Every finding on record at Dermott City Nursing Home

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This failed practice resulted in actual harm for one (Resident #1) of three sampled residents reviewed for neglect. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The immediate Jeopardy (IJ) was related to CFR 483.25 (Quality of Care) at a scope and severity of J. The IJ began on [DATE], when facility staff failed to identify and properly respond on behalf of a resident experiencing a medical emergency resulting in avascular necrosis and subsequent death. The Administrator was notified of the IJ on [DATE] at 1:22 PM. A removal plan was requested and received on [DATE] at 4:35 PM. The facility's removal plan was completed on [DATE] and verified on [DATE] at 2:58 PM. The findings include: A review of Resident #3's Medical Diagnosis indicated the facility admitted the resident on [DATE] with diagnoses of unspecified fracture of the sacrum, (fracture of lower back) cerebrovascular disease (condition that effects blood flow in the brain), heart disease, chronic obstructive pulmonary disease (condition that causes severe breathing difficulty) and chronic kidney disease. A review of Resident #3's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. A review of Progress Notes dated [DATE] revealed Resident #3 was being treated for Covid-19. A review of Progress Notes dated [DATE] revealed Resident #3 was evaluated by nursing staff, and Resident #3's skin was warm and pink with capillary refill less than 3 seconds, with no swelling present. A review of Progress Notes dated [DATE] revealed Resident #3 was complaining of pain to the left inner foot. Stated left great toe area is really sore to touch. Denies any recent injuries to foot. Slight swelling and purple/red discoloration noted. Pedal pulse to left foot positive. Orders per Advanced Practice Registered Nurse (APRN) [to administer] a steroid injection if resident continues to complain of pain may get x-ray. A review of Progress Notes dated [DATE] revealed Resident #3 was, complaining of pain to left foot area. Slight swelling and purple/red discoloration noted. Has edema noted to left foot. Discoloration and edema to left great toe area. X-ray of left foot, and steroid injection. A review of Health Status Note/Nurses Note dated [DATE] revealed staff were, called to room. Resident complaining of leg pain. Says it is shooting all the way to the [resident's] toes. Requesting pain meds at this time. 1 [prescription opioid pain medication]- tab given at this time. A review of Health Status Note/Nurse Note dated [DATE] revealed, Resident has remained in room most of time. Had X-ray of left foot due to complaints of pain. Impressions: No acute fracture. No discoloration noted to left foot but complaints of pain. Resident taking as needed pain medication. A review of Long -Term Care Evaluation: Look back note: dated [DATE] revealed the resident had discoloration of left great toe across base of toes persists, physician aware. No anti-embolic treatment prescribed. Denies calf tenderness. Left pedal pulse weak and thready. Right pedal pulse weak and thready. Discoloration left great toe/base of toes of left foot. Tissue: Cool. A review of Health Status Note dated [DATE] revealed Resident pain to foot, has discoloration noted to foot when sitting up. When foot is elevated normal color, cool to touch. Gait and balance unsteady. Continue to check on often. Family called and concerned about resident complaining of feet and legs hurting. No progress notes or Physicians orders were noted in Resident #3's medical record through the dates of [DATE] through [DATE]. A review of Orders-Administration Note dated [DATE], revealed [prescription opioid pain medication] oral tablet 50 mg give 1 tablet by mouth every 8 hours as needed for pain. A Health Status Note/Nurses Note dated [DATE] revealed [Family member] here and helped [Resident #3] into wheelchair and to private car for transport. [Resident #3] assisted to get in car. Can move self about, but yells when stepping on [affected extremity]. A review of a local hospital Emergency Department (ED) note dated [DATE] at 7:45 AM revealed, left foot pain and discoloration for the past week. Palpable pulse not present on exam. A review of Radiology results dated [DATE] at 11:36 AM revealed significant blockage to the artery above the left knee and significant blockage to the resident's blood vessels, also moderate blockage of the left femoral artery. Final diagnosis/clinical impression: dated [DATE] at 2:00pm revealed, transfer to another facility for specialty care; vascular. A review of Resident #3's hospital records dated [DATE] at 12:10 PM, revealed a final report that showed a CTA )a non-invasive imaging test that combines a standard CT scan with an injection of contrast dye to produce highly detailed 3D pictures of blood vessels and tissues throughout the body) was performed that revealed bilateral aortoiliac occlusion with a popliteal occlusion in the left leg (indicates blockages in the major blood vessels supplying the pelvis/both legs (the aorta and iliac arteries) as well as a blockage behind the left knee (the popliteal artery)). Resident #3 was described as writhing in bed, speaking incoherently. The left leg was cyanotic (blue) from the foot to midway up the lower leg. Both feet were very cold to touch, and the left foot appeared to be without sensation and paralyzed. The record also stated that Resident #3's left leg was without sensation and paralyzed consistent with a left leg that could not be saved. Based on review by the medical doctor (MD), it appeared the left leg had been critically ischemic (lacking in adequate blood flow and oxygen) for at least two days. The MD informed the family that Resident #3 had sustained an occlusion most likely.a week ago, and that the left leg was no longer viable. The option provided to the family was an above-knee amputation, which was described as very high risk, with a 30-day mortality as conservatively 60 to 70% but very well may be approaching 100%. The MD recommended palliative care in-patient hospice as an option. In an interview conducted on [DATE] at 8:41 AM, Resident #3's family member stated that Resident #3 was admitted to the facility for rehab after a fall suffered at home. The resident's family member stated that within being in the facility for two weeks Resident #3 had been complaining of left foot pain. The resident's family member also stated that Resident #3 had been calling complaining of pain to their left foot. The family member stated that the facility was called, and reported speaking to nursing staff to relay what Resident #3 was saying regarding the pain. Resident #3's family member stated that after speaking to nursing staff at the facility, they were informed that the resident's leg would have discoloration when sitting but then return to normal color when standing or when the leg was elevated. Facility staff informed the family member that pain medication was provided, and an x-ray were performed which showed no fracture. Resident #3's family member stated that on [DATE] the facility was called and informed them that the family was taking the resident to the hospital. While at the hospital Resident #3 was started on a blood thinner, and then the family member was informed by hospital staff that Resident #3 was being transferred to another hospital for a consultation with a vascular surgeon. Resident #3's family member stated that they were informed by the vascular surgeon that Resident #3's artery was blocked, and the vascular surgeon informed them that if Resident #3 had gotten to the hospital sooner [the surgeon] might have been able to save Resident #3's leg. The vascular surgeon relayed at the time, there was no hope of saving Resident #3's leg due to the procedure being a high-risk surgery. Resident #3's family member stated the family collectively made the decision to not pursue the surgery but elected to place the resident on hospice. Resident #3 expired on [DATE]. A review of Resident #3's Death Certificate, dated [DATE], revealed that the cause of death was due to infection and dead tissue. In an interview with Licensed Practical Nurse #1 (LPN 1) [DATE] at 8:57 AM, it was revealed that Resident #3's left foot was red and purple at times and was consistently hurting. LPN #1stated that the resident had been complaining of pain off and on for at least two weeks. LPN #1 stated that Resident #3 had an X-ray performed on their left foot and the results were negative for fractures. LPN #1 stated that a steroid injection was ordered by the APRN and the Physician ordered [prescription opioid pain medication] for pain which was given to the resident when they complained of pain. In an interview with the APRN on [DATE] at 1:41 PM, it was revealed that the resident was seen once by the APRN in February before the symptoms began, where Resident #3 was treated for allergies. The APRN stated that the resident had not seen Resident #3 since February due to making rounds at the facility on a monthly basis, but that she had planned on seeing Resident #3. The APRN stated that the only order they had given for Resident #3 was to refill Resident #3's medication due to the Physician being out of his office, and another for the X-ray. The APRN stated that her expectations were to be notified by staff from the facility if a resident's condition worsened so a determination could be made if the resident needed further treatment or to be sent out to the hospital. During an interview conducted with the Director of Nursing (DON) on [DATE] at 1:46 PM, it was revealed that the DON's expectation from the nursing staff was to perform thorough assessments on each resident, and if a resident's condition worsened the nursing staff were to notify the Physician or the APRN for further instructions. The DON also stated that if the nursing staff inform the Physician or APRN about a resident's condition and they do not receive any orders, the staff should inform the DON and she would intervene. The DON also stated that a resident with a possible emergency situation should be sent to the hospital immediately. The facility's plan of removal was received on [DATE] at 4:35 PM. The facility's removal plan was completed on [DATE] and verified by surveyors onsite on [DATE] at 2:58 PM. Plan of Removal: 1. Corrective Action a. All licensed nursing staff were in-serviced beginning on [DATE] (and will continue until all facility staff have been in-serviced prior to start of their shift on common signs and symptoms of deterioration in a resident. Examples of these signs and symptoms included but was not limited to complaints of pain, swelling, discoloration of skin, out of normal range of vital signs, weight loss or gain, grimacing, being lethargic, lack of pedal pulses, coolness of extremities to touch. Who to notify in case any of these and other signs and symptoms were visually or audially observed. Staff were in serviced to notify upon observation the PCP/attending physician, family/POA, Care giver DON (Director of Nursing) and Administration. And to notify the ambulance of choice if sending resident out to the hospital. Nursing staff were also in serviced that if the PCP/attending physician gave an order for x-ray, lab work, or any other service that the order was to be carried out immediately, not passed on to the next shift, but was to be during the shift of the nurse taking the order. b. All current residents and any future resident who have a current BIMS score of 10 or higher were/will be in serviced 1:1 on the Resident's Right to seek medical care or to refuse any or all medical care. This includes medication orders, medication treatment, going to the hospital of their choice, having the facility transport them to the doctor, hospital of choice. Any resident currently in the facility who had a current BIMS score of 10 or less the facility will seek out the resident's POA, responsible party, family, and/or caregiver and educate them on the rights to self- choose if, when and where treatment is accepted or rejected. These tasks will be completed by [DATE]. Resident #3 no longer resides in the facility. 2. Identification of other residents: [DATE], the RN Compliance Officer obtained a roster of all current residents who were in the facility via electronic health record or a resident census report and assessed each resident both visually and verbally inquiring as to their pain, what level on a scale of 0-10, any visual signs of pain, swelling, or mottling. Any negative outcomes verbally or visually were immediately addressed including providing pain medication, notification to PCP/attending physician, family/caregiver. This identification of other residents was completed on [DATE]. All outcomes were documented on the Compliance Officer's roster. 3. Measures put into place: a. Beginning [DATE], the compliance RN began in servicing all staff on change of condition in health or mental status change, physician notification and to ensure they are transferred out in a timely manner. b. On [DATE], the DON in serviced all nursing staff on the use of the new facility nursing tools of the SBAR Communication Form and Progress Note, the new facility nursing tool, the STOP AND WATCH, the STOP AND WATCH EARLY WARNING TOOL. How to use, when to use to whom to notify if there is a change of condition, sending a resident to the hospital, why we are sending the resident and when to notify family/caregivers, DON and administrator. No staff will be allowed to begin their shift without being in serviced prior to completion of in-servicing. The staff will be completed by [DATE], for all staff who are on the facility schedule. 4. Facility Monitoring: a. Beginning on [DATE], the DON or her designee will assess all residents; report changes of condition, and/or transfer resident to higher level of care for evaluation and possible treatment for all residents who are exhibiting declining signs and symptoms to prevent serious harm, serious impairment, serious injury or death. All newly hired staff will have a notification in their hire pack of this policy and new documents. All new documents will be available in the facility's electronic health record. An in-service will also be conducted upon hiring of the location of these new documents in the electronic health record. b. The DON or her designee will monitor 2 random residents 3 times a week (total of 6) for 3 weeks, then 2 random residents 2 times a week (total of 4) and then 1 random resident 1 time a week for 1 week or until compliance is achieved. All completed documentation upon completion will be placed in the 2567 notebook placed in the administrator's office for any review by required agency. 5. QA (Quality Assurance) a. The DON or her designee will provide all monitoring documentation to the QA of any negative outcome, issues, requesting suggestion or improvements on current actions. This interaction with the QA committee will be conducted weekly until compliance is achieved.

Based on interviews, record review and facility document review, it was determined the facility failed to ensure that a resident's transfer or discharge was reported to the ombudsman for one (Resident #3) of one resident reviewed for discharge process. The findings include: A record review of admission Record revealed Resident #3 was admitted on [DATE], was discharged on [DATE] to an acute care hospital and did not return to the facility. A record review of Medical Diagnoses indicated Resident #3 was admitted to the facility with the diagnoses of fracture of sacrum, cerebrovascular disease, atherosclerotic heart disease, chronic obstructive pulmonary disease, chronic kidney disease stage 3, hypertension, and benign prostatic hyperplasia. A review of admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 10, indicating Resident #3 was moderately cognitively impaired. Resident #3 was not receiving scheduled or as needed pain medication. Resident #3 had a fall in the past month with a fracture. A review of facility policy, Transfer or Discharge dated [DATE], indicated the facility would send a copy of the notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman when practicable (in a monthly list of residents that includes all notice content requirements) and to the resident and representative as soon as practicable before the transfer. A review of facility document, Notice of Resident Transfer or Discharge dated [DATE], indicated the Ombudsman was notified of two residents during the month of [DATE] with Resident #3 not included on the list. During an interview on [DATE] at 10:45 AM, the Social Services Director (SSD) stated there were only two residents that were on the ombudsman's list for [DATE]; Resident #3 was not on the list. During an interview on [DATE] at 2:25 PM, the Administrator stated she considered an emergent situation where the facility would need to send a resident out included: a fall, blood, head injury from the fall, if the resident had a bone sticking out, signs and symptoms of an infection, running a fever, nausea and/or vomiting, not eating and weight loss, and anything else the staff thought a doctor should see the resident. The staff cannot diagnose or treat but they can send them out to obtain those services. She stated, The staff should listen to residents when they complain and send them out for that, things that are not normal. During a follow-up interview on [DATE] at 9:19 AM, the SSD stated, it was the nurse's responsibility to fax the discharge/transfer form to the ombudsman at the time of discharge or transfer, then the nurse would give me a copy. She indicated the nurses get a confirmation fax when it goes through. The SSD stated, When I get the copy, I send it via email to the family so they can sign it and return it to me. The SSD stated that any resident that goes to the hospital would be put on the list. She indicated that a resident that goes home would not, but she would do a post discharge on that resident. The SSD stated if a resident was taken to the hospital from the facility by a family member, a notice of transfer/discharge would be sent to the ombudsman for that resident by the nurse. She stated her only interaction with the forms were in making sure the signatures were valid. During an interview on [DATE] at 9:34 AM, the Director of Nursing (DON) indicated the nurse on the floor was responsible for preparing the Notice of Discharge/transfer form for the ombudsman and sending it in. She stated the nurse would fill the form out, fax it, get a confirmation fax, then leave a copy of the form in (the DON's) door tray. The DON stated, Any resident that is being sent out to the Emergency Department (ED), transfers to another facility, and discharged from the facility would have the notice completed and sent in. During an interview on [DATE] at 10:23 AM, the Administrator indicated the SSD was the person that was responsible for preparing the discharge/transfer list that is submitted to the ombudsman. She stated that any resident that goes to the hospital, discharged home with family, expired, and/or transferred to another facility would be included on the list. The Administrator stated that a resident that is taken to the ED and stayed at the hospital would be included on the ombudsman list. We would call to check on them. She indicated if a resident that was leaving the facility for a family day, out to eat, to church, fishing, or family taking them to the doctor would not be on the list.

Based on record review, interview, and facility policy review, the facility failed to ensure Certified Nursing Assistants (CNAs) #1 and #2 demonstrated competency in the care of a resident by moving a resident prior to a nurse assessment following a fall, and by not following the resident's care plan, which indicated the use of a mechanical stand-up lift with two-person assist for transfers, for one (Resident #1) of three residents reviewed for falls. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.35 (Nursing Services) at a scope and severity of J. The IJ began on 12/02/2025 around 10:34 AM, when CNA #1 performed an improper transfer of Resident #1 from the bed to a wheelchair without the use of a mechanical stand-up lift or a second person to assist, which resulted in Resident #1 falling to their knees on the floor. CNA #1 requested CNA #2 assist in moving Resident #1 from the floor to the wheelchair, which was conducted before Resident #1 was assessed by the nurse. Resident #1 sustained an acute right femoral (thigh bone) fracture, which required surgical intervention. The Compliance Officer and Director of Nursing (DON) were notified of the IJ on 12/22/2205 at 2:38 PM. A Plan of Removal was requested. The Removal Plan was accepted by the State Survey Agency on 12/23/2025 at 11:37 AM. The IJ was removed on 12/23/2025 at 4:34 PM after surveyor performed onsite verification that the Removal Plan had been implemented. The findings include: Review of a Staffing, Sufficient and Competent Nursing policy, dated as revised August 2022 and provided by the Compliance Officer (CO), indicated the facility will provide adequate numbers of nursing staff with appropriate skill and competency necessary to provide nursing and related care and services for all residents according with resident care plans and the facility assessment. Review of an admission Record indicated the facility admitted Resident #1 on 10/03/2024, with diagnoses which included scoliosis, unsteadiness on feet, and dementia. Review of the Medicare 5-day Minimum Data Set (MDS) with an Assessment Reference Date of 12/07/2025, revealed a Brief Interview for Mental Status score of 09, which indicated Resident #1 was moderately cognitively impaired. The MDS also indicated the resident was dependent on staff for toileting hygiene, shower/bathe self, chair-/bed-to-chair transfer; had active diagnoses of fractures and other multiple trauma; had experienced falls since admission/entry or reentry or prior assessment; had a recent surgery requiring active Skilled Nursing Facility care and surgical procedures of repair of fractures of the pelvis, hip, leg knee or ankle (not foot). Review of the Care Plan, with a last review date of 10/14/2025, indicated Resident #1 had an activities of daily living self-care performance deficit and for transfers required a mechanical lift, stand up lift with assistance of two staff (date initiated and revised was 01/22/2025). Review of fall risk evaluations for Resident #1 indicated the following: -admission fall risk evaluation dated 10/03/2024, revealed a score of 9.0, which indicated no risk. -Quarterly fall risk evaluation dated 10/16/2025, revealed a score of 10.0, which indicated at risk for falls. Review of an incident report for Resident #1 dated 12/02/2025 at 10:34 AM revealed the following: -Incident description: Licensed Practical Nurse (LPN) #5 reported to the DON that CNA #1 informed LPN #5 that Resident #1 fell to their knees when CNA #1 was transferring Resident #1 from the bed to wheelchair, due to shoes slipping off Resident #1's feet. The nursing description further indicated Resident #1's legs were weak and gave out when pivoting. The LPN #5reported to the DON that Resident #1 was up in a wheelchair when LPN #5 entered Resident #1's room. -Immediate action taken: CNAs #1 and #2 assisted Resident #1 up to a wheelchair and notified LPN #5. X-ray to right knee ordered and Resident #1 was sent to [an acute care facility] due to the results of the x-ray. -Level of pain: 10 (There was no pain scale indicated on the incident report to show what level 10 indicated.) -Other info (information): House shoes with no grips. Care planned for two person-assist with mechanical stand-up lift. Review of the Radiology Interpretation, dated 12/02/2025, revealed an exam date of 12/02/2025, for pain in right knee. The findings revealed an acute obliquely (side) oriented and overriding fracture of the distal right femoral (lower part of the right thigh bone) metadiaphysis (where the flared, growing end of a long bone and the bone's shaft meet) and mild displacement (abnormal positioning) of distal fracture fragments. The impression revealed an orthopedic (bone) consultation was recommended. Review of an Operating Room (OR) Record dated 12/3/2025 at 11:58 AM revealed a pre-operative diagnosis of right femur fracture. Review of an Orthopedic Post Op (operative) note dated 12/4/2025 at 09:52 AM revealed: - status post right retrograde intramedullary nailing (The resident had surgery to fix a broken bone in the right leg using an internal metal rod). Post op day 1. -Chief complaint/Impression/Plan: 1. Closed fracture of distal end of right femur.2. Incision and drainage of femur with insertion of antibiotic-impregnated orthopedic nail. During an interview on 12/19/2025 at 12:27 PM, CNA #1 stated she looked at the care plans to know how to care for residents. She stated she knew how to use a stand-up lift, and two staff members were required to use the stand-up lift. She stated on 12/02/2025, she was assisting Resident #1 into the chair (without using a mechanical lift) and during the transfer, Resident #1 tried to pivot, and the resident's right shoe went one direction and Resident #1's right foot went another direction, and she lowered Resident #1 to the floor. CNA #1 was asked if Resident #1 required assistance with transfers and stated, It's just one to transfer because [Resident #1] can bear weight and [Resident #1] can pivot. CNA #1 stated Resident #1 may have required the use of a stand-up lift before she began working at the facility in October 2025. CNA #1 stated she had received an in-service on transfers on 10/06/2025. CNA #1 reported that since her hire date, she had completed skills checkoffs which included how to transfer residents, which involved using the stand-up lift. CNA #1 admitted that moving Resident #1, who was complaining of pain, after the fall and before being assessed by the nurse was not appropriate. CNA #1 stated she and CNA #2 assisted Resident #1 back to the wheelchair, and then CNA #1 left to get a nurse to assess Resident #1. In a follow-up interview with CNA #1 on 12/19/2025, she stated she did not use a stand-up lift during Resident #1's transfer. During a telephone interview with Licensed Practical Nurse (LPN) #5 on 12/19/2025 at 1:01 PM, she stated a CNA, whose name she did not recall at the time, came to her and stated Resident #1's feet pivoted from under them and that the CNA had lowered Resident #1 to their knees. The LPN went to report the incident to the DON. LPN #5 stated Resident #1 was in the wheelchair when she entered the resident's room, there was nothing visibly wrong with Resident #1's knees, but Resident #1 was complaining of pain in the knees. LPN #5 stated she knew [for transfers] Resident #1 was a two-person assist and required the use of a stand-up lift. LPN #5 stated moving Resident #1 following a fall, before being assessed by the nurse and while complaining of pain, was not appropriate. During an interview on 12/19/2025 at 2:11 PM, the DON stated LPN #5 came and told her Resident #1 had fallen. She stated LPN #5 told her CNA #1 was in the room with Resident #1 and as Resident #1 pivoted from the bed to the wheelchair, the resident's legs gave and CNA #1 lowered Resident #1 to the floor. The DON stated once she entered Resident #1's room, she observed Resident #1 sitting up in a wheelchair. The DON stated she checked Resident #1's right side because of a complaint of pain to the right knee. The DON stated Nurse Practitioner (NP) #3 was telephoned and an order was given to get an x-ray. The DON stated the facility's in-house x-ray service came, completed the x-ray of Resident #1's [right] leg, which later confirmed Resident #1's right leg was broken., Resident #1 was then sent to [an acute care facility]. The DON stated Resident #1 was a two-person assist with transfers and required the use of a stand-up lift, which CNA #1 did not use to transfer Resident #1 on 12/02/2025. The DON stated staff had been instructed to call for help if a resident fell and not to move them until the nurse had assessed them. The DON stated moving Resident #1, who was complaining of pain, before the resident was assessed by the nurse was not appropriate. During a telephone interview on 12/19/2025 at 2:31 PM, CNA #2 stated a resident's plan of care indicated how the resident was to be transferred. She admitted she knew how to use a stand-up lift and, using a stand-up lift required two people. She stated, on 12/02/2025 her co-worker [CNA #1] called her to help with Resident #1. CNA #2 stated when she entered Resident #1's room, Resident #1 was on the floor. She stated the nurse had not looked at Resident #1 before the resident was moved by CNA #1 and herself. She admitted knowing Resident #1 required the use of two-persons to assist with a sit-to-stand lift (stand-up lift). CNA #2 stated moving Resident #1, who had complained of pain and who had not been assessed by the nurse, was not appropriate and that, you always wait on the nurse. During a telephone interview on 12/22/2025 at 1:23 PM, CNA #1 stated she did not remember if she looked at Resident #1's care plan on 12/022/2025, prior to taking care of them that day. CNA #1 stated did not remember the last time she looked at Resident #1's care plan. During a telephone interview on 12/23/2025 at 2:11 PM, NP #4 stated she was notified on 12/02/2025 of Resident #1's fall, but NP #3 had performed the assessment. NP #4 stated she was informed of Resident #1's radiology results which revealed an acute femur fracture. NP #4 stated her expectation for staff transferring residents at the facility was residents with immobility be care planned with how the transfer should be done. NP #4 stated she knew Resident #1 was care planned for two person-assist [for transfers] and her expectation was to have two aides assisting to move them. NP #4 stated her expectation for residents' assessments after a fall was the nurse should be the one to assess the residents before they were moved. NP #4 stated Resident #1 had severe osteopenia and [the resident's] bones were, super-brittle. During an interview on 12/23/2025 at 4:45 PM, the Compliance Officer (CO) stated her expectation for resident care after a fall was that staff needed to assess the residents first, and if they were hurt or hurting, to notify the doctor and to not move them until the nurse came and assessed them. The CO stated her expectation for staff locating, reviewing, and following the resident's care plan was if staff did not know how a resident should be transferred, the staff should go to the [facility's electronic computer system] and look at the care plan to see how to transfer a resident and what care the resident needed. The CO stated her expectation for resident transfers was for staff to know what kind of transfer was needed, such as if the resident needed the stand-up lift. The Immediate Jeopardy was removed on 12/23/2025 at 11:37 AM when the following plan of removal was implemented by the facility: 1. Beginning 12/22/2025, all licensed nursing staff and certified nursing assistants will be in-serviced, those not present will be in-serviced prior to the start of their shift by the Director of Nursing (DON)/designee on the proper steps taken after a resident has sustained a fall, to prevent serious harm, serious injury, serious impairment, or death, by 12/24/2025. 2. Beginning 12/22/2025, all Certified Nursing Assistants (CNAs) and licensed nurses will be educated and those not present will be in-serviced prior to the start of their shift by the DON/designee on proper resident transfers to prevent serious harm, serious injury, serious impairment or death, by 12/24/20254. 3. Beginning 12/22/2025, all CNAs and licensed nurses will be educated and those not present will be in serviced prior to the start of their shift by the DON/designee on locating and reviewing the care plan prior to resident care and implementing the care plan during resident care to prevent serious harm, serious injury, serious impairment, or death, by 12/24/2025. 4. Resident #1 was sent to the hospital after discovery by x-ray to have had an acute right femoral fracture where [pronoun] underwent surgical repair. 5. On 12/22/2025, the DON identified 26 residents, including Resident #1, who required assistance with transfers from mechanical lift with the potential to be affected from the deficient practice, all were assessed with no negative findings by the DON and designee. 6. To ensure the deficient practice does not happen again, beginning 12/22/2025, all licensed nurses and CNAs will be educated to check the Kardex /plan of care, located in the kiosk, on a resident and implement it, also the proper steps to take after a resident sustain a fall, and to be educated on the proper transfer technique to prevent serious harm, serious injury, or death, beginning 12/22/2025. 7. Beginning 12/22/2025, the DON/designee will visually monitor residents being transferred, visually monitor licensed nurses and certified nurse assistants on locating, reviewing the plan of care, and implementing the plan of care, also proper steps taken when a resident sustains a fall, by CNA, and licensed staff, to prevent serious harm, serious injury, or death 5 times a week for 8 weeks or until compliance is verified by Office of Long-Term Care. 8. The DON/designee will present all findings to the monthly QAPI (Quality Assurance & Performance Improvement) committee for further review and recommendations. All corrections were completed on 12/23/2025. Onsite Verification: The IJ was removed on 12/23/2025 at 4:34 PM, after this surveyor performed an onsite verification that the removal plan had been implemented as follows: 1. and 2. On 12/23/2025, this surveyor reviewed an in-service dated 12/22/25-12/23/25, presented by the DON with the subject of: a. Accident and incident-investigating and reporting-policy- investigating and reporting-policy- fall-clinical protocols-policy- fall assessment-policy- fall and fall risk managing-policy-assessing falls and their causes b. Proper transfer technique and guidelines-policy- safe lifting and movement of residents-check list-transferring resident from bed to wheelchair using gait belt-mechanical lift manufacturer Vera lift II transfer procedure written & video-stand up lift manufacturer Vera lift II transfer procedure written & video-hands on in-service with physical therapist in-house-safety when transferring.Different signatures and titles were observed on the in-service. 3. On 12/23/2025, this surveyor reviewed an in-service dated 12/22/25-12/23/25, presented by the DON with the subject of: a. Reviewing and implementing care plan-one on one training from DON to Nurses to CNAs on how to access plan of care-CNAs to check care plan daily for any changes-educated to inform DON/MDS if changes to care plan need to be updated to correlate with residents change in condition.Different signatures and tittles were observed on the in-service. 4. Review of hospital records indicated the resident was sent to an acute care facility on 12/02/2025. 5. Review of a document titles transfers listed 11 residents who required a stand-up lift for transfers and 16 residents who required a body lift, for a total of 27, instead of 26 residents who required assistance with transfers. 6. Review on an in-service dated 12/22/25-12/23/25, covered to check the Kardex /plan of care, located in the kiosk, on a resident and implement it, also the proper steps to take after a resident sustain a fall, and to be educated on the proper transfer technique to prevent serious harm, serious injury, or death beginning 12/22/2025 and different signatures and titles were observed on the in-service. 7. On 12/23/2025, the DON provided a hand-written survey monitoring sheet which indicated which staff was monitored, with the date of the observation, for resident transfers, staff locating and reviewing the plan of care. 8. No QAPI meeting has been performed, but findings to be reviewed in the January 2026 QAPI meeting per DON. On 12/23/2025, 4 -7AM/3PM shift CNAs, 2-3PM/11 PM CNAs, 2-11PM/7AM CNAs, 2- day shift nurses and 2 evening shift nurses were interviewed regarding the topics of the in-services provided with no negative findings.

Based on record review, interview and facility policy review, the facility failed to ensure a Licensed Administrator was hired to oversee the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern nursing facilities for one of one facility reviewed for administrative duties. The findings include: Review of a facility Administrator Job Description, with a revision date of October 2022, indicated that the primary purpose of the position is to direct the day-to-day functions of the facility in accordance with current, federal, state and local standards, guidelines and regulations that govern the nursing facilities to assure the highest degree of quality care can be provided to residents at all times. Experience indicated as, must have a current unencumbered nursing home Administrator's license or meet the license requirements of the state. Review of a facility policy titled Administrative Management Governing Body with a revision date of January 2025, indicated that the governing body shall be responsible for the management and operation of the facility. This policy indicated that the governing body has the responsibility for the management and operation of the facility and that the governing body is responsible for but not limited to oversight of facility care and services in accordance with professional standards of practice and principles. Review of an Office of Long-Term Care (OLTC) Incident & Accident Report (I&A) dated 12/02/2025 at 10:34 AM, indicated that Certified Nursing Assistant (CNA) #1 performed an improper transfer of Resident #1, which resulted in Resident #1 sustaining an acute right femur (thigh bone) fracture which required surgical intervention. The I&A indicated that the Compliance Officer (CO) name was in the area designated for the name of the Administrator. During the entrance conference on 12/19/2025 at 9:15 AM, the Director of Nursing (DON) stated the facility had an interim administrator, [the CO], who was not in the facility at that time. A review of the Key Personnel Sheet did not list the name for the Administrator. During an interview with the CO on 12/22/2025 at 3:38 PM, she stated she was not the Administrator, and she does not have an Administrator's license. She stated no one was filling the capacity as the Administrator at the facility at that time and they were currently working on hiring someone. During an interview with Human Resources (HR) on 12/22/2025 at 4:17 PM, she stated the last Administrator resigned and her last day was 07/28/2025. On 12/23/2025 at 3:51 PM, this surveyor unsuccessfully attempted to reach the Board President (BP) by telephone and a voicemail with contact information was provided with a request for a return call. As of 12/23/2025 at 5:40 PM, this surveyor had not received a return call. During an interview with the CO on 12/23/2025 at 4:45 PM, she stated the facility had been without an Administrator since July 2025. She stated no candidates had been interviewed for the Administrator position since July 2025. She stated the facility was advertising on [an internet site] and in the local newspaper for the open Administrator position at the facility.

Based on record review, interview, and facility policy review, the facility failed to ensure a comprehensive care plan was consistently implemented for one (Resident #1) of three residents whose care plans were reviewed. The findings include: Review of an admission Record, indicated the facility admitted Resident #1 on 10/03/2024 with diagnoses which included scoliosis (lateral deviation of the spine), unsteadiness on feet, and dementia (loss of memory, thinking, and reasoning skills). Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/07/2025, revealed a Brief Interview for Mental Status (BIMS) score of 09, which indicated Resident #1 had moderate cognitive impairment and was dependent on staff for toileting hygiene, shower/bathe self, chair-/bed-to-chair transfers. The MDS indicated active diagnoses which included fractures and other multiple trauma; falls since admission/entry or reentry or prior assessment; recent surgery requiring active Skilled Nursing Facility (SNF) care and surgical procedures for repair of fractures of the pelvis, hip, leg knee or ankle (not foot). Review of a Care Plan, with a last review date of 10/14/2025, indicated Resident #1 had an Activities of Daily Living (ADL) self-care performance deficit and required a mechanical lift, stand up lift with assistance of two staff for transfers. The date initiated and revised was 01/22/2025. Review of an Incident Report dated 12/02/2025 at 10:34 AM, for Resident #1, revealed that Licensed Practical Nurse (LPN) #5 reported to the Director of Nursing (DON) that Certified Nursing Assistant (CNA) #1 informed LPN #5 that Resident #1 fell to their knees, when CNA #1 was transferring Resident #1 from the bed to the wheelchair, due to shoes slipping off Resident #1's feet. The Incident Report also indicated that Resident #1's legs were weak and gave out when pivoting during the transfer. LPN #5 reported to the DON that Resident #1 was up in a wheelchair when LPN #5 entered Resident #1's room. The report indicated the immediate action taken was that CNAs #1 and #2 assisted Resident #1 up to a wheelchair and notified former LPN of the incident. An x-ray of the right knee was ordered due to Resident #1's level of pain being reported as 10 (there was no pain scale indicated on the incident report to show what level 10 indicated.) Resident #1 was sent to [an acute care facility] due to the results of the x-ray. Other information noted in the report indicated the resident had on house shoes with no grips and that Resident #1 was care planned for two person-assistance with a mechanical stand-up lift for transfers. Review of a Radiology Report, dated 12/02/2025, revealed an exam date of 12/02/2025 for pain in right knee. The findings revealed an acute obliquely (side) oriented and overriding fracture of the distal right femoral (lower part of the right thigh bone) metadiaphysis (where the flared, growing end of a long bone and the bone's shaft meet) and mild displacement (abnormal positioning) of distal fracture fragments. The impression revealed that an Orthopedic (bone) consultation was recommended. During an interview on 12/19/2025 at 12:27 PM, CNA #1 stated she looked at care plans to know how to care for residents. She stated she knew how to use a stand-up lift, and that two staff members are required to use the stand-up lift. She stated on 12/02/2025 she was assisting Resident #1 into the chair and during the transfer, Resident #1 tried to pivot, and the resident's [right] shoe went one direction and Resident #1's [right] foot went another direction, she then lowered Resident #1 to the floor. CNA #1 was asked if Resident #1 required assistance and she stated, It's just one to transfer because she can bear weight and she can pivot. CNA #1 stated Resident #1 may have required the use of a stand-up lift before she began working at the facility in October 2025. CNA #1 stated she had received an in-service on transfers on October 6, 2025. CNA #1 admitted since her hire date she had completed skills checkoffs which included how to transfer residents and using the stand-up lift. In a later interview on 12/19/2025 at 1:20 PM, CNA #1 stated she did not use a stand-up lift during Resident #1's transfer on 12/02/2025. During a telephone interview on 12/19/2025 at 2:31 PM, CNA #2 stated that a resident's plan of care indicated how the resident was to be transferred. She stated on 12/02/2025 CNA #1 called her to help with Resident #1. CNA #2 stated that when she entered Resident #1's room, Resident #1 was on the floor. She admitted knowing Resident #1 required the use of two persons to assist Resident #1 with a sit-to-stand lift (stand-up lift). During a telephone interview on 12/19/2025 at 1:01 PM, LPN #5 stated a CNA, whose name she did not recall at the time, came to her and stated Resident #1's feet pivoted from under them and the CNA lowered Resident #1 to their knees. The LPN also stated she then went to report the incident to the DON. The former LPN stated she knew Resident #1 was a two person assist and required the use of a stand-up lift for transfers. During an interview on 12/19/2025 at 2:11 PM, the DON stated LPN #5 came and told her Resident #1 had fallen. She stated LPN #5 told her CNA #1 was in the room with Resident #1 and as Resident #1 pivoted from the bed to the wheelchair, Resident #1's legs gave out and CNA #1 lowered Resident #1 to the floor. The DON stated, once she entered Resident #1's room, she observed Resident #1 sitting up in a wheelchair. The DON stated, she checked Resident #1's right side because of a complaint of pain and a complaint of right knee pain. The DON stated Nurse Practitioner (NP) #3 was telephoned and an order was obtained to get an x-ray. The DON stated the facility's in-house x-ray service came and completed the x-ray of Resident #1's [right] leg and later confirmed Resident #1's right leg was broken. Resident #1 was sent to [an acute care facility]. The DON stated Resident #1 was a two person-assist with transfers with the use of a stand-up lift and that CNA #1 did not use the stand-up lift to transfer Resident #1 on 12/02/2025. During a telephone interview on 12/22/2025 at 1:23 PM, CNA #1 stated she did not remember if she looked at Resident #1's Care Plan on 12/02/2025 prior to taking care of the resident that day. CNA #1 stated she did not remember the last time she looked at Resident #1's Care Plan. During a telephone interview on 12/23/2025 at 2:11 PM, NP #4 stated she was notified on 12/02/2025 of Resident #1's fall, but NP #3 did the assessment. NP #4 stated she was informed of Resident #1's radiology results which revealed an acute femur fracture. NP #4 stated her expectation for staff transferring residents at the facility was that residents with immobility deficits were care planned with how the transfer should be done. NP #4 stated she knew Resident #1 was care planned for two person-assistance for transfers and her expectation was to have two CNA's to transfer them. During an interview on 12/23/2025 at 4:45 PM, the Compliance Officer (CO) stated her expectation for staff locating, reviewing and following the resident's Care Plan was if staff did not know how a resident should be transferred, the staff would go to the [facility's electronic computer system] and look at the Care Plan to see how to transfer a resident and what care the resident needed. The CO stated her expectation for resident transfers was for staff to know what kind of transfer was needed, such as if the resident needs the stand-up lift. Review of a facility policy titled Care Plans, Comprehensive Person-Centered revised March 2022, indicated that the comprehensive care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. This policy also indicated services provided for or arranged by the facility and outlined in the comprehensive care are provided by qualified persons. This policy revealed care plan interventions are chosen after gathering data, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant decision making.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure the required staffing data was posted daily as evidenced by the daily staffing logs did not display the total number and actual worked hours for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nursing Assistants (CNAs) and resident census. The findings are: On 02/24/2025 at 9:38 AM, a review of the nursing schedules posted in the clear glass of the Director of Nursing (DON) office, which was to the right of the nursing station, was dated February 20, 2025, through March 05, 2025. The RN and LPN schedule; 7/3 (7:00 AM to 3:00 PM) shift CNA and [NAME] Clerk schedule; and the 3/11 (3:00 PM to 11:00 PM) and 11/7 (11:00 PM to 7:00 AM) schedule, had an x in some boxes, but the x did not have a number value to indicate the number of hours the x indicated. Some boxes on the RN and LPN schedule had numbers such as 7-3 (7:00 AM to 3:00 PM), 3-7 (3:00 PM to 7:00 PM), 4p-11p (4:00 PM to 11 PM), 3-11 (3:00 PM to 11:00 PM) and 7-11 (7:00 AM to 11:00 PM). The total actual hours were not indicated on the schedule. The 7-3 shift CNA and [NAME] Clerk schedule had an x in the box to indicate the date to be worked and dashes to indicate when the staff member was off. On 02/24/2025 at 10:54 AM, the daily staffing log sheets were observed on a table in the front lobby for the day shift, evening shift, night shift, housekeeping/maintenance and dietary and no census was indicated on any of the staffing logs. There were no staffing logs for the prior day, 02/23/2025, to show the total number of hours worked by the staff. On 02/25/2025 at 9:36 AM, the daily staffing log sheets were observed on a table in the front lobby for the day shift, evening shift, housekeeping/maintenance and dietary and no census was indicated on any of the staffing logs. The staffing log for the night shift for 02/24/2025 was on the table but the total number of hours worked by the staff was not indicated on the staffing log. On 02/26/2025 at 9:44 AM, the daily staffing log sheets were observed on a table in the front lobby for the day shift, evening shift, night shift, housekeeping/maintenance and dietary and no census was indicated on any of the staffing logs. There were no staffing logs for the prior day, 02/25/2025, to show the total number of hours worked by the staff. On 02/26/2025 at 3:09 PM, the Director of Nursing (DON) was interviewed with concurrent observations, and she indicated everyone signs in when asked who was responsible for filling out the staffing logs. She stated the night shift nurse placed the sheets out for the next day. When she was asked if the night nurse was trained in what information needed to be put on the staffing logs, she stated she needed to look at the sheet. After reviewing the daily staffing log sheet on the table dated February 26, 2025, the DON stated the daily census was on a separate sheet that was printed out of their electronic computer system, attached to the staffing log and placed in the collection box on business office door and was not visible to the public. The DON stated she thought the Business Office Manager (BOM) placed the total hours worked on the daily staffing logs. On 02/27/2025 at 9:27 AM, the daily staffing log sheets were observed on a table in the front lobby for the day shift, evening shift, night shift, housekeeping/maintenance and dietary and no census was indicated on any of the staffing logs. There were no staffing logs for the prior day, 02/26/2025, to show the total number of hours worked by the staff. On 02/27/2025 at 9:42 AM, LPN #9 was interviewed by telephone and stated she filled out the staffing log, printed off a census after midnight, indicated if a resident was in the hospital or rehab and placed the sheets in the front door for the front office staff to do the count. She stated she had not been instructed on placing the census on the daily staffing log labeled census and did not total the hours worked for each staff member. She stated she placed the daily staffing logs in the front lobby for each to sign in and out on. On 02/27/2025 at 2:57 PM, the BOM was interviewed and stated once she received the daily staffing logs, she used the census sheet attached to the staffing logs to ensure residents who were out of the facility were reflected in the electronic computer system and the staffing logs and census was given to Human Resources (HR). On 02/27/2025 at 2:58 PM, HR was interviewed and stated once she received the daily staffing logs, she reviewed the staff times in the electronic system to ensure the staff member clocked in and did not have any missed punches. She reviewed the daily staffing log for 02/27/2025 and stated she had not been totaling the hours for staff or placing the daily census on the sheets. A review of a Staffing, Sufficient and Competent Nursing policy, dated as revised August 2022, revealed direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) are posted in the facility for every shift.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 21 residents who received mechanical soft diets from 1 of 1 kitchen. The findings are: 1. The menu for lunch documented residents on pureed diets were to receive a #6 scoop (2/3) cup of pureed chicken and dumplings. a. On 02/24/2025 at 12:49 PM, Dietary [NAME] (DC) #3 was observed using a #8 scoop (1/2) cup to serve a single portion of chicken and dumplings to the residents who required pureed diets, instead of a #8 scoop (2/3) cup. b. On 02/24/2025 at 12:59 PM, DC #3 was interviewed and was asked what scoop she had used to serve pureed chicken and dumplings and how many servings she gave to each resident and if she had looked at the menu before serving. She stated she used a #8 scoop, gave one serving each, and did not look at the menu. 2. On 02/24/2025 at 12:51 PM, the kitchen ran out of cornbread and served regular bread to seven residents. DC #1 was interviewed and was asked how many residents received bread and the reasons those residents were served bread. She stated because the kitchen ran out of cornbread. DC #2 stated the kitchen ran out of cornbread because she fed the employees first. 3. On 02/24/2025 at 1:10 PM, Resident #15 was interviewed and asked if she liked cornbread. She stated she loved cornbread. Residents #25 and #31 were interviewed and asked if they liked cornbread. Both confirmed that they liked cornbread. 4. The menu for supper documented residents on pureed diets were to receive a #8 scoop (1/2) cup of pureed baked beans. a. On 02/24/2025 at 06:21 PM, during the supper meal service residents who required pureed diets were not served pureed baked beans. 5. On 02/24/2025 at 6:23 PM, the Dietary Manager and DC #3 were asked the reason residents on pureed diets were not served pureed baked beans. The Dietary Manager stated she had wasted the pureed baked beans after the DC #3, using the same gloved hand she had used to open a drawer, removed a #8 scoop, contaminating it in the process. The same #8 scoop, then fell into the pureed baked beans prepared for the residents on pureed diets, leading to cross contamination. The residents on pureed diets were supposed to have pureed baked beans like everyone else. DC #3 stated she gave the residents pureed diets mashed potatoes, pureed corn dogs, and tomato juice, and did not give pureed beans since spoon fell in it.

Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff washed their hands and changed their gloves before handling food items; foods stored in the dry storage area, refrigerator, and freezer were covered and sealed; expired food items were promptly removed from stock; 1 of 2 ice machines was maintained in clean and sanitary condition; hot food items were maintained at or above 135 degrees Fahrenheit on the steam table. The findings are: 1. On [DATE] at 8:11 AM, an ice scoop holder on the wall in the kitchen by the ice machine had a wet black and beige residue on it. The Dietary Manager was interviewed and was asked if she could wipe the area. The black and beige residue easily transferred to the tissue. She stated, It was black and beige residue. The surveyor asked the Dietary Manager who uses the ice from the ice machine and how often she cleans it. She stated she cleaned it every day and the kitchen used it to fill beverages served to the residents at mealtimes. 2. On [DATE] at 8:41 AM, the following observations were made on a shelf in the walk-in refrigerator: a. A container of cottage cheese in a box had an expiration date of [DATE]. b. An opened box of bacon. The box was not covered or sealed. 3. On [DATE] at 08:53 AM, the following observations were made on the walk-in freezer shelf: a. An opened box of catfish patties. The box was not covered or sealed. b. An opened box of hamburger patties. The box was not covered or sealed. c. An opened box of garlic bread. The box was not covered or sealed. d. An opened box of dinner rolls. The box was not covered or sealed. e. An opened box of biscuits. The box was not covered or sealed. f. An opened box of hash browns. The box was not covered or sealed. g. An opened box of corn dogs. The box was not covered or sealed. h. An opened box of cheese filled tortillas. The box was not covered or sealed. 4. On [DATE] at 9:03 AM, Dietary [NAME] (DC) #2 was touching a box of plastic sheets while pulling plastic wrap out of the box. Without washing her hands, DC #2 picked up glasses that contained beverages to be served to the residents by their rims and covered each with a piece of plastic wrap. 5. On [DATE] at 9:11 AM, an opened box of raisin bran cereal was on a shelf in the nourishment refrigerator. The box had no received date. 6. On [DATE] at 9:13 AM, an opened container of vanilla ice cream on a shelf in the walk-in freezer, had particles of icicles on it. The Dietary Manager was interviewed and was asked to describe the appearance of the ice cream. She stated it had icicles on the inside and looked like it had been defrosted and refrozen. 7. On [DATE] at 11:49 AM, DC #3 removed fresh tomatoes, cucumbers, and onion from the original box. Without rinsing the tomatoes and cucumbers she placed them on the cutting board. Without rinsing, DC #3 sliced the tomato, cucumber, and onion, and placed the pieces in a container for the vegetable salad to be served to the residents for the supper meal. DC #3 was interviewed and was asked what she should have done before slicing the tomatoes, onion, and cucumbers. She stated she should have rinsed them. DC #3 was then asked if she had rinsed the tomatoes, onion, and cucumbers. She stated that she had not. 8. On [DATE] at 12:28 PM, the temperatures of the food items when checked and read on the steam table by the DC# 2 were as follows: a. Pureed chicken and dumplings - 123.9 degrees Fahrenheit. b. Pureed cut green beans - 129 degrees Fahrenheit. c. Pureed bread with warm milk - 99.5 degrees Fahrenheit. The above food items were not reheated before being served to the residents. 9. On [DATE] at 12:48 PM, DC# 2 was on the tray line serving the lunch meal. She picked up tray cards and placed them on the trays. Without washing her hands, she picked up plates and bowls to be used in portioning food items to be served to the residents and placed them on the trays with her fingers inside the plate and bowls. At 1:06 PM, DC# 2 was interviewed and was asked what she should have done after touching dirty objects and before handling clean equipment. She stated she should have washed her hands. 10. On [DATE] at 5:07 PM, DC #3 was wearing gloves on her hands when she touched the handle of the deep fryer basket that contained corndogs. After that, DC #3 opened the cabinet, took out a spray bottle, and sprayed inside a pan, contaminating the gloves. Without changing gloves and washing her hands, DC #3 picked a clean blade and attached it to the base of the blender to be used in pureeing foods to be served to the residents who required pureed diets. 11. On [DATE] at 5:37 PM, DC #3 was wearing gloves on her hands while sorting tray cards, contaminating the gloves. Then, without changing gloves and washing her hands, DC #3 picked up the tray cards and placed them on the trays. With the same gloves, DC #3 picked up corndogs and placed them on plates. DC #3 then received a bag of bread from the Dietary Manager. Without changing gloves and washing her hands, DC #3 opened the bag of bread, removed slices of bread, and placed them on the plates to be served to the resident who did not receive baked beans. 12. On [DATE] at 5:47 PM, the temperatures of the following food items before been served to the residents were: a. The chicken and dumplings temperature from the container by the steam table was 105 degrees Fahrenheit. b. Ground corn dogs - 106 degrees Fahrenheit. The above food items were not reheated before being served to the residents. 13. A review of facility policy titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary, initiated 2022, provided by the Compliance Officer on indicated, employee should wash their hands during food preparation, as often as necessary and after engaging in other activities that contaminates the hands.

Based on observations, interviews, record review, and policy review, the facility failed to provide appropriate bedding for 1 (Resident #1) of 1 sampled resident observed for bedding. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/2024 revealed Resident #1 had short-term and long-term memory problems. A review of the plan of care for Resident #1 (revised on 09/08/2023) revealed Resident #1 required total assistance to turn and reposition in the bed and the resident could use rail with left hand to assist with turning and repositioning. On 02/24/2025 at 09:15 AM, this surveyor observed Resident #1 lying on [pronoun] back in bed without a pillow. Resident #1 was holding [pronoun] head up from the mattress. This surveyor did not see a pillow on or around the bed. On 02/24/2025 at 02:54 PM, this surveyor observed Resident #1 in bed lying on [pronoun] left side without a pillow. Resident #1's head was resting on the left hand folded into a fist. This surveyor did not see a pillow on or around the bed. On 02/25/2025 at 08:30 AM, this surveyor observed Resident #1 lying in bed on the [pronoun] right side without a pillow. Resident #1 was resting [pronoun] head on the mattress, and this surveyor noted a bend in the neck. This surveyor did not see a pillow on or around the bed. On 02/25/2025 at 03:40 PM, this surveyor observed Resident #1 lying in the bed on [pronoun] left side without a pillow. Resident #1 was resting [pronoun] head on [pronoun] hand folded into a fist. This surveyor did not see a pillow on or around the bed. On 02/25/2025 at 03:55 PM, this surveyor observed Licensed Practical Nurse (LPN) #7 search for Resident #1's pillow, but she was unable to locate a pillow on, under, or near the resident's bed. LPN #7 was also unable to locate a pillow in the resident's closet. On 02/25/2025 at 03:49 PM, during an interview Certified Nursing Assistant (CNA) #5 stated the position in which Resident #1 was lying, did not appear comfortable. CNA #5 stated Resident #1 was not capable of positing alone and was dependent on staff. CNA #5 stated Resident #1 was not capable of voicing discomfort or desired position. CNA #5 stated if she herself was lying in bed she would want a pillow for comfort. CNA #5 stated the resident removes the pillow, but the facility has done nothing to her knowledge differently to ensure the resident was comfortable. On 02/25/2025 at 03:55 PM, during an interview LPN #7 stated Resident #1 did not have a pillow on the bed, around bed, or in the room. LPN #7 stated she thinks she knows where the pillow was and looked over to the resident in Bed A who had 2 pillows. When asked if that resident was ambulatory or able to self-propel, LPN #7 stated no. LPN #7 stated Resident #1 did not look comfortable in the current position. LPN #7 stated the absence of a pillow can affect the resident by preventing the resident from having proper neck alignment. On 02/27/2025 at 11:32 AM, during an interview the Administrator stated Resident #1 was unable to position self and was dependent on staff for positioning, and the resident was not capable of voicing discomfort. The Administrator stated the absence of a pillow can cause contracture if the resident is not position right. On 02/27/2025 at 11:41 AM, during an interview the Director of Nursing (DON) stated Resident #1 was unable to position self and was dependent on staff for positioning. The DON stated the absence of a pillow could affect the resident's neck posture. A policy titled Repositioning, with a revision date of May 2013 noted, The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care pian for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents .

Based on Observation, Interview, Record Review and Facility Policy Review; the facility failed to transfer one (Resident #1) of five (Resident #1, #2, #3, #4 and #5) sampled residents safely and in accordance to the care plan, resulting in a major injury. The findings are: Review of Resident #1's Medical Diagnosis record revealed the resident had diagnoses of renal osteodystrophy (a complication of chronic kidney disease that weakens the bones), cerebral infarction, hemiplegia affecting the right dominant side, and osteoporosis. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/10/2024 noted a Brief Interview for Mental Status (BIMS) of 15, (cognitively intact). The MDS revealed Resident #1 had unclear speech but was able to make self-understood and understands, had an impairment of upper and lower extremities on one side and was dependent for transfers and ambulated via wheelchair. Review of Resident #1's care plan with a revision date of 11/10/2022 revealed the resident had impaired balance, was dependent on 2 staff members for transfers and required use of a mechanical lift. The care plan was revised on 04/02/2024 to include, Resident #1 had a fall with major injury, facture to fibula and tibia (bones of the lower leg). Review of a form titled, OLTC [Office of Long Term Care] Incident and Accident Report (I&A), sent to the state on 04/01/2024 revealed on 03/31/2024 Registered Nurse (RN) #3 was called to resident's room by Resident #1, who requested assistance to transfer from bed to wheelchair. RN #3 attempted to transfer Resident #1 to the wheelchair by herself, but the resident missed the wheelchair and had to be lowered to the floor. A short while later, Resident #1 had complaints of right knee pain and an x-ray was ordered which revealed a non-displaced fracture to the right proximal (nearest to the body) tibia and fibula. On 10/22/2024 at 10:13 AM, during an observation and concurrent interview, Resident #1 was sitting outside. When asked if the resident remembered the fall, Resident #1 said yes, then went on to say he wanted to get up in the wheelchair and asked RN #3, the Weekend Supervisor, to help. Resident #1 said they didn't make it to the wheelchair and RN #3 helped the resident to the floor, later that day, Resident #1's knee was hurting and, after x-rays, it was found out that the resident's leg was broken. On 10/22/2024 at 2:27 PM, during an interview Certified Nursing Assistant (CNA) #1 confirmed she was trained on how to view the Kardex (A medical-patient information system which uses forms preprinted on durable card stock) and care plan on the kiosk during orientation when hired. On 10/22/2024 at 2:30 PM, during an interview CNA #2 confirmed she was trained during orientation on how to look on the kiosk to find information such as how many people it took to transfer a resident and if a lift was required for transfers. On 10/22/2024 at 3:00 PM, during a phone interview RN #3 related she had worked at this facility part time for the past [AGE] years. When asked if she remembered the incident involving Resident #1, she stated yes, she did. When asked if she had known what interventions were used and how Resident #1 transferred, she replied that she had not and was going on instincts to assist them to the wheelchair. When asked if she was trained on the kiosk and how to access the Kardex and care plan on it, she stated, no, she really wasn't, then went on to say that she was in-serviced on using the kiosk but really didn't know how to use it, and that she had never used it RN #3 was asked if she was familiar with Resident #1, and what the resident's ambulatory status was. She replied that she was familiar with Resident #1 and as far as she knew, she only required one person assist for transfers. On 10/22/2024 at 3:25 PM, during an interview, the Director of Nursing (DON) was asked about training on accessing resident's plan of care and Kardex to determine how to care for residents. She said everyone is trained during orientation and she also in-services the staff at least once a year. A review of the facility's policy titled, Falls-Clinical Protocol, revealed residents will be evaluated for risk of falls and successful interventions with be continued to prevent falls.

Based on observation, interview, and record review, the facility failed to operate under the direction of a licensed Administrator, which had the potential to affect all 45 residents who resided in the facility. The findings are: On 10/21/2024 at 1:50 PM, upon entering the facility and requesting to speak to the Administrator, this surveyor was informed by the Director of Nursing (DON), and the Acting Administrator (the Compliance Coordinator), no administrator was currently employed at the facility. During interview, the Acting Administrator stated the Administrator had been gone since 7/15/2024, and the position had been posted on employment websites. When asked if she held a nursing home administrator's license, the Acting Administrator confirmed she did not. On 10/22/2024 at 10:10 AM, during an interview the Acting Administrator was asked if she could provide any documentation assigning her as Acting Administrator. She produced an undated typed document stating she was Acting Administrator with no name or signature of who assigned this position. On 10/22/2024 at 3:30 PM, a review of the facility policy titled, Administrator, revealed the Administrator is responsible for day-to-day functioning of the facility, implementing established resident care policies, ensuring resident's rights, ensuring staffing is adequate to meet the needs of the residents and that only residents who can be adequately cared for by staff are admitted to the facility. The policy statement included the Administrator is duly licensed in accordance with federal, state and local laws.

Based on observation, record review and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage areas were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; leftover foods were in a manner to maintain food quality; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination; 1 of 2 ice scoop holders was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen; and the ceiling tiles were free of stains and walls were free of peeling paint. These failed practices had the potential to affect 35 residents who receive meals from the kitchen (total census: 39) as documented on a list provided by Dietary Supervisor. The findings are: 1. On [DATE] at 08:12 AM, the following observations were made in the kitchen area: a. The ceiling tiles around the 5 ceiling air vents had brown stains on them. b. The wall below the 2-compartment sink, and the wall above the hand washing sink above the trash cans, had paint peeling, exposing the cement. c. The ice scoop holder on the wall by the hand washing sink had water standing. There was black and gray residue floating on top of the water. The ice scoop was resting directly in contact with the black and gray residue. The Surveyor asked the Dietary Supervisor to describe what was observed in the scoop holder. She stated, It is black and gray residue. The Surveyor asked how often the ice scoop holder was cleaned and who uses the ice from the machine. She stated, That's the ice the CNAs [Certified Nursing Assistants] use to fill the water pitchers in the residents' rooms. We use it in the kitchen to fill beverages served to the residents at meals. We clean it daily. The Surveyor asked does it looks like it was cleaned yesterday. She stated, No. d. On [DATE] at 09:08 AM, Dietary Employee #1 used a sanitizer rag to wipe off a utility cart. Without washing her hands, she picked up dishes and stacked them up inside a cabinet with her fingers touching them. e. On [DATE] at 09:25 AM, Dietary Employee #1 picked up a pot from the shelf below the steam table. She turned on the sink faucet and ran water into the pot. She used her bare hand to turn off the faucet, contaminating her hands. She placed the pot on the stove and turned it on. She removed a bag of macaroni from the storage room, opened the bag and emptied it inside the pot. Without washing her hands, she picked up dishes and stacked them inside the cabinet below the steam table with her fingers inside the dishes. The Surveyor asked DE #1 what should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 2. On [DATE] at 09:42 AM, DE #1 removed a spray bottle of nonstick spray from the cabinet and sprayed the inside of the pans on the steam table, contaminating her hands. Without washing her hands, she picked up glasses by their rims and placed them on the counter in front of the juice maker. 3. On [DATE] at 09:52 AM, a bag that contained 8 hamburger buns with an expiration date of [DATE], was in the bread cabinet in the kitchen. 4. On [DATE] at 09:59 AM, a bag that contained leftover sausage and bacon was in a pan on the top shelf in the refrigerator. The Surveyor asked the Dietary Supervisor what was in the bag. She stated, They are leftover sausage and bacon, we used them for ground and pureed meat the next day. 5. On [DATE] at 09:59 AM, the following observations were made of food items on a shelf in the walk-in freezer: a. There was an open box of hamburger patties in the walk-in freezer. The box was not covered or sealed. b. There was an open box of dinner rolls on a shelf in the walk-in freezer. The box was not covered or sealed. 6. On [DATE] 10:05 AM, the following observations were made in the spice cabinet: a. A container of seasoning salt had an expiration date of [DATE]. b. A container of mustard had an expiration date of [DATE]. c. A container of basil leaves had an expiration date of [DATE]. d. A container of ground black pepper had an expiration date of [DATE]. 7. The following spices were in the cabinet and had no dates to indicate when they were opened. a. Mediterranean style oregano leaves. b. Ground nutmeg. c. Ground cumin. d. Ground thyme. e. Ground cayenne pepper. f. Pumpkin pie spice. g. Taco seasoning. h. Ground ginger. i. Lemon pepper seasoning. j. Black pepper. 8. On [DATE] at 11:43 AM, DE #2 threw away a box of oatmeal cream pies in the trash can. Without was washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. At 11:52 AM, when DE #2 was ready to put deboned chicken into the blender, the Surveyor immediately stopped her, and asked DE #2, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. DE #2 stated, We are going to rewash it. 9. On [DATE] at 12:22 PM, DE #1 used a rag on the counter that she had used to wipe off spilled food on the counter to dry her hands, contaminating her hands in the process. Without washing her hands, she picked up a clean blade and attached it to the base of the blender. When DE #1 was ready to put biscuits into the blender, the Surveyor immediately asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 10. The facility policy titled, Handwashing/Hand Hygiene provided by the Dietary Supervisor on [DATE] at 10:51 AM documented, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .Before and after eating or handling food .

Based on observation, interview, and record review, the facility failed to ensure a janitor closet on the 500 Hall containing chemicals remained locked to prevent accidents. This failed practice had the potential to affect 25 residents who were ambulatory or self-propel in a wheelchair as documented on a list provided by the Administrator on 01/05/2024 at 09:41 AM. The findings are: 1. On 01/02/2024 at 01:06 PM, a closet door labeled Janitor was noted with a key on a red key chain in the doorknob. 2. On 01/02/2024 at 01:09 PM, a closet door labeled Janitor was noted with a key on a red key chain in the doorknob. Upon observation of the room, the Surveyor noted 2 mop buckets with mops and a blue chemical dispenser with (disinfectant cleaner) in it on the wall on the right side of the room. 3. On 01/02/2024 at 01:13 PM, a closet door labeled Janitor was noted with a key on a red key chain in the doorknob. Upon observation of the room, the Surveyor noted 2 mop buckets with mops and a blue chemical dispenser with (disinfectant cleaner) in it on the wall on the right side of the room. 4. On 01/02/2024 at 01:14 PM, Licensed Practical Nurse (LPN) #2 was asked, What is stored in this closet? LPN #2 replied, Mops and mop buckets. The Surveyor asked, How should the key to this room be stored? LPN #2 replied, Not supposed to leave the key in there (Pointing to the doorknob). The Surveyor asked, What could happen from the key being left in the doorknob? LPN #2 replied, Residents could get in there and get ahold of something they are not supposed to. 5. On 01/02/2024 at 01:20 PM, Housekeeping Employee #1 was asked, How should the key to the janitor's closet be stored? Housekeeping Employee #1 stated, It hangs beside the door. The Surveyor asked, What is stored in the room? Housekeeping Employee #1 replied, Chemicals. The Surveyor asked, What could happen if a resident goes in the Janitor closet? Housekeeping Employee #1 replied, The resident could get hurt from the chemicals. 6. On 01/02/2024 at 01:26 PM, the Administrator was asked, How should the key to the janitor's closet be stored? The Administrator replied, They are supposed to be stored beside the door on the hook. The Surveyor asked, What is stored in the room? The Administrator replied, Chemicals for mopping. The Surveyor asked, What could happen if a resident goes in the Janitor closet? The Administrator replied, The resident could get in the chemicals and become ill. It's very dangerous. 7. On 01/02/2024 at 02:50 PM, a Safety Data Sheet provided by the Administrator for the chemical documented, Clean on the Go [disinfectant cleaner] .Storage: Store locked up .

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 4 residents who received pureed diets and 20 residents who received mechanical soft diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 01/05/2024. The findings are: 1. On 01/04/2024, the menu for the lunch meal documented residents who received mechanical soft diets were to receive #8 scoop (4 ounces) of ground fried chicken. Residents who received pureed diets were to receive (4 ounces) of pureed fried chicken. a. On 01/04/2024 at 12:54 PM, the following observations were made during the lunch meal: b. The Dietary Supervisor used a 2 ounce (orange spoon) which is equivalent to 1/4 cup (2 ounces) to serve a single portion of pureed cut green beans, to the residents who required pureed diets, instead of #8 scoop as specified on the menu. c. The Dietary Supervisor used a 2 ounce spoon to serve a single portion of pureed fried chicken to the residents on pureed diets, instead of a #8 scoop which is equivalent to 4 (ounces) as specified on the menu. d. The Dietary Supervisor used a 2 ounce spoon to serve a single portion of ground fried chicken to the residents on mechanical soft diets, instead of a #8 scoop which is equivalent to 4 (ounces) as specified on the menu. 2. On 01/04/24 at 12:56 PM, Dietary Employee #1 served 2 fried chicken legs to 7 residents on regular diets and 2 fried chicken wings to 6 residents on regular diets. 3. On 01/04/24 01:11 PM, the Surveyor asked the Dietary Supervisor to weigh the same 2 fried chicken wings served to the residents for lunch. She did so and stated, It weighed 2.2 ounces. On 01/04/24 at 04:07 PM, the Surveyor asked Dietary Employee #3 to weigh the same amount of fried chicken legs served to the residents for lunch. She did so and stated, It weighed 1.8 ounce.

Based on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. The failed practice had the potential to affect 8 residents who received their meal trays in their rooms on the 500 Hall, 8 residents who received meals in their rooms on the 100 Hall, as documented on a list provided by the Dietary Supervisor on 01/05/2024 at 10:51 AM. The findings are: 1. On 01/02/24 at 10:40 AM, Resident #39 was asked if the hot food was hot, and cold food was cold when served? Resident #39 stated, The hot food is cold at times. 2. On 01/05/24 at 07:57 AM, an unheated food cart that contained 8 trays for the breakfast meal was delivered to the 500 Hall by Certified Nursing Assistant (CNA) #4. At 08:19 AM, immediately after the last resident received their tray in their room, the Surveyor asked the Dietary Supervisor to check the temperatures of the food items on the trays. She did and stated, a. Milk - 49 degrees Fahrenheit. b. Ground sausage - 86 degrees Fahrenheit. c. Regular oatmeal - 83 degrees Fahrenheit. 3. On 01/05/24 at 08:05 AM, an unheated food cart that contained 8 trays for the breakfast meal was delivered to the 100 Hall by CNA #5. At 08:22 AM, immediately after the last resident received their tray in their room, the Surveyor asked the Dietary Supervisor to check the temperatures of the food items on the trays. She did and stated: a. Milk - 47 degrees Fahrenheit. b. Pureed eggs - 97 degrees Fahrenheit. c. Pureed grits - 106 degrees Fahrenheit. d. Pureed sausage - 96 degrees Fahrenheit.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 4 residents who received pureed diets, as documented on the Diet List provided by the Dietary Supervisor on 01/05/2024. The findings are: 1. On 01/04/24 at 11:59 PM, Dietary Employee (DE) #1 placed deboned pieces of fried chicken into a blender, added water, thickener and pureed. At 12:02 PM, DE #1 poured the pureed chicken into a pan and placed it on the steam table. The consistency of the pureed chicken was gritty, not smooth. On 01/04/24 at 12:14 PM, DE #1 used a 4 ounce spoon to place 4 servings of cut green beans into a blender, opened two packages of thickener, emptied them on the beans, and pureed. At 12:15 PM, DE #1 poured the pureed cut green beans into a pan and placed it on the steam table. The consistency of the cut green beans was runny. On 01/05/24 at 07:55 AM, the following food items were served to the residents on a pureed diet for breakfast were not smooth: a. Pureed grits served to the residents on pureed diets was thick, gritty, not smooth. b. The pureed sausage served to the residents on pureed diets was gritty, not smooth. c. On 01/05/2024 at 07:56 AM, the Surveyor asked Certified Nursing Assistant (CNA) #3 in the dining room assisting with meal to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, Pureed sausage was not smooth, needed to be pureed longer. Pureed was thick.

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies to ensure residents with Mental Health Diagnosis received a Level II Pre-Admission Screening and Resident Review (PASARR) before being admitted to the facility. The findings are: A Recertification survey was conducted on 10/13/22 at the facility. A review of the facility's Plan of Correction was conducted on 01/05/24. The Plan of Correction, with a completion date of 11/12/22 stated: F644 - To ensure the deficient practice does not recur, on 10/13/22 the MDS [Minimum Data Set] Coordinator was in-serviced on making sure all residents with mental illness diagnosis are screened for preadmission and a resident with a new mental illness diagnosis receives a PASARR. DON [Director of Nursing]/Designee will monitor new admissions and new diagnosis of current residents to ensure any resident with a mental illness diagnosis receives a PASARR 5X week for 8 weeks or until compliance is verified by OLTC [Office of Long Term Care]. Any negative findings will be corrected immediately, and Admin [Administrator] notified. DON/Designee will present all findings to the monthly QA [Quality Assurance] committee for further review and recommendations. On 01/05/24 at 8:28 am, the Administrator was asked When a deviation from expected performance or negative trend occurs how does the Committee know? The Administrator stated, Our QA meetings, we have them monthly. The Surveyor asked, How does the Committee decide on what issue to work on? The Administrator stated, We usually look at what is directly affecting the residents, we address the severity of it. The Surveyor asked, How does the Committee know that a corrective action that has been implemented, is effective, and an improvement is occurring? The Administrator stated, Through walk throughs. We do a follow up on it and depending on what area the problem was in they do a report on it. On 01/05/24 at 8:05 am, the facility Quality Assurance Improvement Plan was reviewed. The policy states, .Concerns are bought up when a certain department or task is not hitting benchmark. The concern is discussed, and an action plan developed. If necessary, it will go on to the Performance Improvement Project .

Based on observation, record review, and interview, the facility failed to ensure a multi-resident use glucometer (a machine to check glucose levels) was properly disinfected after use to prevent potential spread of infection for 3 (Residents #10, #12 and #14) sampled residents who had physician orders for capillary blood glucose monitoring as documented on a list provided by the Administrator on 1/05/23 at 9:31 AM. The findings are: 1. On 1/03/23 at 11:30 AM, during Medication Administration Observation, Licensed Practical Nurse (LPN) #1 performed a fingerstick on Resident #10. LPN #1 took a (Brand Name) disinfectant bleach wipe and cleaned the glucometer for 4 seconds then placed the machine on the medication cart. At 11:37 AM, LPN #1 used the same glucometer and obtained a fingerstick on Resident #14. LPN #1 then cleaned the glucometer with a (Brand Name) disinfectant bleach wipe for 6 seconds. After the fingerstick on Resident #14, LPN #1 used the same glucometer and obtained a fingerstick on Resident #12, then cleaned the glucometer for 5 seconds with a (Brand Name) disinfectant bleach wipe. 2. On 1/04/23 at 02:40 PM, LPN #1 was asked how long the glucometer should be cleaned. LPN #1 stated, I wiped it down all over and I waited four minutes. The Surveyor asked how long the machine should have been left wet. LPN #1 stated, I'm not sure. The Surveyor asked how many glucometer machines are on each cart. LPN #1 replied, One. 3. On 1/04/23 at 03:50 PM, the Director of Nursing (DON) was asked how long the glucometer should be cleaned with wet contact. The DON stated, I know it should be one to two minutes then let dry for four to five minutes. The DON was asked what could happen by incorrectly cleaning the glucometer. The DON stated, Infection and spreading it from one patient to another patient. 4. On 1/05/23 at 9:31 AM, the Administrator provided a document titled, [Brand Name] Bleach Wipes General Guidelines which documented, .4. The treated surface must remain visibly wet for a full four minutes. Use additional wipe(s) if needed to assure continuous 4-minute wet contact time . 6. A Policy titled, Obtaining a Fingerstick Glucose Level, provided by the Administrator on 1/05/23 at 9:31 AM documented, .Steps in the procedure .3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between residents uses . 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice .

Based on interview and record review, the facility failed to ensure resident records, care plans, and physician orders contained accurate documentation of a residents' Cardio-Pulmonary Resuscitation (CPR) status for 1 (Resident #39) of 1 sampled resident. The findings are: 1. On [DATE] at 11:11 AM, a review of Resident #39's electronic medical record (EMR) contained a Living Will Declaration provided by the Administrator which noted the resident does not want Cardiac Resuscitation (CPR), Artificially Administered Feeding (Feeding tubes), or Artificial Breathing Machine (Respirator/ventilator). This document was signed on [DATE], by the Power of Attorney and was witness by the Social Services Director (SSD). 2. The Physician Order dated [DATE] noted an order for Full Code. 3. The Face Sheet printed on [DATE] noted, Full Code. 4. The Care Plan dated [DATE] noted a care plan for Advanced Directives and noted Resident #39 was a Full Code. 5. On [DATE] at 04:11 PM, the SSD was asked, What is Resident #39's code status in the EMR? The SSD stated, Full code. The Surveyor asked the SSD to pull up in the EMR Resident #39's Living Will Declaration and state what Resident #39's wishes are. The SSD stated, No CPR, No Feeding tube, and no ventilator. The Surveyor asked, What could happen from the EMR stating full code, but the resident has elected to not be resuscitated? The SSD stated, We could perform CPR and that is not the residents wishes. The Surveyor asked, What is the code status that should be in the EMR? The SSD stated, Should be DNR [Do Not Resuscitate]. The Surveyor asked who is responsible for ensuring the code status is placed in the EMR? The SSD stated, The Business Office Manager is responsible for placing the code status in the EMR. 6. On [DATE] at 04:17 PM, the Director of Nursing (DON) was asked, What is [Resident #39's] code status in the EMR? The DON stated, Full code. The Surveyor asked the DON to pull up in the EMR Resident #39's Living Will Declaration and state what Resident #39's wishes are. The DON stated, No CPR, No Feeding tube, and no ventilator. DNR. The Surveyor asked, What could happen from the EMR stating Full code but the resident has elected not be resuscitated? The DON stated, You could possibly resuscitate when the resident does not want that. The Surveyor asked who was responsible for verifying accuracy of the code status in the EMR? The DON stated, I do not know that answer. We review them in care plan meetings. 7. On [DATE] at 04:20 PM, the Administrator was asked, Who is responsible for living wills in the facility? The Administrator stated, The SSD is responsible. The Surveyor asked, Who places the code status in the EMR? The Administrator stated, The SSD places the code status in the EMR. 8. On [DATE] at 09:30 AM, the Administrator provided a Policy for Advance Directives which stated, . If the Resident Has an Advance Directive . 3. The residents wishes are communicated to the . staff and physician . 4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive . a. facility staff are not required to provide care that conflicts with an advance directive .

Based on interview and record review, the facility failed to ensure the Ombudsman was notified of a transfer to the hospital for 1 (Resident #42) of 1 sampled resident. The findings are: 1. On 01/04/24 at 11:08 AM, during review of Resident #42's medical record, it was noted Resident #42 was admitted [DATE] with diagnoses of heart failure, diabetes mellitus, hypertension, Stage 3 kidney disease and chronic obstructive pulmonary disease (COPD); was a full code; was in the hospital from 10/4/23 to 10/06/23 for acute-chronic renal insufficiency, hyponatremia, and difficulty swallowing. 2. On 1/4/23 at 11:40 AM, there was no documentation in the medical record that the Ombudsman had been notified of Resident #42 transfer to the hospital. 3. On 1/5/23 at 08:53 AM, the Administrator provided a form titled, Emergency Transfer from Facility Resident #42 was not listed for the second admission to the hospital. 4. On 1/5/23 at 09:00 AM, the Administrator confirmed there was no proof the Ombudsman was notified. 5. On 1/5/23 at 09:57 AM, the DON provided a policy titled, Transfer/Discharge, Facility Initiated, Page 29 documented, Notice of Transfer or Discharge: 4. Notice of Transfer is provided to the resident .and to the Long term care ombudsman when practicable .

Based on record review and interview, the facility failed to ensure 2 persons were utilized when using a mechanical lift to prevent the potential for injury for 1 (Resident #3) of 3 (Residents #3, #4 and #5) sampled residents who were dependent on staff for lift transfers. The failed practice caused or was likely to cause serious harm, injury or death to Resident #3 who was being transferred by Certified Nursing Assistant (CNA) #1 and the resident was hanging upside down within 2 feet of the floor and had the potential to cause more than minimal harm to 13 residents who required a lift for transfers according to a list provided by the Director of Nursing (DON) on 6/8/22 at 8:43 AM. The Administrator and the DON were informed of the Immediate Jeopardy (IJ) situation on 6/7/22 at 4:35 p.m. The findings are: Resident #3 had diagnoses of Heart Failure, [CONDITION(S)], and Sacral Pressure Ulcer. The Annual Minimum Data Set with an Assessment Reference Date of 3/19/22 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status and required extensive physical assistance of two plus persons for transfer. a. The Care Plan with a revision date of 04/14/22 documented, .She has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Limited Mobility, Limited ROM [Range of Motion], Musculoskeletal impairment, Pain D/T [due to] [CONDITION(S)], has impairment to BUE [bilateral upper extremities] and BLE [bilateral lower extremities] . TRANSFER: She is totally dependent on 2 staff for transferring via mechanical lift . b. On 6/7/2022 at 4:20 PM, during initial rounds, the surveyor opened the door to Resident #3's room. The resident was dangling upside down in a lift beside the bed with her head pointing down approximately 2 feet from the floor. Resident #3 was yelling, You are going to drop me. Certified Nursing Assistant (CNA) #1 was pushing the lift sling with her left hip toward the resident's bed. She grabbed the right side of the loops with her right hand and straightened up the resident. She was the only CNA in the room operating the lift and positioning the resident. She positioned the resident over the bed. Resident #3 continued yelling, You are going to drop me. CNA #1 said to the resident, I'm not going to drop you. I would rather fall myself than drop you. CNA #1 removed the lift sling from the lift. She picked the resident up, holding her upper back and lower legs to position her onto the bed. CNA #1 was asked, Are you supposed to operate the lift with one person? She said, No, the other person was helping someone else, and she was wanting to lay down. CNA #1 was asked, Have you been trained on how to operate the lift? She said, Yes. CNA #1 continued to position the resident in the bed alone and moved the lift from the bed. c. On 6/7/22 at 4:38 PM, Registered Nurse (RN) #1 was asked, When a CNA operates a lift, how many staff members should be in the room? She said, Two. She was asked, What could happen, with just one CNA in the room? She said, The strap could break, the resident could fall out of the lift. d. On 6/7/22 at 4:40 PM, the DON was asked, When a CNA operates a lift, how many staff members should be in the room? She said, Two, it depends on what the Care Plan says. She was asked, What could happen, with just one CNA in the room? She said, The resident could fall out of the lift. e. On 6/8/22 at 2:18 PM, CNA # 2 was asked, When you do a transfer lift, how many staff should be present? He said, Two. f. On 6/8/22 at 2:20 PM, CNA # 3 was asked, When you do a transfer lift, how many staff should be present? She said, Two. g. On 6/8/22 at 2:25 PM, CNA #4 was asked, When you do a transfer lift, how many staff should be present? She said, Two. h. On 6/8/22 at 2:28 PM, CNA #5 was asked, When you do a transfer lift, how many staff should be present? She said, Two. 2. Resident #4 had diagnoses of Type II Diabetes Mellites, [CONDITION(S)], and Chronic Gout. An Admission MDS with an ARD of 5/18/22 documented the resident scored 15 (13-152 indicates cognitively intact) on a BIMS and required extensive physical assistance of two plus persons for transfers. On 6/7/22 at 4:40 PM, Resident #4 was asked, How many CNAs are in the room when they use a lift to get you up? She said, One. She was asked, Do you always have just one CNA? She said, No, sometimes there will be two. 3. The facility policy titled, Lifting Machine, using a Portable, provided by the DON on 6/7/2022 at 5:06 PM documented, .Purpose The purpose of this procedure is to help lift residents using a manual lifting device. Preparation l. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines Two (2) nursing assistants are required to perform this procedure . 4. The Immediate Jeopardy was removed on 06/07/22 at 5:35 PM and the scope and severity reduced to a D when the following plan of removal was implemented: a. The DON in-serviced the employee on making sure two staff members are in attendance when using the mechanical lift on a resident during transfer. b. The DON assessed the resident for harm or injuries resulted from the deficient practice with no negative findings c. On 6/07/2022 through census and condition there were 13 found to have the potential to be affected by the deficient practice. On 6/07/2022 the DON/Designee assessed all residents identified for harm or injuries with no negative findings. d. On 6/07/2022, the DON/Designee in-serviced all nursing staff on making sure two nursing staff are present when transferring a resident with a mechanical lift to ensure the residents are free of accidents. e. On 6/07/2022, the DON/Designee inspected the Vanderlift II and slings for proper functioning and condition with no negative findings. f. Beginning on 6/07/2022 the DON/Designee observed a return demonstration from licensed personnel via check off skills assessment for Vanderlift II. g. The DON/Designee will monitor proper use of the mechanical lift 5 times a week for 8 weeks or until compliance is verified by OLTC. Any negative findings will be corrected immediately, and the DON/Designee notified.

Based on record review, and interview the facility failed to ensure accessibility to lighters was limited to maintain safety and prevention of fires 1 (Resident #1) of 5 (Residents #1, #13, #24 #27, and #36) sampled residents who smoked. This failed practice resulted in an Immediate Jeopardy which caused or could have caused serious harm, injury or death Resident #1 who started a fire with the leaves in the parking lot and had the potential to cause more than minimal harm to 4 others smokers according to a list provided by the Administrator on 1/14/19. The Administrator was informed of the Immediate Jeopardy at 4:54 p.m. on 1/17/19. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 10/26/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status) and was independent to limited assist in activities of daily living and had no documentation of tobacco use. a. A Social Note dated 9/4/18 documented, SSD (Social Service Director) was informed that Resident had started a fire twice over the weekend. Conference was held with the resident by Administrator, Director of Nursing (DON), and SSD. Resident stated that he knew what we wanted with him and he was not giving up his (expletive) lighter. He claims that he was only helping Maintenance because they are never here when the wind is from the east. He stated, I'm not a dumb ass and he knows when to start a fire. He said that 'Ya'll gonna be mad when it backs up in the nursing home.' Resident says he did it on purpose. Resident was made aware that we have to let maintenance do the burning. Administrator to make him aware of the consequences and that this is not to happen again. b. The Resident's Safe Smoking Evaluation dated, 10/25/18 documented, The Resident's Short term and long term memory, were adequate, memory to recall adequate, hearing adequate, communication with others, understand others, vision, were all okay. Vision adequate . Resident able to smoke independently. c. The Facility's Smoking Policy, provided by the Administrator on 1/17/19 documented, Smoking is only permitted in designated resident smoking areas, which are located outside of the building . A resident's ability to smoke will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. Residents who have independent smoking privileges are permitted to keep cigarettes . in their possession. Only disposable lighters are permitted . This facility maintains the right to confiscate smoking articles found in violation of our smoking policies. d. On 1/17/19 at 4:15 p.m., the DON was asked about the fire incident and she stated, He (Resident) told them he set the leaves on fire. The DON was asked How did the resident set the leaves on fire? She stated, With his lighter. She was asked, So, he is allowed to keep his lighter on him? She stated, Yes. She was asked, Who reported the incident to the nurse? She stated, A family member. I did not handle that the Administrator did, so just ask her. e. On 1/17/19 at 4:22 p.m., the Administrator was asked about the fire incident and she reiterated what social stated in her notes above, That the resident said he did it, and when questioned said he would not do it again. She was asked if the resident still had his lighter on him she stated, Yes. She was asked, Does the resident go outside by himself? She stated, Yes. She was asked, Does he know the code to the front door? She stated, Yes. At 4:40 p.m., Licensed Practical Nurse (LPN) #4, via phone call (LPN #4 was the nurse who provided care to the resident on the day of the incident) was asked about the incident. She stated, Resident was outside alone, the other nurse came and got me. We saw leaves smoking from the end of the parking lot in the corner of parking lot, near the end by the ditch. I questioned him (Resident) and asked 'Did you do that?' He had been in the smoking area, but left and came to front of the building. The LPN was asked How did you know he was out there? She stated, We were told by a family member of another resident. She was asked if he burned himself. She stated, No. She was asked, Did you do an incident report? She stated, No. I called the Administrator and the DON (DON-I did not get an answer). At 4:48 p.m., spoke with the LPN #5 who had worked the same shift on the day of the incident and asked about the incident. She stated, He was out on the front. When asked was he by himself? She stated, Yes. He had been in the smoking area at the end of 100 hall. She was asked, How did he get to the parking lot? She stated, There is a gate that you can go out of from the smoking area. She was asked, Where was he outside? She stated, On the parking lot to the right of the building. She was asked, Did you all ask what he was doing? She stated, When questioned, he stated he had set the leaves on fire at the end of the parking lot. He said he did it and cussed us out. At 4:54 p.m., spoke with the Administrator and was asked what interventions were put in place to prevent recurrence of this type incident again. She stated, We talked to him. She was asked, Does he still have his lighter on him? She stated, Yes. e. On 1/17/19 at 6:48 p.m., Spoke with the family member of another resident who staff alleged reported the incident to the nurse and she stated, Oh, I don't recall that, it must have been someone else. f. On 1/18/19 at 1:35 p.m., Spoke with the Social Service Director at this time and she stated the same thing that was in her notes on 9/4/18. She reiterated that the resident stated he was trying to help the maintenance man by setting the leaves on fire. 2. The Immediate Jeopardy was removed, and the scope and severity was lowered to an E level on 1/17/19 when the facility implemented the following Plan of Removal: On (MONTH) 17, 2019 at 17:05 p.m., the resident's lighting material and smoking material were confiscated and placed in the med (medication) room by Administrator and DON. The family and the resident was notified of the incident and removal of all smoking material and lighting material. The resident is the only resident that was permitted to have cigarettes and lighter, all other smokers do not have access to lighters or cigarettes. ID (Identify) all other Residents: On (MONTH) 17, 2019 all smokers were assessed for safe smoking. Clothing was inspected for holes related to unsafe smoking. Measures and Systemic Changes: A smoking times will be enforced for the resident as with other residents. Unsafe residents will be supervised during smoking. The Resident Smoking Assessment will be updated. Materials and Controls: Certified Nursing Assistants (CNA'S), Social, Activity, Nursing Staff or family will supervise unsafe smokers while smoking and resident will have smoking apron if needed. MDS Coordinator will assess smoking residents on admission, quarterly, and as needed/change of condition. Director of Nursing/Designee will monitor all smokers daily and any changes will be reported to the Director of Nursing/Designee immediately.

Based on observation, record review, and interview, the facility failed to ensure a resident with multiple [MEDICAL CONDITION] his clothing was correctly assessed to require supervision while smoking, failed to ensure a protective apron or other protective gear was offered, and that his cigarettes and lighter were not left in his possession to prevent potential burn injuries for 1 (Resident #26), failure to ensure smoking materials and lighters were stored in a secure location in accordance with the facility's smoking policy for 2 (Residents #26 and #30), and failed to ensure a resident who was assessed to require supervision with smoking was correctly care planned for supervision and was consistently supervised by staff while smoking to prevent potential injury for 1 (Resident #30) of 2 (Residents #26 and #30) case mix residents who smoked. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #26, who was observed smoking without supervision and had multiple burn holes in his clothing, and #30, who was assessed to require supervision with smoking, but was incorrectly care planned to smoke unsupervised, and had the potential to cause more than minimal harm to 5 residents who smoked, as identified by the Administrator on 1/8/17. The Administrator was notified of the Immediate Jeopardy condition on 1/8/17 at 4:30 p.m. The findings are: 1. A facility policy titled Smoking Policy - Residents received on 1/8/18 from the Director of Nursing documented, .This facility shall establish and maintain safe resident smoking practices .residents shall be informed of the facility smoking policy .smoking is only permitted in designated resident smoking areas .the resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: current level of tobacco consumption, method of tobacco consumption . ability to smoke safety with or without supervision (per a completed Safe Smoking Evaluation) .The staff shall consult with the attending physician and the Director of Nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation .A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff .Any smoking related privileges, restrictions, and concerns . shall be noted on the care plan and all personnel caring for the resident shall be alerted to these issues . Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking . Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc (et cetera), except when they are under direct supervision . 2. Resident #26 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 11/2/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required limited one person assistance for transfers, was independent with locomotion on and off the unit, required a wheelchair for mobility out of room, and had functional limitation in range of motion on one side of the upper extremities and one side of the lower extremities. a. A Care Plan dated 5/2/17 documented, .(Resident) wishes to smoke and is designated as a safe smoker . The care plan indicated review dates of 8/3/17 and 11/2/17 with the notation, .cont (continue) P(NAME) (plan of care) . b. A Safe Smoking Assessment form dated 11/2/17 documented, Resident smokes safely . Does not allow ashes or lit material to fall while smoking, inhaling or holding smoking item. Remains alert and aware during smoking. Does not forget he/she is smoking or falls asleep while holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self, or others. Has fine motor skills needed to securely hold cigarette. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas. Resident utilizes ashtray safely and properly. Gets ashes into ashtray. Does not cause/allow sparks or lit tobacco to fall anywhere but into the ashtray. Able to extinguish cigarette safely and completely when finished smoking . Resident may smoke independently or with set up . c. On 1/8/18 at 2:06 p.m., Resident 26 was in the smoking area unsupervised by staff. The resident was smoking unfiltered cigarettes, using a metal and plastic device to hold his cigarette. He was wearing a flannel type jacket and there was a large burn mark on the left front of the jacket. When questioned about the burn hole, the resident stated that he burned his clothes, a lot. The Surveyor identified 5 burn holes in his warm-up type pants and 6 burn holes in his green t-shirt. When questioned about the holes in his clothes, he stated, I got a lot of clothes with holes burned in them. e. On 1/8/18 at 4:38 p.m., the Minimum Data Set (MDS) Coordinator was asked, Do you observe how they (residents) smoke, hold the cigarette, put the ashes in the proper place and if they are able to extinguish it? She stated, Yes. She was asked, Do you actually go out and observe the resident smoking? She stated, Yes. She was asked, Since November, has he (Resident #26) had any change in his condition? She stated, Not that I know of, maybe in his paranoia. The MDS Coordinator was asked, What would you consider a change to warrant a reassessment? She stated, Just what you just told me, burn holes in his shirt and his hands shaking. f. On 1/8/18 at 2:14 p.m., Registered Nurse (RN) #1 and the Assistant Director of Nursing (ADON) were asked about the availability of smoking aprons. The ADON stated, I don't think we have any. RN #1 stated, We have 2 in the store room. The ADON returned from the storeroom with 2 new smoking aprons, still in the original packaging. 3. Resident #30 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 11/6/17 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required limited one person assistance for transfers, had functional limitation in range of motion on both sides of lower extremities, and had no existing wounds. a. A Safe Smoking Assessment form dated 8/3/17, with a review date of 11/2/17, documented the following: .Resident smokes safely - No . Does not allow ashes or lit material to fall while smoking, inhaling or holding smoking item - No. Remains alert and aware during smoking - No. Does not forget he/she is smoking or falls asleep while holding item - No. Does not endanger self or others while smoking - No. Does not burn furniture, clothing, skin, self, or others - No. Turns oxygen off prior to lighting cigarette - No. Smokes only in designated areas - No. Resident utilizes ashtray safely and properly - No. Gets ashes into ashtray - No. Does not cause/allow sparks or lit tobacco to fall anywhere but into the ashtray - No . The Summary of the Safe Smoking Assessment documented, .Resident must be supervised by staff, volunteer or family member at all times when smoking . b. A Care Plan dated as reviewed on 11/2/17 documented, .Requires extensive assist (assistance) with ADLs (activities of daily living) . (Resident) wishes to smoke and is designated as safe smoker . c. On 1/8/17 at 2:06 p.m., the resident was in the smoking area without supervision, smoking a cigarette. The resident stated, I keep my cigarettes and lighter in my room. 4. The Immediate Jeopardy was removed and the scope and severity decreased to E on 1/8/18 at 6:00 p.m. when the facility implemented the following Plan of Removal: a. Identification - The total number of residents at risk is 5. b. Plan of Removal c. Corrective action: On January 8, 2018 resident in (Resident #26's room number) cigarettes, lighting material and all smoking material were confiscated and placed in the med-room (medication room). A smoking apron will be applied when resident goes out to smoke. The family and resident was notified of the incidence and removal of all smoking material and lighting material. (Surveyor Note: The Care Plan for Resident #30 was also updated 1/8/18 by the facility to include, resident must be supervised at all times when smoking; must request smoking materials from staff. Resident / Family informed of smoking evaluation results.) d. ID (identification) all other resident: On January 8, 2018 all smokers were reassessed for safe smoking. Clothing was inspected for holes related to unsafe smoking. All residents who were found unsafe will have all smoking material and lighting material removed and placed on a smoking schedule. e. Measures and Systemic Changes: A smoking time will be enforced for all residents who fail the smoking assessments. The unsafe residents will be supervised during smoking. Resident will also wear smoking apron if needed during smoking. On January 8, 2018 all staff will begin in-service on smoking policy and unsafe smokers by Director of Nursing and continue until all staff are in-serviced. All smoking care plans were updated via MDS (Minimum Data Set) Coordinator. f. Monitoring and Controls: CNAs (Certified Nursing Assistants), Social, Activity, Nursing staff or family member will supervise unsafe smokers while smoking and resident will wear a smoking apron if needed. MDS Coordinator will assess smoking residents on admission, quarterly, and as needed / change of condition. Director of Nursing / Designee will be monitor for all smokers daily and any changes will be reported to the Director of Nursing / Designee immediately. g. QA (Quality Assurance): Any negative findings will be reported to QA Team monthly.

Complaint # was substantiated (all or in part) in these findings: A. Based on observation, record review and interview, the facility failed to ensure that 2 people performed a lift transfer as care planned to prevent falls / injuries for 1 (Resident #3) of 2 (Residents #3 and #8) case mix residents who were transferred via Vander Lift. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Resident #3 who fell from a Vander Lift resulting in a head injury and had the potential to cause more than minimal harm to 10 residents who were transferred with the Vander Lift, according to a list provided by the Administrator on 6/5/13. The facility removed the Immediate Jeopardy prior to the survey entrance date. The facility was informed of the Immediate Jeopardy removed on 6/6/13 at 9:30 a.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/17/13 documented the resident had severely impaired cognitive skills for daily decision making per staff assessment for mental status, continuously had inattention and psychomotor retardation, had total dependence on the physical assistance of two-plus people for bed mobility and transfers. a. The Plan of Care dated 5/20/13 documented, "Resident is total care for all ADL (activities of daily living) needs related to... Needs assistance with... Transfer: Total care (times) 2 staff with mechanical lift..." b. A Nurses Note dated 5/14/13 at 8:30 a.m. documented, "Notified by bath aide, res (resident) had a fall. Entered res room (and) found res (lying) on the floor on her (right) side. A puddle of blood medium in size was on the floor beside the R (right) side of her face. CNA (Certified Nursing Assistant) stated 'Res was up in lift and the sling broke and res fell on the floor hitting her (right) side of her face on the bottom of the lift.' N.O. (New order) to send to ER (emergency room ) for eval (evaluation)... 2 in (inch) gash to (right) optical and 2 cm (centimeter) skin tear to (right) cheek that is raised..." 1) An Incident / Accident Report dated 5/24/13 at 8:35 a.m. documented, "Person Involved - (Resident #3) ...Equipment involved - Lift strap broke. Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured... CNA was transferring Res in lift to bed. Res fell out of lift and hit the (right) side of her face on the lift. Res has 2 (inch) gash to (right) occipital and 2 cm (centimeter) skin tear to (right) cheek that is raised... Name, title (if applicable, address (and) phone (number) of witness(es) - (CNA #3) 5/24/13 Staff instructed to (check) lifts slings before putting on resident... Additional comments and / or steps taken to prevent recurrence: Notified staff to make sure residents are secured when using lift and to use two staff members when using lift." 2) An OLTC (Office of Long Term Care) Witness Statement Form dated 5/24/13 at 7:40 a.m. and signed by CNA #3 documented, "...I was bringing (resident) back to her room from a shower using a lift to transfer back to bed while doing so the sling that was being used broke (resident) fell the nurse was notified right away nurse came to check pt (patient) was sent out to the ER (emergency room )." On 6/5/13 at 1:17 p.m., CNA #3 was asked, "What happened when the resident fell ?" The CNA stated, "I was just in the process of taking resident back to room from the shower. The sling broke." She then demonstrated on the lift sling where it broke at and stated, "I immediately got the nurse." The CNA was asked, "Were you transferring the resident by yourself?" CNA #3 stated, "Yes. It was during lunch, everyone was in the dining room for lunch. I was written up." The CNA was asked what action the facility took after the incident. CNA #3 stated, "Make sure two people when transferring and inspect sling before using." 3) An OLTC (Office of Long Term Care) Witness Statement Form dated 5/24/13 and signed by the Director of Nursing documented, "...Called to room... resident on (right) side. Note skin tear approx (approximately) 2 cm to (right) cheek (and) approx 2 (inch) long (by) .25 open area to occipital (right) area... Asked CNA what happened. States sling strap broke. This nurse looked (at) strap (and) noted sling strap broke where joined together to make hook that goes on lift..." c. The Emergency Nursing Record dated 5/24/13 documented, "...Chief Complaint: fell from mechanical lift during transfer at NH (nursing home) and hit head. (fell from 5 feet to floor) ...Head / Face diagram documented 4 cm laceration to right side of head and skin tear to right side of forehead just above brow ...Additional Findings Skin tears (right) toes... " The hospital Observation Discharge Summary documented, "Admission Diagnosis: [REDACTED]. Dementia. Hospital Course: The patient is a nursing home resident who dropped several feet on her head. She sustained a laceration, which was repaired by the emergency room physician. A CT (Computerized Tomography) scan showed no acute bleed. She was placed in observation due to the risk of her developing a subsequent bleed" d. On 6/5/13 at 1:41 p.m., the Director of Nursing (DON) was asked, "What happened on (Resident #3's) fall?" The DON stated, "She was taken from shower to room. She (CNA #3) was lifting the resident and the strap broke. I did not see any areas that were frayed or worn on the sling." The DON was asked, "Was she being transferred with two people?" The DON stated, "No." The DON was asked, "How often are the lift slings inspected for wear and tear?" The DON replied, "No, do not have system to check the slings." 2. The Vander-Lift II Operating Manual documented, "Safety Information... ...Pre-Use and Monthly Inspections... It is important... that you know that materials can fail due to normal wear caused by use over time. Doing the inspections described below will help your facility make sure that lifts and slings are kept in safe working condition and that potential problems are noted before hazardous conditions result... Warning - Before each patient transfer, it is important for staff to inspect the Vander-Lift II to make sure no parts are missing or overly worn and that all parts work correctly. If a problem is noted, the lift should not be used until qualified maintenance staff has made repairs. It is also required that qualified maintenance staff inspect the lift at least monthly for missing parts and excessive wear that might cause the lift to fail. A permanent record of each of these inspections and repairs made should be kept by the facility... Warning - Before each patient transfer, the sling must also be inspected for signs of damage, for loose and missing stitching, and for tears and excessive wear that might cause it to fail. If a sling is damaged or overly worn, it must be thrown away and replaced with an undamaged sling. It is important that qualified maintenance staff inspect all Vander-Lift II's monthly. It is also required that a nurse or professional rehabilitation staff member inspects all Vander-Lift II slings for the above types of damage at least monthly. A permanent record of each of these inspections and action taken should be kept by the facility... Warning - It is important that a nurse or professional rehabilitation staff member inspects all Vander-Lift II slings monthly... Warning - Although one person can perform patient transfers, certain patients or situations may require the help of one or more additional staff members... Warning - A nurse or professional rehabilitation staff member must inspect slings at least once a month for signs of damage, loose and missing stitching, and/or tears and excessive wear that might cause them to fail ... A permanent record of each of these inspections and action taken should be kept by the facility... It is important that a nurse or professional rehabilitation staff member inspects all slings monthly..." 3. An undated VanderLift Policy and Procedure was provided by the Administrator on 6/5/13 and documented, "...Policy: It is the policy of (nursing home) to use the VanderLift for all lifts and transfers requiring 2 or more CNA's (Certified Nursing Assistants) or for lifting and transferring of any total care resident... Disciplinary Action: If this policy is not followed by an employee, the disciplinary action that would result is termination." 4. The Immediate Jeopardy was removed and the scope/severity reduced to "G" (isolated actual harm) prior to the survey when the facility implemented the following corrective actions: a. An Inservice form provided by the Administrator on 6/5/13 documented, "Date: 5/24/13... Presented / Conducted By: (Director of Nursing)... Subjects Covered: When transferring resident in Vander Lift 'Big Lift' two (2) people must be present. Staff to inspect sling when transferring resident. If you see that sling is not in good working condition or having any (frayed) strings let your charge nurse know (and) do not use. Do not bleach slings." The form was signed by 26 nursing personnel. b. An Inservice form provided by the Administrator on 6/17/13 documented, "Date: 5/24/13... Presented / Conducted By: (Director of Nursing)... Subjects Covered... Please remember not to wash slings (with) bleach... If you see (frayed) slings please give it to charge nurse..." The form was signed by the facility's 4 full time laundry / housekeeping personnel. c. An Employee Warning Report dated 5/24/13 documented CNA #3 was counseled by the Director of Nursing, with a reprimand placed in the CNA's employee file. d. A statement signed by the Assistant Director of Nursing (ADON) and provided by the Administrator on 6/6/13 documented, "5/24/13 ...inspection on all slings to ensure all were in good condition, with no tears or weak threads. All defected material were discarded immediately and replaced with new sling..." e. The Vander Lift Representative was contacted on 5/25/13 by the Director of Nursing to provide an inservice; this was scheduled for 6/5/13 to cover inspection of the slings and lift prior to use. An Inservice form provided by the Administrator on 6/5/13 documented, "Date: 6/5/13... Presented / Conducted By: (Vander Lift representative)... Subjects Covered... Vander Lift Stand-up (Vera)... Assessment of lift and slings prior to each use... Remove any sling from facility if defect is found... Report any defect on lift and remove from floor for repair... Step by step how to use the lifts..." The form was signed by 22 nursing personnel. f. According to the Administrator on 6/6/13 at 12:45 p.m., the Maintenance Supervisor was instructed by the Administrator to inspect all slings monthly effective 5/29/13. B. Based on observation, record review and interview, the facility failed to ensure personal alarms were in place and functioning for 2 (Residents #4 and #7) of 5 (Residents #1, #4, #6, #7 and #9) case mix residents with bed or chair alarms. This failed practice had the potential cause more than minimal harm to 13 residents who had bed or chair alarms, according to a list provided by the Administrator on 6/6/13. The findings are: 1. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 5/7/13 documented the resident scored 5 (0-7 indicates severe cognitive impairment) on the brief interview for mental status (BIMS), required the extensive physical assistance of one person for bed mobility, was totally dependent on the physical assistant of two people for transfers, did not walk, was totally dependent on the physical assistance of one person for locomotion and was unsteady and only able to stabilize with staff assistance when moving from a seated to a standing position. a. A physician's orders [REDACTED]." b. The Fall Risk assessment dated [DATE] documented a total score of 15 (10 or above high risk). c. The Resident Plan of Care up dated 5/8/13 documented, "2/8/12 ...Resident is at risk for falls and / or injury related to falls AEB (as evidenced by) need for extensive assist with most ADLs (activities of daily living) (and) use of hypnotic meds(medications)... Sensory pad bed alarm to alert staff of attempts at unassisted transfers." d. On 6/4/13 at 9:37 a.m., the resident was in bed. There was not an alarm on the bed. e. On 6/4/13 at 12:10 p.m., the resident was in bed. There was not an alarm on the bed. 2. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/7/13 documented the resident scored 0 (0-7 severe cognitive impairment) on the BIMS and was totally dependent on the physical assistance of two people for transfers, did not walk, was totally dependent on the physical assistance of one person for locomotion, was unsteady and only able to stabilize with staff assistance when moving from a seated to standing position and had limitation in range of motion of both lower extremities. a. A physician's orders [REDACTED]." b. The Fall Risk assessment dated [DATE] documented a total score of 15 for the resident. The form further documented that a score of 10 or above indicated a high risk for falls. c. The Resident Plan of Care for 5/28/13 through 5/28/14 documented, "10/5/12 Resident is at risk for falls and / or injury related to falls AEB instability, (incontinence), and need for extensive to total assist with ADLs (times) 2 staff members... Sensory pad chair alarm when up in chair to alert staff of attempts at unassisted transfers..." d. On 6/3/13 at 4:44 p.m., the resident was up in a wheelchair. There was a pressure pad alarm on the chair, but the indicator light was not on to indicate that it was working. e. On 6/3/13 at 6:13 p.m., the resident was eating her evening meal. The resident's chair alarm did not have a light on indicating that it was on. The DON looked at the alarm and turned it on. f. On 6/4/13 at 8:37 a.m. and 10:08 a.m., the resident did not have an alarm on his wheelchair. g. On 6/5/13 at 8:55 a.m., the resident was up in a wheelchair. There was not an alarm on his chair. h. On 6/5/13 at 1:55 p.m., the DON was asked why the resident did not have the chair alarm on his wheelchair. She stated, "He should have it on."