Every finding on record at Desoto Health and Rehab

Based on observation, interviews and record review, the facility failed to arrange routine and emergency dental services to meet the needs and address the dental pain of 1 (Resident #8) of 3 residents reviewed for dental services.The findings included:Review of the facility Resident Rights policy (last revised December 2016) noted Federal and state laws guarantee certain basic rights to all residents in this facility. These rights include the resident's right to: communication with and access to people and services, both inside and outside the facility.Review of the facility Dental Services policy (last revised December 2016) noted routine and emergency dental care services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care . Routine and 24-hour emergency dental services are provided to our residents through: a contract agreement with a licensed dentist that comes to our facility monthly, referral to the resident's personal dentist, referral to community dentists, or referral to other health care organizations that provide dental services . Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. On 2/24/26 at 10:42 a.m., during an interview, Resident #8 said he had been having dental issues for a while. He's been asking to see the dentist but he is unable to get in a wheelchair. He's asked for the dentist to come to the facility but no one has ever seen him. A long, yellow, hard and pointy object, approximately 1 inch long was observed in a medicine cup at the resident's bedside. Resident #8 said, Oh that's my tooth. He said he's had a loose tooth for a while and a piece of bacon got stuck in it this morning. Resident #8 said he got tired of it and ripped it out.Review of the clinical record for Resident #8 revealed an admission date of 8/16/2019. Diagnoses included Hemiplegia (Paralysis of one side of the body) affecting the left side and dysphagia (Difficulty swallowing).Review of the Brief Interview for Mental Status dated 1/5/26 revealed Resident #8 scored 15, indicating intact cognition.Resident #8's care plan last revised 1/16/26 noted that the resident was at risk for dental/oral problems due to broken/missing teeth. Interventions included monitor/document/report as needed any s/sx (signs or symptoms) of oral/dental problems including teeth missing, loose, broken, decayed, dental consult as needed, notify physician of any changes .Review of a progress note dated 10/15/25 at 1:45 p.m., noted, Resident c/o (complaining of) loose tooth, Social worker informed.Review of a progress note dated 11/23/25 at 2:38 p.m., noted, Resident c/o dental pain states he has a loose tooth to bottom left side. Resident given tramadol at his request for pain.The clinical record lacked documentation of a dental consultation, or dental notes. The provider's notes from October 2025 had no documentation of dental concerns for Resident #8.On 2/24/26 at 12:10 p.m., in an interview, Resident #8 said he's been telling the facility just about every day that his left lower tooth was bothering him. It made it hard to eat and could not chew his food. He said the facility told him he had to go out to see the dentist. He said he's never refused to go to the dentist but he is unable to get in a wheelchair due to pain and contractures (fixed bend of a joint). Resident #8 said the tooth had been loose for a while so he just pulled it out.On 2/24/26 at 12:18 p.m., in an interview, Licensed Practical Nurse (LPN) Staff A said she was nurse assigned to Resident #8 and saw the resident's tooth at bedside. LPN Staff A said the resident told her he had bacon stuck in the loose tooth so he pulled the tooth himself. LPN Staff A said Resident #8's tooth has been loose prior to today but he will not go out to the dentist.On 2/24/26 at 1:02 p.m., in an interview, Unit Manager Staff B said when there are dental concerns, they usually notify the resident's Primary Care Physician and Social Services. Unit Manager Staff B said Resident #8 has requested to see a dentist prior to today, but he won't go to an outside dentist because he can't get into a wheelchair. She said getting into the wheelchair causes Resident #8 to be uncomfortable and in pain. Unit Manager Staff B said Social Services was notified on 2/19/26 of Resident #8's dental concerns.On 2/24/26 at 1:11 p.m., in an interview, the Social Services Director said she found out about Resident #8's loose tooth a week ago. She said that there is a free basic dental program that can be requested which would cover basic dental care such as checkups, cleanings and an exam but the issue is that Resident #8 can't get out of bed to go to the dentist. Upon reviewing the notes dated 10/15/25 and 11/23/25 in which Resident #8 complained of dental issues, she said she did not know what happened.On 2/25/26 at 10:43 a.m., in an interview, the Social Services Director said she was unable to locate any dental requests or records for Resident #8.On 2/25/26 at 1:30 p.m., in an interview, the Social Services Director said the facility in-house dental company responded and confirmed they have never seen Resident #8.On 2/25/26 at 1:38 p.m., in an interview, the Director of Nursing (DON) said that if a dental issue is identified, they need to reach out to social services. The DON said they complete an application to see if the resident qualifies for dental services. The DON said Resident #8 won't get into a wheelchair to go to a dentist outside of the facility. She said the issue was reported last week. The DON verified that the progress notes dated 10/15/25 and 11/23/25 documented that Resident #8 complained of dental issues. She said the expectation is to notify the physician and document it in the resident's medical record. The DON confirmed that a dental consultation was never obtained for Resident #8.

Based on record review and interview, the facility failed to have an arbitration agreement that explicitly grants the resident the right to rescind the agreement within 30 calendar days of signing it. This has the potential to affect all residents residing in the facility.The findings included: Review of the facility's arbitration agreement revealed that Each party to this agreement shall have three (3) business days from execution of this agreement to cancel the agreement by notifying the other party in writing, by certified mail return receipt or retractable overnight delivery, of its desire to cancel. Residents #35, #47 and #42 were sampled from the facility provided list of new admissions who had signed the arbitration agreement. During an interview on 2/26/26 at 8:50 a.m., Resident #35 said she was familiar with arbitration due to being in and out of facilities. Resident #35 was unable to say how long she has to rescind the arbitration agreement. During an interview 2/26/26 at 8:57 a.m., Resident #47 said he was explained the arbitration process when he entered the facility. Resident #47 was unable to explain how long he has to rescind the arbitration agreement. During an interview on 2/26/26 at 9:02 a.m., Resident #42 said she has no knowledge related to the facility arbitration process. During an interview on 2/25/26 at 3:18 p.m., the Social Services Director said she explains the arbitration process to the residents upon admission before they sign it. The Social Services Director verified that the facility's arbitration agreement did not explicitly grant the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing it.The Social Services Director confirmed the facility's arbitration agreement stated that each party to this agreement shall have three (3) business days from execution of this agreement to cancel the agreement.During an interview on 2/25/26 at 3:25 p.m., the Director of Nursing (DON) was unable to show where the facility arbitration agreement stated that the residents have 30 calendar days to rescind the agreement. The DON confirmed the arbitration agreement stated there were 3 business days to rescind the agreement.During an interview on 2/26/26 at 8:03 a.m., the Nursing Home Administrator confirmed the arbitration agreement did not have a 30-calender day rescind period.

Based on record review and interviews, the facility failed to have an arbitration agreement that provides the selection of a venue that it convenient for both parties when there is a dispute. This has the potential to affect all residents residing in the facility.The findings included:Review of the facility's arbitration agreement revealed, Venue: In the event that any litigation arises under, or in any manner in relation to this agreement, whether ex contractor, or ex delicto, the venue of same shall lie exclusively in [NAME] County, Florida and no other location.Residents #35, #47 and #42 were sampled for review from the facility provided list of newly admitted residents who signed the arbitration agreement.During an interview on 2/26/26 at 8:50 a.m. Resident #35 said she is familiar with arbitration due to being in and out of facilities. Resident #35 was unable to explain the facility arbitration process.During an interview 2/26/26 at 8:57 a.m. Resident #47 said he was explained the arbitration process when he entered the facility. Resident #47 said arbitration is when they use a mutual party to resolve issues at the facility. Resident #47 was unable to explain any other details related to arbitration.During an interview on 2/26/26 at 9:02 a.m. Resident #42 said she has no knowledge related to the facility arbitration process. Resident #42 said she is unable to explain what arbitration is.During an interview on 2/25/26 at 3:18 p.m. the Social Services Director said she explains the arbitration process to the residents upon admission before they sign it. The Social Services Director confirmed the arbitration agreement said the venue was only in [NAME] County, Florida and no other location.During an interview on 2/25/26 at 3:25 p.m., the Director of Nursing (DON) was unable to show where the facility arbitration agreement stated that the residents have a right to a neutral venue. The DON confirmed the arbitration agreement said the venue was only in [NAME] County, Florida and no other location.During an interview on 2/26/26 at 8:03 a.m., the Nursing Home Administrator confirmed the arbitration agreement said the venue was only in [NAME] County, Florida and no other location.

Based on observations, facility policy review, staff, resident, and resident representative interviews, the facility failed to ensure dignity during dining for 18 of 22 residents observed in the dining room during meals. The findings included:Review of the facility provided Policy for Resident Rights revised March 2021 statement revealed, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity; self-determination; be supported by the facility in exercising his or her rights; exercise his or her rights without interference, coercion, discrimination or reprisal from the facility; be informed about his or her rights and responsibility.On 2/23/26 at 11:43 a.m., 22 residents were observed sitting at tables in the dining room during the lunch meal. A staff member was observed going from resident to resident and applying a long clothing protector to approximately 18 residents without their request or permission. An unidentified female resident stated, I guess I am a messy eater.On 2/24/26 at 11:39 a.m., 22 residents were observed in the dining room during the lunch meal. A staff member was observed placing a clothing protector at each table setting. The staff member then went from resident to resident and applied a clothing protector without the resident's request or permission.On 2/24/26 at 12:20 p.m., in an interview, Resident #59 said she did not like having the clothing protector. She said, It makes me feel like an old lady.On 2/24/26 at 12:22 p.m., Resident #9 was observed in the dining room, wearing a clothing protector. Resident #9 was not able to answer interview questions. In an interview, Resident #9's sister said she visits four days a week and everyone in the dining room gets a clothes protector. She said she does not see staff asking residents if they would like to wear a clothing protector. The resident's sister said it would be upsetting if she was at a restaurant and someone walked up and applied a clothing protector without her permission.On 2/24/26 at 1:30 p.m., in an interview, Certified Nursing Assistant (CNA) Staff G said she has been employed at the facility for a year and a few months. When asked about applying clothing protectors to all residents during dining, she stated, We usually put it on everyone unless they refuse but most don't refuse. She said they do not ask the residents if they want to wear a clothing protector or not.On 2/25/26 at 2:50 p.m., in an interview, the Director of Nursing (DON) said that staff should be asking the residents before applying a clothing protector. She said that it was not right to apply the clothing protector without asking the resident first. She said she would not like it if someone put a bib on her without asking.

Based on record review, review of facility's policy and procedure, and interviews, the facility failed to ensure ongoing communication and collaboration with the dialysis center for 1 (Resident #5) of 2 residents reviewed for dialysis.The findings included:Review of the facility's undated policy and procedure for Dialysis Residents revealed the purpose was, To establish standardized clinical pathways for residents receiving dialysis services to ensure safe, coordinated, and high-quality care in compliance with federal and Florida state regulations . Dialysis Coordination . Communication with Dialysis Provider. Share clinical updates. Document dialysis treatment summaries. Participate in interdisciplinary care meetings.Review of the facility provided communication form used to coordinate with the dialysis center revealed a section to be completed by the Charge Nurse prior to dialysis which included vital signs, examination of shunt site, pain, concerns, time of last meal, fluid restrictions and amount. A section to be completed by a Dialysis Center Representative included pre-dialysis weight, vital signs, monitor shunt site, concerns, amount of meal eaten, supplement consumed, lab results, and follow-up orders. The last section to be completed by the Charge Nurse after dialysis included examine shunt site, location, dressing, pain, and concerns.Review of the clinical record for Resident #5 revealed an admission date of 5/22/25. Diagnoses included hemiplegia (paralysis of one side of the body), end-stage renal disease, and dependence on renal dialysis.Review of the care plan with a target date of 4/10/26 revealed that Resident #5's dialysis schedule was on Monday, Wednesday and Friday.On 2/24/26 at 1:43 p.m., in an interview, Resident #5 said she goes to dialysis on Monday, Wednesday and Friday. She said the facility does not give her a binder with the communication forms to take to dialysis.On 2/24/26 at 2:52pm in an interview, Licensed Practical Nurse (LPN) Staff E said she takes the resident's vital signs before she goes to dialysis but has not been filling out the communication form since the dialysis center never sends the form back to the facility. When asked about how the facility informed the dialysis center of changes to the resident's status, LPN Staff E said, I do not know how to answer that. She said she would assume the resident would tell them if there was a change in condition. LPN Staff E said Unit Manager Staff F calls the dialysis center to request the communication form to be faxed to the facility.On 2/24/26 at 3:01 p.m., in an interview, Unit Manager Staff F said the nurse should complete and send the communication form with the resident to dialysis. The dialysis center should complete their section and return the form with the resident. Unit Manager Staff F said it was hit or miss if the dialysis center returns the form. She said the dialysis center and the facility usually communicate via telephone but that communication was not documented.On 2/26/26 at 10:33 a.m., the facility provided two dialysis communication forms for Resident #5 for 11/24/25 and 1/15/26. The forms were incomplete. In an interview, Unit Manager Staff F verified there was no documentation of coordination with the dialysis center for Resident #5 from November 2025 through February 24, 2026. She said that somewhere along the line the dialysis communication binder went missing and it fell through the crack.On 2/26/26 at 10: 53 a.m., in an interview, the Director of Nursing (DON) said the Dialysis Communication Form should be sent with the resident to each dialysis session. She said the Dialysis Communication Form should come back completed by the dialysis center. The DON verified there was no documentation for the period November 2025 through February 24, 2026.

Based on observation, record review, review of facility's policy and procedure, and interviews, the facility failed to provide nail care necessary to maintain good personal hygiene for 1(Resident #8) of 3 dependent residents reviewed for nail care.The findings included:Review of the facility Activities of Daily Living (ADL) policy revised December 2016 revealed, It is the policy of [NAME] Health and Rehab to ensure all residents receive needed assistance with Activities of Daily Living (ADLs) in a manner that promotes independence, dignity, and the highest practicable level of physical, emotional, and psychosocial well-being, consistent with state and federal long-term regulations.Dressing/Grooming . Support grooming tasks (hair care, shaving, nail care) per resident preference . All DDL care must be documented in the resident record . documentation must be completed by the end of each shift for nursing services and included in the ongoing care record.On 2/24/26 at 10:42 a.m., Resident #8 was observed in bed. The resident's left hand was contracted (fixed bend of joint preventing extension) with all fingers curled inward in a tight fist. The resident's left index was protruding from the fist, and the left index jagged fingernail extended approximately 2 inches from the fingertip.In an interview during the observation, Resident #8 said he was not able to extend the fingers of his left hand and was not able to trim his fingernails. He said the staff trim his nails, except his left hand fingernails. Resident #8 said when he asks staff to trim his left hand fingernails, they say that they needed a special tool and would tell someone. Resident #8 said he did not remember the last time they trimmed the fingernails on his left hand. Record review for Resident #8 showed an admission date of 8/16/2019. Diagnoses included cerebral infarction (a blockage of brain blood vessels leading to inadequate oxygenation of the brain), Hemiplegia (paralysis of one side of the body) affecting the left side and dysphagia (difficulty swallowing).Review of the Brief Interview for Mental Status dated 1/5/26 revealed Resident #8 scored 15, indicating intact cognition.Review of Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 12/1/25 noted that Resident #8 required substantial/maximal assistance with personal hygiene. Review of Resident #8's Care Plan revealed that the resident had an ADL self-care deficit and needed assistance with all his ADL tasks. The interventions as of 2/28/2020 included to check the resident's nail length, clean and trim them on bath day and as necessary. Staff was to report any changes to the nurse.On 2/25/26 at 11:06 a.m., in an interview CNA Staff C said residents fingernails are trimmed twice a week, on shower days. She said nail care is documented on the shower sheets placed in the shower book. CNA Staff C said that refusals were also documented in the shower sheets. CNA Staff C verified that Resident #8's left index fingernail extended approximately 2 inches from the tip of the fingers. She said the resident's fingernail should be trimmed or filed down. On 2/25/26 at 11:35 a.m., in an interview CNA Staff D said that CNAs trim residents' fingernails. She said that nail care is provided as needed and documented on the resident's shower sheet. Upon observation of Resident #8's left index fingernail, CNA Staff D said the resident's nail was too long and should be trimmed. On 2/25/26 at 11:41 a.m., in an interview Unit Manager Staff B said that CNAs or nurses trim residents' fingernails. She said that nail care was offered twice a week during showers and documented on the shower sheet. Unit Manager Staff B said refusal of nail care was also documented on the shower sheet. When shown Resident #8's left index fingernail, she said it should be trimmed.Review of the shower sheets for January and February 2026 revealed that on 1/15/26, 1/22/26, 1/24/26, 1/29/26 and 2/7/26, Resident #8 received a shower but no nail care was provided.The shower sheets for 1/3/26, 1/17/26, 1/31/26 and 2/21/26 documented that nail care was provided to Resident #8.On 2/25/26 at 1:38 p.m., in an interview, the Director of Nursing (DON) said residents' nails should be trimmed as needed, as requested and offered with showers. The DON said nail care should be documented on the shower sheet. The DON said refusals of nail care should be documented on the shower sheet. The DON said her expectation was that refusals of nail care or the reason why nail care was not done needs to be documented and reported to the nurse. The DON reviewed the shower sheets and verified the documentation that on 2/21/26, nail care was provided to Resident #8. Upon observation of Resident #8's left index finger, the DON verified that the fingernail extended approximately 2 inches from the fingertip and said that the nail did not grow that long since 2/21/26. She said the resident's fingernail should have been trimmed.

Based on observation, record review, review of facility's policies and procedures, and staff interview, the facility failed to maintain a clean and sanitary environment in the kitchen and 2 of 2 nourishment rooms observed. The findings included: Review of the facility's policy titled Cleaning and Disinfection of Environmental Surfaces, last updated 8/19 indicated under 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g. daily, three times per week) and when these surfaces are visibly soiled. On 4/9/25 from 9:00 a.m., to 10:30 a.m., the following observations were made during a tour of the kitchen and nourishment rooms: On 4/9/25 at 9:10 a.m., and 10:21 a.m., a milky, brown liquid with solid particles was observed on the floor behind the ice machine in the kitchen. Photographic evidence obtained On 4/9/25 at 9:11 a.m., and 10:22 a.m., the floor under the dry storage shelf near the bathroom door in the kitchen was dirty with debris. Photographic evidence obtained On 4/9/25 at 9:12 a.m. and 10: 23 a.m., a green film was observed in the top corner of walk-in refrigerator in the kitchen. Photographic evidence obtained On 4/9/25 at 9:13 a.m., and 10:24 a.m., the pipes under the three compartment sink in the kitchen were dirty and actively leaking. A bucket with grey water was observed on the floor under the leaking pipes. Photographic evidence obtained On 4/9/25 at 9:15 a.m. and 10:25 a.m., food like debris and white film were observed on the fryer basket. Photographic evidence obtained On 4/9/25 at 9:16 a.m. and 10:25 a.m., a thick grease-like coating and dust-like substance was observed on the pipes and valves behind the stove. Photographic evidence obtained On 4/9/25 at 9:20 a.m., coffee ground sized debris were observed on the counter behind the microwave in the nourishment room in patient care area. Dried food like residue was observed stuck to the baseboard and cabinet. Photographic evidence obtained On 4/9/25 at 9:25 a.m. and 9:40 a.m., black and green debris were observed under the sink in the memory care unit nourishment room. Photographic evidence obtained On 4/9/25 at 9:40 a.m., in an interview, the Maintenance Director stated, The housekeeping staff should be cleaning behind the microwave and on the cabinets if there is food debris. This is part of daily cleaning. The maintenance director was unable to identify the brown coffee ground sized debris behind the microwave. The Maintenance Director said the housekeeping staff should be cleaning under cabinets and could not say what the debris under the cabinets were. She said the staff does daily cleaning and should also be doing an assigned deep cleaning. Review of the cleaning record for the nourishment room of the Memory Care Unit revealed the most recent deep cleaning was done on 3/31/25. On 4/9/25 at 9:30 a.m., in an interview, the Maintenance Director said the leaking pipes under the three compartment sink were fixed before and she was not aware they were leaking again. She said staff should have put the leaking pipes in the TELS (electronic work order) system. On 4/9/25 at 9:42 a.m., in an interview the Director of Nursing (DON) was unable to identify the brown coffee ground sized debris behind the microwave of the nourishment room. The DON then brought some bleach wipes and stated, I need to clean this. On 4/9/25 at 10:21 a.m., in an interview the Dietary Manager stated, The kitchen staff will mop the whole kitchen at the end of their shift. She said she could see the debris under the shelving but did not know what it was. She again said it was the dietary department's job to clean it. She said they had to let go of the person who did the deep cleaning. She also verified there was green film in the walk in refrigerator and could not say what it was. She acknowledged the triple sink pipe was actively leaking but had not put in a work order to have it repaired. She said she has been employed at the facility since January and had identified concerns. She was slowly trying to get this place back together. On 4/9/25 at 11:13 a.m., in an interview with Housekeeping Staff A said, Part of my daily clean for a nourishment room, if I am assigned to them, is to wipe down sinks, remove the trash and wipe the outside of cabinets. The inside of the cabinet is part of the deep clean day. There is not a checklist for what exactly needs to be done in each area.

Based on observation, record review, review of facility's policy and procedure, and staff interviews, the facility failed to ensure proper sanitizing of manually washed cooking pots and pans, creating a potential for foodborne outbreak. The findings included: Review of the undated facility's policy titled, Equipment Sanitation and Safety noted, All cleaning and sanitizing compounds are used following manufacturer's instructions for concentration and precautions . On [DATE] at approximately 9:30 a.m., during the initial tour of the kitchen, observation of the three-compartment (wash, rinse and sanitize) sink revealed the facility used Quaternary (Multi-Quat) as their sanitizing agent. On [DATE] at 10:00 a.m., Dietary Staff B was observed washing cooking pots in the three-compartment sink. Staff B used the first sink to wash the pots with soapy water. She placed the pots in the middle sink to rinse them. The third sink was empty. It did not contain the sanitizing Quaternary solution. On [DATE] at 10:05 a.m., during interview the kitchen manager verified Staff B was using the three compartment sink to wash the cooking pots and the sanitizing sink was empty. She said the drain stopper was broken and the sanitizing solution drained out. The kitchen manager said she was not sure how long the drain stopper had been broken. The kitchen manager was not able to say how the facility ensured the pots and pans were sanitized. Review of the Pot Sink Sanitizer Strength log for [DATE] showed documentation the sanitizer concentration was 200 parts per million (ppm) when the sink was used for breakfast, lunch, and dinner [DATE], through [DATE], and for breakfast on [DATE]. On [DATE], at 10:30 a.m., the kitchen manager provided three containers of chlorine test strips from different manufacturers with expiration dates of 2018, ,d+[DATE] and [DATE]. She said the facility used the chlorine strips to test the concentration of the Quaternary sanitizing solution used in the three compartment sink. The kitchen manager verified the expired chlorine test strips could not be used to test the concentration of the Quaternary sanitizing solution. She said the facility did not have the appropriate Quaternary testing strips to ensure the sanitizing solution was within the manufacturer's specified range to ensure the pots and pans were sanitized. On [DATE] at 11:17 a.m., Dietary Staff B was observed using the three-compartment sink to wash, rinse, and sanitize pots. The Director of Nursing was observed testing the sanitizing solution with Quaternary test strips with a result of 100 ppm. Review of the Multi-Quat Sanitizer Product Description revealed, Broad range sanitizer effective at ,d+[DATE] ppm.

Based on observation, record review, review of facility's policy and procedure, staff and resident interview, the facility failed to ensure the safe storage of medications at the bedside for 1 (Resident #27) of 3 residents reviewed for storage of medications. The findings included: The facility policy for Self-Administration of Medications Revised February 2021 noted self-administered medications are stored in a safe and secure place, which is not accessible by other residents. Review of Resident #27's clinical record revealed two Medication Self-Administration Safety Screens dated 7/28/22 and 2/2/23 which noted Resident #27 may self administer respectively antacids and Velphoro (phosphate binder) medications unsupervised. The forms documented the medications were to be stored at bedside with the resident and Resident #27 was completely capable to demonstrate secure storage of medications kept in room. On 11/7/23 at 3:36 p.m., 11/8/23 at 10:13 a.m., and 10:37 a.m., observation of Resident #27's room revealed a bottle of nasal spray, a bottle of antacid tablets, and a bottle of vitamins stored on a bedside tray table. The bedroom door was wide open, and Resident #27 was not in the room. On 11/8/23 at 11:13 a.m., the bottle of nasal spray, the bottle of antacids and the bottle of vitamins remained stored on the resident's bedside tray. Resident #27 said the facility did not require him to lock the medications. He said he kept the medications on his bedside tray table and took them when he needed to. He said he obtained the nasal spray from an outside physician and was not sure the facility was aware he had it. On 11/8/23 at 11:45 a.m., Licensed Practical Nurse (LPN) Staff E confirmed the medications on the tray table were not being stored in a safe and secure place. She said she was unaware Resident #27 had the nasal spray. On 11/8/23 at 11:46 a.m., Nursing Supervisor Staff F confirmed the medications were not being stored in a safe and secure place. On 11/9/23 at 1:37 p.m., the Director of Nursing (DON) said the facility's policy specifies to keep medications safely secured and not accessible to other residents.

Based on observation, interview, and record review, the facility failed to provide adequate and appropriate health care to address the [CONDITION(S)] (swelling) for 1 (Resident #8) of 15 residents reviewed for treatments and care. The findings included: The facility policy titled Nursing Admission Assessments and Orders with a revised date of 9/2017 read, . This initial or temporary plan of care is to address major medical needs/ concerns and total ADL [Activities of daily living] needs . The ADL needs of the resident and current care and treatment approaches shall be identified . on the MAR [Medication Administration Record] and TX [Treatment] records. Review of the Admission Minimum Data Set (MDS) assessment with a target date of 1/20/22 showed Resident #8 was admitted to the facility on [DATE]. The active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Order Summary Report listed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/24/22 at 10:15 a.m., Resident #8 was observed sitting in a wheelchair in his room. His legs were not elevated. The resident's bilateral lower extremities were noted with [CONDITION(S)] (swelling caused by excess fluid trapped in the tissues), the right leg greater than the left leg. Resident #8 was wearing yellow socks and black shoes. The socks were rolled down to the ankle. Both lower legs were discolored. The right leg had dry, cracked skin. Resident #8 said he was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Interim Admission Care plan dated 1/14/22 did not list interventions to address the [CONDITION(S)] of the resident's legs. On 1/24/22 at 2:38 p.m., Resident #8 was observed sitting in a recliner wearing yellow socks and black shoes. His legs remain swollen. The legs were not elevated, and the resident was not wearing the offloading boots as ordered. On 1/25/22 at 9:29 a.m., Resident #8 was observed awake and alert sitting in a recliner. Resident #8's legs were swollen with [CONDITION(S)] with the right being worse than the left. There was dry, cracked skin on Resident #8's right lower leg. Resident #8 was wearing yellow socks rolled down to his ankles and black shoes. The feet were in the down position and resting on the floor. On 1/26/22 at 9:38 a.m., Resident #8 was awake and alert sitting in a recliner in his room. His legs were not elevated, and he was not wearing the offloading boots as ordered. The resident was wearing yellow socks and black shoes. Resident #8 said he has not had his shoes and socks off for a few days. On 1/26/22 at 9:45 a.m., in an interview Certified Nursing Assistant (CNA) Staff A said she was taking care of Resident #8 today. She said she got report from the night shift CNA who told her about Resident #8's continence status, and that he needed two people to assist with transfers. CNA Staff A said the night shift CNA did not tell her anything else about Resident #8's care. On 1/26/22 at 11:00 a.m., during an interview, Licensed Practical Nurse (LPN) Staff B said she lets the CNAs know what's going on with the residents. She said for instance, Resident #8 refuses to elevate his legs and is non-compliant with stuff. On 1/26/22 at 11:00 a.m., in an interview with the Director of Nursing (DON) present, Resident #8 said his shoes or socks had not been removed since he's been at the facility except for when the doctor came. The DON acknowledged Resident #8's [CONDITION(S)] of the lower legs. The DON said staff should be treating Resident #8 for [CONDITION(S)] with interventions to alleviate the symptom. Review of the Treatment Administration Record (TAR) showed on 1/24/22, 1/25/22 and 1/26/22, staff signed indicating the offloading boots were applied to the Resident's lower extremities. On 1/26/22 at 03:07 p.m., in an interview the DON confirmed Resident #8 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed the baseline care plan did not address the [CONDITION(S)] and said there should have been interventions in the baseline care plan to address the Resident's lower extremities [CONDITION(S)]. 1/27/22 at 9:35 a.m., Resident #8 was observed in his room, sitting in the recliner with lower legs elevated and wearing offloading boots. Resident #8 said he was more comfortable. On 1/27/22 at 9:53 a.m., in an interview Physical Therapist Assistant (PTA) Staff C he said he has not seen Resident #8 wearing offloading boots to the bilateral lower legs. He said no one told him Resident #8 needed the off-loading boots applied. On 1/27/22 at 10:02 a.m., the DON confirmed staff had been signing off on the treatment administration record (TAR) the offloading boots were applied to Resident #8, but they had not been doing it.

Based on record review, and interview the facility failed to ensure the representative of 1 (Resident #1) of three sampled residents reviewed was informed in advance of the use, side effects, risks and benefits of the use of antipsychotic medication to control mood and behaviors. The findings included: Resident #1 was admitted to the facility on [DATE] with a history of frequent falls, general weakness, and, urinary tract infection. Review of the clinical record revealed a progress note dated 12/11/2020 that read Noted increased agitation and confusion. Resident states, I'm going home. While writing a list of random numbers stating, I don't know who to call. After redirecting resident would continue to repeat himself several times. PCP (Primary Care Physician) notified and gave order for [MEDICATION NAME] 25 mg (milligrams) now and one daily at bedtime. On 12/13/20 the physician increased the [MEDICATION NAME] to 50 mg one tablet by mouth at bedtime for [MEDICAL CONDITION], restlessness. On 12/21/20 a physician's orders [REDACTED]. On 12/29/20 a physician's orders [REDACTED]. Review of the progress notes, Medication Administration Record [REDACTED]. There was no documentation in the clinical record the resident's representative was notified of the resident's behavior or the use of antipsychotic medication to treat Resident #1. On 3/23/21 at 3:00 p.m., in an interview the Director of Nursing (DON) said residents sign a general consent for treatment when they are admitted to the facility. On 3/23/21 at 5:00 p.m., in an interview Resident #1's attending physician said he used the medication on an emergency basis because the resident was yelling out at night and keeping residents up. He said he was not aware he had to inform the resident or representative of the use of [MEDICAL CONDITION] medications. The attending physician said he requested a psychiatry consult for Resident #1 in December 2020. The facility was starting with a new psychiatry service and resident #1 was not seen by psychiatry services until 2/4/21.

Based on record review and interview the facility failed to designate a healthcare professional with specialized training as the Infection Preventionist for the facility. The findings included: On 3/23/21 at 1:30 p.m., in an interview related to infection prevention and control the Administrator said the facility's Infection Preventionist had gone back to school in 10/2020 and the Director of Nursing was currently the Infection Preventionist. On 3/24/21 at 2:00 p.m., the Director of Nursing said she was not aware she was the designated infection preventionist nurse and had not completed specialized training in infection prevention and control.

Based on record review, facility policy and procedures review, and staff interview the facility failed to follow their policies and procedures and neglected to provide the influenza (flu) vaccine in a timely manner to 33 of 43 residents who requested the flu administration, which resulted in 3 (Resident #99, #14, #45) unnecessary hospitalization s due to the flu virus. The facility failed to order the flu vaccine in a timely manner. The facility failed to notify the Medical Director when the residents did not receive the flu vaccine. The facility did not develop a plan of action to ensure the timely vaccination of the residents. The facility failed to implement measures to protect the residents who cannot receive the flu vaccine. These actions resulted in immediate jeopardy that started on [DATE]. The facility was informed of the immediate jeopardy on [DATE] and was provided the Immediate Jeopardy Template. The jeopardy was removed on [DATE] when corrective actions were verified in place. The scope and severity was reduced to E. The findings included: 1. Review of the facility's policy 200.460.1 (revised ,[DATE]) titled Infection Control, Immunizations and Vaccinations indicated It is the policy of this facility that all residents receive immunization and vaccinations that help in preventing infectious diseases, unless medically contraindicated or otherwise ordered by the resident's attending physician .The flu vaccine should be administered at least two months before the expected start of the flu season in the community. On [DATE] at 3:11 p.m., during a review of the facility's immunization program the Director of Nursing (DON) said the facility experienced a flu outbreak in late (MONTH) early December. The DON said she realized around [DATE] the facility had not initiated the flu immunization for residents and staff. The DON said although they immediately obtained consents and started to administer the vaccines on [DATE] to the residents who requested it, it did not prevent the outbreak. She collaborated with the local Health Department who recommended [MEDICATION NAME] for residents that contracted the flu, but it would be very costly to the residents. 2. The DON said Resident #99's responsible party requested the flu vaccine on [DATE]. On [DATE] the resident was sent to the hospital with a high temperature and was diagnosed with [REDACTED]. The DON said the resident expired at the facility on [DATE]. Healthline information about the flu explains, If you develop a secondary infection while you have the flu, that can also cause your organs to fail. The bacteria from that infection can get into your bloodstream and [MEDICAL CONDITION], as well. (downloaded [DATE] from: https://www.healthline.com/health/can-you-die-from-the-flu). 3. The DON said Resident #14's granddaughter requested the flu vaccine for her loved one on [DATE]. She received the vaccine on [DATE] but on [DATE] the resident experienced a high temperature and was transferred to the hospital. Resident #14 was diagnosed with [REDACTED]. 4. The DON said Resident #45 requested the flu vaccine on [DATE] but the vaccine was not administered until [DATE]. On [DATE] the resident developed a high fever and altered mental status. Resident #45 was transferred to the hospital on [DATE] where he was diagnosed with [REDACTED]. 5. According to the Centers for Disease Control and Prevention: .is that it is possible to be exposed to [MEDICAL CONDITION], which cause the flu, shortly before getting vaccinated or during the two-week period after vaccination that it takes the body to develop immune protection. This exposure may result in a person becoming ill with flu before protection from the vaccine takes effect. (Downloaded [DATE] from: https://www.cdc.gov/FLU/PREVENT/MISCONCEPTIONS.HTM) 6. The DON said when the first case of flu was discovered in the facility, she instructed the Unit Manager to obtain residents consents for the flu vaccine. She said employees were not encouraged to have the flu vaccine before (MONTH) 2019. She said the facility offered the vaccines to the employees at a cost of $25.00 that could be paid through payroll deduction. The DON said employees declined to receive the immunization due to the expense. Staff were then advised to take [MEDICATION NAME] (a medication for the prevention and treatment of [REDACTED]. The DON said she did not keep track of employees who did not receive the flu shot and did not enforce the wearing of the mask for those employees who were not immunized. The DON said, unfortunately, the Activity Assistant who conducts group and individual activities for all the residents was diagnosed with [REDACTED]. 7. Review of a tracking log indicated on [DATE] the Activity Assistant started experiencing a high temperature, headache, nausea and weakness. The employee time detail report revealed the Activity Assistant worked on [DATE] and [DATE] despite the onset of symptoms. The DON said Licensed Practical Nurse (LPN) N worked on [DATE] and was diagnosed with [REDACTED]. 8. The DON presented a flu vaccine order dated [DATE] in which the facility requested 8 multidose vials (80 doses) of the flu vaccine. She said they never received it. On [DATE] at 5:30 p.m., in an interview with the Unit Manager (UM), he said he was assigned the UM position in ,[DATE] but did not receive training. He said he was responsible for getting consents, obtaining, and administering the flu vaccine to the residents but was not aware to do so until the pharmacy called (MONTH) 31, 2019. The pharmacy wanted to know why the facility had not ordered the flu vaccines for the residents. The UM said, I did not know and was told I was supposed to order the vaccine in April. The UM said he realized he had a big problem and notified the DON he was not trained to order the vaccine. The UM said in orientation, he was told the pharmacy sends the vaccine all he had to do was get the consents. He said he started obtaining the consents on (MONTH) 31, 2019. On [DATE] at 10:57 a.m., in an interview LPN Staff O said she has been employed at the facility for approximately 5 years and was the UM from (MONTH) (YEAR) to (MONTH) 2019 but did not order the flu vaccine for the current flu season. She said she was not informed it was her responsibility. LPN Staff O said, I have never ordered the flu vaccine, it has always been the responsibility of the Infection Control Nurse. Staff O said in (MONTH) and (MONTH) 2019, she and the previous DON received emails from the pharmacy regarding ordering of the flu vaccines but we were in transition with a new DON and with staff changes. Staff O said she trained the current Unit Manager for a one week and gave him a quick overview. She showed him the form to order the vaccines but there were no directions to go by. On [DATE] at 12:51 p.m., in a telephone interview the Pharmacy Supervisor said the facility ordered 8 vials of the flu vaccine in April, which contained 80 doses. The facility never completed the required paperwork for the vials to be sent, including the individual questionnaires for the residents and staff and the medical orders for the vaccine. The Pharmacy Supervisor said he received approximately 36 individual flu vaccine requests for residents in (MONTH) 2019 and (MONTH) 2019 and the pharmacy sent them. 9. On [DATE] at 12:36 p.m., in an interview with the attending Physician, he said the flu is spreading everywhere and he recommends the facility vaccinates in October. He said, I don't know why the facility did not give the influenza vaccine and said the residents who had the flu were sent to the hospital. On [DATE] at 1:28 p.m., in an interview the Medical Director said he was not aware the facility did not order the flu vaccine in a timely manner. He said he was not notified about the flu outbreak until late after the residents contracted the flu. He said his expectation was to administer the flu vaccine in (MONTH) and (MONTH) to the residents. The Medical Director said his recommendation was to give the flu vaccine to the staff for free and they did not do it. 10. During a review of the facility's Quality Assurance and Performance Improvement (QAPI) program on [DATE] at 3:40 p.m., the DON verified the facility failed to order and administer the flu vaccine to the residents prior to the start of the flu season. She said she did not realize until [DATE] that the residents had not received the flu vaccine. The corrective action was to immediately obtain the consents and administer the flu vaccine to the residents who requested it. The DON admitted she did not inform the Medical Director of the failure to obtain the vaccines in a timely manner, did not address it in QAPI, and did not develop a plan of action to ensure the timely vaccination of the residents. The facility did not implement measures to protect the residents who cannot receive the flu vaccine. The DON said although they have a QAPI meeting monthly, those items were not discussed and were not a priority on their agenda. She said she recently appointed LPN Staff M to be the infection control nurse, even though she has not been trained. Verification of the removal plan included: Reviewed documentation of written consent and administration to all residents who consented to receive the flu vaccine. Reviewed QAPI meeting notes and QAPI action plan dated [DATE] which included education of professional staff on influenza and infection control practices. Sign in sheets were reviewed and staff attendance was verified. Reviewed draft of new policy for Immunization and Vaccination which documents the Infection Control Nurse/DON will be responsible for obtaining and administration of the flu vaccine to residents before the beginning of the flu season effective immediately. Verified facility employees were educated regarding the importance of the flu vaccination, and that the employees were offered the vaccine free of charge. Sign in sheets for in-service reviewed. All employees who did not consent to vaccine will be required to wear a mask until the end of the flu season. Reviewed draft of new policy for Immunization and Vaccination included employees will continue to be educated on the importance of the flu vaccine and offered the flu vaccine free of charge.

Based on record review, facility policy and procedures review, and staff interview the facility failed to follow their policies and procedures and neglected to provide the influenza (flu) vaccine in a timely manner to 33 of 43 residents who requested the flu vaccine, which contributed to (Resident #99, #14, #45) hospitalization s due to the flu virus. The facility did not develop a plan of action to ensure the timely vaccination of the residents. The facility failed to implement measures to protect the residents who cannot receive the flu vaccine. The facility failed to notify the Medical Director when the residents did not receive the flu vaccine. These actions resulted in immediate jeopardy that started at the beginning of the flu season on 10/1/19. The facility was informed of the immediate jeopardy on 1/9/20 and was provided the Immediate Jeopardy Template. The jeopardy was removed on 1/10/20 when corrective actions were verified in place. The scope and severity was reduced to E. The findings included: Review of the facility's policy 200.460.1 (revised 8/2016) titled Infection Control, Immunizations and Vaccinations indicated It is the policy of this facility that all residents receive immunization and vaccinations that help in preventing infectious diseases, unless medically contraindicated or otherwise ordered by the resident's attending physician .The flu vaccine should be administered at least two months before the expected start of the flu season in the community. On 1/8/20 at 3:11 p.m., during a review of the facility's immunization program the Director of Nursing (DON) said the facility experienced a flu outbreak in late (MONTH) early December. The DON said she started employment at the facility on 10/1/19 and realized around 10/30/19 the facility had not initiated the flu immunization for residents and staff. The DON said although they immediately obtained consents and started to administer the vaccines on 10/31/19 to the residents who requested it, it did not prevent the outbreak. She collaborated with the local Health Department who recommended [MEDICATION NAME] for residents that contracted the flu, but it would be very costly to the residents. On 1/9/20 at 5:26 p.m., the DON verified the facility had not provided the flu vaccine to staff and residents prior to the beginning of flu season. The DON said, The residents did not receive the care they needed. Review of the QAPI (Quality Assurance and Performance Improvement) minutes dated 11/13/19 and 12/11/19 did not have documentation the facility failed to offer and administer the flu vaccine in a timely manner to the residents. On 1/9/20 at 4:46 p.m., during an interview the Assistant Administrator verified neglect could be unintentional lack of care of residents. He said he realized not administering the flu shots to residents in a timely manner was neglect he would have notified the ombudsman. He said the family members should have been made aware three residents were hospitalized and had not been administered the flu vaccine prior to the start of flu season. He said he was not aware why the Medical Director was not informed by the facility of the incident. On 1/9/20 at 5:26 p.m., the Nursing Supervisor said he had not been oriented to the facility policy on providing the flu vaccine. He said when he found out he was late with providing the vaccine to residents he got the consent forms to the residents and families as quickly as he could. On 1/10/20 at 10:00 a.m., the Pharmacist said eight vials of flu vaccine were available at the pharmacy for the facility and have been sitting at the pharmacy since (MONTH) of 2019. The Pharmacist said the eight vials were enough to vaccinate 80 residents. On 1/10/20 at 10:15 a.m., the Administrator said she defines neglect as intentionally not taking care of residents and not providing the care and services needed. The Administrator said a resident not being offered or receiving a flu vaccine when the vaccine was available for the residents in the facility was considered neglect. On 1/10/20 at 10:35 a.m., the Medical Director said a resident not receiving the flu vaccine when the resident, their family/or legal representative had requested to be vaccinated was neglect. The Medical Director said if the vaccine was available and was not administered in a reasonable time from the time the facility had the consent to administer the vaccine, he would consider it to be unintentional neglect. The Medical Director said the facility has no excuses for not administering the vaccine to the residents when it was available. On 1/9/20 at 3:40 p.m., the DON verified the facility failed to order and administer the flu vaccine to the residents prior to the start of the flu season. The corrective action was to immediately obtain the consents and administer the flu vaccine to the residents who requested it. The DON admits she did not inform the Medical Director of the failure to obtain the vaccines in a timely manner, did not address it in QAPI, and did not develop a plan of action to ensure the timely vaccination of the residents. The facility did not implement measures to protect the residents who could not receive the flu vaccine. The DON said although they have a QAPI meeting monthly, the lack of administration of the flu vaccine to the residents was not discussed and was not a priority on their agenda. The DON said she recently appointed Licensed Practical Nurse Staff M to be responsible for the infection control program, even though she had not been trained. Verification of the removal plan included: Reviewed documentation of written consent and administration to all residents who consented to receive the flu vaccine. Reviewed QAPI meeting notes and QAPI action plan dated 1/9/20 which included education of professional staff on influenza and infection control practices. Sign in sheets were reviewed and staff attendance was verified. Reviewed draft of new policy for Immunization and Vaccination which documents the Infection Control Nurse/DON will be responsible for obtaining and administration of the flu vaccine to residents before the beginning of the flu season effective immediately. Verified facility employees were educated regarding the importance of the flu vaccination, and that the employees were offered the vaccine free of charge. Sign in sheets for in-service reviewed. All employees who did not consent to vaccine will be required to wear a mask until the end of the flu season. Reviewed draft of new policy for Immunization and Vaccination included employees will continue to be educated on the importance of the flu vaccine and offered the flu vaccine free of charge.

Based on observation, interview, and record review the facility failed to provide sufficient and competent staff for providing restorative care, activities of daily living care, and assistance with eating to 6 (Residents #24, #40, #41, #45, #21 and #46 ) of 12 residents surveyed resulting in the residents not receiving care and services to maintain the residents highest practical physical, mental, and psychosocial well-being. The findings included: 1. Review of Resident #24's Minimum Data Set ((MDS) dated [DATE] showed in section C the resident was not interviewable. Section D Mood shows the resident was rarely or never understood by staff. Section G showed Resident #24 was dependent on the assistance of two staff members for bed mobility, transfer, dressing, and toileting. Resident #24 needed the extensive assistance of one staff member for eating. The MDS showed the resident had a decline in movement with no services. Review of the Restorative Nursing Programs policy and procedure approved by the facility in 2001 and revised 8/2016 reads, It is the policy of the facility to provide nursing restorative services .All appropriate employees will be informed and trained regarding their responsibility and role in resident restorative care .13. Restorative services are all employee's responsibility after appropriate training. The restorative plan will be available and explained to all nursing personnel and other departments coming in contact with the resident .16. If restorative nursing assistants are utilized in this facility, they and the Therapy Program Manager will be responsible for the Restorative Program. On 1/6/20 at 10:30 a.m., Resident #24 was observed lying on his back with the On 1/6/20 at 10:30 a.m., Resident #24 was observed lying on his back with the head of the bed elevated. He was observed to be positioned so that his body was leaning to the left. The resident was observed to have contractures in both side of his upper extremities. The resident was observed to be alert with his eyes opened but non responsive verbally to questioning. There was no television or radio observed to be providing auditory stimulus. On 1/6/20 at 12:24 p.m., Resident #24's daughter said she had seen the resident out of bed and in activities, but she did not believe the resident was capable of participating in bingo or socialization with other residents due to his dementia. On 1/6/20 at 1:30 p.m., Resident #24 was observed in the same position lying on his back and leaning toward the left with his head elevated. Certified Nursing Assistant Staff I was observed feeding the resident lunch. At that time the resident was observed to have contractures to both of his legs. Both lower extremities were bent and fixed. Staff I verified the resident's legs were stiff and not able to be straightened. On 1/6/20 at 3:25 p.m., Resident #24 was observed in the same position, lying on his back and leaning to the left. On 1/7/20 at 10:20 a.m. Resident #24 was observed in the same position as the day before, lying on his back with his head elevated and leaning to the left. The resident's roommate had his television turned up loudly. On 1/7/20 at 10:40 a.m., Staff I verified she had not gotten the resident out of bed on 1/6/20. She said the resident was dependent on two staff members using a Hoyer lift to transfer the patient and there was not another staff person available to transfer the patient. She said when there were only 3 aides on the floor on 1/6/20 and there was not enough assistance to provide care to the residents that needed transferred with a Hoyer. Staff I said her current assignment had two resident which includes Resident #24 that need to be transferred with a Hoyer. She said her current assignment has two more residents that need the assistance of two staff members to transfer in and out of bed. Staff I said there used to be a shower aide that floated and assisted staff with transfers, but, the facility had not had a shower aide for about a month. The Director of Nursing (DON) had told Staff I that she was going to try to get four aides during the day for the west side of the facility. Staff I verified she had not repositioned Resident #24 after 10:00 a.m., on 1/6/20. She said she had left the facility with another resident being transferred to the hospital at 2:00 p.m., on 1/6/20, and, she had reported Resident #24's care to another aide. Staff I said she had not been off for a week prior to 1/6/20. She said Resident #24 at one time had a blue palm protector. She said the Resident did not have a palm protector available on 1/6/20. Staff I said she thinks the blue palm protector had been lost in the laundry. On 1/7/20 at 2:40 p.m., the Physical Therapy Director (PTD) said Resident #24 had been on occupational therapy from 12/9/19 to 12/27/19. The PTD said the resident was placed on restorative program which included range of motion exercises to his upper extremities and placing a palm protector to his right hand. The PT director said he thought the resident had lost his original palm protector in the laundry. The PTD said he had reordered the palm protector and the resident had the palm protector on Monday (1/6/20). After hearing the surveyor's observations on 1/6/20, the PTD said he was not aware the resident was not wearing the palm protector on 1/6/20. The PTD said he felt the palm protector was available for the resident on 1/6/20. The PTD said the palm protector may have been in the resident's bedside table yesterday. The PTD said he had assisted the aide in transferring the aide today (1/7/20) because she could not find any staff to assist her. He said he was happy to assist the staff member. The PTD said the palm protector and passive range of motion should be interventions on the resident's care plan. He said once the resident was transferred to restorative care it is the nursing staff who are responsible to supervise restorative and ensure the resident's positioning care was provided. On 1/7/20 at 3:51 p.m. the Nursing Supervisor verified Resident #24 was started on active range of motion today. The Nursing Supervisor said the PTD had given him the restorative program on 1/3/20 and told him he did not need to start the program until Monday (1/6/20). The Nursing Supervisor said the only thing he was aware the resident was receiving as a restorative intervention before today was for a rolled-up washcloth in his right hand. He said he did not remember how long it had been since the resident had the blue palm protector. He said he thought he had seen the blue palm protector a couple of weeks ago when he worked on the med cart. The Nursing Supervisor said he knew the restorative aide documents the care she provided to Resident #24. He said he did not know how she documented the care and the documentation was not available to him at the time. On 1/8/20 at 1:00 p.m., the Restorative Aide, Staff B said she had started doing restorative Monday through Friday for residents in (MONTH) of 2019. She said she was the only aide providing restorative care Monday through Friday. Staff B said she only documented the minutes she spends with residents electronically. Staff B was not able to find documentation Resident #24 received any restorative minutes at that time. She said the resident was only receiving a splint on his hand. Staff B said when the resident was initially receiving range of motion, he was fighting her when she tried to move him. She said she had gone to her supervisor at the time and her supervisor told her if Resident #24 was fighting the restorative aide she (the supervisor) would just remove Resident #24 from receiving range of motion exercises. The aide did not remember the date the resident was removed from range of motion exercises. The aide was not aware of any interventions to deal with the resident's discomfort while receiving range of motion exercises. Review of a nursing note dated 4/12/2019 reads, Resident Exercised right to refuse (restorative) program due to mood/behaviors. Participation is dependent upon occasional outbursts .no signs or symptoms of pain noted. On 1/8/20 at 1:50 p.m., the current Nursing Supervisor said he was not aware Resident #24 was on a splinting program only with no range of motion because of his behaviors while being moved by staff. The Nursing Supervisor said he was not aware of any interventions to assist the resident's comfort while having his joints moved by staff. On 1/8/20 at 1:55 p.m., both the Administrator and the Nursing Supervisor verified Resident #24 was not able to verbally express when he was in pain and discomfort. The Administrator and Nursing Supervisor verified Resident #24's continued lack of joint movement had the potential to cause pain and discomfort to the resident. The Administrator and the Nursing Supervisor verified Resident #24's had an ongoing need for passive range of motion as tolerated. The Administrator and the Nursing Supervisor verified Resident #24 should have interventions in place to provide comfort to the resident prior to initiating passive range of motion exercises. On 1/10/20 at 8:30 a.m., the Nursing Supervisor said he could not provide documentation for any minutes Resident #24 had received for restorative care. The Nursing Supervisor said there had been a glitch and the care plan for restorative had not transferred to the restorative aide. The Nursing Supervisor said he could not explain why the restorative aide had not informed the supervisor she was unable to document Resident #24's restorative minutes and still she was providing restorative care to the resident. The Nursing Supervisor said he had not been supervising the restorative aide prior to the survey. He said all he could do was input the plan provided by the PTD electronically as a care plan. He said he had only had four days of orientation prior to taking the Nursing Supervisor Job. On 1/10/20 at approximately 9:00 a.m., the PTD said he could not explain why Resident #24 went eleven days from 12/27/20 to 1/7/20 before receiving restorative care. The PTD said when he assessed the resident quarterly, he would speak with the aides to determine the care the resident was receiving. The PTD said he could not explain why he was not informed the resident had not been receiving range of motion exercises. The PTD said he never reviewed the resident's care plan or the nursing assistant task list to determine if the resident was receiving the care he needed. The PTD verified there had been a lack of communication between the Therapy Department and the Nursing Department. On 1/10/20 at approximately 4:30 p.m., the Administrator Assistant said he could not provide any documentation Certified Nursing Assistant (CN)/Restorative Aide Staff B had received any training or in-services regarding restorative care prior to becoming the facility's restorative aide. On 1/10/20 the Nursing Supervisor provided a current list of 38 residents receiving restorative care from one restorative aide Monday through Friday. On 1/10/20 at approximately 6:30 p.m., the Owner said she has seen the list of residents on the restorative care. The Owner said she had told Staff B at the time there was no way she could provide care to all those residents. The Owner said the restorative aide (Staff B) had told her, I do the best I can. 2. On 1/6/2020 at 10:30 a.m., Resident #45 was observed to be unshaven and his fingernails were long and dirty. Resident #45 said it had been a month since he had been shaved. He said he kept asking staff and no one assisted him. He said he was told by staff when he asked that they can't touch him because he was diabetic. On 1/7/20 at 9:56 a.m., Resident #45 said the staff were supposed to wrap his legs with ace bandages to prevent them from swelling. He said they had not wrapped his legs today. He said staff would miss days. He said when he reminded staff, he needed his wraps put on his legs, they would tell him in a little while. Resident #45 said when staff told him in a little while it usually meant it would be in three hours. Review of the physician's orders [REDACTED]. On 1/9/20 at 3:00 p.m., Resident #45 said staff had not wrapped his legs. Ace bandages were observed on the resident's dresser. On 1/9/20 at 3:05 p.m. Licensed Practical Nurse (LPN), Staff M verified she had not wrapped the resident's lower legs with Ace wraps. After reviewing the Treatment Administration Record (TAR) Staff M said the Ace wraps should have been placed on the resident at 6:00 a.m. 3. On 1/9/20 at approximately 4:00 p.m., Resident #40's daughter said she was very upset because there is not enough staff at night to care for her mother. The resident's daughter said she had spoken to the Assistant Administrator because her mother was calling her at night and complaining that the night time staff were leaving her on the toilet for long periods of time. The resident's daughter said her mother called her last night crying and saying staff had just set her supper tray in front of her and left it without assisting he mother in setting up her tray. She said her mother told her another staff member came in after 6 p.m., and found her mother sitting in the dark having not eaten because she could not reach the items on her tray. She said she was ready to take her mother out of the facility. 4. On 1/6/20 at 11:27 a.m., Resident #41 stated the call light response time during dinner time (12:00 p.m., to 1:00 p.m.) could be over an hour. 5. On 1/9/20 at 10:00 a.m. LPN, Staff N said there was not enough nursing staff when there were only three nurses in the building to provide care to the residents. She said the owners did not allow for enough hours. She said the owners did not take into account the acuity of the residents. On 1/9/20 at 10:05 a.m., LPN, Staff H said she did not feel there was enough staff for the residents to receive the care they needed on a daily basis. She said if there were three nurses then the nurse in the memory care unit would have to leave the memory care at times to pass medications on the west side. She said that would leave two aides on the memory care unit to supervise the residents. Staff H said several of the residents on the memory care are two staff member assist. If a resident needs a shower in a shower bed, both aides will be off the memory care unit to the shower room with the one resident on the shower bed. She said this leaves the nurse assigned to the nursing care unit to supervise all the memory residents while she was passing her medications. Staff H said the owners decided how many the staff to resident ratio without taking into account the acuity of the residents. On 1/9/20 at 10:20 a.m., Certified Nursing Assistant (CNA), Staff [NAME] said she was currently assigned to 7 resident and 2 of the residents require two staff members for transfers with a Hoyer lift. Two more of her residents require two staff members to provide transfers and Activates of Daily Living (ADL) care. Staff [NAME] verified there were days when residents did not get out of bed due to a lack of staff. Staff [NAME] verified there were days when residents get bed baths instead of showers because there was not enough staff. On 1/9/20 at 10:30 p.m., Staff B said there were currently thirteen residents that needed two staff members to transfer with a Hoyer lift. Staff B said there are approximately ten more residents who require two staff members to assist with transferring and ADL care. On 1/9/20 at 10:40 a.m., no aides were observed on the memory care unit. LPN, Staff O was observed at the front of the memory care unit near the nurses' station at her medication cart. Staff O verified two aides were in the shower room assisting a resident. She verified she was the only staff member on the memory care unit. Staff O said on the weekends when physical therapy staff and administrative staff were not in the building, all residents did not receive assistance in getting out of bed and getting showers due to lack of staff. On 1/9/20 at 11:00 a.m., the Staff Coordinator and the DON verified they have no input into how many hours of staffing each resident receives. The DON said she has told the owners the facility needed more staff and they did not listen. The DON said she felt the memory care unit needed 3 CAN's daily due to the resident acuity. The Staffing Coordinator said the Chief Operating Officer (COO) said she can only staff to 2.6 hours of CNA's and 1.1 hour of nurses to each resident daily. The DON said she did not feel she has any input into ensuring appropriate nursing staff. On 1/9/20 at 11:30 a.m. the COO said his background was in radiology and he had no nursing experience. The COO verified he was not aware of the need to account for acuity in resident care. The COO verified he staffed the building above what the state requires at 2.6 hours per resident for CNA's and 1.1 hour per resident for nursing care. On 1/10/20 at 5:37 p.m , the DON said she had only met with the owners twice since accepting the position of DON in (MONTH) of 2019. She said she had come out at night to pass medication from the medication cart because staff had called off and there was not enough staff to provide care to the residents. The DON said she feels she has no say in the nursing care provided to the residents. 6. The facility policy 250.1390.1 Activities of Daily Living stated, It is the goal of the facility to provide necessary care and services to attain or maintain the highest practicable functioning of the resident. On 1/6/20 at 1:00 p.m., during observation with Resident #21, his fingernails were long, extending approximately 1/2 inch past his fingertips with an accumulation of brown substance under the nailbeds. Resident #21 said his nails were long and need to be cut. He said someone usually came around to cut them, but they had not recently been in to assist him with nail care. A review of the medical record for Resident #21, revealed a care plan (a detailed approach to care customized to an individual patient's needs) indicating the resident required extensive to total assistance with his ADL's On 1/7/20 at 2:55 p.m., in an interview Certified Nurse Aide (CNA) Staff [NAME] confirmed the resident was unable to clip his fingernails and it was her responsibility to clip the resident's nails. Staff [NAME] said she honestly hadn't paid attention to Resident #21's fingernails lately. 7. On 1/6/20 at 12:30 p.m., in an interview the spouse of Resident's #46 said the staff were not assisting the resident when she was eating her meals. He said his wife's appetite and intake at meals was better when she was assisted to eat. A medical record review revealed a care plan documenting Resident #46 had difficulty swallowing and was holding food in her mouth. The care plan indicated the resident was at risk for aspiration (accidental ingestion of fluid or food into the lungs), and instructed the resident was to eat only with supervision. The CNA Kardex (an information system used by nursing staff to communicate important patient information) instructed Resident #46 was to eat only with supervision. On 1/8/20 at 10:45 a.m., in an interview, CNA Staff A said, she was in and out of other resident's rooms to monitor and assist them during meals. The CNA verified that she did not stay with Resident #46 unless the resident requested that she needed assistance. On 1/8/20 at 12:31 p.m., in an interview the Consultant Dietician said the resident's diet was changed to puree consistency because the resident was pocketing her food and chewing for extended periods. The Consultant Dietician said if the CNA leaves Resident #46's room after setting up her meal, then the resident was not being supervised On 1/8/20 at 12:47 p.m., in an interview with the Unit Manager, he said when a resident was identified as supervised feeding, it meant that the CNA should remain in the room during the resident's meal. The facility policy 250.3080.1 Restorative: Contractures, documented Residents admitted with contractures (limited movement of a joint) will receive appropriate treatment and services. A review of the medical record for Resident #46 revealed a Restorative Nursing care plan instructing the Restorative Aide was to apply the left-hand resting splint 6 days per week. The Physician order [REDACTED].#46 was to wear a left resting hand splint on during the day and off at night. The medical record also documented Resident #46 had a [DIAGNOSES REDACTED]. On 1/6/20 at 10:30 a.m., Resident #46 was observed in her room in bed. The resident had a contracture of her left hand. The resident did not have a splint on her left hand. On 1/7/20 at 9:50 a.m., Resident #46 was in her room in bed and she did not have a splint on her left hand. On 1/7/20 at 10:22 a.m., in an interview the Therapy Director said he was not working with Resident #46 and had not worked with her in the last six months. The Therapy Director confirmed he did not have a restorative program for Resident #46's left hand splint. On 1/7/20 at 3:24 p.m., in an interview with Licensed Practical Nurse, Staff D said Resident # 46 had a left-hand contracture, however she was not aware Resident #46 had a left-hand splint. On 1/8/20 at 8:45 a.m., in an interview the Restorative Aide said she does not have a restorative program to work with Resident# 46 and confirmed she had not been applying a splint to the residents left hand. On 1/08/20 at 8:55 a.m., in an interview the Unit Manager, said Resident #46 had a splint but confirmed there was no documentation of who was responsible for applying and monitoring the splint. The Unit Manager confirmed Resident #46 had a contracture of the left hand and was not receiving restorative nursing care.

Based on record review and staff interview the facility failed to utilize its resources effectively to ensure the safety and wellbeing of the residents. The administration failed to adequately staff the facility and failed to demonstrate oversight or follow up to obtain and administer influenza vaccination timely. The findings included: 1. On 1/9/20 at 3:40 p.m., the Director of Nursing (DON) said she has been employed at the facility since 10/1/19 and was aware of the staffing issues in the building. She said her concern was the number of falls and family complaining about not getting things done timely for their loved ones. She said although she was aware of the issues, she did not develop a plan of action to rectify the lack of adequate staffing to meet the needs of the residents. The DON said she spoke to the Administrator about the staffing concern, but it was not a formal conversation. She said the Chief Operating Officer (COO) was the only one making the decisions for the staffing pattern of the building based on the State's number requirement, not on the acuity of the residents. 2. During the interview, the DON verified the facility failed to order and administer the influenza (flu) vaccine to the residents prior to the start of the flu season. She said she started employment at the facility on 10/1/19 but did not realize until 10/30/19 that the residents had not received the flu vaccine. The corrective action was to immediately obtain the consents and administer the flu vaccine to the residents who requested it. The DON admitted she did not inform the Medical Director of the failure to obtain the vaccines in a timely manner and did not develop a plan of action to ensure the timely vaccination of the residents. The facility did not implement measures to protect the residents who cannot receive the flu vaccine. She said she recently appointed Licensed Practical Nurse Staff M to be the infection preventionist, even though she has not been trained. 3. On 1/09/20 at 1:28 p.m., in an interview the Medical Director said he was not aware the facility did not order the flu vaccine on time. He said his recommendation was to give the flu vaccine to the staff for free and they did not do it. He said he was not involved in any corrective action. The Medical Director said there was a problem with communication in this facility. He added I have said they need to work on their communication with everyone. There are no set rules here, everyone seems to come up with their own. Three people give orders between the owners and if we have one person hopefully things will be done right. The Medical Director added I think the issue is communication, they don't know which one of them here is responsible to give the vaccine. There have been too many changes with the DON. I see it as the owners are in charge not the DON. I can tell you we did not have the staffing here to cover a few months back. I don't know about now. The facility did not inform me of the flu outbreak here, I heard about it from (name). I did not know about the flu outbreak here until late December, I was just recently informed of it. I found out about the flu outbreak when (Resident #99) was admitted to the Hospital. We need to have a policy here going forward. The medical director added he expected the facility to administer the flu vaccine to the residents in (MONTH) and September. 4. On 1/10/20 at 10:40 a.m., during a telephone interview, the Medical Director said he used to be involved in administrative decisions a long time ago such as developing and approving facility policies related to residents' care. He said the facility had been without a DON and it's been more than a year for sure that he has not participated in any recommendation, development, and approval of the facility policies and procedures. 5. Review of the Quality Assurance and Performance Improvement (QAPI) minutes dated 11/13/19 and 12/11/19 failed to reveal documentation the facility's administration addressed the lack of adequate staffing to meet the needs of the residents or the failure to offer and administer the flu vaccine on a timely manners to the residents.

Based on interview and record review the facility failed to have an active governing body to ensure effective management of the facility. The Governing Body failed to establish and implement policies for the effective management and operation of the facility. The findings included: In an interview on 1/9/20 at 1:28 p.m., the Medical Director said, There are no set rules here, everyone seems to come up with their own. Three people give orders between the owners and if we have one person hopefully things will be done right. In an interview on 1/9/20 at 11:30 a.m. the Chief Operating Officer (COO) said his background was in radiology and he had no nursing experience. The COO verified he was not aware of the need to account for acuity in resident care. The COO verified he staffed the building above what the state requires. In an interview on 1/9/20 at 3:40 p.m., the Director of Nursing (DON) said she spoke to the Administrator about the staffing concern, but it was not a formal conversation. She said the COO was the only one making the decisions for the staffing pattern of the building based on the State's minimum requirement, not on the acuity of the residents. During a telephone interview on 1/10/20 at 10:40 a.m., the Medical Director said he used to be involved in administrative decisions a long time ago such as developing and approving facility policies related to residents' care. He said the facility had been without a DON and it's been more than a year for sure that he has not participated in any recommendation, development, and approval of the facility policies and procedures. In an interview on 1/10/20 at 12:10 p.m., the DON said she had never seen the facility assessment tool. In a telephone interview on 1/10/20 at 12:15 p.m., the Administrator said she was not aware of the facility assessment tool and was not aware that it was used to assess the acuity of the residents at the facility. In an interview on 1/10/20 at 12:15 p.m., the COO said he had never seen the facility assessment and was not aware it should be used for assessing the acuity of the residents at the facility and the staff needed to provide care to the residents. In an interview on 1/10/20 at 5:37 p.m., the DON said she had only met with the owners twice since accepting the position of DON in (MONTH) of 2019. She said she had come out at night to pass medication from the medication cart because staff had called off and there was not enough staff to provide care to the residents. The DON said she felts she has no say in the nursing care provided to the residents. On 1/10/20 at about 10:30 a.m., documentation of governing body activity was requested. Review of the QAPI minutes dated 11/13/19 and 12/11/19 failed to reveal documentation the facility addressed the lack of adequate staffing to meet the needs of the residents or the failure to offer and administer the influenza vaccine on a timely manner to the residents. On 1/10/20 at about 1:30 p.m., the Assistant Administrator was reminded about the request for governing body information. He responded he had provided the Quality Assurance Program Improvement (QAPI) documents and asked, What is the governing body? On 1/10/20 at 2:21 p.m., the facility provided a single-page document prepared this day that named the members of the governing body. This policy (revised date 1/2020) stated, The Governing Body represents the owner(s), an owner appointed Administrator and Director of Nursing. Together the Governing body shall aide in the implementation and monitoring of policies and procedures of the facility. The procedure stated, In executive order: President/Owner Chief Operating Officer Administrator Assistant Administrator Director of Nursing The Governing Body shall meet at least on a bi-monthly basis to discuss and address all appropriate issues. All meeting minutes will be documented and saved for reference.

Based on interview and record review the facility failed to revise the facility assessment tool when the acuity level of the residents changed resulting in insufficient staff to provide transferring and mobility of the residents and the care of residents needing assistance with eating. The findings included: Review of the Facility Assessment revealed it was created in (MONTH) of 2019. Under 1.5 the document reads Describe your resident's acuity levels that help you understand potential implications regarding the intensity of care and services needed. The assessment showed in (MONTH) 2019 there were 10 residents dependent on transfers. In (MONTH) 2019 there were 5 residents dependent on staff for toileting. In (MONTH) 2019 here were 3 residents dependent of staff eating. Review of the Census and Condition dated 1/6/20 showed there was currently a census of 43 residents. 18 of the residents at the facility were dependent on staff for transferring. 20 residents were dependent on staff for toileting, and 10 residents were dependent on staff for eating their meals. Currently 33 of the 43 residents in the facility need assistance from 1 or 2 staff members with eating. On 1/10/20 at 11:50 a.m., the Contracted Physical Therapist said she had had no input in creating the facility assessment tool. On 1/10/20 at 11:55 a.m., the Director of Physical Therapy said he had been at the facility since (MONTH) 2019 and he had not been involved with the facility assessment tool. On 1/10/20 at 12:10 p.m., the Director of Nursing said she had never seen the facility assessment tool. On 1/10/20 at 12:15 p.m., the Administrator said she was not aware of the facility assessment tool and was not aware that it was used to assess the acuity of the residents at the facility. On 1/10/20 at 12:15 p.m., the Chief Operating Officer said he had never seen the facility assessment and was not aware it should be used for assessing the acuity of the residents at the facility and the staff needed to provide care to the residents. (Refer to F725)

Based on record review and staff interview the facility failed to have an effective on-going Quality Assurance Performance Improvement (QAPI) that recognizes, prioritizes, and implement corrective actions to address quality deficiencies that pose a high risk to residents' safety and well-being. The failure to maintain an effective quality assurance program causes ongoing deficient practices with a likelihood of negative consequences to the residents. The findings included: Review of the facility's policy and procedure titled Quality Assurance Performance Improvement (QAPI) with an original date of 6/16 revealed The QAPI committee has the responsibility for designing and implementing corrective action plans as needed to resolve identified resident care/service problems. This is accomplished within local, state, federal and facility guidelines. All improvement plans will contain: * What is to be changed * When and how the corrective action will be implemented * Who is responsible for the implementation of the corrective action * What time interval is set for reassessment of the implemented changes Improvement plans and effectiveness of actions will be documented in the committee minutes. 1. During a review of the facility's QAPI program on 1/9/20 at 3:40 p.m., the Director of Nursing (DON) said she has been employed at the facility since 10/1/19 and was aware of the staffing issues in the building. She said her concern was the number of falls and family complaining about not getting things done timely for their loved ones. She said although she was aware of the issues, she did not bring it as a priority item to the QAPI meetings, nor did she develop a plan of action to rectify the lack of adequate staffing to meet the needs of the residents. The DON said she spoke to the Administrator about the staffing concern, but it was not a formal conversation. She said the Chief Operating Officer (COO) was the only one making the decisions for the staffing pattern of the building based on the State's number requirement, not on the acuity of the residents. 2. On 1/9/20 at 3:40 p.m., the DON verified the facility failed to order and administer the influenza (flu) vaccine to the residents prior to the start of the influenza season. She said she started employment at the facility on 10/1/19 but did not realize until 10/30/19 that the residents had not received the flu vaccine. The corrective action was to immediately obtain the consents and administer the flu vaccine to the residents who requested it. The DON admitted she did not inform the medical Director of the failure to obtain the vaccines in a timely manner, did not address it in QAPI, and did not develop a plan of action to ensure the timely vaccination of the residents. The facility did not implement measures to protect the residents who cannot receive the flu vaccine. The DON said although they have a QAPI meeting monthly, those items were not discussed and were not a priority on their agenda. She said she recently appointed Licensed Practical Nurse Staff M to be the infection preventionist, even though she had not been trained. 3. Review of the QAPI minutes dated 11/13/19 and 12/11/19 failed to reveal documentation the facility addressed the lack of adequate staffing to meet the needs of the residents or the failure to offer and administer the influenza vaccine on a timely manner to the residents.

Based on record review and staff interview, the facility failed to notify the state's Long-Term Care Ombudsman Council (LTC[NAME]) of facility-initiated transfers and discharges since 9/17/18. The Ombudsman was not notified of 11 (Resident #3, #14, #15, #17, #22, #25, #31, #35, #37, #45, and #99) of 11 sampled facility-initiated transfer/discharges. The failure to send notices of facility-initiated transfers and discharges to the LTC[NAME] potentially prevents inappropriately discharged resident's access to an advocate to inform them of their options and rights. The findings included: Review of the documentation dated 1/6/20 provided by a representative of the LTC[NAME] revealed their office had not received any notices of transfers or discharges since 9/17/18. Review of the facility discharge log from 2/3/19 through 1/6/20 revealed a total of 168 discharges; which included 67 discharges to the community, 89 transfers to acute care hospitals and 3 transfers to other healthcare facilities. Sampling of facility-initiated discharges 2/3/19 through 1/6/2020 found: Resident #3 had an unplanned discharged to an acute hospital on [DATE]. Resident #14 had a transfer to an acute care hospital on [DATE]. Resident #15 had an unplanned discharge to an acute care hospital on [DATE] and 9/25/19. Resident #17 had an unplanned discharge to an acute care hospital on [DATE]. Resident #22 had an unplanned discharge to an acute care hospital on [DATE]. Resident #25 had an unplanned discharge to an acute care hospital on [DATE]. Resident #31 had an unplanned discharge to an acute care hospital on [DATE]. Resident #35 had an unplanned discharge to an acute care hospital on [DATE]. Resident #37 had an unplanned discharge to an acute care hospital on [DATE] and 6/21/19. Resident #45 had an unplanned discharge to an acute care hospital on [DATE]. Resident # 99 had an unplanned discharge to an acute care hospital on [DATE]. There was no documentation at the time of the survey that the facility had notified the LTC[NAME] of the facility-initiated discharges. During an interview on 1/6/20 at 2:55 p.m., with the Administrator, Director of Nursing and Social Worker, they all said they had not been sending the transfer/discharge notices to the Ombudsman's office. The Social Worker said the nurses completed the transfer/discharge notices, but were never sent to the LTC[NAME] office

Based on staff interview, clinical record review and facility record review the facility failed to ensure that 2 (Residents #1 and #29) of 3 residents reviewed for prevention of accidents as resulting from failure to follow the plan of care for Resident #1 for fall prevention and failure to operate a mechanical lift in a safe manner to prevent an injury to Resident #29. The findings include: 1. During an interview with nursing staff and a clinical record review revealed that Resident #1 was found on the floor on [DATE] at approximately 8:30 a.m. The resident's Hospital Assessment #3008, dated [DATE], documented the resident needs assistance for transfer and the admission assessment noted Resident #1 was found to be able to transfer and ambulate with minimal assist and supervision. A review of the resident's Care Plan dated [DATE] documents the resident has moderately impaired vision putting her at risk for falls and risk for falls related to a fall history, gait and balance, visual impairment, high risk medications, noncompliance with safety needs. Care plan interventions identify safety approaches and modifications, use pressure sensitive alarms when resident in bed or chair. Encourage early mobility programs such as walking to and from the Dining Room and participate in scheduled exercise program. A scheduled toileting program was added [DATE]. On [DATE] at 11:05 a.m., an interview was conducted with the CNA (Certified Nursing Assistant) assigned to Resident #1. The CNA said that she had responded on [DATE] when the housekeeper found the resident on the floor. She said the resident may have needed to go to the bathroom and gets confused sometimes. When asked if the resident's alarm was in place and had gone off when Resident #1 was on the floor, she said no. During an interview with the Director of Nurses (DON), on [DATE] at 9:45 a.m., revealed that the nurse said when she went in there was not an alarm to the chair. The DON said that she called the aide from the ,[DATE] shift that gets her up; the CNA said she was positive she put the alarm there and the day shift CNA said she did not check to see if the alarm was there. The DON said that Resident #1 should have had alarm on, the resident had left the dining room and must have not been able to hold it and tried to go to the bathroom in some else's room without help. The facility failed to ensure that the Care Plan intervention for a chair alarm for the resident's risk for falls was implemented on [DATE]. 2. A clinical record review for Resident #29 documented that on [DATE] the resident had a comprehensive assessment completed for a significant change in condition. The assessment noted that the resident required extensive assist with bed mobility and transfer. The resident's Care Plan, dated [DATE], documented a Fall Risk due to physical limitations, use of a sedative and antidepressants. It noted a deficit in the area of ADL's (Activities of Daily Living) because of total dependence for transfer. The care plan shows Hoyer Lift for transfer and Pummel cushion to keep upright in wheelchair. The resident's record shows a physician order, dated [DATE], for the use of a Hoyer Lift (mechanical lift for transfers) or two person transfers. On [DATE] at 2:10 p.m., the Director of Nurses (DON) was interviewed regarding a fall with injury which occurred on [DATE]. The DON said that Resident #29 required a Hoyer Lift to transfer. On [DATE], the resident was being transferred from the bed to the chair and was dropped. The facility concluded that the aide assigned to the resident operated the lift without a second person in room as required. The resident was lifted and the aide left the room to get help. When second person came in the resident was lifted over the bed with legs dangling. The assigned aide did mechanical part of the lifting. The second aide guided the resident and the resident fell out of the lift. One of the straps was dangling. After the incident, she removed the lift from the floor and had the maintenance department check it to make sure there was no mechanical malfunction and no malfunction was found. An interview was conducted with the Minimum Data Set (MDS) and Care Plan Coordinator, on [DATE] at 12:20 p.m., revealed that Resident #29 was weak in the knees most of the time and couldn't pivot well so the lift was used most of the time to transfer the resident. The resident's record and facility documentation shows that on [DATE] the resident was being transferred by Hoyer lift and fell to the floor. On [DATE] at 10:10 a.m., an interview was conducted with a CNA who was present when the resident fell out of the Hoyer lift on [DATE]. She said that the aide with the resident saw her in the hall and asked her if she would help with transferring Resident#29. When she went in room resident was in the sling already and was lifted above the bed. She said held resident's buttocks to help guide the resident over to the wheel chair as they moved him/her from the bed to the chair. The right strap came loose and resident fell . The resident was hospitalized with a subdural hematoma (bleeding in the brain). The facility suspended the involved staff until after the completion of the investigation. The interviewed CNA has been reassigned to the laundry and the other CNA, who had been in-serviced on using a Hoyer Lift, was still on suspension at the time of survey. The facility staff failed to ensure that the Hoyer lift was used in a safe manner resulting in a fall with a significant injury to Resident #29. After being hospitalized the resident aspirated on food and expired on [DATE].