per the manufacturer's recommendations for the cleaning products and could not ensure the personal care equipment had not been contaminated with blood or other body fluids.

Based on observation, and interview, the facility failed to ensure personal hygiene items were stored in a sanitary manner for 4 (Rooms #108, #109, #112 and #113) of 14 (Rooms #101, #103, #105, #108, #109, #110, #112, #113, #114, #115, #116, #201, #214 and #217) resident bathrooms observed. The findings are: 1. On 04/10/23 at 11:30 AM, 04/11/23 at 8:15 AM and 04/11/23 at 2:30 PM, the bathroom in room [ROOM NUMBER] had a metal basket on the back of the toilet with a toothbrush handle in the basket and the bristles of the toothbrush laying on the toilet tank lid. The toothbrush was not stored in a bag or storage container. A dirty wash basin was on the floor under the bathroom sink. The wash basin was not stored in a bag or a storage container. 2. On 04/10/23 at 12:16 PM, 04/11/23 at 8:26 AM and 04/11/23 at 2:32 PM, in the shared bathroom in room [ROOM NUMBER], there was a dirty, dried wash cloth, a urinal with dark yellow stains inside, and a wash basin on the back of the toilet. The wash basin and urinal were not labeled or stored in a bag or storage container. a. On 04/11/23 at 8:26 AM and 04/11/23 at 2:32 PM, on the overbed table in room [ROOM NUMBER], a brown substance was on the bottom half of the table leg. 3. On 04/10/23 at 1:35 PM and 04/11/23 at 2:42 PM, in the shared bathroom in room [ROOM NUMBER], there was a urinal with yellow stains, a hairbrush, toothpaste, and an empty styrofoam cup on the back of the toilet. The urinal was not labeled or stored in a bag or storage container and the brush and toothpaste were not labeled with the resident's name. 4. On 04/11/23 at 10:25 AM, and on 04/11/23 at 2:45 PM, in the shared bathroom in room [ROOM NUMBER] there was a dirty urine collection container on the floor under the sink. The urine collection container was not labeled or stored in a bag or storage container. a. On 04/11/23 at 2:45 PM, in the shared bathroom in room [ROOM NUMBER] there was a toothbrush in a styrofoam cup between the wall and the shower grab bars. The toothbrush was not in a storage container and was not labeled. 5. On 04/11/23 at 9:07 AM and 04/11/23 at 2:54 PM, in the shared bathroom in room [ROOM NUMBER] there was a box of denture cleaner, a denture cup, a toothbrush, a bottle of white liquid, mouthwash, shampoo, a cup with two toothbrushes and 3 bars of soap on the shelf above the sink. The items were not marked with the resident's name. 6. On 04/12/23 at 9:45 AM, the Administrator accompanied the Surveyor to Rooms #103, #108, #109, #112 and #113 and confirmed the above observations and stated, I can't disagree with what you are saying. The Administrator indicated she visits the rooms every day, but her focus is on the resident, and not the condition of the room. 7. On 04/13/23 at 8:10 AM, the Assistant Director of Nursing, (ADON) indicated the night staff wash and disinfect the personal care equipment, such as the wash basins, then store them in a bag for re-use. The ADON stated, The items are not labeled with the resident's name and are used on other residents.

Based on observation, interview, and record review, the facility failed to ensure a resident's urinary catheter drainage bag was kept in a privacy bag to promote dignity for 1 (Resident #11) of 5 (Residents #1, #11, #13, #15 and #28) sampled residents who had catheters as documented on the Matrix provided by the Administrator on 04/11/2023. The findings are: Resident #11 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Urinary Tract Infection, Alzheimer Disease and Overactive Bladder. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/23 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and had an indwelling catheter and an ostomy. a. A Physicians Order dated 10/04/22 documented, .Foley catheter care wash with soap and H2O [water] per CNA [Certified Nursing Assistant]. Secure catheter with anchoring device to prevent trauma or dislodgement . b. The Care Plan with a review date of 02/08/23 documented, .Urinary Catheter Care .Keep catheter tubing free of kinks. Keep drainage bag below level of bladder . The Care Plan does not address keeping the drainage bag in a privacy covering for dignity. c. On 04/10/23 at 11:22 AM, Resident #11 was lying in bed. Foley catheter attached to bedrail draining cloudy yellow urine. Catheter bag was not in a privacy bag. c. On 04/10/23 at 12:56 PM, Resident #11 was lying in bed. Foley catheter attached to bedrail not in a privacy bag. d. On 04/11/23 at 8:38 AM, Resident #11 was lying in bed. Foley catheter was in a privacy bag. e. On 04/13/23 at 7:55 AM, Resident #11 was lying in bed. Foley catheter attached to bedrail not in a privacy bag. f. On 04/13/23 at 8:02 AM, Licensed Practical Nurse (LPN) #1 and Certified Nursing Assistant (CNA) #1 were at Resident #11's bedside, the catheter bag was in a privacy bag. The Surveyor asked LPN #1 about catheter bag being uncovered Monday, 04/10/23 and this morning, she stated, Aides, I think they empty the bag and tend to forget to cover it. LPN #1 acknowledged the catheter bag is supposed to be in a privacy bag. g. The facility policy titled, Catheter Care, Urinary, provided by the Assistant Director of Nursing (ADON) on 04/13/23 at 9:46 AM did not address privacy bags.

Based on observation, and interview, the facility failed to ensure medical devices were plugged into a properly grounded electrical outlet and not into a power strip for 1 (Resident #15) of 15 (Residents #1, #6, #9, #11, #12, #13, #15, #21, #22, #28, #30, #31, #35, #36 and #38) sampled residents utilizing pressure relief air mattresses; and failed to maintain an environment free from hazards, as evidenced by a cable cord lying on the floor, running from one resident room, through the bathroom, into the adjoining room for 2 (rooms [ROOM NUMBERS]) rooms of 15 (room [ROOM NUMBER], 103, 105, 10, 109, 110, 112, 113, 114, 115, 116, 126, 201, 214 and 217) resident rooms and bathrooms observed. The findings are: 1. Resident #15 had diagnoses of Stage IV decubitus to coccyx, Type II diabetes with other skin ulcer, and Cerebrovascular accident. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/2023 documented a score of 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. On 04/11/23 at 10:44 AM, the Surveyor observed a power strip plugged into an electrical outlet with a fan, a cell phone charger, the resident's bed, and a pressure relief air mattress plugged into it simultaneously. b. On 04/11/23 at 3:40 PM, the Administrator provided documentation indicating the facility did not have a policy on extension cords and power strips. The documentation stated, Don't have policy for extension cords, power strips. c. On 04/12/23 at 10:32 AM, the Surveyor asked Certified Nursing Assistant (CNA) #2 to verify the pressure relief air mattress and bed were plugged into a power strip. She stated, Yes, it is. The Surveyor asked if medical devices should be powered through power strips. She stated, I don't know anything about that. The Surveyor asked if she had received any training regarding the use of power strips or electrical cords from the facility. She stated, No. d. On 04/12/23 at 10:51 AM, the Surveyor asked the Administrator if medical devices could be plugged into power strips. She stated, I don't know. The Surveyor asked if medical devices could be affected if a power strip malfunctioned. She stated, Yes. e. The pressure relief air mattress User's Manual provided by the Administrator on 04/13/23 at 9:47 AM documented, .WARNING . Connect this product to a properly grounded outlet only . 41718 2. Resident #17 had diagnoses to include Deep Vein Thrombosis, Hypertension, Anxiety Disorder, and Osteoarthritis. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/23 documented the resident scored 8 (8 to 12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. On 04/11/23 at 9:07 AM, 04/11/23 at 2:54 PM and 04/11/23 at 4:18 PM, in Resident room [ROOM NUMBER] a television cable from the back of the Resident ' s television set through the shared bathroom, around the back of the toilet and into the next room. Approximately 2 feet of the cable wire was in in the shared bathroom floor, with the potential to cause a trip hazard. The Resident stated, I can walk into the bathroom, but I usually ask for help. b. On 04/12/23 at 9:45 AM, the Administrator accompanied the Surveyor into Resident room [ROOM NUMBER] and confirmed the above observation and stated, I can't disagree with what you are saying. The Administrator confirmed there was a potential for a fall hazard.

Based on observation, and interview, the facility failed to adequately maintain and repair the resident call light system to ensure there was a functioning communication system between the residents and nursing staff for 1 (Resident #19) of 1 sampled resident during the survey. The findings are: 1. Resident #19 had diagnoses of Atrial Fibrillation, Chronic Obstructive Pulmonary Disease and Heart Failure. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). 2. On 04/10/23 at 10:54 AM, in Resident #19's call light was wrapped around his walker. The end of the call light was taped to the wall at the plug. Resident #19 stated, The button was coming on by itself. It does not bother me, but it was a problem for the staff. It has been taped about a week. 3. On 04/11/23 at 2:56 PM, the call light continued to be taped to the wall and wrapped around the Resident #19's walker. The Surveyor pushed the call light button, the light outside the door did not come on, and no staff responded to the light. 4. On 04/12/23 at 9:55 AM, the Administrator accompanied the Surveyor to Resident #19's room and observed the call light plug taped to the wall. The Administrator tested the call light and confirmed it did not work and confirmed all residents require a working call light. The Administrator stated there was no policy related to the call light system.

Based on observation, interview, and record review, the facility failed to ensure resident's right to self-determination, as evidenced by the lack of accommodation of a resident's choice to be escorted out of the facility to watch the cats for 1 (Resident #14) of 40 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39 and #40) residents that relied on the facility to maintain the highest practicable level of autonomy. The findings are: Resident #14 had diagnoses of Major Depression, Bipolar Disorder and Hypertension. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/14/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. On 04/11/23 at 11:20 AM, the Surveyor asked Resident #14 how she was feeling that morning. She stated, Depressed . two things are bothering me. One is I miss my cats. Resident #14 pointed at a photo on the wall. She stated, Before I came in here, I had cats at home. I'd really like to go outside and see the ones out there. The Surveyor asked if she had told staff she wished to go outside. She stated, Yes, but they said that if they let me go outside and state drove by and saw me, they'd get in trouble. The Surveyor asked who had told her that. She stated, One of the aides. I'd really just like to go out and sit in the sunshine to watch and feed the cats. b. On 04/12/23 at 10:32 AM, the Surveyor asked Certified Nursing Assistant (CNA) #2 if Resident #14 had asked to go outside. She stated, Yes. I know she's been asking. The Surveyor asked if the resident had ever been taken out when she requested it. She stated, I don't know. c. On 04/12/23 at 10:51 AM, the Surveyor asked the Administrator if she was aware that Resident #14 had requested to go outside. She stated, Yes, I've told her she can go out in the Courtyard, so she doesn't have to be supervised. The Surveyor told the Administrator that Resident #14 had requested to sit out front specifically so she could feed and observe the cats outside the facility. She stated, I know, but we feed the cats in the morning, and she only wants to go out later, like at 5:00 [PM], and she can't go out there alone.

Complaint # (AR 708) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure the transport staff consistently utilized the Vehicle Anchorages for the 4-Point Wheelchair Securement System in accordance with the manufacturer's instructions, and that all transport staff members were properly trained on them to prevent a fall with a serious injury for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents who utilized a wheelchair during transport in the facility van. This failed practice resulted in past noncompliance at the level of actual harm to Resident #1 who was anchored incorrectly in her wheelchair on the van and fell out of wheelchair during transportation resulting in the resident being airlifted to a Hospital Trauma Center for treatment of [REDACTED]. 1. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/6/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); was totally dependent for bed mobility, transfers, and activities of daily living (ADLS); was always incontinent of bowels and bladder; required a wheelchair for mobility; and was totally dependent for locomotion off the unit. a. The manufacturer's instructions titled Installation Instruction Vehicle Anchorages and Accessories for 4-Point Wheelchair Systems provided by the Administrator on 6/1/2020 at 1:50 p.m. documented, .Introduction . Q'Straint's 4-Points wheelchair and occupant systems, when used as recommended, provide the safest means of transportation for wheelchair passengers unable to transfer from their wheelchairs when traveling in motor vehicles . Each component has been designed, engineered and tested to work as one comprehensive system . We highly recommend the use of lap and shoulder belts to reduce possibility of head and chest impacts with vehicle components . b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long Term Care Facilities, Division of Medical Services, (DMS) Form 762 dated 5/9/2020 at 3:15 p.m. documented, .Date and Time . 5/9/2020 at 3:15 p.m.Date and Time of Discovery . 5/9/2020 at 3:15 p.m.(Resident #1) was on her way back from [MEDICAL TREATMENT] with driver (Certified Nursing Assistants (CNA) #1) and passenger (CNA #2) are suspended until investigation is completed on the Facility Van. The staff hit their brakes at the stop sign and (Resident #1) fell out of the wheelchair. Staff called the facility and Assistant Director of Nursing (ADON) was told to take (Resident #1) to the emergency room (ER) . (ADON) met staff at the ER with (Resident #1). One CNA got to go back with (Resident #1). We received a phone call about 5:10 p.m. that (Resident #1) was being airlifted to (Name) Trauma Center . c. The Summary of Incident Report on DMS Form 731 dated 5/29/2020 at 2:45 p.m. documented, .(Resident #1) was pushed on the Van per staff . (CNA #1) was inside. She locked the wheelchair and then locked the straps in the front . then the seat belt was placed across abdomen . then (CNA #2) locked the straps in the back. At 3:15 p.m., transportation (CNA #1) and (CNA #2) were coming back from [MEDICAL TREATMENT] with resident. While driving, (CNA #1) made it to the stop sign. When (CNA #1) pushed on the break to stop, resident slid out of the wheelchair. (CNA #1) put van in park, then got in the back of the van to see what was wrong with (Resident #1). (CNA #1) noted that legs were under resident. (CNA #1) and (CNA #2) moved the wheelchair to get access of (Resident #1) . (CNA #1) noted that the (resident's) legs were under the resident. The wheelchair was still in the upright position and the resident was sitting on the foot petal. The CNAs called the facility and there was no answer at 3:23 p.m. and then called at 3:25 p.m. ADON and was told to take resident to the ER (emergency room ). Waiting on results from Hospital X-rays. (CNA #1 and CNA #2 have been suspended until the investigation is over . d. The hospital x-ray report dated 5/9/2020 at 16:41 (4:41 p.m.) provided by the Administrator via e-mail on 5/29/2020 at 3:06 p.m. documented, .CT (Computed Tomography) of Bilateral Upper Legs without IV (intravenous) Contrast . Findings . There are comminuted and moderately displaced and impacted fractures of both distal femoral Metadiaphysis with no intra-articular extension. Associated soft tissue swelling and hematoma is noted adjacent to the fracture sites . e. On 6/1/2020 at 1:39 p.m., the Administrator was asked, Have all the employees that drive / ride on the facility van been trained / in-serviced on the Van? She stated, We have in-serviced everyone now. We had an in-service on 5/9/2020 and gave everyone certificates. There were no in-services prior to the incident. There is a notebook in the Van also that the employees are supposed to fill out before transporting a resident, but it has not been completed since November 2019. The DON stated, We have talked to the staff about one of them sitting in the back of the van with the resident while transporting them. That's why we sent two staff members on the van. The Administrator was asked, Do you have any documentation of informing the staff to sit in the back with the resident? She stated, No, we don't have it documented anywhere prior to 5/9/2020. The Administrator was asked, Did the facility re-assess the residents that use wheelchairs for transport in the facility van? The Administrator stated, No we didn't. The Administrator was asked, How are you monitoring to ensure that it doesn't happen again? The Administrator stated, We are monitoring the residents that are being transported via facility van. I go out and check the residents and make sure they are secured correctly before they leave. This was implemented after the incident. We had no monitoring prior to the incident on 5/9/2020. She was asked, Did you do a return demonstration on securing the residents in the van? She stated, Yes, we did in the in-service on 5/9/2020. The Administrator was asked, What do you feel like happened that resulted in this resident falling out of her wheelchair? She stated, I feel like the CNAs did not anchor the back wheels on the wheelchair. Both of them said the back wheels came up off the floor of the van, and if the shoulder strap and the lap belt had been secured correctly, there is no way she would have fallen out of the wheelchair. We haven't been able to talk to the resident to see if she could tell us what happened because she is still in the hospital. f. On 6/1/2020 at 2:17 p.m., CNA #6 was asked, Have you had any concerns with residents' wheelchairs? She stated, No ma'am. I haven't. She was asked, Do you ever drive the van or ride on the van when a resident is transported? She stated, Yes, I do. She was asked, Where do you sit on the van? She stated, I sit in the back with the resident. She was asked, Who secures the resident on the van? She stated, We both do. One does the back and the other one does the front. We strap them in the seat belt, then we put the strap across the shoulder, and one belt around their waist. g. On 6/1/2020 at 2:21 p.m., CNA #3 was asked, Have you had any concerns with residents' wheelchairs? She stated, No ma'am, I haven't. She was asked, Do you ever drive the van or ride on the van when a resident is transported? She stated, No. I haven't ridden on or driven the van. She was asked, Have you had any training on the facility van? She stated, Yes, they trained us all on the sure-loc safety issues on the van. We watched a video. I have never actually anchored a wheelchair down with a resident in it. h. On 6/1/2020 at 3:15 p.m., the Administrator was asked for the facility security logs checklist before transports, and wheelchair repair logs, and how often wheelchairs are checked for safety? She stated, The safety log hasn't been filled out since 2019. I don't have a policy and procedure for the van, only checks for oil changes and tires if needed. The transport staff should be filling out a checklist daily whenever they transport a resident. There are no logs for wheelchair checks, only maintenance randomly checks them. We haven't monitored wheelchair transports. i. On 6/1/2020 at 5:56 p.m., the Administrator was asked, Should the staff always check for safety prior to transporting resident? She stated, Yes ma'am, they should have. She was asked, Should a safety check be performed on wheelchairs in a timely manner? She stated, Yes, they should be. She was asked, Should all staff drivers and riders be in-serviced and trained on safety measures for the facility van? She stated, Yes, they should. j. A facility form titled Wheelchair Tiedown Strap, Belt and Anchorage Maintenance provided by the Administrator on 6/4/2020 at 4:46 PM via email documented, .Inspect strap and belt assemblies frequently . Any defects such as strap / belt cuts, fraying, or malfunctioning, call for replacement of the entire strap / belt assembly . Floor anchorage pockets must be cleaned and not worn, bent, or otherwise damaged . (prohibiting proper strap / belt attachment). If there is any sign of damage, wear, abnormal condition, or improper operation of straps, belts, strap / belt, hardware (hooks, keepers, latch plate, receptacle), or floor pockets, discontinue use and replace components immediately . 2. The facility initiated corrective action immediately after the van incident on 5/9/2020 by implementing the following: a.All staff was in-serviced on 5/9/2020 and 5/10/2020 with the Sure-Loc System for strapping down wheelchair securely with return demonstrations. b. All 56 residents that ride in the van will be observed prior to leaving facility to ensure they are securely placed in van and staff will check equipment before placing resident in the van to make sure it is working properly and will do monitoring log. Designee will check the check-off list weekly to ensure staff is checking-off daily. c. Staff will be re-in-serviced on the Van Procedure and Maintenance starting 6/1/2020 and Transportation Staff will be in-serviced by 6/2/2020 on doing check-off daily on van equipment to ensure safety of residents and will document when they have. Any negative findings will be reported to the Administrator / Designee. d. All negative findings will be corrected immediately and reported to the Administrator and Designee will report to QA (Quality Assurance) three times a week .

Complaint # was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure staff were adequately supervised to prevent resident injury during staff assisted transfers as evidenced by the facility failure to ensure Certified Nursing Assistants were trained and competent in the use of mechanical lifts to prevent the potential for injury for 1 (Resident #4) of 5 (Residents #3, #4, #5, #6, and #7) case mix residents requiring transfer with a mechanical lift. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death for Resident #4 who suffered a fracture of the right and left femur as a result of a fall from a mechanical lift, and had the potential to affect 17 residents who required the use of a mechanical lift for transfers as identified by a list received from the Director of Nursing on 11/15/12 at 10:00 a.m. The Immediate Jeopardy was removed by the facility prior to the survey entrance date, however the underlying deficient practices were not fully corrected. The facility was notified of the Immediate Jeopardy removed on 11/15/12 at 8:55 a.m. The findings are: 1. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 9/20/12 documented the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status, required the assistance of 2 or more staff members for transfers and bed mobility and had no falls since admission. a. An Incident/Accident Report dated 10/26/12 documented, "Resident on floor (with) lift pad in place. Resident complained of left leg pain. X (times) 2 staff members stated that the hoyer lift tilted over and resident fell on floor." The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long-Term Care Facilities form dated 10/26/12 Section II documented, "On 10/26/12 both (CNA #1) and (CNA #2) transferred (Resident #4) from the bed to the Geri-chair. Employees stated that during the transfer the lift tilted and caused it to fall. While transferring resident from bed to Geri-chair lift tilted and resident fell to the floor." b. An undated witness statement signed by CNA #1 documented, "I went into (Resident #4's) room to get her out of bed with the lift and while in there (CNA #2) assisted me as I opened the lift. I lifted her clear off the bed and as soon as (CNA #2) moved over by the chair we were about to put her in, I looked down as the lift began to tilt over. I placed my foot on the lift and tried to balance it but when that didn't work I put my arm under (Resident #4's) head so that it wouldn't hit the bed as we both went down. She fell on her bottom on the floor and the top of the lift fell on my back at that time I removed my arm unhooked (Resident #4) from the lift and (CNA #2) went for help." On 11/14/12 at 12:55 p.m., CNA #1 was interviewed via telephone. CNA #1 stated, "We were using the lift. The legs were apart. The side-rail was down as we were lifting her up. As I moved her backwards the lift flipped to the left and she landed on the floor. It could have been slightly at an angle to the left when I moved her back. As it began to tilt over to the left I placed my foot as far as I could to the right leg of the lift at the back of it. I wasn't heavy enough to hold it down so I grabbed her head as we were both falling. My left knee hit the floor and the lift fell on my back and some of it on my right side. I caught the upper part of her back and her head. She fell to the floor near the bed. The Geri-chair was 4 or 5 steps away from the bed. The left leg of the lift was about a quarter of it under the bed." c. A witness statement dated 10/26/12 and signed by CNA #2 documented, "10-26-2012, I spotted (CNA #1) while she got (Resident #4) out of bed. (Resident #4) was on the center of the pad and the pad was criss-crossed between her legs. All four loops on the pad were connected to the lift. When (CNA #1) lifted (Resident #4) above the bed, I walked around the bed to get the Geri-chair. When I turned my back to get the chair, I heard a loud thud sound. It scared me so I jumped around and saw (CNA #1) pulling the lifter off the bathroom door. (Resident #4) was sitting on the floor in front of the bathroom door. I asked (CNA #1) what happened. Did she hit her head? (CNA #1) said she didn't hit her head and to go get help ... (Administrator) was there and said go get the nurse. He asked me what happened. I told him I don't know. (CNA #1) disconnected the loops from the lifter and stood behind (Resident #4) so she would not fall backwards. After that, the room was filled with several coworkers. (Resident #4) was hysterical ... I was paged to the office. (Director of Nursing) told me she heard (CNA #1) version. Now she wanted to hear my version. I told her. After that she told me she needed me to clock out and wait until I heard from her before I came back. I clocked out ..." d. A witness statement dated 10/25/12 signed by the Administrator documented, "Around lunchtime, I was walking the halls making rounds. When I heard a loud sound coming from (Resident #4)'s room. I made it to the door and I heard her (Resident #4) on the floor. I opened (the door) and saw that the resident was on the floor and I asked a passing CNA to get the nurse as soon as possible. While the CNA was getting help I asked the two ladies (CNA #1 and CNA #2) what had happened. (CNA #1) stated that she and (CNA #2) were attempting to transfer the resident from the bed to the Geri-chair, the lift tilted over, causing the resident to hit the floor. As I was looking over the room I noticed that the Geri-chair was too far from the bed, when I entered the room." On 11/14/12 at 10:22 a.m., the Administrator was interviewed and stated, "The incident happened on 10/26/12. The two girls involved in the incident were suspended pending investigation on 10/26/12. On 11/2/12 (Friday) both girls returned to the facility without pay to pick up their checks. At that time I asked them to demonstrate and re-enact the incident with (Resident #4) that occurred on 10/26/12. We had them demonstrate individually - not together. (CNA #1) came in first. She did everything correct except the Geri-chair position was too far away from the bed. I felt that the distance was excessive. There was too much chance of error. (CNA #2) was second. Her error was she didn't let down the siderails. This put the resident at risk because she had to lift the resident too high off the bed. That was all she did wrong. Both girls remained suspended without pay until they were terminated on 11/5/12. The demonstration of the lifts were observed by me, by the staffing development CNA and the Director of Nursing. The day of the accident I was the first one in the room. I heard a loud noise. The Vanderlift was tilted on its side. The legs of the lift were pointed toward her (Resident #4). I believe the legs were spread apart. The Geri-chair was approximately 6 to 8 feet away from the bed." e. A Hospital "Imaging Report" dated 10/26/12 documented, "The right femur demonstrates a spiral fracture at the junction of the middle and distal 3rd of the right femoral shaft ... The left femur demonstrates a comminuted fracture of the proximal diaphysis with extension into the left intertrochanteric region of the left femoral neck." f. On 11/14/12 at 1:45 p.m., the Director of Nursing was interviewed and stated, "On 11/2/12, I observed a demonstration of each of the female employees using the Vanderlift to transfer a staff CNA - one at a time. (CNA #1) was first to demonstrate. They came at different times. The Geri-chair was not positioned right for the transfer. The Geri-chair was at the foot of the bed. She would have to swing the Vanderlift around to put the staff member in the chair. (CNA #2) came in later. She did not let the side rails down and she did not position the Geri-chair correctly. After the demonstration I did not feel like either of the girls were competent and safe in transferring residents. Since the accident we investigated, interviewed residents that are transferred by mechanical lift, had the equipment lifts both checked out by the service company, held nursing inservices on transferring with the mechanical lifts with return demonstrations and since then we have monitored all CNA's utilizing the Vanderlift." g. On 11/14/12 at 9:50 a.m., a review of the employee files for CNA #1 and CNA #2 was completed. A form titled "Certification of Training" was found in each of the employees file. The form documented a section for "Subject", "Date(s) of Training", and "Trainer." A section for "Resident Lifting/Transfer" was included on the form. The form in both of the employees' files contained no documentation of completion. 1) On 11/15/12 at 9:30 a.m., the CNA Staff Development Coordinator was interviewed and was asked in regard to the form, "Certification of Training" was there any employees in the facility that had been trained as indicated using the form. The CNA Staff Development Coordinator stated, "No. We were going to initiate this form as a training tool based on OSHA (Occupational Safety and Health Administration) requirement but we have not started the process. There is no formal orientation for new employees." 2) On 11/15/12 at 9:45 a.m., the Administrator was interviewed and was asked in regard to the form, "Certification of Training" was there any employees in the facility that had been trained as indicated using the form. The Administrator stated, "No there were not. The training and the form haven't been implemented yet." h. On 11/14/12 at 9:55 a.m., an Inservice Sign-in sheet dated 7/13/12 titled, "Restorative Nursing and Transfers" was received from the CNA. Staff Development Coordinator. The Coordinator stated, "This inservice was presented on 7/13/12. We had a mechanical lift there and demonstrated using it but we did not have any return demonstrations." On 11/15/12 at 8:46 a.m., the Director of Nursing was asked prior to the accident how she insured all employees were proficient in the use of the Vanderlift before they were allowed to utilize the lift to transfer a resident. The Director of Nursing stated, "Other than me making walking rounds and observing I don't have any documentation that every nursing employee was proficient in using the lift. I have documented on a few of the employees." i. On 11/14/12 at 10:02 a.m., the Administrator was interviewed and stated, "Since the incident with the lift on (Resident #4) every lift in the facility has been checked for proper functioning and safety by (Company #1). We purchase our lifts from them and they service them." On 11/15/12 at 8:45 a.m., the Administrator was interviewed and stated, "We took the Vanderlift II out of commission immediately after the accident." 2. The facility removed the Immediate Jeopardy and reduced the scope/severity to "G" prior to the survey entrance date when the following actions were taken: a. CNA #1 and CNA #2 were suspended immediately. b. The Vanderlift utilized in the transfer was taken out of commission immediately until such time that the lift could be checked by the service company on 11/2/12. c. The incident was investigated by the Administrative team to include interviews with other residents requiring the use of a lift for transfers. d. An inservice regarding resident transfers dated 11/2/12 was presented with return demonstrations and check-off procedures implemented. e. Monitoring of the staff while performing transfers was initiated.

Based on record review and interview, the facility failed to ensure adequate supervision was provided to prevent resident injury during staff assisted transfers, as evidenced by failure to ensure manufacturer's instructions were followed during use of a Mechanical Lift to prevent potential injury for 2 (Residents #5 and #6) of 7 (Residents #1, #2, #3, #4, #5, #6, and #7) case mix residents who required the use of a mechanical lift during a transfer. The failed practice had the potential to affect 24 residents who required the use of a mechanical lift, according to a list provided by the Administrator on 1/14/13. The findings are: 1. The Invacare Operating Manual, received from the Administrator on 1/3/13, page 36 documented, " ...8.3 Transferring to a Wheelchair. WARNING: When the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are NOT properly in place, lower the patient back onto the stationary surface and correct this problem - otherwise, injury or damage may occur. Adjustments for safety and comfort should be made before moving the patient. The patient's arms should be inside of the straps. Invacare does NOT recommend locking the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. Invacare DOES recommend that the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed or any stationary object. The legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs are no longer under the bed, return the legs of the lift to the maximum open position and lock the shifter handle immediately. 2. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/12 documented the resident scored 7 (0-7 indicates severely impaired) on the Brief Interview for Mental Status, required total assistance with transfers and extensive assistance with bed mobility. On 1/3/13 at 11:45 a.m., Certified Nurse Assistants (CNA) #1 and #2 transferred Resident #3 from a low bed to a wheelchair using the facility's mechanical lift. CNA #1 rolled the lift to the resident's bed, positioning the base of the lift underneath the low bed. The legs of the lift were not spread. The resident was raised to the height of the resident's wheelchair, turned and moved toward the wheelchair. CNA #2 stayed with the resident continuously to help support the resident during the transfer. When the lift came near the wheelchair, CNA #1 spread the legs of the lift in order to get close enough to lower the resident onto the seat of the of the wheelchair. After the transfer was completed, CNA #1 was asked why the legs of the lift weren't opened while moving the resident from the bed to the chair. CNA #1 stated, "Oh I didn't, did I? I forgot." 3. Resident #6 had [DIAGNOSES REDACTED]. The Annual MDS with the ARD of 11/29/12 documented the resident scored 0 (0-7 indicates severely impaired) on the Brief Interview for Mental Status and was totally dependent for bed mobility and transfers. a. On 1/3/13 at 4:00 p.m., CNA's #3 and #4 transferred the resident from the bed to a gerichair. The lift was positioned with the base underneath the bed. The legs were not opened. The resident was lifted to approximately 45 inches above the floor in order to clear the side rail on the bed, which was in the elevated position and had a full-length pad attached to it. CNA #3 opened the legs as the resident was moved from the bed to the chair. CNA #4 was in contact with the resident continuously as they moved the lift approximately 5 feet. The resident was calm and cooperative during the transfer. The Surveyor asked CNA #3 why the side rail was left up during the transfer. CNA #3 stated, "I knew I was supposed to put it down. I just forgot." b. On 1/13/13 at 4:15 the Administrator was informed of the CNA's lifting the resident over the side rail. The Administrator stated, "They are supposed to put the side rails down and only lift the resident as high as necessary to clear the bed and to get into the chair."

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure Resident #2 and #5 received the necessary treatment and services to promote healing for pressure ulcers. The facility failed to ensure added protein and nutritional supplements were promptly provided to promote wound healing for 2 (Residents #5 and #2) of 4 (Residents #1, #2, #3 and #5) case mix residents who had pressure ulcers. The facility failed to ensure accurate and complete pressure ulcer assessments that included wound measurements were completed on at least a weekly basis for 1 (Resident #5) of 4 (Residents #1, #2, #3 and #5) case mix residents who had pressure ulcers. The facility failed to ensure physician-ordered antibiotic therapy was promptly implemented for 2 (Residents #5 and #2) of 4 (Residents #1, #2, #3 and #5) case mix residents who had pressure ulcers. The facility failed to ensure physician orders [REDACTED].#5) of 4 (Residents #1, #2, #3 and #5) case mix residents who had pressure ulcers. The failed practices likely caused a pattern of harm for Residents #2 and #5, who had pressure sores that deteriorated, and were likely to cause more than minimal harm for 3 residents with pressure ulcers, as documented on a list provided by the Director of Nursing (DON) on 4/27/12 at 1:40 p.m. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/8/11 documented the resident scored 15 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), was independent with bed mobility, required 1 person to assist with transfers, frequently incontinent of urine and bowel, was at risk for developing pressure ulcers and had no unhealed pressure ulcers. The Resident Plan of Care dated 11/28/11 documented, "Pressure Ulcers Problem Date: 12/12/11... Report Changes in skin status to physician and provide treatment as ordered. Complete Weekly Skin Check... Provide diet as ordered and monitor nutritional status and dietary needs; consult dietitian PRN (as needed). Provide preventive measure/ointments as needed. a. The Weekly Skin Audit Records dated 12/28/11 and 1/4/12 documented the coccyx was reddened. b. The Weekly Skin Audit Records, the Weekly Pressure Ulcer QI (Quality Improvement) Log, provided by the DON on 4/26/12 at 10:47 a.m., and Nurses' Notes, documented the following: 1) Pressure Ulcer QI - "1/10/12 ... Facility acquired, perineal rectal, stage II, Size and Depth-Entire area, Odor-N (No) Drainage-N, Culture- N, Treatment-See orders, Intervention/Treatment Documented-Y (Yes)." No measurements were provided for the Stage II pressure sore. The spaces provided for Dietary Intervention was marked with a "Y". Pressure Ulcer QI - "1/10/12 ... perineal rectal, stage I, Size and Depth-Entire area, Odor-N, Drainage-N, Culture- N, Treatment-See orders, Intervention/Treatment Documented-Y." The Nurse's Note dated 1/10/12 documented, "Perineal & rectal area dark red chaffened area (with) superficial skin break noted, notified (doctor) office via telephone, new orders noted, may apply A&D oint (ointment) to perineal and rectal areas q (every) shift and PRN until healed then d/c (discontinue) T.O.(Telephone Order)" There was no documentation that the physician was advised the resident had a current order dated 12/8/11 for A&D ointment. The December 2011 and the January 2012 Treatment Administration Records (TAR) documented the use of A&D ointment prior to the 1/10/12 physician order. 2) Skin Audit - "1/11/12 Coccyx Reddened, Heels Reddened, Feet Reddened. Tx (treatment) per MD (medical doctor) orders." c. The Resident Plan of Care, Nurses Notes, Physician Orders, and Dietary Progress Notes documented the following: 1) The Resident Plan of Care dated 11/28/11 documented, "1/12/12 Stage III to coccyx area...TX as ordered per MD. Monitor for S/S (signs and symptoms) of decline in healing progress. Notify MD of any decline... " 2) The Nurse's Note dated 1/12/12 at 10:45 a.m. documented, "Decub (decubitus ulcer) worsened to stage III on coccyx (with) yellow/green slough, diarrhea remains, called (doctor) office spoke with (name) APN (Advanced Practice Nurse) new orders noted, Send to (hospital) for lab draw CBC (complete blood count), & BMP (basic metabolic panel), collect stool guiac send to lab for Lukocytes, [MEDICAL CONDITIONS] & C&S (culture and sensitivity). (after) lab is completed, start [MEDICATION NAME], 500 mg (milligrams) BID (two times a day) x (times) 7 days,[MEDICATION NAME] mg BID x 7 days, may cleanse coccyx area (with) wound cleanser, pat dry, apply thin sheet of santyl oint per (cotton swab), cover (with) hydrogel gauze, cover (with) dry drsg (dressing) daily until healed then d/c." 3) The Physician order [REDACTED]." The Nurse's Note dated 1/14/12 at 4:00 p.m. documented, "Started initial dose [MEDICATION NAME] mg BID x 7 days and [MEDICATION NAME] 500 mg BID x 7 days..." The January 2012 MAR indicated [REDACTED]. On 4/27/12 at 11:57 a.m., the surveyor asked the DON about [MEDICATION NAME] was ordered on [DATE] and not administered until 1/14/12 at 4:00 p.m. She stated she was not aware of the delay and, "I need to see which pharmacy is involved. I will have to check that out." 4) The Dietary Progress Notes documented, "1/12/12 Wt. (weight) 311 (arrow down) from 323 in Dec. (December) desirable weight loss. Receiving Tx to St. (stage) I in perineal area and also St. II in same area. Reduced conc (concentrated) sweets NAS (no added salt) diet and res (resident) with very good intake: Lab (laboratory) 12/19/11 H&H (Hemoglobin and Hematocrit) 39.0/12.8, BS (blood sugar) 159 (arrow up) BUN (bilirubin urea nitrogen) 18. Diet provides > (greater than) 2000 calories and > 90 grams protein - needs no change." The Dietary Progress Notes did not address the resident's additional caloric and protein needs to promote healing of stage III pressures (stage II inaccurate). There were no dietary recommendations for any type of dietary supplement to promote healing (the Weekly Pressure Ulcer QI dated 1/10/12 documented dietary intervention "Y" (yes). d. The Weekly Skin Audit Records and the Weekly Pressure Ulcer QI Log, provided by the DON on 4/26/12 at 10:47 a.m., documented the following: 1) Skin Audit - "1/18/12 Coccyx Reddened Open Wound, Heels Reddened, Feet Reddened." 2) Pressure Ulcer QI - "1/20/12 " 1/10/12... Facility acquired, coccyx, stage III, Size and Depth-2.5x2 cm (centimeters), Odor-N, Drainage-Y, Culture- N, Treatment-See orders, Intervention/Treatment Documented- Y." The spaces provided for Dietary Intervention and Add to CP (care plan) Intervention was marked with a "Y". There was no documentation of dietary interventions to promote healing in the January Dietary Progress Notes nor did the care plan document an update after 1/12/12 until 1/31/12. This pressure sore was first identified on 1/10/12. Nurses Notes, Weekly Skin Audits, and Weekly Pressure Ulcer QIs did not document measurements until 1/20/12. e. The Weekly Skin Audit Records and the Nurses' Notes documented the following: 1) The Nurse's Note dated 1/24/12 documented, "Tx administered to decub site as per Rx (prescribed) orders, tolerated well, (no) c/o (complaints of) pain/discomfort during tx. Coccyx stage III 2.5 x 2 cm malodorous (with) 1 cm depth, sloughing noted to wound bed, surrounding tissue redden, wound has small amt (amount) of serosanguinous drainage present, drsg clean, dry & intact." On 4/26/12 at 5:30 p.m., the surveyor asked the Director of Nursing (DON) about the nurse who documented the Nurse's Note on 1/24/12 staging the resident's wound at stage III with measurements of 2.5 x 2 x 1 cm. She stated, "She no longer works here. I had to let her go because she was not (paused) I was not satisfied with her work, including measurements of wounds and the way she did the treatments, so I let her go." The surveyor asked the DON about having no new treatment orders until 1/31/12, after the documentation the wound was deteriorating. On 4/27/12 at 9:42 a.m., LPN #4 stated the 1/29/12 Nurse's Note regarding not being able to notify the physician was her note. The surveyor asked LPN #4 what she did when she could not notify the physician. She stated, "I passed it on to the next nurse... I should have called the Medical Director." 2) Skin Audit - "1/25/12 Front Torso Reddened, Back Torso Reddened, Coccyx Reddened, Heels Reddened, Feet Reddened. Tx to coccyx & red areas per orders." f. Nurses' Notes, the Weekly Skin Audit Records, the Weekly Pressure Ulcer QI (Quality Improvement) Log, provided by the DON on 4/26/12 at 10:47 a.m., Physician Orders, and the Care Plan documented the following: 1) The Nurse's Note dated 1/29/12 documented, "1 PM (1:00 p.m.) Skin break (down) coccyx deteriorating. Eschar on outer side, beginning to tunnel unable to notify (Physician)." On 4/26/12 at 5:30 p.m., the DON stated, "It looks like the pressure sore got really bad and the doctor was not notified until the 31st." The DON stated she was not aware the physician was not notified until 2 days after deterioration (noted 1/24/12 and 1/29/12) and tunneling (noted 1/29/12) of the wound. At 6:10 p.m., the surveyor showed the DON the Nurse's Note dated 1/29/12 regarding the resident's wound having eschar and tunneling and not being able to reach the physician. She stated, "That is why we have a Medical Director. She should have called the Medical Director." 2) Pressure Ulcer QI - "1/31/12 1/10/12 ... Facility acquired, coccyx, stage III, Size and Depth-10 x 7 cm 2 cm, Odor - Y, Drainage - Y, Culture - N, Treatment - See orders, Intervention/Treatment Documented-Y." The spaces provided for Dietary Intervention and Add to CP were marked with a "Y." There was no documentation of dietary interventions to promote healing in the January Dietary Progress Notes. 3) The Nurse's Note dated 1/31/12 documented, "...Stage III 10 cm x 7 cm depth 2 cm. Greenish color slough to wound bed. Malodorous (with) moderate amt of serosanguinous drainage present, surrounding tissue redden & irritated, (Phsycian) office notified via telephone, new orders noted..." The physician was not notified until 2 days after a nurse identified the wound (1/29/12) was deteriorating and tunneling had begun. 4) The Physician order [REDACTED]. (by mouth) daily, Liquid protein 30 cc (cubic centimenters) PO (by mouth) daily." The nutritional supplements were not added until 21 days after the resident's skin had was identified to have a stage II pressure sore (1/10/12). 5) Skin Audit - "2/1/12 Front Torso Reddened, Back Torso Reddened, Coccyx Reddened Wound, Heels Reddened, Feet Reddened. Tx to coccyx per orders. Tx continued. Stay off bottom/back." 6) The Resident Plan of Care dated 11/28/11 documented, " 1/31/12 Vitamin C - Liquid Protein (See MAR) (Medication Administration Record)." g. Nurses Notes dated 2/2/12 at 10:15 p.m. documented, "(Resident) out of facility @ (at)(Hospital) in Memphis for wound treatment... " On 4/26/12 at 12:17 p.m., the DON stated, "She (resident) got a pressure ulcer because she had a bout of diarrhea causing her skin to break down. She was a heavy woman but we try very hard not to have any skin breakdown...We sent her to consult with the wound doctor and he put her in the hospital." A Discharge Summary no date noted documented, "...Resident is out of facility... for wound treatment. Family member decided to d/c from this facility on 2/22/12 ..." 2. Resident #2 was admitted on [DATE] and had [DIAGNOSES REDACTED]. a. Nurses' Notes dated 2/6/12 at 10 a.m. documented, "...noted an old healy (unable to clearly read) end of Lt (left) toe... eschar approx (approximately) 2 1/2 (2.5) cm in diameter..." The Weekly Pressure Ulcer QI Log dated 2/8/12 documented, "... Admit with (checked) Lt great toe deep tissue injury 1.3 (centimeters (cm)) x (by) 1.5... depth N/A (not applicable)..." (documented as healed on 2/28/12) b. The Resident Plan of Care last updated on 2/9/12 documented, "... Problem Date: 2/9/12 Resident has pressure ulcer(s) related to Immobility, Incontinence, and [MEDICAL CONDITION]. Pressure ulcer (s) will exhibit signs of healing evidenced by decrease in size, improved appearance, and be free from signs & symptoms of infection by: Resident will not develop any new areas of skin breakdown through next review date: ... Approaches: ... Provide diet as ordered and monitor nutritional status and dietary needs; consult dietitian PRN... Monitor for pain and medicate PRN per physician order. Treatment as ordered by MD." c. The admission MDS with an ARD of 2/14/12 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, required supervision for bed mobility, dependent on 2 plus persons for transfer, always incontinent of bowel and bladder, had no pressure sores (Weekly Pressure Ulcer QI log documented deep tissue injury to toe on 2/8/12) and was at risk for developing a pressure ulcer. d. Nurses' Notes dated 2/16/12 at 2:00 p.m. documented, "...Stage 2 break(down) between buttocks 3 cm diameter unable to notify (Physician)." A Physician order [REDACTED]. Apply hydrogel gauze (and) cover (with) dry gauze (and) tape... and notify PCP (primary care physician) in the am." e. Nurses' Notes dated 2/17/12 at 10 a.m. documented the physician was notified that resident requested to be seen and had Stage II wound to coccyx area appointment set for 10:30 a.m. Nurses' Notes at 11:45 a.m. documented an order to apply [MEDICATION NAME] cream BID to buttocks and to refer to wound specialist. The Notes at 12:30 p.m. documented the resident had appointment scheduled for 3/1/12 at wound specialist. (The February 2012 Treatment Record documented the [MEDICATION NAME] cream was applied on once (2/18/12) at 8 a.m. and was discontinued on 2/20/12.) f. The Weekly Pressure Ulcer QI Log dated 2/18/12 documented, "... Admit with (checked) Lt buttock unstageable 2 cm x 3 cm... depth (blank)..." The Wound/Skin Record dated 2/18/12 documented the pressure sore had no odor, no exudates and the wound bed had slough. Under Comments, the form documented, "Evaluation scheduled (with) wound specialist." g. The February 2012 Treatment Record documented, "2/20/12 ... Cleanse Lt buttocks crease (with) wound cleanser, pat dry Apply Santyl ointment to slough (and) necrotic areas then apply hydrogel gauze, cover (with) dry dsg (dressing) of choice at hs (hour of sleep) until slough (and) necrotic areas are removed..." The treatment was documented as performed only on 2/20/12 and 2/25/12. h. The Weekly Pressure Ulcer QI Log dated 2/28/12 documented, "...Admit with (checked) Lt buttock Stage III 2 cm x 3 cm... depth .5 cm..." The Wound/Skin Record documented the pressure sore had no odor, no exudates and the wound bed had slough. Under Comments, the form documented, "Evaluation scheduled (with) wound specialist." The Wound/Skin Record dated 2/28/12 documented the pressure sore had yellow exudate. i. The Nurse's Note dated 2/28/12 documented, "10 a.m. out to appt (Physician #1) per van... 11:30 a.m. return (with) meds (medication) orders and dis chg (discharge) home orders. [MEDICATION NAME] mg BID. Dis chg home 3/1/12..." The Nurse's Note dated 2/29/12 at 2:30 a.m. documented, "... has order to [MEDICATION NAME] mg, will notify a.m. nurse to request clarification..." The Nurse's Note dated 2/29/12 at 11:50 a.m. documented, "Order clarification:[MEDICATION NAME] mg tablet (one) tab (tablet) PO BID x 10 days for Tx of wound infection." The Nurse's Note dated 2/29/12 at 11:00 p.m. documented, "... gave initial dose [MEDICATION NAME] mg. PO BID x 10 days for wound infection..." Facility initially received physician order [REDACTED]. The February 2012 MAR indicated . There were no initials documenting the medication was administered in February. On 4/27/12 at 11:30 a.m., the surveyor informed the DON of the order [MEDICATION NAME] 2/28/12 that was not given until 11 p.m. on 2/29/12. The DON stated this would have to be reviewed. j. Nurses Notes dated 3/1/12 documented the wound specialist wanted the resident admitted to hospital in Memphis for treatment and that the resident at 4:45 p.m. The hospital history and physical examination k. The Resident - Data Collection form documented, "...Date of Admission: 4/3/12... Skin condition 2.5 x 3 cm wound in midline of buttocks, 1.5 cm deep, pink moist tissue edges approximated..." l. The Wound/Skin Record for Resident #2 documented, "... Site/Location: rt (right) buttock... 4/4/12, Stage III, 2 x 2.3 (cm), Depth 1 (cm)..." m. The Dietary Summary Evaluation dated 4/4/12 included an entry signed by the Dietary Manager that documented, "Resident does not eat much." 1) The Dietary Summary Evaluation, signed by the Registered Dietician (RD) and dated 4/12/12, documented, "At risk for impaired nutritional status and dehydration r/t (related to) the disease process. Res (Resident) has hx (history) of weight loss since previous adm (admission)... admitted with decub Stage III... Res needs Provide Liquid Protein 1 x daily, Vit C x1 [MEDICATION NAME] BID." The nutritional assessment was not completed until 8 days after the resident was readmitted with Stage III pressure sore. 2) A physician's orders [REDACTED]. 3. The facility's policy and procedure titled "Decubitus Ulcer/Pressure Sores", provided by the DON on 4/26/12 at 4:56 p.m., documented the following: "...Routine skin check will be done on all residents at admission on a regular ongoing basis. Any reddened or open areas will be reported to the physician immediately and orders will be obtained for treatment. The course of the treatment will be documented until the problem is resolved. Classification of Decubiti: Stage I: Inflammation or reddening of the skin. Stage II: Superficial skin break with redness of surrounding skin. Stage III: Skin break with deep tissue involvement. Stage IV: Skin break with deep tissue involvement with necrotic tissue present...Licensed personnel shall document any reddened or open area in the residents record. (including location, depth and size, drainage and action taken). Note: Physician and family will be immediately notified of findings. Physician orders [REDACTED]. Also determine need for protein supplements and use of multivitamins, zinc and vitamin C. Charting will be done as follows: Decubitus will be charted and reassessed weekly till healed. If no progress in healing occurs on a resident then it shall be documented and physician shall be notified for a follow up or possible order change at that time...Licensed nurses are to notify M.D. and apply treatments as ordered by physician and record. Decubitus are measured by licensed nurses on a weekly basis..."