Every finding on record at Diversicare of Pell City

Based on observation, interviews, and review of a facility policy titled, Dispose of Garbage and Refuse the facility failed to ensure trash bags were placed in the refuse dumpster with a closed lid and a discarded mattress was not on the ground in the dumpster area. This was observed on 03/01/2022 and 03/02/2022, two of three days of the survey, and had the potential to affect all 64 residents in the facility. Findings Include: A facility policy titled Dispose of Garbage and Refuse dated 8/2017 documented: Policy Statement All garbage and refuse will be collected and disposed of in a safe and efficient manner. Procedures 1. The Dining Services Director coordinates . to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris. 2. The Dining Services Director will ensure that: . Appropriate lids are provided for all containers. On 03/01/2022 at 8:50 AM, an observation was made of two closed dumpsters and a big open dumpster containing five clear plastic bags with Personal Protective Equipment (PPE) in bags on top of the big open dumpster that was higher than the container. On 03/02/2022 at 9:22 AM, an observation was made of two closed dumpsters and a big open dumpster containing five clear trash bags with PPE visible in the bags. The garbage was observed coming over the sides of the container and the container was not covered. There was also a mattress observed on the ground next to the dumpster. On 03/02/2022 at 9:22 AM, Employee Identifier (EI) #7 Dietary Manager was asked if the clear bags belonged in that dumpster. EI #7 replied, no. On 03/02/2022 at 12:24 PM EI #7 was asked what was in the big outside dumpster. EI #7 replied, bed parts, and construction stuff. EI #7 was asked what was the risk of those garbage bags being in that dumpster. EI #7 replied, pests and safety. EI #7 was asked if the dumpster was covered. EI #7 replied, no, she had never seen it covered. EI #7 was asked where the garbage belonged. EI #7 replied, in the regular dumpster. EI #7 was asked, what was the policy for garbage in the dumpsters. EI #7 replied, garbage should be in the cans and covered and the garbage was to be picked up around the dumpsters.

Based on observations, interviews and review of a facility policy titled Storage and Expiration Dating of Medications, Biologicals, the facility failed to ensure all resident medications were stored in the original containers on 03/03/2022, when loose pills and capsules were observed in drawers of all three resident medication carts. This affected three of three resident medication carts observed in the facility. Findings Include: Review of facility policy titled Storage and Expiration Dating of Medications, Biologicals, last revised 01/01/2022, revealed: . PROCEDURE . 2. Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, . 10. Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received. On 03/03/2022 at 7:55 AM, an observation of medication cart #2 was made with Employee Identifier (EI) #4, Licensed Practical Nurse (LPN). One loose white pill and one loose small white pill was found on the bottom of the second drawer. On 03/03/2022 at 7:55 AM, EI #4 was asked if she knew what the pills were. EI #4 replied, she did not know what medications they were. On 03/03/2022 at 8:00 AM, an interview with EI #4, LPN, was conducted. EI #4 was asked, what was the policy on medications being loose in the medication drawers. EI #4 replied, the loose pills should be disposed of. EI #4 was asked, should medication be loose in the drawers of the medication cart. EI #4 replied, no. EI #4 was asked, what was the risk of medications being loose in the drawers. EI #4 replied, medication errors. On 03/03/2022 at 11:19 AM, an observation was made of medication cart #1 with EI #5, LPN. In the second drawer one white loose pill and one loose blue and white capsule was observed in the bottom of the drawer. On 03/03/2022 at 11:22 AM, an interview with EI #5, LPN, was conducted. EI #5 was asked, should loose pills have been in the bottom of the drawer. EI #5 replied, no ma'am. EI #5 was asked, what was the risk of loose pills being on the bottom of the drawers. EI #5 replied, accidentally picking them up and giving them to a resident or the risk of them popping out of the cart onto the floor and a resident picking it up and taking the medication. On 03/03/2022 at 4:14 PM, a follow-up interview with EI #5 was conducted. EI #5 was asked did she know what medications were on the bottom of the drawer, the one white loose pill and the one loose blue and white capsule in the bottom of the second drawer. EI #5 replied, no. On 03/03/2022 at 11:30 AM, an observation was made of Medication cart #3 with EI #6, LPN. The second drawer slot had one loose oblong mauve colored pill and one round yellow loose pill. On 03/03/2022 at 11:30 AM, an immediate interview was conducted with EI #6, LPN. EI #6 was asked, should loose pills have been in the bottom of the medication cart drawers. EI #6 replied, no there should not have been. EI #6 was asked, what were the loose mauve colored oblong pill and the round yellow loose pill observed in cart #3. EI #6 replied, the mauve colored oblong pill might have been a [MEDICATION(S)] ([CONDITION(S)] medication) and she did not know what the yellow round one was. EI #6 was asked, what was the risk of the loose pills being on the bottom of the drawers. EI #6 replied, they could have been given to someone by accident. EI #6 was asked, what was the policy on loose pills being in the medication drawers. EI #6 replied, they should have been cleaned out and destroyed. On 03/03/2022 at 11:03 AM, an interview with EI #2, the Director of Nursing (DON)/Registered Nurse (RN) was conducted. EI #2 was asked, what was the policy on medication carts and loose pills. EI #2 replied, pick them up and then destroy the pills. EI #2 was asked, who should have looked for loose pills in the medication cart. EI #2 replied, any nurse could. EI #2 was asked, what was the risk of loose pills being in the bottom of the medication cart drawers. EI #2 replied, a nurse could pick it up and use it. When asked how many medication carts there were in the facility, EI #2 replied, three.

Based on observation, interviews, resident record review and review of a facility policy titled Handwashing/Hand Hygiene, the facility failed to ensure Employee Identifier (EI) #8, a Certified Nursing Assistant (CNA), washed or sanitized her hands during lunch meal delivery and set up on 03/01/2022. EI #8 delivered and set up trays for Resident Identifier (RI) #29 and RI #13 without performing hand hygiene between residents. This had the potential to affect RI #13, one of two residents observed to have lunch meal trays passed to them by EI #8 on 03/01/2022. Findings Include: A facility policy titled Handwashing/Hand Hygiene, with an effective date of March 2020, documented: . POLICY This center considers hand hygiene the primary means to prevent the spread of infections. POLICY INTERPRETATION AND IMPLEMENTATION . 5. Use an alcohol-based hand rub or, alternatively, soap . and water for the following situations: . b. Before and after direct contact with residents; . m. Before and after eating or handling food; . RI #29 was readmitted to the facility on [DATE]. RI #13 was readmitted to the facility on [DATE]. On 03/01/2022 at 12:18 PM, an observation was made of EI #8, CNA, delivering a lunch tray to RI #29. EI #8 used RI #29's remote bed control to position RI #29 for lunch and set up RI #29's lunch tray, opening containers, removing lids from drinks and using the spoon from RI #29's hand to put condiments on food for RI #29. EI #8 then walked out to the hall, without sanitizing or washing her hands, and removed another lunch tray from the food cart and delivered the tray to RI #13. EI #8 used RI #13's remote bed control, set up RI #13's tray, removing lids from containers and passing silverware to RI #13. EI #8 then began to feed RI #13, but then stopped and exited RI #13's room without washing or sanitizing her hands. On 03/01/2022 at 12:27 PM EI #8 was asked when she sanitized or washed her hands when she exited RI #29's room. EI #8 replied, she did not. EI #8 was asked, what was the risk of not sanitizing her hands. EI #8 replied, infection. EI #8 was asked, what did the facility's policy say about hand washing. EI #8 replied, she was supposed to wash her hands or sanitize them when coming out of a room. On 03/03/2022 at 10:35 AM, EI #3, Infection Preventionist, was asked what was the policy for staff to wash or sanitize their hands after a meal tray was set up for a resident, before delivering another tray for another resident. EI #3 replied, a staff member should wash/sanitize their hands in between each resident. EI #3 was asked, when should a staff member not wash their hands after setting up a tray and picking up another tray. EI #3 replied, they should always wash or sanitize their hands. EI #3 was asked, what was the risk of a staff member not washing their hands after setting up a tray and picking up another residents tray. EI #3 replied, transmission of any contaminant from one resident to another. On 03/03/2022 at 11:03 AM an interview was conducted with EI #2, Director of Nursing (DON). EI #2 was asked, when should a staff member sanitize her hands after setting up a resident's tray and before picking up another resident's tray from the meal cart. EI #2 replied, she should sanitize her hands in between each resident and if the hands are visibly soiled she needed to wash them. EI #2 was asked, when did the policy say staff should sanitized their hands after setting up a resident's tray. EI #2 replied, she should have sanitized before and after touching a resident or touching a resident's tray. EI #2 was asked, what was the risk of not sanitizing or washing hands after setting up a resident's tray and before picking up another resident's tray. EI #2 replied, infection control and contamination.

Based on record reviews, interviews and a review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to ensure staff members: 1.) did not write checks and use a debit card belonging to Resident Identifier (RI) #1 for personal gain, and 2.) did not take money belonging to RI #2, and 3.) did not take money and food from RI #3 to use for personal gain. This affected RI #1, RI #2 and RI #3, three residents of six residents sampled for misappropriation/exploitation. Findings include: The facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, with an Effective Date: [DATE], documented: . Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Exploitation: Taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion. Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money . On [DATE], the facility's Administrator reported to the State Agency an incident of exploitation. According to the report, EI #3, a Certified Nursing Assistant (CNA) borrowed $20.00 from RI #3 and never paid it back and EI #4, CNA, often asked RI #3 to buy her food. The facility's INVESTIGATION TEMPLATE, dated [DATE], documented: . In conclusion, after investigation the facility does substantiate that exploitation occurred. EI #3 and EI #4 did confirm that they accepted items from RI #3. On [DATE], the facility's Administrator reported to the State Agency an incident of exploitation. According to the report, after reviewing RI #1's bank information it was determined that several checks had been written to EI #6, a housekeeper. The facility's INVESTIGATION TEMPLATE, dated [DATE], revealed: . Conclusion: After investigation facility substantiates exploitation occurred. With the checks written out to EI #6 and the Automated Teller Machine (ATM) withdraws, whether a loan or not, EI #6 should not have accepted or taken any funds from RI #1. It was also found during the investigation that EI #6 asked another resident RI #2 for money and promised to pay him/her back. Contained within the facility's investigative file, there were seven canceled checks from RI #1's account written out to EI #6: 1) Check #1206 for $70.00 on [DATE], 2) Check #1212 for $80.00 on [DATE], 3) Check #1207 for $80.00 on [DATE], 4) Check #1209 for $100.00 on [DATE], 5) Check #1203 for $65.00 on [DATE], 6) Check #1213 for $60.00 on [DATE], and 7) Check #1216 for $140.00 on [DATE]. RI #1 was originally admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1 expired in facility on [DATE]. RI #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on [DATE] at 10:06 AM, RI #3 was asked about the incident involving EI #3, CNA, and EI #4, CNA, borrowing money and asking him/her to buy them food. RI #3 stated, I felt sorry for EI #4. She had a lot going on like her kids being taken from her and stuff and she didn't have anything and was hungry. I feel like you should give to those in need, so I did. EI #4 was hungry and I bought her some ribs. EI #3 is a different story. She borrowed $20.00 from me because she said she was short and hadn't got her first paycheck yet and would pay me back if I would loan her the $20.00 to get gas to come to work, so I did. When she got paid though, she never paid me back and she was going out of town to see her boyfriend and stuff and I thought if she had the money and gas to go out of town she should be able to pay me back my $20.00. RI #3 was asked how he/she felt when EI #3 did not pay back the $20.00 as promised. RI #3 said, I was hurt and felt like she was taking advantage of me when she didn't pay me back and was making her trips out of town and such. In an interview on [DATE] at 11:01 AM, EI #5, CNA, was asked about the incident with EI #3, EI #4 and RI #3. EI #5 stated RI #3 just told her about loaning EI #3 $20.00 but she heard EI #4 ask RI #3 for money for cigarettes and food. EI #5 further stated that one day when she was changing RI #3, EI #4 came in and asked RI #3 to buy her a rack of ribs and a pack of cigarettes. EI #5 said RI #3 told her to get $10.00 out of a book bag and give to EI #3 for cigarettes and RI #3 then asked her to go get EI #4 a rack of ribs and she did. EI #5 said that RI #3 later told her that he/she bought stuff for EI #4 all the time. On [DATE] at 11:24 AM, an interview was conducted with RI #2. RI #2 was asked has any staff member asked you to loan them money. RI #2 said, Yes, EI #6, a housekeeper, told me a pitiful story and asked me to borrow $40.00 because her power was going to get cut off and it was cold outside. It was on a Thursday and she said that her husband was getting paid the next day and she would give it back to me. After I loaned it to her, I found out that they had told her not to come back to the facility. RI #2 was asked how it made him/her feel when he/she realized she was not coming back to give you your $40.00. RI #2 stated, I thought she was a good Christian girl that was having a hard time when I gave it to her, but after I found out she had lied to me, I felt used and hurt that somebody would do me like that. It was a hard lesson, but I learned that I just can't trust everything I hear. I don't have much and it hurt me to know somebody that I thought was a good person would take advantage of me. In an interview on [DATE] at 12:43 PM, EI #6, a former housekeeper, was asked what information she could provide about the checks that she wrote to herself from RI #1's account. EI #6 stated she wrote checks to herself from RI #1's account but he/she was there when she did. EI #6 was asked why did RI #1 allow her to write checks from his/her account. EI #6 said she asked RI #1 for it. EI #6 was asked did she use RI #1's debit card. EI #6 stated yes, she would get food and bring it back to him/her. EI #6 was asked when she used RI #1's debit card did she ever buy herself food too. EI #6 said yes, RI #1 would tell her to just go ahead and pick her up something too. EI #6 was asked how often did she buy herself food. EI #6 stated that she got RI #1 lunch every day that she worked and she would buy herself food too. EI #6 was asked how many checks did she write herself from RI #1's account. EI #6 said she did not know, but thought it was six or seven. EI #6 was asked why did she take money from RI #2. EI #6 said she needed some money for gas. EI #6 was asked how much money did she get from RI #2. EI #6 stated it was $40.00. EI #6 was asked when was she going to pay RI #1 and RI #2 back their money. EI #6 stated she could not because she was not working now. EI #6 was asked why RI #1 said that he/she had no knowledge that she was writing checks from his/her account to herself. EI #6 said she did not know. In an interview on [DATE] at 6:07 PM, EI #1, Administrator, was asked what her determination was after the investigation of the facility reported incident she reported on [DATE], involving exploitation/misappropriation of RI #3's money by EI #3, CNA, and EI #4, CNA. EI #1 said, I substantiated exploitation. EI #1 was asked what she did as a result of that determination. EI #1 replied that both EI #3 and EI #4 were terminated. EI #1 was asked what her determination after the investigation of the facility was reported incident, she reported on [DATE], involving exploitation/misappropriation of RI #1 and RI #2 by EI #6, housekeeper. EI #1 stated, It was substantiated as exploitation. EI #1 was asked what she did as a result of that determination. EI #1 said EI #6 was terminated. EI #1 was asked when did she in-service the staff for these incidents. EI #1 explained, We actually combined what happened between the time of RI #3's incident and the incident for and RI #1 and RI #2 since it was pertaining to the same thing and we did the in-service on [DATE]. EI #1 was asked what the effect of those incidents for the residents was. EI #1 said RI #1 and RI #2 were hurt and RI #1 stated he/she could not believe that EI #6 would do that to him/her. ************************* Once the facility became aware that EI #3, CNA, and EI #4, CNA, had admitted they took items that belonged to RI #3, the facility implemented the following corrective actions: * EI #3 and EI #4 were suspended and not allowed back to work pending the investigation findings. EI #3 and EI #4 last worked in the facility on [DATE]. EI #3 and EI #4's employment with the facility was terminated on [DATE]. * EI #6 was suspended and not allowed back to work pending the investigation findings. EI #6 last worked in the facility on [DATE]. EI #6's employment with the facility was terminated on [DATE]. * The facility timely reported the allegations and the subsequent findings to the Alabama Department of Public Health, the local Police Department, the facility's Medical Director and the representatives of the residents involved. * The facility conducted staff in-service on [DATE] for both allegations regarding Abuse Prevention, specific to Exploitation and Misappropriation of Resident Property. ************************* After review of the facility's investigation file, in-service/education records, staff and resident interviews, the facility implemented corrective actions from [DATE] to [DATE]. This deficiency was cited as a result of the investigation of complaint/report numbers AL 046 and AL 194.

Based on record reviews, interviews and a review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to ensure a staff member did not verbally abuse Resident Identifier (RI) #5 and RI #6 on 3/24/21. This affected RI #5 and RI #6, two residents sampled for abuse. Findings Include: The facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, with an Effective Date: January 2019, documented: . Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, . Verbal abuse: May be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. On 3/25/2021, the facility's Administrator reported to the State Agency an incident of verbal abuse. According to the report, Employee Identifier (EI) #7, a Registered Nurse (RN) told RI #5 to Shut the [OBSCENITY] up, I am trying to do my job!. The facility's INVESTIGATION TEMPLATE, dated 4/1/2021, documented . In conclusion, due to the witnesses confirming EI #7's behavior the center is substantiating verbal abuse. Several staff members and residents stated that EI #7 was hateful and cursed at RI #5 and RI #6. RI #5 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #6 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 5/19/2021 at 8:56 AM, RI #5 was asked what happened on 3/24/2021 involving EI #7, RN. RI #5 stated that EI #7 told him/her, Shut your [OBSCENITY] ing mouth. I'm the boss of this hall tonight. RI #5 was asked what it was considered when EI #7 made that statement. RI #5 said Harassment and verbal abuse. Verbal abuse is not as bad as assault, but it upset me, and I stayed mad for two or three days. RI #5 was asked how that made him/her feel. RI #5 stated, It made me feel like I wasn't worth nothing. On 5/19/2021 at 10:30 AM, an interview was conducted with RI #6. RI #6 was asked what happened involving EI #7 on 3/24/2021. RI #6 stated, Me and RI #5 was talking, and the nurse got real rude and smart [NAME] and stuff when I asked her for my medicine and told me that she had other people to deal with. RI #6 was asked what the nurse said. RI #6 replied, She told RI #5 to shut the [OBSCENITY] ing hell up and told me that she knew people that were low down that would take care of my ass. RI #6 was asked what it was considered when EI #7 made those statements. RI #6 stated, It was abuse, verbal abuse, like when you talk smart to somebody or go off on them that is verbal abuse. If she had hit me it would have been physical. When she told RI #5 to shut the [OBSCENITY] up it was verbal abuse and it was uncalled for. RI #6 was asked how he/she felt when EI #7 said those things. RI #6 said, It made me feel bad and made me cry. It hurt my feelings and when I feel bad, I cry. In an interview on 5/19/2021 at 11:01 AM, EI #5, a Certified Nursing Assistant(CNA), was asked had she ever witnessed a staff member curse a resident. EI #5 said yes, she heard EI #7, RN, yell at RI #5 to shut the [OBSCENITY] up. In an interview on 5/20/2021 at 6:07 PM, EI #1, the Administrator, was asked what the determination of the investigation was concerning EI #7 and RI #5 and RI #6 that you reported on 3/25/2021. EI #1 stated, It was substantiated as verbal abuse. EI #1 was asked why she substantiated it. EI #1 said, Even though EI #7 did not admit to making the statements, both residents and another staff member witnessed it and other staff reported that she had been hateful to some of them as well. EI #7 was terminated and I in-serviced the team on abuse and also reviewed the Elder Justice Act and made sure that they knew who the abuse coordinator was, which is me. ************************* Once the facility became aware that EI #7, an RN, cursed at RI #5 and RI #6, the facility implemented the following corrective actions: * EI #7 was suspended and not allowed back to work pending the investigation findings. EI #7 last worked in the facility on 3/24/2021. EI #7's employment with the facility was terminated on 4/1/2021. * The facility timely reported the allegation and the subsequent findings to the Alabama Department of Public Health, the facility's Medical Director and the representatives of the residents involved. * The facility's licensed staff assessed the residents affected. All other residents were assessed and interviewed with no concerns noted. * The facility conducted staff in-service regarding Abuse Prevention, specific to Code of Conduct - Service Standards and Elder Justice Act. ************************* After review of the facility's investigation file, in-service/education records, staff and resident interviews, the facility implemented corrective actions from 3/25/2021 to 4/7/2021. This deficiency was cited as a result of the investigation of complaint/report number AL 379.

Based on observation, medical record review and interviews, the facility failed to ensure a care plan was developed and implemented when Resident Identifier (RI) #10 developed a diabetic ulcer to his/her left lateral foot on 3/18/2021. This affected RI #10, one of ten residents whose care plans were reviewed. Findings Include: RI #10 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/18/2021 at 1:05 PM, the surveyor observed RI #10 sitting on the side of the bed. RI #10's feet were bare, and I observed a wound on his/her left lateral foot and second toe right foot. In an interview on 5/18/2021 at 3:57 PM, Employee Identifier (EI) #2, Licensed Practical Nurse (LPN)/Treatment Nurse was asked what areas she was treating for RI #10. EI #2 said a diabetic ulcer to left lateral foot. EI #2 was asked what care plans should be in place for RI #10's wound. EI #2 stated an at risk for and an actual wound care plan. EI #2 was asked to review RI #10's care plans and was asked did RI #10 have a care plan for his/her diabetic foot ulcer. EI #2 said he/she does not. EI #2 was asked should RI #10 have a care plan for the diabetic ulcer. EI #2 said yes. EI #2 was asked what the concern with RI #10 was not having a wound care plan. EI #2 replied that it was not being taken care of properly. EI #2 was asked what could happen if the wound was not taken care of properly. EI #2 said infection and worsening of the wound. On 5/20/2021 at 7:32 PM, an interview was conducted with EI #8, Registered Nurse (RN)/MDS (Minimum Data Set) Coordinator. EI #8 was asked who was responsible for care plans. EI #8 said that would be her. EI #8 was asked should RI #10 have a care plan for a diabetic foot ulcer. EI #8 stated yes, and he/she does now because she put it on May 18th. EI #2 was asked when the care plan should have been implemented. EI #8 said upon us finding the diabetic ulcer. EI #8 was asked RI #10's wound evaluation documented the ulcer was identified on 3/18/2021, was that the date she was referring to that it should have been implemented. EI #8 stated yes. EI #8 was asked what was the concern with RI #10 not having a current care plan in place. EI #8 stated not being able to communicate the care of RI #10's diabetic ulcer and making all staff aware of his/her ulcer. EI #8 was asked what could result in the the staff not being aware of the ulcer and how to provide care. EI #8 stated infection, skin breakdown and possibility of worsening of the wound.

Based on interviews and review of Employee Identifier (EI) #1, the Administrator and EI #2, the Director of Nursing Service's JOB DESCRIPTION, the Administrator and DNS, responsible for the overall day to day operations of the facility and nursing department, failed to ensure routine and outbreak testing for COVID-19 was performed as directed by the Centers for Medicare & Medicaid Services (CMS) and the facility's policy. They further failed to ensure there was delegation of duties for COVID-19 testing when the DNS, who serves as the Infection Preventionist, was not present in the facility. The Administrator further failed to provide monitoring and oversight to ensure residents and staff were tested at the required frequency for COVID-19. These deficient practices placed all residents currently residing in the facility in immediate jeopardy as it was likely to cause serious injury, harm, impairment or death. On 12/4/2020 at 9:43 PM, the Administrator, Assistant Director of Nursing Service and the Senior Director of Clinical Operations were given a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy in the area of Administration, F835. Findings include: The facility failed to conduct routine and outbreak testing for seven of 12 sampled residents and 41 of 42 sampled staff, when it was indicated. Since the week ending 10/7/2020, the facility's county positivity rate has been greater than 10%, which indicates routine testing of staff twice per week. The facility failed to consistently conduct routine testing for the months of October and November 2020. Furthermore, the facility failed to conduct outbreak testing when Unsampled Resident #1, UR #2, UR #3 and Employee Identifier (EI) #6 tested positive for COVID-19. Refer to F886 The undated, unsigned Director of Nursing (Director of Nursing Service) POSITION DESCRIPTION documented . ACCOUNTABILITY OBJECTIVE: Manages the Department of Nursing in accordance with policy and procedure, state and federal regulations to promote high quality care and service to the facility and community. KEY RESPONSIBILITIES . 1. Implements policies/procedures . to ensure compliance; . 4. Directs and delegates management of professional and ancillary nursing personnel . In a telephone interview on 12/2/2020 at 12:03 PM, EI #2, the DNS was asked where the breakdown occurred in not testing the staff for COVID-19 as required. EI #2 stated accountability, not holding staff accountable to show up and be tested . When asked whose responsibility it was to ensure the staff showed up to be tested for COVID-19, EI #2 stated it was his responsibility. When asked has he followed the facility's policy for staff testing, EI #2 said no. EI #2 was asked what the concern was with not testing the staff as required. EI #2 replied, there was a potential for staff to bring COVID-19 into the facility. EI #2 explained this was just an oversight on him. According to EI #2, the Assistant DNS was his backup; however, she was out of the facility for an extended period of time on medical leave. In a follow-up interview on 12/4/2020 at 9:43 AM, EI #2, the DNS acknowledged he was responsible for COVID-19 testing in the facility. According to EI #2, the facility was currently in the red zone (greater than 10%), which requires twice weekly testing. EI #2 stated the facility has been in the red zone ever since the numbers started to be reported. When asked if the staff was tested twice weekly, EI #2 replied, no not all of them. When asked why not, EI #2 stated due to oversight, not holding staff accountable to show up and be tested , and him having to perform other duties. The undated, unsigned Administrator POSITION DESCRIPTION documented Accountability Objective Directs, oversees and manages the 24/7 day to day operations of the Diversicare post-acute care center. Key Responsibilities . * Ensures compliance with State and Federal Regulations; . In an interview on 12/2/2020 at 3:39 PM, EI #1, the Administrator stated the DNS, EI #2, was responsible for COVID-19 testing in the facility. EI #1 was asked during the month of November 2020 was the staff tested twice weekly for COVID-19. EI #1 answered, the facility's current records indicate it was not done. When asked if the staff was tested twice weekly in the months of September and October 2020, EI #1 stated she was still reviewing that information. EI #1 was asked to explain the breakdown in the staff COVID-19 testing. EI #1 stated there was no Director of Clinical Education, the ADNS was out due to illness for an extended period of time, and the DNS was covering medication carts, flu and pneumonia vaccinations, staffing schedules and other nursing duties. EI #1 was asked if she was tested twice weekly for the month of November 2020. EI #1 answered no. When asked what the concern was in not testing the staff as required, EI #1 replied transmission of COVID-19 to residents or other staff members, which could lead to sickness, death or other health issues. EI #1 was asked if the facility's policy was followed to ensure staff were tested for COVID-19 as required. EI #1 replied, no. In a follow-up interview on 12/4/2020 at 1:02 PM, EI #1, the Administrator was asked how did she become aware staff were not being tested according to the county's positivity rate. EI #1 explained she became aware when she was completing the log for the State Surveyor on Tuesday, 12/2/2020. When asked what she did after becoming aware of the concern, EI #1 stated she immediately put a plan of correction in place and started inservicing the staff on the requirement to be tested twice weekly. When asked who was responsible to ensure staff and residents were tested , EI #1 stated the DNS, EI #2. When asked who was responsible to ensure EI #2 performed his assigned job duties, EI #1 stated she was. According to EI #1, she was ultimately responsible for ensuring the staff and residents were tested as directed by CMS guidelines and the facility's policy. When asked how EI #2, the DNS was to conduct staff and resident testing when he worked the medication cart, assisted with showers and other Certified Nursing Assistant duties, EI #1 stated they should have had someone in place to assist the DNS (EI #2) with testing. EI #1 was asked what was the result of not having someone in place to assist the DNS. EI #1 replied, there was testing that was not completed per guidelines for residents and staff. ************************* The facility submitted an acceptable Removal Plan on 12/6/2020 at 6:26 PM, which documented: F835 Administration - . *The Administrator, Director of Nursing Service, Assistant Director of Nursing Service and the Director of Clinical Education was educated by the Senior Director of Clinical Operations regarding their roles and responsibilities in the implementation of infection control practices and procedures as outlined in Appendix PP, CDC recommendations related to COVID-19, Facility Policies and Practices for Infection Control and the Facility overview of the role of Infection Preventionist are implemented to decrease the transmission and spread of the COVID-19 Virus by 12.06.2020 *The Director of Clinical Education (DCE) was delegated as backup for the Director of Nursing Services who functions as the ICP. The Director of Clinical Education and/or ADNS will conduct all surveillance and testing duties when the DNS is not in the center to assure accurate and complete infection control practices and appropriate and timely testing and documentation based on the county positivity rates for the facility *The Director of Nursing Service and/or Director of Clinical Education will provide Resident and staff testing logs to the Administrator for review of frequency of testing based on the county positivity rate weekly. The Director of Nursing Service, Assistant Director of Nursing Service and/or the Director of Clinical Education will conduct Infection Control Rounds daily. *The Regional Senior Director of Operations was provided with education by the Senior Vice President of Clinical Operations on 12.06.2020 regarding the expectations of monitoring infection control practices to include at a minimum; testing per county positivity rate with documentation for team members and residents, infection control line listing, PPE compliance and hand hygiene. The resident and team member rosters will be used to assure all have been tested appropriately. The Regional Senior Director of Clinical Operations will report findings to the Administrator and the Regional Vice President for any follow-up as needed. Results will be reported to month QAPI. *The Regional Senior Director of Clinical Operations will oversee the facility implementation of infection Control Policies & procedures by weekly visits to review testing logs for Residents and staff as well as Infection Control rounds during visits to assure compliance. *A focused QAPI meeting addressing the Survey findings was initiated and completed on 12/05/2020 at 11:30 AM with the attendance of the Administrator, Regional Vice President, Regional Senior Director of Clinical Operations, Medical Director, DNS, ADNS, DEC and LPN Charge Nurse per on-line video conference. *The facility will review the removal plan on a daily basis and make changes to achieve substantial compliance from recommendations from the facility QAPI committee. * The facility requests that the Immediate Jeopardy be removed on 12.06.2020 ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F835 was lowered to a F level on 12/7/2020, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 616.

Based on interviews, review of the Centers for Medicare & Medicaid Services QSO (Quality, Safety & Oversight)-20-38-NH, the facility's policy titled Education, Prevention & Response Guide, the Patient COVID-19 Roster, the Team Member Testing Log, the Team Member COVID-19 Roster, the TEAM MEMBER TESTING DATES and data.cms.gov, the facility failed to conduct routine and outbreak testing for seven of 12 sampled residents and 41 of 42 sampled staff, when it was indicated. Since the week ending 10/7/2020, the facility's county positivity rate has been greater than 10%, which indicates routine testing of staff twice per week. The facility failed to consistently conduct routine testing for the months of October and November 2020. Furthermore, the facility failed to conduct outbreak testing when Unsampled Resident #1, UR #2, UR #3 and Employee Identifier (EI) #6 tested positive for COVID-19. These deficient practices placed all residents currently residing in the facility in immediate jeopardy as it was likely to cause serious injury, harm, impairment or death. On 12/4/2020 at 9:43 PM, the Administrator, Assistant Director of Nursing Service and the Senior Director of Clinical Operations were given a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy in the area of COVID-19 Testing - Residents & Staff, F886. Findings include: The Centers for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey & Certification Group Ref: QSO-20-38-NH dated 8/26/2020, documented . Memorandum Summary . facilities are required to test residents and staff, including individuals providing services under arrangement and volunteers, for COVID-19 based on parameters set forth by the HHS (Health and Human Services) Secretary. This memorandum provides guidance for facilities to meet the new requirements. GUIDANCE FOR F886 Testing of Nursing Home Staff and Residents To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set for by the HHS Secretary . Testing of Staff and Residents in Response to an Outbreak An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [MEDICAL CONDITION] transmission . Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that tested negative should be retested every 3 to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result . Routine Testing of Staff Routine testing should be based on the extent of [MEDICAL CONDITION] in the community, therefore facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency . According to Table 2: Routine Testing Intervals Vary by Community COVID-19 Activity Level indicated if the community COVID-19 activity is medium, the county positivity rate is between 5% and 10%, the facility should perform testing at a minimum of once a week. If the community COVID-19 activity is high, the county positivity rate is greater than 10%, the facility should be testing at a minimum of twice a week. The facility's policy titled, Education, Prevention & Response Guide dated 11/6/2020 documented Appendix J. COVID-19 Testing Regulations The following guidance is in compliance with CMS QSO memo 20-38 . Testing Frequency There are three triggers for testing: symptomatic, outbreak and routine/surveillance. Outbreak Testing: Test all team members and residents in response to an outbreak (defined as any single new infection in team member or any center onset infection in a resident). Continue to test all team members and residents that previously tested negative every three to seven days until testing identifies no new cases of COVID-19 infection among team members or residents for a period of at least 14 days since the most recent positive result. Routine Testing: All residents, regardless of previous COVID-19 test result status, must be tested every 90 days. Test all team members based on the extent of [MEDICAL CONDITION] in the community, using CMS published county positivity rate in the prior week as the trigger for team member testing frequency . According to the facility's Patient COVID-19 Roster a COVID-19 specimen was collected on 9/29/2020 for Unsampled Resident (UR) #1. On 9/30/2020, it was determined UR #1 was positive for COVID-19. The facility was unable to provide evidence of outbreak testing for Resident Identifier (RI) #1, RI #2, RI #3, RI #4, RI #5, RI #6 and staff for the month of October 2020, after UR #1 was confirmed COVID-19 positive. RI #7 was tested during the month of October 2020 on 10/2/2020, 10/9/2020 and 10/14/2020. According to the facility's Patient COVID-19 Roster a COVID-19 specimen was collected on 10/2/2020 for UR #2. On 10/3/2020, it was determined UR #2 was positive for COVID-19. The facility was unable to provide evidence of outbreak testing for RI #1, RI #2, RI #3, RI #4, RI #5, RI #6 and staff for the month of October 2020, after UR #2 was confirmed COVID-19 positive. RI #7 was tested during the month of October 2020 on 10/2/2020, 10/9/2020 and 10/14/2020. According to the facility's Patient COVID-19 Roster a COVID-19 specimen was collected on 10/9/2020 for UR #3. On 10/10/2020, it was determined UR #3 was positive for COVID-19. The facility was unable to provide evidence of outbreak testing for RI #1, RI #2, RI #3, RI #4, RI #5, RI #6 and staff for the month of October 2020, after UR #3 was confirmed COVID-19 positive. RI #7 was tested during the month of October 2020 on 10/2/2020, 10/9/2020 and 10/14/2020. The facility's undated TEAM MEMBER TESTING DATES document indicated Employee Identifier (EI) #6, a housekeeper, tested positive for COVID-19 on 10/26/2020. The facility was unable to provide evidence of outbreak testing for RI #1, RI #2, RI #3, RI #4, RI #5, RI #6, RI #7 and staff after it was confirmed EI #6 was COVID-19 positive. According to data.cms.gov, the facility's county positivity rate was: For the week ending 9/30/2020, 9.8% For the week ending 10/7/2020, 10.0% For the week ending 10/14/2020, 11.2% For the week ending 10/21/2020, 13,9% For the week ending 10/28/2020, 17.5% For the week ending 11/4/2020, 19.2% For the week ending 11/11/2020, 15.3% For the week ending 11/18/2020, 18.7% For the week ending 11/25/2020, 17.7% For the week ending 12/2/2020, 21.3% Of the facility's 60 employees, 42 employees were reviewed for COVID-testing. Of the 42 employees, 41 employees were not tested according to regulations and the facility's policy during the months of October and November 2020 per the Team Member COVID-19 Roster and the Team Member Testing Log. In an interview on 12/2/2020 at 8:39 AM, EI #7, a Licensed Physical Therapy Assistant (LPTA) stated she was last tested for COVID-19 on 11/30/2020. EI #7 stated for about a couple of weeks, she was not tested at all for COVID-19. When asked what the concern was with not being tested as required, EI #7 stated exposure to COVID-19 for the residents. According to documents provided by the facility, EI #7 was not tested 12 times during the month of October and November 2020 as required. In an interview on 12/2/2020 at 8:44 AM, EI #8, a Registered Nurse (RN) stated the last time she was tested for COVID-19 was on yesterday, 12/1/2020. When asked how often she should be tested in the facility for COVID-19, EI #8 stated twice a week. When asked if this was being done, EI #8 stated sometimes yes and sometimes no. EI #8 was asked if the facility was consistently testing for COVID-19 as required and she said no. According to documents provided by the facility, EI #8 was not tested seven times during the month of October and November 2020 as required. In an interview on 12/2/2020 at 8:53 AM, EI #9, a Certified Nursing Assistant (CNA) stated she couldn't recall the last time she was tested for COVID-19 in the facility. When asked how often she should be tested , EI #9 stated twice a week. EI #9 stated she has not expressed any concern with not being tested because she has been busy doing her work. When asked what the concern was with not being tested as required, EI #9 stated she could be positive for COVID-19 and potentially spread it to other residents. According to documents provided by the facility, EI #9 was not tested 10 times during the month of October and November 2020 as required. On 12/2/2020 at 9:06 AM, EI #10, a CNA stated the staff was supposed to be tested twice a week for COVID-19; however, she has not been tested since sometime in September/October. When asked what the concern was with not being tested as required, EI #10 stated spreading COVID-19 to the residents. According to documents provided by the facility, EI #10 was not tested 11 times during the month of October and November 2020 as required. On 12/2/2020 at 11:09 AM, EI #11, a floor technician stated he has never tested positive for COVID-19. When asked how often he should be tested for COVID-19, EI #11 said twice a week. When asked has this been occurring, EI #11 said no. EI #11 was asked what the concern was with not conducting staff testing as required. EI #11 replied, one could spread COVID-19 to residents who are vulnerable. According to documents provided by the facility, EI #11 was not tested seven times during the months of October and November 2020 as required. In a telephone interview on 12/2/2020 at 12:03 PM, EI #2, the DNS/Infection Preventionist (IP) was asked where the breakdown occurred in not testing the staff for COVID-19 as required. EI #2 stated accountability, not holding staff accountable to show up and be tested . When asked whose responsibility it was to ensure the staff showed up to be tested for COVID-19, EI #2 stated it was his responsibility. When asked has he followed the facility's policy for staff testing, EI #2 said no. EI #2 was asked what the concern was with not testing the staff as required. EI #2 replied, there was a potential for staff to bring COVID-19 into the facility. EI #2 explained this was just an oversight on him. According to EI #2, the Assistant DNS was his backup; however, she was out of the facility for an extended period of time on medical leave. In a follow-up interview on 12/4/2020 at 9:43 AM, EI #2, the DNS/IP acknowledged he was responsible for COVID-19 testing in the facility. According to EI #2, the facility was currently in the red zone (greater than 10%), which requires twice weekly testing. EI #2 stated the facility has been in the red zone ever since the numbers started to be reported. When asked if the staff was tested twice weekly, EI #2 replied, no not all of them. When asked why not, EI #2 stated due to oversight, not holding staff accountable to show up and be tested , and him having to perform other duties. During an interview on 12/2/2020 at 3:15 PM, EI #3, the Assistant DNS was asked has the facility's policy been followed to ensure staff were tested for COVID-19 twice weekly when the county positivity rate was greater than 10%. EI #3 replied, no. On 12/3/2020 at 6:29 PM, an interview was conducted with EI #3, the Assistant DNS. EI #3 was asked how she became aware staff were not being tested according to the county's positivity rate. EI #3 said when they were compiling things for the survey. According to EI #3, she had been out of facility on medical leave from 7/2/2020 until 11/11/2020. EI #3 was asked what her role in COVID-19 testing was for residents and staff. EI #3 stated prior to survey, she was assisting the DNS (EI #2) as needed. When asked what system was in place for ensuring the residents and staff were tested according to regulatory guidelines and county positivity rate, EI #3 replied, from her audit she could not tell there was one. EI #3 was asked what the concern was with not having a system in place to ensure the residents and staff were tested as required. EI #3 replied, there were no checks and balances to ensure they are all tested according to guidelines, which could potentially lead to transmission of COVID-19. In an interview on 12/2/2020 at 3:39 PM, EI #1, the Administrator stated the DNS (EI #2) was responsible for COVID-19 testing in the facility. EI #1 was asked during the month of November 2020 was the staff tested twice weekly for COVID-19. EI #1 answered, the facility's current records indicate it was not done. When asked if the staff was tested twice weekly in the months of September and October 2020, EI #1 stated she was still reviewing that information. EI #1 was asked to explain the breakdown in the staff COVID-19 testing. EI #1 stated there was no Director of Clinical Education, the ADNS was out due to illness for an extended period of time, and the DNS was covering medication carts, flu and pneumonia vaccinations, staffing scheduled and other nursing duties. EI #1 was asked if she was tested twice weekly for the month of November 2020. EI #1 answered no. When asked what the concern was in not testing the staff as required, EI #1 replied transmission of COVID-19 to residents or other staff members, which could lead to sickness, death or other health issues. EI #1 was asked if the facility's policy was followed to ensure staff were tested for COVID-19 as required. EI #1 replied, no. In a follow-up interview on 12/4/2020 at 1:02 PM, EI #1, the Administrator was asked how she became aware staff were not being tested according to the county's positivity rate. EI #1 explained she became aware when she was completing the log for the State Surveyor on Tuesday, 12/2/2020. When asked what she did after becoming aware of the concern, EI #1 stated she immediately put a plan of correction in place and started inservicing the staff on the requirement to be tested twice weekly. When asked who was responsible to ensure staff and residents were tested , EI #1 stated the DNS, EI #2. When asked who was responsible to ensure EI #2 performed his assigned job duties, EI #1 stated she was. According to EI #1, she was ultimately responsible for ensuring the staff and residents were tested as directed by CMS guidelines and the facility's policy. When asked how EI #2, the DNS was to conduct staff and resident testing when he worked the medication cart, assisted with showers and other Certified Nursing Assistant duties, EI #1 stated we should have had someone in place to assist the DNS (EI #2) with testing. EI #1 was asked what the result was of not having someone in place to assist the DNS. EI #1 replied, there was testing that was not completed per guidelines for residents and staff. ************************* The facility submitted an acceptable Removal Plan on 12/6/2020 at 6:26 PM, which documented: F886 Testing - . * All residents were tested for week ending 12/06/2020 and test results verified by the Regional Senior Director of Clinical Operations on 12.06.2020. Resident census was 61, 49 residents tested negative, 1 refusal and 11 previously tested positive, which includes 1 new positive for the week * All team members were tested twice by the Assistant Director of Nursing and the Director of Clinical Education per positivity rates for week ending 12.06.2020. Results will be reviewed when available by the Senior Director of Clinical Operations, the Assistant Director of Nursing and the Administrator with appropriate actions taken. For week ending 12.06.2020 the facility has 60 staff members, 2 new positive for the week, 3 staff members in 90 day window for retesting. All staff notified that no one will work without testing weekly based on the county positivity rates. * A schedule was developed by the Administrator for testing of residents and staff and posted within the facility as well as included in the education provided for all staff. * The Regional Senior Director of Operations was provided with education by the Senior Vice President of Clinical Operations on 12.06.2020 regarding the expectations of monitoring infection control practices to include at minimum; testing per county positivity rate with documentation for team members and residents, infection control line listing, PPE compliance and hand hygiene. The resident and team member rosters will be used to assure all have been tested appropriately. The Regional Senior Director of Clinical Operations will report findings to the Administrator and the Regional Vice President for any follow up as needed. Results will be reported to month QAPI. * Education was provided to the Administrator, Director of Nursing Services, Assistant Director of Nursing Services and the Director of Clinical Education on the roles and responsibilities for implementation of the infection control program as well as the testing guidelines/regulations for twice weekly when the positivity rate for the county is greater than 10 percent for team members and weekly for residents that are negative. * Education started immediately for all staff regarding: infection control practices to include appropriate use of personal protective equipment (PPE); hand hygiene; care of the residents in different zones; and requirements of outbreak testing as well as testing using the county positivity rates. * The Director of Nursing Services and/or Director of Clinical Education will provide Resident and staff testing logs to the Administrator for review of frequency of testing based on county positivity rate weekly. The Director of Nursing Service, Assistant Director of Nursing Service and/or the Director of Clinical Education will conduct Infection Control Rounds daily. * The Regional Senior Director of Clinical Operations will oversee the facility implementation of Infection Control Policies & procedures during weekly visits to review testing logs for Residents and staff as well as Infection Control rounds during visits to assure compliance. * The Regional RVP or Designee and/or the Regional Senior Director of Clinical Operations will conduct weekly visits to assure that if the DNS is not present to function as the ICP, the DCE is present and able to function as the ICP. * A focused QAPI meeting addressing the Survey findings was initiated and completed on 12/05/2020 at 11:30 AM with the attendance of the Administrator, Regional Vice President Regional Senior Director of Clinical Operations, Medical Director, DNS, ADNS, DCE, and LPN Charge Nurse per on-line video conference. * The facility will review the removal plan on a daily basis and make changes to achieve substantial compliance from recommendations from the facility QAPI committee * The facility requests that the Immediate Jeopardy be removed on 12.06.2020 ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F886 was lowered to a F level on 12/7/2020, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 616.

Based on medical record review, review of Resident Identifier (RI) #47's Clinical Health Status Evaluation 1.0-V2 assessment, Resident Assessment Instrument Manual and interview, the facility failed to ensure baseline care plans, including a risk for falls, were developed and implemented with instructions necessary to direct RI #47's care within 48 hours after RI #47's admission to the facility on [DATE]. This affected RI #47, one of 22 residents sampled for care plans. Findings Include: The Centers for Medicaid and Medicare, Resident Assessment Manual, Version 3.0, Chapter 2, page 2-41, documented: .2.7 The Care Area Assessment (CAA) Process and Care Plan Completion . Within 48 hours of admission to the facility, the facility must develop and implement a Baseline Care Plan for the resident that includes instructions needed to provide effective and person-centered care . A facility document titled, Clinical Health Status Evaluation 1.0-V2, Effective Date 04/29/2019, documented: .1. Evaluation Type 1. Admission .2. Medications 1. Antipsychotic Yes .4. Psychosocial . 2. Behaviors .f. Resistant to care . 6. Fall Risk Factors 1. Impairment in gait or balance a. Yes . 6. Diminished awareness of safety a. Yes . 9. Medications include . [MEDICAL CONDITION] . a. Yes . Any Yes answer indicates Fall Risk - Proceed to Care Plan . RI #47 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #47's medical record revealed no baseline care plans were present in the medical record. All care plans had an initiation date of 05/07/19; nine days after RI #47's admission. On 05/20/19 at 5:50 p.m., an interview was conducted with Employee Identifier (EI) #5, Registered Nurse/Director of Nursing. EI #5 was asked when was RI #47 admitted to the facility. EI #5 said 04/29/19. EI #5 was asked what baseline care plans were put in place at that time. EI #5 replied, none. EI #5 was asked according to RI #47's Clinical Health Status Evaluation assessment on admission, what care plans should have been put in place. EI #5 answered, Dementia, Diabetes, Constipation, Falls, Antipsychotic, Behaviors, ADLS( activity of daily living), Bowel and Bladder, were some. EI #5 was asked what was the concern with a resident not having baseline care plans to direct their care. EI #5 said, they (staff) would not know how to take care of them (residents). EI #5 was asked how many falls had RI #47 sustained since admission to the facility. EI #5 replied, four. EI #5 was asked when the fall care plan was initiated for RI #47. She replied, 05/07/19. EI #5 was asked what interventions were in place at the time of the resident's falls. She replied none.

Based on observations, record reviews, interviews and a facility policy titled, Medication Storage Storage of Medication, the facility failed to ensure vials of nebulization solutions were properly stored and not left on Resident Identifier (RI) # 68's bedside table. This affected 1 of 21 sampled residents. Findings Include: The facility policy titled, Medication Storage Storage of Medication, with a date of 09/18, revealed: POLICY: Medications and biological are stored properly . The medication supply shall be accessible only to licensed nursing personnel . PR[NAME]EDURES 1. Medications are to remain in these containers and stored in a controlled environment. . 3. In order to limit access to prescription medications, only licensed nurses . should remain locked when not in use . RI #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #68's (MONTH) 2019 Physician order [REDACTED].>On 05/18/19 at 10:42 AM, the surveyor observed a nebulizer machine and 4 vials of [MEDICATION NAME] lying on top of the resident's bedside night stand. On 05/18/19 at 3:42 PM, the surveyor observed the nebulizer machine and 4 vials of [MEDICATION NAME] lying on top of resident's bedside night stand. On 05/19/19 at 10:23 AM, the surveyor observed the nebulizer and 4 vials of [MEDICATION NAME] lying on top of resident's bedside night stand. On 05/19/19 at 10:38 AM, Employee Identifier (EI) #4 Licensed Practical Nurse (LPN), was asked if RI #68 was currently receiving breathing treatments. EI #4 replied, no ma'am, none right now. The surveyor asked EI #4 why was the nebulizer breathing machine and four vials of [MEDICATION NAME] at the bedside of RI #68. EI #4 replied, she did not know. On 05/20/19 at 01:16 PM, EI #2 Registered Nurse (RN)/ Assistant Director Of Nursing, was asked was RI #68 currently receiving breathing treatments. EI #2 replied, no ma'am. The surveyor asked when was the last time RI #68 received a breathing treatment. EI #2 replied, 04/23/2018. Surveyor asked EI #2, on 05/19/19 was she aware of a nebulizer machine and 4 Vials of [MEDICATION NAME] Inhalation Solution 3 milliliters removed from RI #68's room. EI #2 replied, yes. EI #2 was asked if RI #68 have an order for [REDACTED].#2 replied, no. On 05/20/19 at 04:28 PM, EI #3 RN/ Clinical Educator, was asked what date was the last nebulizer treatment ordered for RI #68. EI #3 replied, 04/10/18. EI #3 was asked if medication should be stored in resident rooms upon completion of physician's orders [REDACTED].

Based on observation, record review, interviews and review of the Potter and Perry, Fundamentals of Nursing manual, the facility failed to ensure RI #16's nasal spray and inhaler were cleaned after medication administration and prior to storing them in the medication cart. A review of POTTER AND PERRY, FUNDAMENTALS OF NURSING, NINTH EDITION, CHAPTER 32, Medication Administration, BOX 32-16 PR[NAME]EDURAL GUIDELINES, Administering Nasal Medications, documented: 16. Administer nasal spray: .18. Wipe tip of bottle with clean, dry tissue and replace the cap, .remove and dispose of gloves and perform hand hygiene. RI #16 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #16's Physician order [REDACTED]. 1 inhalation inhale orally . On 05/20/19 at 8:16 a.m., Employee Identifier (EI) #6 was observed during medication pass observation for RI #16. EI #6 was observed capping RI #16's nasal spray after it was administered without cleaning the tip and placing the cap back on RI #16's inhaler without wiping the mouthpiece and storing them in the medication cart. On 05/20/19 at 1:51 p.m., an interview was conducted with EI #6, RN (Registered Nurse). EI #6 was asked what should be done after administration of nasal spray. EI #6 said the bottle should be wiped down with antibacterial wipes and the tip should be wiped with a tissue. EI #6 was asked did she clean RI #16's nasal spray before she placed it in the box and into the medication cart. EI #6 replied, she did not. EI #6 was asked what should be done after an inhaler was administered. EI #6 stated, wipe it down and return it to the tray because RI #16's was in a metal tray. EI #6 was asked did she clean RI #16's inhaler before she placed it in the tray and back in the medication cart. EI #6 said no. EI #6 was asked what was the concern with not cleaning the nasal spray and inhaler prior to putting them back in the container and storing them in the medication cart. EI #6 answered, introducing bacteria in the rest of her cart and infection control. On 05/20/19 at 4:28 p.m., an interview was conducted with EI #3, RN/ Clinical Educator/ Infection Control. EI #3 was asked should nurses clean nasal sprays and inhalers after medication administration and before placing them in containers and storing them in the medication cart. EI #3 said yes.

Based on observation, interview and a facility policy titled, Refrigerated Storage, the facility failed to ensure an opened bag of diced potatoes were labeled with a used by date. This was observed during the initial tour of the kitchen with Employee Identifier (EI) #3, Dietary Manager on 06/12/18 at 8:01 a.m. This had the potential to affect 64 residents receiving meals from the kitchen. The facility had a census of 66. Findings Include: A facility policy titled: Refrigerated Storage with an Effective Date: (MONTH) 1, 2013, documented: POLICY . PR[NAME]EDURE . 7. All foods will be properly wrapped and/or stored . dated and labeled, . During the initial tour of the kitchen with EI #3 on 06/12/2018 at 8:01 a.m., the surveyor observed an opened bag of diced potatoes, not labeled with a used by date. On 06/12/2018 at 6:21 p.m., an interview was conducted with EI #3. EI #3 was asked should there be a used by date on the opened bag of diced potatoes. EI #3 said yes ma'am. The surveyor asked EI #3 what would happen when there was no used by date. EI #3 said if it was old and it was used, it could make the residents sick. EI #3 was asked what was the potential harm with food items not having a used by date. EI #3 said it could cause the resident to get sick. EI #3 was asked what type symptoms could a resident have. EI #3 replied nausea, vomiting and diarrhea.

Based on interview, record review and a document titled, Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument .Version 3.0, the facility failed to ensure RI (Resident Identifier) #1's Discharge MDS (Minimum Data Set) Tracking Entry was transmitted in a timely manner. This affected one of eighteen sampled residents whose MDS assessments were received. Findings Include: A review of a document titled, Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument .Version 3.0 with a date of (MONTH) (YEAR) revealed: .CH 2 .Assessments for the Resident Assessment Instrument (RAI) . Assessment Management Requirements . for Entry Tracking Records: . 08. Death in Facility Tracking Record . Must be completed when the resident dies in the facility . Must be completed within 7 days after the resident's death, . Must be submitted within 14 days after the resident's death, . RI #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #1 died in the facility on [DATE]. RI #1's Discharge MDS was completed on [DATE], but not submitted to CMS. An interview was conducted with Employee Identifier (EI) #1, MDS Coordinator on [DATE] at 5:10 p.m. EI #1 was asked if RI 1's Discharge/Tracking MDS was transmitted after it was completed. EI #1 said, no it was not. EI #1 was asked when should RI #1's Discharge/Tracking MDS have been transmitted to CMS. EI #1 said 14 days after completion.

Based on record review, interview and review of a policy titled, Disposal of Medications, the facility failed to ensure two signatures were present on all of the non-controlled medication destruction sheets for the month of April, (YEAR). This affected one of 12 months of non-controlled medication destruction sheets reviewed. Findings Include: A review of a facility policy titled, Disposal of Medications with a date of 12/12 revealed: .A non-controlled medication disposition log shall be used for documentation .The log shall contain the following information: .Signatures of the required witnesses . On 06/14/18 at 10:56 AM, the surveyor reviewed the non-controlled medication destruction record and found 11 of 29 pages for (MONTH) (YEAR) had one signature present. 06/14/18 at 0:45 PM the surveyor conducted an interview with EI (Employee Identifier) #5, DON/Director of Nurses. The surveyor asked EI #5 how many signatures should be on the non-controlled medication destruction sheet. EI #5 said two. The surveyor asked EI #5 what month did not have two signatures as required. EI #5 said (MONTH) (YEAR), 11 of 28 pages. On 06/14/18 at 02:29 PM, the surveyor conducted an interview with EI #6, the facility's Consultant Pharmacist. The surveyor asked EI #6 how many signatures should be on the non-controlled medication sheet. EI #6 said two.

Based on interviews and medical record review, the facility failed to ensure a licensed nurse obtained an order to treat Resident Identifier (RI) #1's right foot wound and a wound on RI #1's left lower quadrant wound on the abdomen before providing treatment to those two areas. The facility further failed to provide evidence a surgical wound to RI #3's left fourth toe was treated on 11/02/17, 11/03/17 and 11/04/17. This affected RI #1 and RI #3, two of three sampled residents whose wound treatments were reviewed. Findings Include: 1) RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #1's Treatment Administration Record (TAR) for July 2017 documented the following statement: No site of administration data found for TREATMENT ADMINISTRATION RECORD Review of RI #1's Medication Administration Record [REDACTED]. Review of RI #1's Progress Notes revealed the following on 07/29/17 at 2:33 p.m., signed by Employee Identifier (EI) #4, LPN (Licensed Practical Nurse): Wound to bottom of right foot cleaned with wound cleanser and dressing applied.Wound to LLQ (left lower quadrant) cleaned with wound cleanser and covered with dressing. On 11/06/17 at 3:20 p.m., an interview was conducted with EI #4. The surveyor asked EI #4, how did she become aware of RI #1's open areas. EI #4 said, RI #1's family showed her the dressing on RI #1's foot and asked her when they were going to be changed. EI #4 said she remembered taking the wound cleanser and cleaning it and covering it with a dressing like what was on it. EI #4 was asked, did she write an order for [REDACTED].#4 was asked, did the family mention the areas on the abdomen, back and left and right iliac crests to her. EI #4 responded, the abdomen and the foot were all that she remembered. EI #4 said she cleaned the abdomen with wound cleanser also. EI #4 was asked, if she was supposed to have a physician's orders [REDACTED].#4 said, yes. EI #4 was asked, did she see any evidence of a treatment order on RI #1's orders, MAR indicated [REDACTED]. 2) RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #3's TAR for November 2017 revealed there were blank areas on 11/02, 11/03 and 11/04/ beside the order to cleanse surgical site with wound cleanser and pat dry and cover with secondary dressing and changed QD (every day) every day shift On 11/07/17 at 3:31 p.m., a telephone interview was conducted with EI #2, LPN. EI #2 was asked, could she tell the surveyor why RI #3's treatment record was blank on 11/02/17, 11/03/17 and 11/04/17. EI #2 said, she put a late entry note in under the progress notes and signed her initials on the dates that she did them. EI #2 said she did not know why they did not show up, but she knew she did them. EI #2 said they just were not charted.

Based on interviews and medical record review, the facility failed to ensure Resident Identifier (RI) #1's wounds were treated by licensed staff in a manner to prevent worsening of RI #1's wounds on 07/28/17, 07/29/17 and 07/30/17. This occurred on three of three days that RI #1 resided in the facility. This affected RI #1, one of three residents whose wound care orders were reviewed. Findings Include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #1's medical record revealed no evidence of treatment being provided to RI #1's wounds which were present on RI #1's admission to the facility. Review of RI #1's Treatment Administration Record (TAR) for July 2017 documented the following statement: No site of administration data found for TREATMENT ADMINISTRATION RECORD On 11/06/17 at 1:18 p.m., an interview was conducted with EI (Employee Identifier)#3, Licensed Practical Nurse (LPN). EI #3 was asked, did she perform RI #1's admission assessment on 07/28/17. EI #3 answered, yes. EI #3 was asked to look under the skin section and tell the surveyor what was documented on admission. EI #3 said, diabetes, 1, 2, 3 amputated toes on right foot, total of ten staples on abdomen in four separate surgical sites, right iliac crest (front) open area with drainage, left iliac crest (front) open area, area to bottom of right foot, and abrasion to right knee. The surveyor asked EI #3, did she find any evidence of treatments to those areas in RI #1's chart. EI #3 replied, No. It says no order data found for treatment administration record. On 11/06/17 at 3:20 p.m., an interview was conducted with EI #4, LPN. EI #4 was asked, do she see any evidence of a treatment on RI #1's TAR. EI #4 replied, no. On 11/07/17 at 11:08 a.m., an interview was conducted with EI #1, Registered Nurse/Director of Nursing. EI #1 was asked, were there any evidence for wound treatments for RI #1 during his/her stay. EI #1 said, she did not see any in the PCC (Point Click Care) computer system, but there was an order on a progress note to continue [MEDICATION NAME]. EI #1 said it was on a progress note not an order. EI #1 was asked, should there have been orders and evidence of treatments. EI #1 replied, Yes ma'am. EI #1 was asked, how many areas did RI #1 have. EI #1 answered, eight open and one abrasion. The surveyor asked, when should orders for treatments be obtained. EI #1 responded, Immediately after you know they have an issue. EI #1 was asked, was that done. EI #1 said, No ma'am. EI #1 was asked, if a resident came to the facility with no treatment orders or unclear orders what should be done. EI #1 said, Call the doctor and clarify the orders or obtain an order.

Based on observations, interview, review of a facility policy titled, Personal Protective Equipment - Gloves, and review of a facility document titled, Hand Hygiene Care Audit, the facility failed to ensure a licensed nurse washed his hands when removing his gloves after cleaning Resident Identifier (RI) #2's buttocks during wound care. The facility further failed to ensure a licensed nurse did not place a trash bag that contained soiled items from RI #3's wound care on the floor. This affected RI #2 and RI #3, two of three sampled residents. Findings Include: Review of a facility policy titled, Personal Protective Equipment - Gloves, (Revised August 2009) documented: Highlights Policy Statement . Using Gloves Policy Interpretation and Implementation . 8. Wash your hands after removing gloves. Review of a facility document titled, Hand Hygiene Care Audit, with no date, revealed: Action . 3. Hand washing is done every time you remove gloves. Gloving . 9. Washes hands every time gloves are removed. 1) RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/06/17 at 2:30 p.m., Employee Identifier (EI) #2, Licensed Practical Nurse (LPN)/ Treatment Nurse, was observed performing wound care for RI #2. EI #2 was observed removing his gloves after cleaning RI #2's buttocks. Without washing his hands, EI #2 applied another pair of gloves and pulled the covers over RI #2's exposed area. On 11/07/17 at 9:42 a.m., an interview was conducted with EI #2. EI #2 was asked, when should he wash his hands during wound care. EI #2 said, at the beginning before starting, every time gloves were changed and at the end. The surveyor asked EI #2, when he cleaned RI #2's buttock area and pulled off his gloves on yesterday, did he wash his hands before putting on another pair of gloves. EI #2 replied, no. EI #2 was asked, what concern was not washing his hands after removing his gloves. EI #2 stated, infection control. 2) RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/06/17 at 3:13 p.m., EI #2 was observed performing wound care for RI #3. EI #2 was observed placing a trash bag on RI #3's floor. EI #2 placed the soiled dressing from RI #3's left fourth toe surgical amputation wound into the trash bag along with soiled gloves and discarded paper from items used throughout RI #3's wound care. On 11/07/17 at 9:42 a.m., an interview was conducted with EI #2. EI #2 was asked, where did he put the trash bag during RI #3's wound care on yesterday. EI #2 said, on the floor to the right side. The surveyor asked, what the facility policy said about where to place the trash bag. EI #2 replied, the policy said to put it on the foot of the bed. EI #2 was asked, what concern was placing the trash bag on the floor. EI #2 answered, infection control.

Based on interviews, medical record review and review of a facility document titled, Admission Agreement, the facility failed to ensure Resident Identifier (RI) #1, a continent resident, was not placed in a brief. This affected RI #1, one of three sampled residents. Findings Include: A complaint was received by the State Agency on 08/03/2017. The complainant alleged the facility was short of staff on the weekend and placed RI #1 in a diaper on 07/29/2017, which was unnecessary because the resident was able to go to the bathroom. This made RI #1 feel nasty and humiliated. Review of a facility document titled, Admission Agreement with no date documented: Alabama Your Resident Rights and Protections Under State and Federal Law As a resident of a nursing home, you have the same rights and protections as all United States citizens. Nursing home residents also have certain rights and protections under state and federal law. QUALITY OF LIFE A nursing home must care for you in a manner and environment that promotes the maintenance and enhancement of your quality of life. Dignity and Respect. You have the right to be treated with consideration and respect in full recognition of your dignity and individuality. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/30/17 documented: Urinary Continence.Always continent . Bowel Continence.Always continent . The MDS revealed RI #1 required extensive physical assistance of one person with most Activities of Daily Living (ADLs). On 11/07/17 at 8:06 a.m., an interview was conducted with Employee Identifier (EI) #5, Certified Nursing Assistant (CNA). EI #5 was asked, did she tell RI #1 to use (her/his) diaper and she would clean it. EI #5 said, No ma'am. (She/he) said, I don't know how long I can hold it, I might go in my diaper. I said, if that happens I will be glad to clean you up, but I will be right back to take care of you when I finish with the other resident. On 11/07/17 at 3:13 p.m., a second interview was conducted with EI #5. The surveyor asked EI #5, was RI #1 continent or incontinent. EI #5 replied, (She/he) was continent. EI #5 was asked, why did she provide RI #1 with a brief if (she/he) was continent. EI #5 said, I put one back on (her/him) because (she/he) had one on before and I assumed it was because (she/he) was having trouble getting around and it was in case (she/he) had an accident or something. I don't know who started (her/him) in the brief. I just know (she/he) had one on when I took care of (her/him). The surveyor asked EI #5, was the brief because she was short-handed and for staff convenience and why did she not change (her/him) when (she/he) asked. EI #5 stated, No, I think it was because therapy had not released (her/him) to be up by (herself/himself) and I'm assuming it was put on in case (she/he) had an accident or something. I was busy with another resident. I had just stepped out to get some linen. On 11/07/17 at 3:41 p.m., an interview was conducted with EI #1, Registered Nurse, Director of Nursing. EI #1 was asked, why would someone that was continent be placed in a brief. EI #1 said, That, I don't know. The only thing I can think of is if they are non-ambulatory or unable to stand, pivot and transfer, I would put one on them in case of an accident, if they agree. If they request one, I would give them one.

Based on interviews and medical record review, the facility failed to ensure admission physician's orders were obtained for the immediate care and treatment of [REDACTED].#1's wounds on 07/28/17. This affected RI #1, one of three residents whose physician's orders were reviewed. Findings Include: RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of RI #1's Clinical Health Status Evaluation 1.0 - V2 with an effective date of 07/28/2017, documented: .1. Admitting Information 1. Evaluation Type 1. Admission .12. Skin Condition .has toes 1,2,3 amputated on right foot, ulcer to right foot 5. Skin issues: location and description Site Description 14) Abdomen staples to abdomen intact, 4 separate surgical sites on abdomen consist of total of 10 staples. 19) Right iliac crest (front) open area with drainage 20) Left iliac crest (front) open area. Review of RI #1's Order Review Report with an admission date of [DATE], revealed there were no orders for treatments for the identified skin areas noted on the report. Review of RI #1's Medication Administration Record [REDACTED]. Review of RI #1's TREATMENT ADMINISTRATION RECORD, dated 07/1/2017 through 07/31/2017, documented: No site of administration data found for TREATMENT ADMINISTRATION RECORD. On 11/06/17 at 1:18 p.m., an interview was conducted with EI (Employee Identifier)#3, LPN (Licensed Practical Nurse). EI #3 was asked, did she perform RI #1's admission assessment on 07/28/17. EI #3 answered, yes. EI #3 was asked to look under the skin section and tell the surveyor what was documented on admission. EI #3 said, diabetes, 1, 2, 3 amputated toes on right foot, total of ten staples on abdomen in four separate surgical sites, right iliac crest (front) open area with drainage, left iliac crest (front) open area, area to bottom of right foot, and abrasion to right knee. EI #3 was asked, did she put the admission orders [REDACTED]. The surveyor asked EI #3, after having seen the areas that were documented on the clinical evaluation on RI #1, what should have been done regarding those areas. EI #3 said, We should have made sure there were orders in place for those areas. The surveyor asked EI #3, did she find any treatment orders in RI #1's chart. EI #3 replied, No. It says no order data found for treatment administration record. EI #3 was asked, did she know why RI #1 did not have treatment orders in his/her record. EI #3 said, I don't know. There has to have been a breakdown in communication somewhere. On 11/07/17 at 11:08 a.m., an interview was conducted with EI #1, Registered Nurse/Director of Nursing. EI #1 was asked, if there was any evidence for wound treatments for RI #1 during her stay. EI #1 said, she did not see any in the PCC (Point Click Care) computer system, but there was an order on a progress note to continue [MEDICATION NAME]. It was on a progress note not an order. EI #1 was asked, should there have been orders and evidence of treatments. EI #1 replied, Yes ma'am. EI #1 was asked, how many areas did RI #1 have. EI #1 answered, eight open and one abrasion. The surveyor asked, when should orders for treatments be obtained. EI #1 responded, Immediately after you know they have an issue. EI #1 was asked, was that done. EI #1 said, No ma'am. EI #1 was asked, if a resident came to the facility without treatment orders or unclear orders what should she do. EI #1 said, Call the doctor and clarify the orders or obtain an order. On 11/07/17 at 3:03 p.m., a second interview was conducted with EI #1. EI #1 was asked, what was the protocol for obtaining orders at the time of RI #1's admission. EI #1 said, To call and get orders if they didn't have them if they had wounds. EI #1 was asked, whose responsibility would it have been to obtain those orders for RI #1. EI #1 answered, The admitting nurse. They are responsible regardless if there is a wound nurse or not since they do the admission assessment and will know if they need orders for something. On 11/07/17 at 3:38 p.m., a telephone interview was conducted with EI #3. EI #3 was asked, who was ultimately responsible to obtain the treatment orders for RI #1 on admission. EI #3 said, Me, the admitting nurse.

Based on interviews and a review of residents' bathing records, the facility failed to ensure residents received their showers three times a week as scheduled. This affected Resident Identifiers (RI) #2, #5 and #6, as well as five of eight residents who attended the resident group meeting on 04/12/17. Findings included: The facility provided an undated document titled Bath Schedule that indicated residents were scheduled to receive baths three times per week, either on Mondays, Wednesdays, and Fridays or Tuesdays, Thursdays, and Saturdays. The Group Meeting was held on 04/12/2017 at 10:00 a.m. with eight residents in attendance. Five of the eight residents voiced concerns about not getting their showers as scheduled. The other three indicated they were independent with bathing. However, of these three independent residents, two of them voiced concerns about their roommates not getting showered. RI #2: RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/30/17 determined this resident was cognitively intact (Brief Interview for Mental Status score/BIMS of 14 of a possible 15), and in need of physical help from one staff member during the bathing process. On 04/11/17 at 4:40 p.m., RI #2 stated his/her last shower was two weeks ago, which was common for this hall. The resident stated the day shift wanted him/her to wait until the night shift came on duty and vice versa; it was miserable not having a shower. On 04/13/17 at 8:45 a.m., RI #2 explained his/her showers were scheduled for Tuesday/Thursday/Saturday during the night shift. The bathing records revealed RI #2 was bathed on 01/16/17, then not again until 01/24/17 (eight days later). RI #2 was bathed on 03/09/17, six days later on 03/15/17, seven days later on 03/22/17, and then on 04/03/17 (12 days later). The resident received a bath on 04/09/17 and again three days later, on 04/12/17. RI #5: RI #5 has resided in the facility since 02/17/17 with [DIAGNOSES REDACTED]. The admission MDS with an ARD of 02/24/17 identified this resident as having no cognitive impairments with a BIMS score of 15 of a possible 15. RI #5 was assessed to need the physical help of one staff member with transfers only, during the bathing process. During the initial tour on 04/11/17 at 3:00 p.m., RI #5 complained he/she had not been bathed for four days; that showers had to be requested, because staff did not offer to bathe. On 04/12/17 at 8:00 a.m., RI #5 stated his/her showers were scheduled for Monday/Wednesday/Friday during the 7 a.m. to 7 p.m. shift. The resident explained he/she could bathe independently once assisted into the shower. The resident explained they could ask for a shower and the staff would promise to come, but the staff would not come back. It had happened numerous times. At the request of the surveyors, a bathing record was printed by facility staff on 04/13/17. These records (beginning on 02/18/17) revealed RI #5 was not bathed between 03/22/17 and 03/29/17 (seven days apart). RI #6: RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #6's Quarterly MDS Assessment with an ARD of 03/30/2017 indicated RI #6 had both short and long term memory problems and severely impaired daily decision making skills. This assessment also documented RI #6 was totally dependent on staff for bathing. The facility's Bath Schedule indicated RI #6 was scheduled to have baths three times a week on Tuesdays, Thursdays, and Saturdays, on day shift. During the Group Meeting on 04/12/2017 at 10:00 a.m. RI #6's roommate stated staff were not providing showers to RI #6 as scheduled. Review of RI #6's bathing records from 01/01/2017 through 04/12/2017 revealed the following: In February 2017 RI #6 went 5 days without a bath, from 02/09/2017 until 02/14/2017. In March 2017 RI #6 went 6 days without a bath, from 03/09/2017 until 03/15/2017. In April 2017 RI #6 went 5 days without a bath, from 04/06/2017 until 04/11/2017. The Certified Nursing Assistants (CNAs), Employee Identifier (EI) #s 6 and #18 responsible for the care of RI #2 and RI #5 were interviewed on 04/13/17 regarding the shower protocol. EI #6 stated (at 9:45 a.m.) the facility had a daily list of residents who were to receive showers. EI #6 explained it was her responsibility to provide showers, We all have showers to do. The staff tried to get them when they could, with no set time. The surveyor mentioned residents' complaints of staff who promised to provide showers, but never followed up, and asked why. EI #6 explained there were sometimes only two staff members and they ran out of time. EI #6 stated they lacked staff, needing assistance. EI #18 stated on 04/13/17 at 9:55 a.m. the CNAs worked in teams of two, trying to shower residents before noon. She too explained the Monday/Wednesday/Friday schedule or Tuesday/Thursday/Saturday schedule, leaving Sundays for additional showers as requested by residents. Showers (according to EI #18) were the CNAs' responsibility, and when not given it was because they ran out of time. EI #18 explained they did not have enough help; they had a hard time getting to all the residents on the hall. Employee Identifier (EI) #20, a Registered Nurse (RN) stated during an interview on 04/12/2017 at 11:20 a.m. that there were never enough CNAs to care for the residents. She said the ones they had worked hard but were only able to give residents their showers 70 to 80 percent of the time. During an interview with Employee Identifier (EI) #12, the Director of Nursing Services, on 04/13/2017 at 12:50 p.m., EI #14 said Certified Nursing Assistants (CNAs) document when baths or showers are completed. EI #12 said residents should be bathed or showered per the schedule to promote the residents' well being and make them feel better.

Based on interviews, record review and review of a facility policy titled Falls Management Guidelines'', the facility failed to ensure the information from Resident Identifier (RI) #1's Admission Minimum Data Set (MDS) assessment (1/09/2015) and Quarterly MDS assessment (07/05/2015), which stated RI #1 needed extensive assistance and two plus persons to physical assist when transferring was included in RI #1's Potential for Falls care plan. On October 6, 2015, EI #1 failed to have two or more persons to assist with transferring RI #1 out of bed. During the transfer, EI #1 said RI #1 released his/her hands from the handle bars and slipped out of the lift sling/pad, that was used to support the resident, and fell down in a squatting position. RI #1 complained of pain in the lower legs and x-rays were obtained. The x-ray results showed RI #1 sustained a [MEDICATION NAME] fracture involving the proximal tibia and fibula with no displacement of the right leg and an impacted fracture involving the distal tibia and fibula with no displacement of the left leg. RI #1 was transported to a local hospital for treatment. RI #1, one of three residents sampled, was affected by this deficient practice. Findings Included: RI#1 was admitted to the facility 01/02/2015, with [DIAGNOSES REDACTED]. RI #1's Admission MDS (Minimum Data Set) assessment dated [DATE], assessed in Section G - Functional Status; under G0110, Activities of Daily Living (ADL) Assistance, in Transfers - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet), RI #1 needed Extensive assistance with self performance and two + (plus) persons physical assist with support provided by staff. Under Section G - Balance During Transitions and Walking, Surface - to - surface transfer (transfer between bed and chair or wheelchair), RI #1 was assessed as Not steady, only able to stabilize with staff assistance. Section G0400 - Functional Limitation in Range of Motion, assessed RI #1 had Impairment on both sides in the Lower extremity (hip, knee, ankle or foot). RI #1's CAA (Care Assessment Areas) Worksheet for ADL's with an ARD (Assessment Reference Date) of 01/09/2015, documented: Transfers: . Physical limitations: weakness, limited range of motion, poor coordination, poor balance, visual impairment, pain, etc. Under Care Plan Considerations the following was documented: Will ADL Functional / Rehabilitation Potential -Functional Status be address in the care plan? Yes . RI #1's CAA Worksheet for Falls with an ARD date of 01/09/2015, documented under Analysis of Findings: . Nature of the problem/condition: increased potential for falls . Physical performance limitations: balance, gait, strength, muscle endurance . Impaired balance during transitions . RI #1's Fall care plan documented the following: potential for falls related to: Use of medication New environment, History of falls with hip fx (fracture), Impaired mobility, requires assist with transfers, debility, weakness . OA ([MEDICAL CONDITION]). Date Initiated: 01/15/2015. RI #1's Interventions included: . transfers assistance . A facility policy titled Fall Management Guideline, with an effective date of 01/22/2015, documented the following: . PROCESS: The falls prevention and intervention program includes: . Newly admitted /readmitted residents are assessed for fall risk . Following the completion of the Minimum Data Set (MDS), if a resident triggers at risk for falls, the resident has further assessment utilizing the CAA guidelines . Appropriate interventions are implemented . RI #1's Quarterly MDS assessment dated [DATE], assessed in Section G - Functional Status; under G0110, Activities of Daily Living (ADL) Assistance, in Transfers - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet), RI #1 needed Extensive assistance with self performance and two + (plus) persons physical assist with support provided by staff. Under Section G - Balance During Transitions and Walking, Surface - to - surface transfer (transfer between bed and chair or wheelchair), RI #1 was assessed as Not steady, only able to stabilize with staff assistance. Section G0400 - Functional Limitation in Range of Motion, assessed RI #1 had Impairment on one side in the Lower extremity (hip, knee, ankle or foot). On 10/20/15 at 11:45 a.m., the surveyor conducted an interview with the MDS Coordinator, Employee Identifier (EI) #7. The surveyor asked EI #7 where does the facility gather information to develop the residents' care plan. EI #7 said, from the MDS and CAA assessments, formerly know as the RAPS (Resident Assessment Protocol Summary). The surveyor asked EI #7, if a resident needed to be transferred with a lift, where would that information come from in order to develop a care plan. EI #7 replied, The MDS. Section G - for Transfers and ADL's. A review of RI #1's Progress Notes dated 10/06/2015 at 15:19 (3:19 p.m.) . Note text: Situation: Summoned to room per (by) CNA taking care of (RI #1). Resident in floor. Background: Resident has been resting in bed today. Per staff assist and by the way of Sara lift, resident was being assisted up to go to the shower . Assessment: . Upon entering room, resident noted to be in the floor laying on (RI #1's) back, feet and legs extending out in front . Location of fall was by (RI #1's) bed. Bleeding noted coming from lower extremities. Normal ROM (range of motion) noted to extremities. No abnormality noted to shape of resident extremities . CNA taking care of resident reports that she assisted resident up into the Sara lift and that resident let go of handle bars; when (RI #1) did so, resident began sliding down. This CNA along with another CNA (who was in the room assisting roommate) lowered resident to the floor. As resident was being lowered to the floor, front of lower extremities bumped against the lift, resulting in skin tears. Resident assisted up onto (resident's) bed by way of Marissa lift for further evaluation and tx (treatment) of skin tears. Resident did not bump head during fall. Response: . CRNP (Certified Registered Nurse Practioner) notified of fall . Orders received for bloodwork and x-rays of lower extremities. Message left with sponsor/next of kin to call facility regarding update on resident. This progress Note was documented by EI #2, a LPN. RI #1's Radiology Report dated 10/6/2015, documented the following: TIBIA/FIBULA AP (Anterior Posterior) and LAT (Lateral), LEFT Results: There are impacted fracture involving the distal tibia and fibula with no displacement. The knee and ankle joint are intact in alignment. Conclusion: Recent left lower leg fracture as described. Another Radiology Report for RI #1 dated 10/6/2015, documented the following: TIBIA/FIBULA AP and LAT, RIGHT Results: There is a [MEDICATION NAME] fracture involving the proximal tibia and fibula with no displacement. The knee and ankle joint are intact in alignment. Conclusion: Acute right lower leg fracture as described. On 10/19/15 at 1:45 p.m., the surveyor conducted an interview with the Director Of Nursing (DON), EI #8. The surveyor asked EI #8 if she asked EI #1 if she had a second person to physically assist to transfer RI #1 while on the Sara lift on 10/06/15. EI #8 stated, (EI #1) said no, not to get (RI #1) out of bed, one person can do that with the Sara lift. As long as they were able to bear weight on one foot. The surveyor asked EI #8 how was RI #1 assessed to be transferred according to the Quarterly MDS assessment dated [DATE]. EI #8 stated, According to that, (RI #1) is assessed to be transferred by two people. On 10/20/15 at 8:15 a.m., the surveyor conducted an interview with EI #1, the CNA (Certified Nursing Assistant) caring for RI #1 on 10/06/15 on the 3-11 shift. The surveyor asked EI #1, according to RI #1's care plan for falls and transfers, how many staff members/people are needed to transfer RI #1 when using the Sara lift or just transferring RI #1 from one surface area to another. EI #1 stated, I am not really sure, the day I looked at the care plan it said the stand up lift and you are not required to use 2 (two) people. This was not on (RI #1's name) Kardex. On 10/20/15 at 10:20 a.m., the surveyor conducted an interview with EI #2, the LPN (Licensed Practical Nurse) assigned to care for RI #1 on 10/06/15 on the 3-11 shift. The surveyor asked EI #2 how many staff the Quarterly MDS dated [DATE] assessed RI #1 needed for transfers between surfaces, bed, chair, wheelchair, standing position, excluding toilet /bath. EI #2 stated, Two person to physically assist to transfer. This deficiency is being cited as a result of the investigation of complaint/report number AL 949.

Based on interviews, record review and review of a facility policy titled Transfer Activities, the facility failed to ensure a Certified Nursing Assistant (CNA), Employee Identifier (EI) #1, safely transferred Resident Identifer (RI) #1 with a mechanical lift from the bed to a shower chair. Further, EI #1 failed to have two or more persons to assist her with transferring RI #1 out of bed. During an interview with EI #1, it was determined she attempted to transfer RI #1 from the bed to a shower chair by herself. EI #1 stated on October 6, 2015, when using a mechanically lift to tranfer RI #1, the resident released his/her hands from the handle bars and slipped out of the lift sling/pad, which was used to support the resident, causing the resident to fall into a squatting position. EI #1 said she called for assistance and EI #3, another CNA, entered the room and helped EI #1 lower RI #1 to the floor. After the transfer, RI #1 complained of pain in the lower legs. X-rays were obtained revealing a transverse fracture involving the proximal tibia and fibula with no displacement of the right leg and an impacted fracture involving the distal tibia and fibula with no displacement of the left leg. RI #1 was transported to a local hospital for treatment. RI #1, one of three residents sampled for falls and transfers, was affected by this deficient practice. Findings Included: RI#1 was admitted to the facility 01/02/2015, with [DIAGNOSES REDACTED]. A review of RI #1's medical record revealed on 01/03/15, RI #1 was assessed for transfer capabilities by a Licensed Practical Nurse (LPN), Employee Identifier (EI) #2, using a facility form titled Lift Mobility Status Form. Included in the assessment was RI #1's [DIAGNOSES REDACTED]. Documented on the form was Resident can bear weight on at least one leg? Left leg only was circled. This assessment determined RI #1 was a candidate for a SARA Lift for transfers but failed to indicate the number of staff required with transfers. RI #1's CAA (Care Assessment Areas) Worksheet for ADL's with an ARD (Assessment Reference Date) of 01/09/2015, documented: Transfers: . Physical limitations: weakness, limited range of motion, poor coordination, poor balance, visual impairment, pain, etc. RI #1's CAA Worksheet for Falls with an ARD date of 01/09/2015, documented under Analysis of Findings: . Nature of the problem/condition: increased potential for falls . Physical performance limitations: balance, gait, strength, muscle endurance . Impaired balance during transitions . RI #1's Admission MDS (Minimum Data Set) assessment dated [DATE], assessed in Section G - Functional Status; under G0110, Activities of Daily Living (ADL) Assistance, in Transfers - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet), RI #1 needed Extensive assistance with self performance and two + (plus) persons physical assist with support provided by staff. Under Section G - Balance During Transitions and Walking, Surface - to - surface transfer (transfer between bed and chair or wheelchair), RI #1 was assessed as Not steady, only able to stabilize with staff assistance. Section G0400 - Functional Limitation in Range of Motion, assessed RI #1 had Impairment on both sides in the Lower extremity (hip, knee, ankle or foot). RI #1's Fall care plan documented the following: potential for falls related to: Use of medication New environment, History of falls with hip fx (fracture), Impaired mobility, requires assist with transfers, debility, weakness . OA (Osteoarthritis). Date Initiated: 01/15/2015. RI #1's Interventions included: . transfers assistance . A facility's policy titled Transfer Activities with an effective date of 01/26/2015, documented the following: PROCEDURE PURPOSE: · To transfer the resident from bed to chair, toilet or tub safely. ASSESSMENT GUIDELINES: May include, but not limited to: . · Ability to stand and bear weight . EQUIPMENT: . · Mechanical lift, if necessary. GENERAL INSTRUCTIONS . 4. Obtain help when necessary. PROCEDURE: . 1. Obtain assistance of another individual if necessary for safe transfer . DOCUMENTATION GUIDELINES Documentation may include: . · Amount of assistance resident requires . RI #1's Quarterly MDS assessment dated [DATE], assessed in Section G - Functional Status; under G0110, Activities of Daily Living (ADL) Assistance, in Transfers - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet), RI #1 needed Extensive assistance with self performance and two + (plus) persons physical assist with support provided by staff. Under Section G - Balance During Transitions and Walking, Surface - to - surface transfer (transfer between bed and chair or wheelchair), RI #1 was assessed as Not steady, only able to stabilize with staff assistance. Section G0400 - Functional Limitation in Range of Motion, assessed RI #1 had Impairment on one side in the Lower extremity (hip, knee, ankle or foot). A review of RI #1's Progress Notes dated 10/06/2015 at 15:19 (3:19 p.m.) . Note text: Situation: Summoned to room per (by) CNA taking care of (RI #1). Resident in floor. Background: Resident has been resting in bed today. Per staff assist and by the way of Sara lift, resident was being assisted up to go to the shower . Assessment: . Upon entering room, resident noted to be in the floor laying on (RI #1's) back, feet and legs extending out in front . Location of fall was by (RI #1's) bed. Bleeding noted coming from lower extremities. Normal ROM (range of motion) noted to extremities. No abnormality noted to shape of resident extremities . CNA taking care of resident reports that she assisted resident up into the Sara lift and that resident let go of handle bars; when (RI #1) did so, resident began sliding down. This CNA along with another CNA (who was in the room assisting roommate) lowered resident to the floor. As resident was being lowered to the floor, front of lower extremities bumped against the lift, resulting in skin tears. Resident assisted up onto (resident's) bed by way of Marissa lift for further evaluation and tx (treatment) of skin tears. Resident did not bump head during fall. Response: . CRNP (Certified Registered Nurse Practioner) notified of fall . Orders received for bloodwork and x-rays of lower extremities. Message left with sponsor/next of kin to call facility regarding update on resident. This progress Note was documented by EI #2, a LPN. RI #1's Radiology Report dated 10/6/2015, documented the following: TIBIA/FIBULA AP (Anterior Posterior) and LAT (Lateral), LEFT Results: There are impacted fracture involving the distal tibia and fibula with no displacement. The knee and ankle joint are intact in alignment. Conclusion: Recent left lower leg fracture as described. Another Radiology Report for RI #1 dated 10/6/2015, documented the following: TIBIA/FIBULA AP and LAT, RIGHT Results: There is a transverse fracture involving the proximal tibia and fibula with no displacement. The knee and ankle joint are intact in alignment. Conclusion: Acute right lower leg fracture as described. On 10/19/15 at 1:45 p.m., the surveyor conducted an interview with the Director Of Nursing (DON), EI #8. The surveyor asked EI #8 if she asked EI #1 if she had a second person to physically assist to transfer RI #1 while on the Sara lift. EI #8 stated, (EI #1) said no, not to get (RI #1) out of bed, one person can do that with the Sara lift. As long as they were able to bear weight on one foot. The surveyor asked EI #8 how was RI #1 assessed to be transferred according to the Quarterly MDS assessment dated [DATE]. EI #8 stated, According to that, (RI #1) is assessed to be transferred by two people. On 10/20/15 at 8:15 a.m., the surveyor conducted an interview with EI #1, the CNA caring for RI #1 on 10/06/15 on the 3-11 shift. The surveyor asked EI #1, what happened to RI #1. EI #1 said she got RI #1 up in the stand - up lift by herself. EI #1 said another CNA, EI #3, was in the room changing EI #1's roommate. EI #1 said RI #1 could not stand up any longer and RI #1 let go of the handle bars. EI #1 said RI #1 had been holding on the handle bars about 2 - 3 minutes. EI #1 said the only thing that was holding RI #1 up was the lift pad /sling that was under RI #1's arms. EI #1 said RI #1 squatted down and RI #1's legs were pressed up against the padded shinned guards on the lift. EI #1 said she called for EI #3 to see if they could lift RI #1 up to put RI #1 on the shower chair. EI #1 said EI #3 came over and tried to help her put RI #1 on the shower chair so RI #1 would not fall on the floor. EI #3 said she and EI #3 could not lift RI #1's buttock high enough to place RI #1 on the shower chair. EI #3 said she placed a sheet and pillow on the floor and she and EI #3 lifted RI #1's arms up and unbuckled the lift pad/sling and lower RI #1 to the floor. EI #1 said they realized RI #1's legs were under RI #1's buttocks and RI #1 was sitting on top of her/his legs. EI #1 said she and EI #3 lifted RI #1's thigh and pulled each leg out, one at a time. The surveyor asked EI #1 was there any injury to RI #1's legs. EI #1 said there was a big skin tear on RI #1's right leg and it was bleeding. EI #1 also said there was a little skin tear on RI #1's left leg. The surveyor asked EI #1 was RI #1 complaining of pain. EI #1 said after RI #1 was layed down and RI#1's legs were removed from under the resident, RI #1 did complain of pain. The surveyor asked EI #1 who did she notify about RI #1's injury. EI #1 said she had EI #3 to stay with RI #1 and then she (EI #1) notified the nurse (EI #2). The surveyor asked EI #1 what did EI #2 do when she arrived to RI #1's room. EI #1 said EI #2 assessed RI #1 and asked RI #1 how did she/he feel. EI #2 said EI #2 asked RI #1 if she/he was in any pain and where the pain was coming from. EI #1 said RI #1's legs were hurting. EI #2 said after that, she went to get the Marisa Lift to put RI #1 back to bed. EI #1 said when RI #1 was put back to bed the treatment nurse, EI #4, started cleaning the skin tears and RI #1 started complaining of pain in the right leg, which had the worst skin tear. The surveyor asked EI #1, according to RI #1's care plan for falls and transfers, how many staff members/people were needed to transfer RI #1 when using the Sara lift or just transfers from one surface area to another. EI #1 stated, I am not really sure, the day I looked at the care plan it said the stand up lift and you are not required to use 2 (two) people . The surveyor asked EI #1 if she ever transferred RI #1 before using the Sara lift or any kind of lift. EI #1 said, no sir. The surveyor asked EI #1 to review RI #1's Lift Mobility Status Form dated 01/03/15. After reviewing the form, EI #1 stated it did not say how many staff were required to transfer RI#1. The surveyor asked EI #1 what would she have done if the assessment had been completed and said to use two staff. EI #1 said, I would have gotten the help and used two staff to ensure EI #1 was not hurt. On 10/20/15 at 10:20 a.m., the surveyor conducted an interview with EI #2, the LPN assigned to care for RI #1 on 10/06/15 on the 3-11 shift. The surveyor asked EI #2 what happened to RI #1 on 10/06/15. EI #2 stated, (RI #1) had a fall on October 6, 2015 at approximately 3:20 p.m. I was sitting at the nursing station doing my charting. A CNA (EI #1) told me (RI #1) had a fall and I was needed in room . EI #2 stated, When I got to the room (RI #1) was laying flat on (RI #1's) back with a pillow under the head and the Sara lift - (stand up) was at the base of (RI #1's) feet. (EI #3) and (EI #1) were in the room. I asked (EI #1), who was taking care of (RI #1), what happened. (EI #1) said (RI #1) let go of the handle bars and started sliding (and) with (EI #3's) assistance (RI #1) was lowered to the floor . The surveyor asked EI #2 did RI #1 start complaining of pain. EI #2 stated, After we cleaned the skin tears and the CNA's provided ADL (Activites of Daily Living) care, (RI #1) started complaining of pain in (his/her) legs. The surveyor asked EI #2 if the RI #1's physician and family was notified. EI #2 said she notified the CRNP (Certified Registered Nurse Practitioner) and called the sponsor and left a message for the sponsor to call back. EI #2 said this was around 6:05 p.m. After EI #2 reviewed RI #1's Lift Mobility Status Form dated 1/3/15, the surveyor asked EI #2 how many staff members are needed to transfer RI #1 with the Sara Lift according to this assessment form. EI #2 stated, It does not have a number of staff listed for the lift mobility assessment. EI #2 also said she did not know how many staff were needed to transfer RI #1 according to RI #1's Admission MDS assessment. The surveyor asked EI #2 who was responsible for completing the lift mobility assessment. EI #2 stated, The admitting nurse, that would have been me. The surveyor asked EI #2 if instructions were given to the CNA's on how many staff members were to transfer RI #1. EI #2 stated, No sir. EI #2 stated, We have care sheets and they were not given out that day. The charge nurses are responsible for passing out the care sheets to the CNA's and that did not happen. Why, because I did not do it. EI #2 said she just did not do it. The surveyor asked EI #2 how many staff members, according to the Quarterly MDS dated [DATE], were needed to to transfer RI #1. EI #2 stated, Two person to physically assist to transfer. On 10/19/15 at 1:04 p.m., the conducted a phone interview the facility's Medical Director, EI #6. EI #6 said he was informed by facility staff that RI #1 had fallen because RI #1 let go of the bar on the Sara Lift. EI #6 said he was informed RI #1 slipped while standing on the Sara lift. The surveyor asked EI #6 what kind of injury RI #1 received from the incident. EI #6 said RI #1 had 4 broken bones in the legs according to the X-rays results. The surveyor asked EI #6 since the the X-ray's revealed RI #1 sustained a transverse (Left Lower Leg) fracture and a (Right Lower Leg) Impacted fracture, how were each fracture acquired. EI #6 said, a transverse fracture you could get just by laying in bed, it is a pathological fracture and an Impacted fracture is caused by blunt trauma. On 10/20/15 at 1:35 p.m., the conducted a phone interview RI #1's Orthopedic Doctor. The Orthopedic Doctor said RI #1 was being transferred at the nursing home and fell off the Hoyer/Sara Lift. The Orthopedic Doctor said RI #1 has severe osteoarthritis and brittle bones. The Orthopedic Doctor said what he was told was RI #1 was dropped. The Orthopedic Doctor said RI #1 sustained very bad fractures to both legs. The surveyor asked the Orthopedic Doctor which fracture was the worst. The Orthopedic Doctor said pick one, they are nine to ten on a scale of ten, either one of them. The surveyor asked the Orthopedic Doctor in his professional opinion what did he think casued these fractures. The Orthopedic said the patient was probably dropped. The surveyor asked the Orthopedic Doctor what caused the transverse fracture or comminuted fracture. The Orthopedic Doctor said if a person is dropped, blunt trauma or force causes this to occur. This deficiency is cited as a result of the investigation of complaint/report number AL 949.

Based on interviews, record review and review of the facility's "Admissions Orders", the facility failed to ensure Resident Identifier (RI) #1, a resident with a history of UTI's (Urinary Tract Infections), Foley Catheter (F/C) was changed in a timely manner after the resident was readmitted to the facility with a F/C on 05/20/14. On 06/23/14 an order was written to change RI #1's F/C. On 07/10/14, 17 days after the order had been written to change the F/C, and 51 days after RI #1 had been readmitted to the facility, the resident was noted to have dark amber urine and sediment in the F/C tubing. RI #1 began to experience pain by crying out when urinating and the F/C was changed at that time. This affected RI #1, one (1) of three (3) residents sampled for the use of an indwelling catheter. Findings Include: RI #1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #1's care plans revealed the resident had a care plan titled "Alteration in elimination of bowel and bladder ... History of UTI's (Urinary Tract Infections), [MEDICAL CONDITION] with use of foley ..." The care plan had an initiated date of 1/24/2014. A review of a facility form titled "Clinical Health Status" revealed RI #1 was readmit to the facility again on 05/20/14. Under Section F Urinary Incontinence, it was documented "has foley" and "History of catheter use last 48 hours." A review of RI #1's May 2014 MAR (Medication Administration Record) revealed no order had been written for the resident's F/C to be changed. RI #1's progress notes documented the following: "5/20/2014 20:15 (8:15 p.m.) ... Note Text: Resident arrived on a stretcher by (name of EMTS (Emergency Medical Transport Service)) ... Foley catheter remains intact ... 5/27/2014 20:58 (8:58 p.m.) ... Note Text: ... Foley catheter patent and draining dark yellow urine ... 6/3/2014 23:09 (11:09 p.m.) ... Note Text: ... Foley patent and draining dark urine ... 6/5/2014 22:59 (10:59 p.m.) ... Note Text: ... Foley catheter patent and draining dark urine ... 6/7/2014 22:14 (10:14 p.m.) ... Note Text: ... Foley catheter patent and draining dark urine ... 6/8/2014 23:32 (11:32 p.m.) ... Note Text: ... Foley catheter patent and draining dark urine ... 6/9/2014 01:38 (1:38 a.m.) ... Note Text: ... foley intact draining dark urine ... 6/10/2014 00:19 (12:19 a.m.) ... Note Text: ... Foley catheter patent and draining dark urine ... 6/10/2014 04:22 (4:22 a.m.) ... Note Text: ... Foley catheter patent and draining dark urine ... 6/11/2014 03:06 (3:06 a.m.) ... Note Text: ... Foley catheter patent and draining dark urine ... 6/15/2014 14:22 (2:22 p.m.) ... Note Text: ... Catheter in place and draining dark amber urine into cath bag ... 6/20/2014 15:44 (3:44 p.m.) ... Note Text: ... Foley in place ... small amount of sediment noted ... A review of RI #1's June 2014 MAR revealed an order which documented: "Change foley every month ... every 30 day(s) ..." According to the order RI #1's F/C was to be changed on June 23, 2014. After reviewing the MAR, there was no indication on the MAR that the F/C was changed at this time. RI #1's progress notes documented the following: "7/10/2014 22:31 (10:31 p.m.) ... Note Text: ... Resident crying out in pain when urinating. Urine dark amber in color. Sediment noted in tubing. Removed existing catheter, replaced catheter without difficulty with #18 fr (french) foley catheter ..." On 07/23/14 at 7:37 a.m., the surveyor conducted an interview with Employee Identifier (EI) #1, a LPN (Licensed Practical Nurse) who provided care for RI #1 on the 11-7 shift. The surveyor asked EI #1 when a resident has a F/C how often is it changed. EI #1 replied every 30 days. The surveyor asked EI #1 which shift changed the F/C. EI #1 said she was pretty sure it was the 11-7 shift. When asked who would have been responsible for changing RI #1's F/C on 6/23/14, EI #1 said she thought it would have been EI #5 (the nurse assigned to care for RI #1 on the 11-7 shift on 06/23/14). EI #1 said when a F/C was changed, it usually would be documented on the MAR. EI #1 said she did not see where it was documented on RI #1's MAR that the F/C had been changed. On 07/23/14 at 11:40 a.m., the surveyor conducted an interview with EI # 2, a LPN who provided care for RI #1 on the 7-3 shift. The surveyor asked EI #2 how often were residents F/C changed. EI #2 replied the F/C was to be changed on the night shift every 30 days or once a month. The surveyor asked EI #2 had RI #1's family ever approached him about RI #1's F/C not being changed. EI #2 said RI #1's sponsor did ask him when the last time it was changed. EI #2 said (when he looked at RI #1's records) he could not find where it had been changed. EI #2 said when the sponsor asked him about the F/C, RI #1's urine was very cloudy. On 07/23/14 at 11:40 a.m., the surveyor conducted an interview with EI #3, the RN (Registered Nurse) MDS (Minimum Data Set) Coordinator. EI #3 said RI #1 came back from the hospital on [DATE] with the F/C. The surveyor asked EI #3 how often were F/C changed. EI #3 replied monthly, usually on the night shift. The surveyor asked EI #3 where it would be documented that the F/C had been changed. EI #3 replied, sometimes in the nurses notes. A review of RI #1's Progress Notes (nurses notes), dated 6/23/2014 (the day the MAR indicated RI #1's F/C was to be changed), did not reveal any evidence that the F/C had been changed. On 07/23/14 at 3:45 p.m., the surveyor conducted an interview with EI #4, a LPN who provided care for RI #1 on the 3-11 shift. The surveyor asked EI #4 if she had ever changed RI #1's F/C. EI #4 replied she changed the F/C on the 10th of July (2014). EI #4 said the F/C had a lot of sediment and it was cloudy and RI #1 said it hurt. When asked how often the facility changed the F/C of residents, EI #4 replied monthly. EI #4 said the night shift usually changed the F/C out once a month. EI #4 said RI #1's F/C was due to be changed on the 23 rd of June (2014) but she didn't see a signature (on the MAR) where it had been changed. The surveyor asked EI #4 why she changed RI #1's F/C on 07/10/14. EI #4 said RI #1's sponsor said RI #1 wanted a pain pill and the F/C changed. EI #4 said RI #1's sponsor said she did not believe RI #1's F/C had been changed since the resident had come back from the hospital (5/20/14). EI #4 said RI #1's F/C was changed because the resident was pretty uncomfortable. EI #4 said after the F/C was changed, RI #1 was better. On 07/23/14 at 5:00 p.m., the surveyor conducted a phone interview with EI #5, the RN who provided care for RI #1 on the 11- 7 shift on 06/23/14 (the date and shift RI #1's F/C was scheduled to be changed). The surveyor asked EI #5 if she had ever changed RI #1's F/C. EI #5 replied she had never changed RI #1's F/C. The surveyor asked EI #5 how often were the residents F/C scheduled to be changed. EI #5 said at least every 30 days. The surveyor asked EI #5 if she recalled if she checked RI #1's MAR on 06/23/14 to see if the F/C was scheduled to be changed. EI #5 said she didn't remember if she had checked the MAR or not. EI #5 said if she changes a F/C she would put it on the MAR or in the nurses notes. On 07/24/14 at 3:26 p.m., the surveyor conducted an interview with the DON (Director of Nursing), EI #6. The surveyor asked EI #6, when a resident is admitted to the facility with a F/C, are orders for the care and the changing of the F/C written at that time. EI #6 replied yes. The surveyor asked EI #6 why this was not done for RI #1 when he was readmitted on [DATE]. EI #6 said the nurse who did the assessment was not the one who put the orders in. The surveyor asked EI #6 why an order was written for RI #1's F/C to be changed every 30 days on 06/23/14. EI #6 said the order was written because the nurse, EI #7, the Assistant Director of Nursing (ADON), was reviewing the chart and noticed that there was no order for RI #1's F/C. The surveyor asked EI #6 should RI #1's F/C have been changed at that time. EI #6 replied it depended on what RI #1's F/C looked like at that time. The surveyor asked EI #6 why EI #7 had written the order for the F/C to be changed every 30 days. EI #6 said that was a facility protocol. The surveyor asked EI #6 did she think leaving a F/C in for 51 days was too long. EI #6 replied no. The surveyor asked EI #6 if she thought 51 days was not to long to have a F/C in, why did the facility have a protocol for the F/C to be changed every 30 days. EI #6 replied that was just what the nurses did. On 07/24/14 at 4:40 p.m., the surveyor conducted an interview with EI #7, the ADON. The surveyor asked EI #7 how often were residents F/C changed. EI #7 replied the F/C was usually changed once a month and as needed. The surveyor asked EI #7 should orders be written for the F/C to be changed when a resident is admitted to the facility. EI #7 replied yes. The surveyor asked EI #7 why this was not done when RI #1 was readmitted to the facility on [DATE]. EI #7 said she did not know RI #1 was readmitted back to the facility with a F/C. EI #7 said when she wrote the order for RI #1's F/C to be changed every 30 days she thought she was updating the order to include the size of the F/C. The surveyor asked EI #7 if she thought 51 days was too long for a F/C to be in if there was orders for it to be changed every days. EI #7 replied if there was an order yes. The surveyor showed RI #7 a copy of the facility's "Admission Order" and asked whose admission order were they. EI #7 said the orders are the ones the facility uses when a resident is admitted to the facility. The surveyor asked EI #7 did RI #1 had a history of [REDACTED].#7 replied yes. A review of the facility's "admission orders [REDACTED] "The Following orders are needed when admitted to the facility ... Foley Cath (Catheter) Orders ... They must be changed monthly ..." On 07/24/14 at 5:35 p.m., the surveyor conducted the exit conference with the Administrator and the DON, EI #6. When asked if there were any questions, EI #6 stated she would like to change her statement given to the surveyor earlier. EI #6 said she wanted to change her answer to "yes" when the surveyor asked if she felt 51 days was too long for leaving a F/C in. This deficiency was written as a result of the investigation of complaint/report #AL 464.