Every finding on record at Dugan Memorial Home

Based on resident and staff interviews, record reviews, and facility policy review, the facility failed to ensure a cognitively intact resident was provided the opportunity to participate in and make informed decisions regarding her advance directive, including end-of-life preferences for one (1) of 24 advance directives reviewed. (Resident #1) Findings Include:Review of the facility policy titled Advance Directives Policy and Acknowledgment, updated 9/3/25, revealed, Resident has the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.Record review of the facility's Advance Directives/Medical Treatment Decisions form, dated 2/17/22, revealed Resident #1 was designated as Do Not Resuscitate (DNR); however, the form was not signed by Resident #1 and was instead signed by her sister.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #1 was cognitively intact.During an interview on 3/17/26 at 10:35 AM, Resident #1 revealed the facility had never discussed end-of-life decisions with her and revealed her sister had made those decisions on her behalf. During an interview on 3/17/2026 at 3:10 PM, the Social Services Director confirmed that although cognitive assessments are completed through the MDS Section C and a BIMS score of 13 or higher indicated a resident can make their own decisions, Resident #1, who was assessed as cognitively intact, was not provided the opportunity to discuss or complete her own advance directive.During an interview on 3/17/2026 at 3:30 PM, the Executive Director (ED) acknowledged that, based on Resident #1's cognitive status, she should have been able to make her own end-of-life decisions, but we deferred to the sister, who is the conservator. The ED confirmed that she has struggled with balancing resident rights and conservatorship, but expressed that the decision should have been Resident #1's.In an interview on 3/18/2026 at 9:32 AM, the Nurse Practitioner (NP) confirmed Resident #1 should have been allowed to make her own advance directive decisions.Record review of the admission Record revealed the facility admitted Resident #1 on 2/17/22 with medical diagnoses that included Rheumatoid arthritis, Paraplegia, and Major depressive disorder.

Based on record review, staff interview, and facility policy review, the facility failed to ensure informed consent was obtained prior to the initiation of a psychotropic medication for one (1) of five (5) residents reviewed for unnecessary medications. Resident #9 Findings include:Record review of facility policy titled, Use of Psychotropic Medications, with an implemented date of 10/2025, revealed, .9. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medications .11. The facility will document that the resident or resident representative was informed in advance (e.g., written consent form, narrative note, etc.)Record review of Resident #9's Order Summary Report revealed an order dated 7/28/25 for Trazadone Hydrochloride (HCL) oral tablet 50 milligrams (mg) to be given by mouth at bedtime for sleep.Record review revealed no signed informed consent for Trazadone was present in medical record.On 3/18/2026 at 12:33 PM, during an interview with the Administrator, she confirmed there should have been a signed consent for Trazadone, but she was unable to locate one. Record review of Resident #9's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease and Depression.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/2025 revealed a Brief Interview for Mental Status (BIMS) score of 6, indicating the resident was severely cognitively impaired.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure residents were provided with a dignified dining experience when one (1) of three (3) residents at the table did not receive their meal at the same time. Resident #11 Findings include: Record review of facility policy titled, Promoting/Maintaining Resident Dignity During Mealtimes dated March 2025, revealed, It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. During an observation of lunch in the dining room on 3/16/26 from 12:10 PM through 12:15 PM, it was noted that the two residents sitting at the table with Resident #11 both had their meal and were eating their lunch. Resident #11 was observed without food. She continued to sit and watch the other two residents at her table as they ate their lunch. At 12:15 PM, Resident #11 reached to her right and slid that resident's piece of iced cake in front of herself and started eating it with her hands. There was no silverware in her area. During an interview on 3/16/26 at 12:15 PM, Licensed Practical Nurse (LPN) #1 revealed it was unacceptable for Resident #11 to be without her meal while other residents at the table were eating their meals. She acknowledged that each resident at a table should be served at the same time to promote dignity during mealtime. During an interview with the Director of Nursing on 3/18/26 at 8:30 AM, it was revealed that each resident at a community table in the dining room should be served their meals at the same time. She acknowledged that one resident should not have to watch their tablemates eat their meal for an extended period of time and not have their own meal to enjoy. She confirmed that each resident had the right to be treated with dignity during meals and the facility failed to honor this right by not serving meals to all residents at a table at the same time. Record review of Resident #11's admission Record revealed she was admitted to the facility on [DATE] with diagnoses which included Dementia. Record review of Resident #11's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/15/25 indicated a Brief Interview for Mental Status (BIMS) of 5 which indicated the resident had a severe cognitive impairment.

Based on staff interview, observation of video camera footage, record review, and facility policy review, the facility failed to ensure a resident's right to be free from sexual abuse by another resident for one (1) of four (4) residents sampled. (Resident #1) Specifically, the facility failed to prevent Resident #2, a cognitively intact resident with mental health diagnoses, from engaging in non-consensual sexual contact with Resident #1, a severely cognitively impaired resident, in a supervised common area of the facility. This failure resulted in actual harm to Resident #1, as she experienced inappropriate sexual contact without the ability to consent, resist, or report the incident. Findings include: Record review of facility policy titled, Abuse, Neglect, and Exploitation, dated 11/2017, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Sexual abuse is non-consensual sexual contact of any type with a resident. During an interview on 6/16/25 at 10:40 AM, the Administrator stated an incident occurred on 6/6/25 around 6:15 PM where Resident #2 was discovered by a visitor with his hand underneath Resident #1's blanket in the common area of the facility. The visitor immediately reported it to Certified Nursing Assistant (CNA) #1 and as she approached the residents, Resident #2 stopped what he was doing and wheeled himself back to his room. CNA #1 immediately reported this to Licensed Practical Nurse (LPN) #1, and when they went to check on Resident #2 he had returned and was attempting to raise her blanket again and LPN #2 stopped him and he returned to his room again. Resident #2 was immediately placed on 1:1 observation and an investigation began. She revealed that when this incident first occurred, the staff were unaware of the full extent of what was being done due to the positioning of the residents, the staff, the wheelchairs, and the wall, but the camera's position allowed the full extent of the incident to be seen with an unobstructed view. When the video footage was viewed, the Administrator acknowledged that the extent of the touching was realized, and she noted how disturbing it was. She stated during the video review you could see that Resident #1 was sitting in the rotunda area and Resident #2 approached in his wheelchair and sat next to her. During the first part of their interaction, it appeared that they were talking to each other, then Resident #2 raised the blanket and rubbed the back of the resident's right thigh and then moved his hand up to her private area. She was notified at that time and Resident #2 was placed on one-on-one observation and a consult for behavioral health was obtained and he was transferred out later that evening. Observation of incident on the facility's video on 6/16/25 at 11:00 AM, the video revealed Resident #1 in her geriatric-type chair in the rotunda which was a common area in the facility. She appeared to be alert and moving her arms to her face and back to her lap and moving her legs slightly. Resident #2 was in his wheelchair and rolled up to her left side at 6:15 PM. Resident #2 appeared to be speaking to Resident #1. Being in the geriatric chair, Resident #1 had her left leg extended and her right leg positioned where her knee was raised with her foot resting flat on the reclining part of the chair. At 6:17 PM, Resident #2 lifted Resident #1's blanket, at 6:18 PM, Resident #2 uses his left hand and rubs the back of her lower thigh and moved his hand up towards her genital area on the back side of her thigh. He switched to his right hand and began a repetitive movement with his hand at Resident 1's vaginal area. Video footage revealed that this interaction continued for almost three (3) minutes until CNA #1 intervened at 6:21 PM. From the view of the approaching CNA, it would have been difficult to see what was occurring since she was approaching from behind Resident #2 and next to a wall. The camera view was straight towards the residents so the view and ability to see what occurred was not obstructed and when CNA #1 approached, Resident #2 left the area. During an interview on 6/16/25 at 4:20 PM, the Administrator acknowledged each resident had the right to be free from abuse and she confirmed the facility failed to ensure a resident was free from sexual abuse by another resident. Record review revealed that Resident #2 was placed on 1:1 observation and was sent out to a geri-psych facility later that night and remains there at the present time. Record review of Resident #1's admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Dementia, and Anxiety Disorder. Record review of Resident #1's quarterly Minimum Data Set (MDS) Section C dated 5/6/25 revealed Resident #1 was rarely/never understood and a Brief Interview for Mental Status (BIMS) was not able to be obtained, which indicated the resident had severe cognitive impairment. Record review of Resident #2's admission Record revealed resident was admitted to the facility on [DATE] with diagnosis that included Bipolar Disorder and Schizophrenia. Record review of MDS Section C dated 4/22/25 revealed a BIMS score of 13 which indicated the resident was intact cognitively.

Based on staff interview, record review, and facility policy review, the facility failed to ensure the medical provider was notified of a resident refusing multiple doses of prescribed antibiotics for one (1) of six (6) residents reviewed for medication use. Resident #21 Findings include: Record review of facility policy titled Medication Administration dated 1/24, revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .18. Report and document any adverse side effects or refusals . During an interview on 9/25/24 at 3:50 PM, Registered Nurse (RN) #2 revealed Resident #21 had recently been in the hospital and diagnosed with pneumonia and was on antibiotics. She revealed the resident would often refuse her medications and that if a resident refused medications, the nurse was to notify the provider and the resident's representative. On 9/25/24 at 4:10 PM, an interview with the Director of Nursing (DON) revealed Resident #21 refused several doses of the antibiotic medication ordered for the treatment of pneumonia and the provider was not notified. She confirmed it was important to notify the provider so that appropriate care could be ordered. She confirmed the facility failed to notify the provider of the antibiotic medications refused by this resident. During a phone interview on 9/25/24 at 4:30 PM, the Nurse Practitioner stated she was in the facility last week and was aware the resident refused to take her medications for a few days but thought she had restarted taking them. She stated she was unaware that the resident refused her antibiotics which included the past two doses that would have completed her 10-day course of antibiotics. She stated it was important for the provider to be notified of refusals of medications so treatment could be reevaluated, and the treatment course could be changed to ensure the resident received appropriate care. She also stated that not receiving ordered antibiotic medications could lead to an infection not being treated effectively. An interview with the Administrator on 9/26/24 at 8:20 AM, confirmed the facility failed to notify the provider that a resident refused multiple doses of an antibiotic ordered for pneumonia. She confirmed that notifying the provider was necessary so an alternate treatment could be ordered if the provider chose that option. During an interview on 9/26/24 at 12:10 PM, RN #2 stated she was not notified that Resident #21's antibiotic medication was not administered due to the resident refusing. She stated that typically the Licensed Practical Nurse (LPN) would notify the RN and the RN would notify the provider and enter any new orders that were given by the provider. She confirmed that since she was unaware of the resident refusing her last two doses of her antibiotics, the provider was not notified. A phone interview with LPN #1 on 9/26/24 at 12:15 PM, revealed she attempted to give Resident #21 her antibiotics on several different days and would attempt several times each day, but the resident refused each time. She stated during the previous week, she had notified RN #1 of the refusals, but on 9/23/24 and 9/24/24, she did not notify RN #2 of the refusals. She admitted she did not see RN #2 immediately after the refusals and she just forgot. She stated she did document the refusals in the Electronic Medication Administration Record (EMAR), but for the dates of 9/23/24 and 9/24/24, she did not notify the RN. She stated she had been in-serviced on medication administration and was aware of the process for notification to the RN if the resident refused medications and the RN would notify the provider. During a phone interview on 9/26/24 at 12:25 PM, RN #1 stated she had notified the provider of the resident's refusals of medications last week. She stated the process for refusals are for the LPN to inform the RN and the RN would notify the provider. During an interview on 9/26/24 at 12:45 PM, the DON confirmed the facility failed to notify the provider of the resident's refusal of her antibiotics. She confirmed a resident not receiving antibiotics as ordered could lead to the infection not being treated properly. She stated LPN #1 had been in-serviced on medication administration and should have notified the RN so the RN could have notified the provider. Record review of Progress Note of Registered Nurse (RN) #2 dated 9/13/24, revealed, Notified by Cart Nurse that resident was having chest pain. Asked resident if she (by pointing and verbally asking) resident was she having chest pain and resident nodded, 'yes'. Notified (proper name removed) Nurse Practitioner (NP), NP gave orders to send out the the ER (emergency room ). Record review of Order Summary Report revealed an order dated 9/13/24 to send resident to ER for c/o (complaints of) chest pain. Record review of hospital Emergency Department Note dated 9/14/24, revealed a diagnosis of Pneumonia of left lower lobe due to infectious organism. Record review of nursing Progress Note dated 9/14/24, revealed, Elder returned from hospital per ambulance. Alert and oriented with eyes opened. Report received from ER. Elder x-ray showed pneumonia . Prescription given for Elder's condition. Record review of Resident #21's Order Summary Report revealed an order dated 9/14/24 for Cefdinir Oral Suspension 250 mg (milligrams)/5 ml (milliliters) give 12 ml by mouth in the morning for pneumonia for 10 days with start date of 9/15/24 and end date of 9/25/24. Record review of Resident #21's Electronic Medication Administration Record (EMAR) revealed on 9/23/24 and 9/24/24, the resident did not receive the ordered antibiotic with the reason documented as Drug Refused. Record review of Resident #21's Admission Record revealed the facility admitted the resident on 5/6/2016 with diagnoses that included Shortness of breath and Dementia. Record review of Resident #21's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/27/24, revealed Should Brief Interview for Mental Status be conducted? Response to this was, No (resident is rarely/never understood).

Based on staff interviews, record review, and facility policy review, the facility failed to implement a care plan for one (1) of 18 sampled residents' care plans. Resident #21 Findings Include: Record review of facility's policy titled, Comprehensive Care Plans dated 10/22, revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Record review of Resident #21's care plan revealed a focus area dated 9/15/24 of Elder has pneumonia. Interventions listed included administer medications as ordered, Cefdinir for ten days for pneumonia, and to keep informed of changes and update MD as needed. An interview with the Director of Nursing (DON) on 9/25/24 at 4:10 PM, revealed Resident #21 refused several doses of the antibiotic medication ordered for the treatment of pneumonia and the provider was not notified. She stated the care plan gives information to care for the resident's needs and she confirmed the care plan for antibiotic medication administration as ordered for treatment for pneumonia and to keep informed of changes and update RP (Resident's Representative) and MD (Medical Doctor) as needed, was developed but was not followed. During an interview on 9/26/24 at 10:30 AM, the Minimum Data Set (MDS) Coordinator revealed she is one of the facility staff members responsible for developing the care plans for the residents. She stated the care plan is to inform staff of the needs of the residents and the care needed for the resident and should be followed to ensure the care is appropriate. She stated the care plan for Resident #21's diagnosis of pneumonia was developed and included the interventions to administer the medications as ordered, antibiotics each morning for 10 days for pneumonia, and to update Medical Doctor as needed and keep informed of changes. She confirmed the care plan was not implemented. Record review of Resident #21's Order Summary Report revealed an order dated 9/14/24 for Cefdinir Oral Suspension 250 mg (milligrams)/5 ml (milliliters) give 12 ml by mouth in the morning for pneumonia for 10 days with start date of 9/15/24 and end date of 9/25/24. Record review of Resident #21's Electronic Medication Administration Record (EMAR) revealed on 9/23/24 and 9/24/24, the resident did not receive the ordered antibiotic with the reason documented as Drug Refused. Record review of Resident #21's Admission Record revealed the facility admitted the resident on 5/6/2016 with diagnoses that included Shortness of breath and Dementia. Record review of Resident #21's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/27/24, revealed Should Brief Interview for Mental Status be conducted? Response to this was, No (resident is rarely/never understood).

Based on observation, interview, record review and facility policy review the facility failed to initiate contact isolation precautions for a resident with Methicillin-resistant Staphylococcus Aureus (MRSA) and failed to prevent the possibility of the spread of infection by not utilizing proper hand hygiene for one (1) of four (4) resident care observations. Resident #19. Findings Include: Review of the facility policy Clean Dressing Change dated 10/2022 revealed, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Review of the undated facility policy Transmission-Based Precautions revealed, It is our policy to take appropriate precautions to prevent transmission of infectious agents Contact Precautions - Intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment . On 09/24/24 at 1:00 PM, on entrance into the facility, a brief interview with Administrator (ADM), revealed that there were no residents on Transmission Based Precautions (TBP). On 09/24/24 at 2:30 PM, an interview with Resident #19 revealed that he had two wounds on his bottom, that the nurses were cleaning them and changing the dressings every day. On 09/25/24 at 10:40 AM, an observation revealed Licensed Practical Nurse (LPN) #1, completed wound care to Resident #19's pressure ulcers to his sacrum and left buttock using enhanced barrier precautions (EBP). LPN #1 washed her hands and donned a gown and gloves. She removed the old dressing and then cleaned the sacral wound and cleaned the wound to his left buttock with normal saline without changing her gloves. LPN #1 changed gloves after cleaning both wounds, applied the ordered treatment to both wound beds and covered the wounds with bordered foam dressings. LPN #1 did not perform hand hygiene between glove changes, and she used the same gloves to clean both wounds. LPN #1 removed her gown and gloves, disposed of them in a trash can designated for Personal Protective Equipment (PPE) just inside the resident's door, and she washed her hands. There was no Contact Precaution signage observed on Resident #19's room door and there were no biohazard containers in his room. On 09/25/24 at 10:50 AM, an interview with LPN #1, revealed that Resident #19 had the wounds to his sacrum and left buttocks for several months and they were improving. She revealed that they used enhanced barrier precautions with any resident with wounds to protect the residents as well as themselves. LPN #1 confirmed that she did not change her gloves after removing the soiled dressing before cleaning both of the wound areas and also failed to change gloves between the two different wound care areas. She also confirmed that she had cleaned both wounds using the same gloves and agreed that she should have completed wound care on one wound before going to the next to prevent cross contamination. In an interview on 09/25/24 at 10:55 AM, LPN #1 revealed that she Just remembered that Resident #19 was diagnosed with MRSA (Methicillin-Resistant Staphylococcus Aureus) to one of the wounds a couple weeks ago and she was Pretty sure he still had it. She also confirmed that any resident with MRSA should be on contact isolation precautions to prevent the spread of infection. On 09/25/24 at 11:00 AM, an interview with Infection Control Nurse (ICN) revealed that Resident #19 was on EBP because of his wounds. She revealed that Resident #19 had a wound culture a couple weeks ago and was on antibiotics. ICN pulled up Resident #19's wound culture results on his Electronic Medical Record (EMR) and confirmed the positive MRSA results and stated, I was not aware that he had MRSA, I didn't catch that. She revealed that Resident #19 should be on contact isolation precautions to prevent the spread of infection and that she would take care of that now. ICN revealed that contact precaution signage should be on the door and that there should be PPE outside the resident's door and they should have red barrels placed inside his room for staff to dispose of their used PPE. She revealed that they reviewed all antibiotics in their Quality Assurance (QA) meetings every month and went over antibiotics and infections weekly in their high-risk meetings. ICN revealed that it was important to follow the correct guidelines when doing wound care on a resident with MRSA to prevent the spread of infection. On 09/26/24 at 9:10 AM, an interview with Certified Nursing Assistant (CNA) #1, revealed that she had heard a couple weeks ago that Resident #19 had MRSA to one of his wounds. She revealed that she was already wearing masks, gloves and gowns and was not told to treat him any differently. She revealed that the ICN placed the contact precaution sign on his door and red barrels in the room yesterday. CNA #1 revealed that usually when a resident was placed on contact precautions, they had in-services, and the nurses let them know. She revealed that it must have been a miscommunication problem. On 09/26/24 at 12:22 PM, a phone interview with Registered Nurse (RN) #1, revealed that Resident #19 had wounds and that the wound center had called in positive MRSA culture results to her a couple weeks ago. RN #1 revealed that Resident #19 was currently taking two antibiotics for the MRSA and was ordered to take it for thirty days. She revealed that this resident should be on contact precautions to prevent the spread of infection in the facility. On 09/26/24 at 1:15 PM, an interview with Director of Nursing (DON) and Administrator (ADM), revealed that the person who took the call about the positive culture results, should have initiated the Contact Isolation Precautions for Resident #19. She revealed that it was everyone's responsibility who knew about the infection to get it initiated. She revealed if they had staff members in the room caring for a resident who they knew had MRSA, the staff should look at protecting the resident and ensuring that measures were in place to prevent the spread of infection. Record review of Resident #19's Wound Culture revealed that the culture of his left buttock pressure ulcer was collected on 08/30/24 and final MRSA results were received on 09/02/24. Record review of Resident #19's Admission Record revealed an admitted [DATE] and had diagnoses that included Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease, Stage 2 Pressure Ulcer of Sacral Region, and Stage 4 Pressure Ulcer of Left Buttock. Record review of Resident #19's Order Summary Report revealed an order with start date of 09/04/24 for Amoxicillin Oral Capsule 500 MG (milligrams) . Give 1 capsule by mouth three times a day for MRSA for 30 Days and Bactrim DS Oral Tablet 800-160 MG .Give 1 tablet by mouth two times a day for MRSA for 30 Days. Record review of Resident #19's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/12/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated that he was cognitively intact. Record review of Resident #19's Progress Note dated 09/03/24 revealed new order for antibiotics related to MRSA infection in wound and was signed by RN #1.

Based on resident and staff interview, record review and facility policy review, the facility failed to prevent verbal abuse to a resident from a staff member for one (1) of three (3) residents reviewed for abuse. Resident #1 Findings Include: Review of the facility policy titled, Abuse, Neglect and Exploitation-2019 with a review date of 2019 revealed, Policy .It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. This review revealed under, IV. Identification of Abuse, Neglect and Exploitation .B. 5. Verbal abuse of a resident overheard. An interview on 6/11/24 at 8:05 AM, with the Administrator revealed she was notified on 5/26/24 by the Director of Nurses (DON) that Certified Nurse Assistant (CNA) #1 had been witnessed by CNA #2 and CNA #3 talking ugly to Resident #1 and was sent home that day pending an investigation. She stated that she investigated the incident and could not determine that it was verbal abuse, because of different stories from the witnesses and the resident. She stated that CNA #1 had issues with being disrespectful to co-workers and attendance issues and they determined that despite not substantiating that this incident was verbal abuse it was disrespectful to the resident, and she was terminated. She confirmed that telling a resident to stay off of their call light or threatening a resident would be considered verbal abuse and that all staff are in-serviced on abuse on hire. An interview on 6/11/24 at 9:27 AM, with the DON confirmed that Registered Nurse (RN) #1 called her on the morning of 5/26/24 to inform her that CNA #1 had been witnessed talking ugly to Resident #1 by CNA #2 and CNA #3. She revealed that she interviewed CNA #2 and CNA #3 over the phone with RN #1 present and they told her that CNA #1 had yelled at Resident #1 to stay off of his call light because she was shorthanded. She revealed that at that time she told RN #1 to immediately send CNA #1 home until the investigation was complete and to not return until they called her on Monday 5/28/24. An interview on 6/11/24 at 10:36 AM, with CNA #1 confirmed that she had been terminated by the facility for some interaction with resident, (Resident #1.) She denied saying anything inappropriate to Resident #1 but admitted to telling the resident that he had just used his call light to have his remote and cell phone given to him, which was right in front of him on his overbed table. She stated that she was not sure if she had attended any in-services at the facility about abuse, but she knew not to abuse a resident. She admitted to working two jobs but stated that it did not affect her work here at the facility. She admitted that her partner had called in that day, so she had to work alone with about 12 residents. An interview on 6/11/24 at 10:45 AM, with CNA #2 confirmed she was sitting out in the hall not far from Resident #1's room and CNA #1 was standing outside of his door yelling at him for pushing his call light again. She stated that she overheard CNA #1 tell the resident I'm not having it today, I'm shorthanded; keep it up and I'm gonna take that cell phone. She revealed that she thinks CNA #1 took the residents call light away from him. She admitted that she had worked with CNA #1 about 6 months, and she had a bit of an attitude, but she had never heard her talk to any residents that way. She stated that CNA #1's partner had called in that morning, and she thought she was frustrated about that, but that her and CNA #3 had offered to help, but she had refused. An interview on 6/11/24 at 11:00 AM, with CNA #3 confirmed that she was in the hall and heard CNA #1 yell at Resident #1 saying, Did I not tell you to not be on that d _ _ n light, I'm the only one here today, which was not true. Her partner had called in, but CNA #2 and I were there and had offered to help her, but she refused. She stated that shortly after this incident RN #1 walked down the hall toward them and asked why Resident #1 was calling her from his cell phone and that is when we told her what had happened. She stated she had heard CNA #1 talk smart to residents before, but not to this extent. An observation on 6/11/24 at 11:08 AM, of the camera footage during the time of the alleged verbal abuse with Resident #1 on 5/26/24 at approximately 9:35 AM revealed CNA #1 went into Resident #1's room around 9:35 AM and CNA #2 was sitting in the hall and CNA #3 walked out of the laundry room and stopped in the hall for a brief moment as CNA #1 came out of Resident #1 room and stood outside his door facing into the room. The video footage showed that the two CNA's were in hearing distance of Resident #1's room when CNA #1 went into the room. An observation on 6/11/24 at 11:10 AM of the area that CNA #2 and CNA #3 were standing in relation to Resident #1's room according to the camera footage was approximately 20 feet. An interview on 6/11/24 at 11:18 AM, with RN #1 confirmed that CNA #2 and CNA #3 reported to her on the morning of 5/26/24 that CNA #1 had told Resident #1 that he did not need to be on his call light because she was busy. She stated that she talked with Resident #1, and he told her that CNA #1 had told him that if he did not stay off of his call light that she was going to put him in his chair. She revealed she notified the DON and was told to send CNA #1 home, so she did after telling her it was concerns about how she was talking to Resident #1. An interview on 6/11/24 at 11:30 AM, with Resident #1 confirmed that CNA #1 had taken his call light and put it behind his bed because she said he was using it too much, so he used his cell phone and called the facility. He stated that (CNA #1's proper name) told him if he did not stay off of his call light, she was going to put him in his chair. He revealed he did not think she was yelling but was talking loudly and it did not upset him because he still had his phone and was able to call the facility to ask for help in his room. He revealed this was not the first time she had talked to him that way but admitted that he had never reported it to anyone. Record review of the facilities in-services on abuse revealed an in-service was held 2/21/24 but was not attended by CNA #1. Record review of CNA #1's new hire information revealed she was hired at the facility on 11/17/23 and signed acknowledgement of the Vulnerable Adults Act on 11/17/23. Record review of CNA #1's timesheet revealed she came in on 5/26/24 at 6:38 AM and left at 10:48 AM. Record review of Resident #1's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Infarction and Aspergers Syndrome. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/15/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on observations, staff interview and facility policy review, the facility failed to store food items in a manner that maintains the safety of the food as evidenced by uncovered, unlabeled and undated food in the refrigerator and freezer for one (1) of two (2) kitchen tours. Findings include: Record review of the facility policy titled Storage of Food and Supplies with a revision date of [DATE] revealed, Description: all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Also revealed under, Method/How To/Procedure: . Cover, label and date unused portions and open packages. An observation of the chest freezer with the Dietary Supervisor on [DATE] at 9:15 AM, revealed a large round clear container with a dark yellow substance inside and no covering. There was no label observed to identify the substance or the date it was opened. An interview with the Dietary Supervisor revealed the item was frozen mango ice cream that was left over from 2 days ago. She confirmed that the mango ice cream did not have a cover and was unlabeled and undated. She confirmed that all items placed in the freezer should have a lid or cover over it and a label with the date it was opened so that food does not become contaminated. An observation of the refrigerator with Dietary Staff #2 on [DATE] at 9:45 AM, revealed three (3) small clear bowls with a tan substance inside and no covering. There were no labels noted to identify the substance or the date it was prepared. An interview with Dietary Staff #2 revealed the substance was applesauce, and she confirmed the bowls were uncovered and undated. She stated, I'm not going to lie to you; I don't know how long that's been in there. She stated, That's not supposed to be in there like that. She revealed it's important to label and date everything in the kitchen so that the food can be thrown out when the use by date has expired. She also stated, It's no way to know how long it's (the applesauce) been in there. An observation of the walk-in freezer with the Dietary Supervisor on [DATE] at 9:55 AM, revealed an open package of four (4) ounce whole kernel corn and an open clear bag of fries that were both unlabeled and undated. An interview with the Dietary Supervisor confirmed that the package of corn and fries had been opened and were not labeled or dated. She stated, They should have labeled it when they opened the bag. She confirmed that placing items in the refrigerator and freezer without a cover could cause contamination of the food item. She also confirmed that placing unlabeled, undated items in the refrigerator and freezer could be a concern to the residents health. An interview with the Administrator on [DATE] at 3:45 PM, acknowledged that all open items in the refrigerator and freezer should be covered, labeled, and dated.

Based on record review, staff interview and facility policy review the facility failed to develop a person-centered care plan for a resident with a contracture for one (1) of 14 resident care plans reviewed. Resident #16 Findings Include: Review of the facility policy titled, Comprehensive Care Plans with an implementation date of 10/2022 and no revision date revealed, Policy .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. An observation on 07/11/23 at 9:55 AM, of Resident #16 revealed the resident had a right-hand contracture with a carrot roll placed in the right hand. Record review of Resident #16's care plans revealed there was no care plan regarding the right-hand contracture or placement of the carrot roll as to how long, how often or which days to apply the hand roll. An interview on 7/12/23 at 2:45 PM with the Minimum Data Set (MDS) nurse revealed she is responsible for developing care plans and entering them into the computer for nursing issues. She confirmed that Resident #16 had a hand contracture and did not have a care plan regarding her contracted right hand but she should have and stated that the care plan directs the care for the residents. An interview on 7/12/23 at 3:00 PM, with the Director of Nurses (DON) confirmed that Resident #16 did not have a care plan regarding her right-hand contracture. She confirmed that the resident should have a care plan regarding the hand contracture because that is what helps the staff to know how to care for the resident. Record review of the Task List Report revealed tasks with the date initiated of 3/8/23, Apply carrot orthosis in right hand with large end of carrot closest to thumb. Position at level II for up to 6 (six) hours every day and Remove carrot orthosis to right hand every day at 1 pm. May remove earlier if elder complains of intolerance. Record review of Resident #16's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Parkinson's Disease. Record review of Resident #16's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/22/23 revealed in Section G that the resident had functional limitations in both upper extremities and in Section C a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident is moderately cognitively impaired.

Based on observations, staff interviews and facility policy review, the facility failed to provide personal hygiene to a resident requiring assistance as evidenced by long nails with a brown substance underneath for one (1) of 14 residents sampled. Resident #5 Findings include: Review of the facility policy titled Nail Care with no revision date revealed, Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: . 3. Routine cleaning and inspection of nails will be provided during Activity of Daily Living (ADL) care on an ongoing basis. 4. Principles of nail care: a. Nails should be kept smooth to avoid skin injury. b. Only licensed nurses shall trim or file fingernails of residents with diabetes . An observation on 7/12/23 at 8:15 AM, revealed a contracture to Resident # 5's right hand with all fingers bent inwardly toward the palm of the hand. A hand roll was observed intact and inside the palm of the hand and the skin was intact. Fingernails noted to be approximately three-eighths (3/8) inch in length with a brown substance underneath. An observation and interview on 7/12/23 at 9:32 AM, with Certified Nurse Aide (CNA) #1 confirmed that Resident # 5's fingernails on the right hand were long and had a brown substance underneath. She stated, Yeah, they are pretty long and need cleaning. She acknowledged that Resident # 5's long nails and hand contracture could result in skin breakdown. Furthermore, she revealed that the CNA's should clean and trim the residents' nails whenever they are needed. An interview with the Director of Nursing (DON) on 7/12/23 at 9:38 AM, confirmed that Resident #5's fingernails on the right hand were long and had a brown substance underneath. She stated, They are dirty and way too long. She confirmed that the aides are responsible for cleaning and trimming the fingernails of the residents that are not diabetic. She stated, They should be looking at the nails every day and during bathing; This is everyday stuff. Record review of the Admission Record revealed Resident #5 was admitted to the facility on [DATE] with medical diagnosis that included Alzheimer's disease, Unspecified Osteoarthritis and Cerebrovascular Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/28/23 revealed under section C a Brief Interview for Mental Status (BIMS) score of 09, indicating Resident #5 is moderately cognitively impaired and in Section G that the resident was totally dependent on staff for personal hygiene and bathing.

Based on observation, staff interview, record review and facility policy review, the facility failed to prevent decrease in range of motion as evidenced by failure to apply a splint as ordered for one (1) of three (3) residents reviewed for splints. Resident #1. Findings include: Review of facility policy titled, Prevention of Decline in Range of Motion, dated 11/1/2016, revealed Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. An observation, during initial tour, on 11/01/21 at 11:55 AM, revealed Resident #1, had a resting hand splint on her bedside table. An observation, on 11/2/21 at 01:30 PM, revealed Resident #1 was not wearing the resting hand splint on her right wrist. The resting hand splint was not observed visible on any surface in the room. An observation, on 11/3/21 at 09:16 AM, revealed Resident #1 did not have her resting hand splint on the right wrist. Resident #1 did respond to the request to pull her covers back and allow her right wrist to be observed for resting hand splint placement. The resting hand splint was observed across Resident #1's room in a chair. An interview with Certified Nurse Aide (CNA) #1, on 11/3/21 at 9:16 AM, revealed the facility CNAs were trained by the therapy department to apply splints on the facility's residents. She stated the CNA's are responsible to remove and reapply the braces for residents to get a bath and to complete hand hygiene. An interview, on 11/3/21 at 03:11 PM, with CNA #2, revealed she had been assigned to Resident #1 on second shift for the past two (2) weeks. CNA #2 stated she had noticed Resident #1 had not been wearing the resting hand splint much in the past 2 weeks and Resident #1 did not have the resting hand splint on yesterday, 11/2/21. CNA #2 stated that she did not put the resting hand splint on Resident #1 on 11/2/21, because she could not find it in Resident #1's room. CNA #2 stated she was one of the staff members responsible for putting the resting hand splint on Resident #1's right wrist and Resident #1 was supposed to wear the resting hand splint every day, for a certain number of hours, and it needed to be taken off to let Resident #1's hand rest. CNA #2 also stated the splint had to be removed to clean Resident #1's hand and she did not know why the resting hand splint was not being used on Resident #1's wrist as ordered. CNA #2 stated she and other CNA's, who are assigned to Resident #1, had been in-serviced last week by the therapy department about putting the resting hand splint on Resident #1's right wrist. An interview, on 11/3/21 at 03:20 PM, with Licensed Practical Nurse, (LPN) #1 revealed she did not remember how many times Resident #1 had not worn the resting hand splint for the past 3 days this week. An interview, on 11/3/21 at 3:37 PM, with the Certified Occupational Therapy Assistant (COTA), revealed no in-service was held with CNA's regarding applying the resting hand splint on Resident #1 last week. An interview, on 11/3/21 at 03:45 PM, with the Physical Therapist (PT), revealed no in-service was done by her, with the nurse aides, regarding the resting hand splint for Resident #1's right wrist. An interview, on 11/3/21 at 03:55 PM, with the Rehabilitation Director, revealed no in-service had been completed in the past week with the CNAs regarding the resting hand splint for Resident #1. The Rehabilitation Director stated an in-service was completed with nursing staff, at the time Resident #1 was on the active therapy case load, when the resting hand splint was ordered. An interview, on 11/3/21 at 04:10 PM, with the Director of Nursing (DON), revealed she had no knowledge the resting hand splint was not applied on Resident #1 as ordered in the medical record. The DON was not aware the documentation of the order and the documentation on the care plan was different regarding the use of the resting hand splint for Resident #1. The DON revealed she was not aware of an in-service with the CNAs, by the therapy department, last week, regarding applying the resting hand splint for Resident #1. During an interview, on 11/3/21 at 04:10 PM, the Administrator stated, If the splint was not being used correctly on resident's contracted wrist, this could cause more contracture. An interview, on 11/4/21 at 08:36 AM, with Minimum Data Sheet (MDS) Nurse, revealed she was not aware the care plan, for Resident #1, did not match the physicians orders for the resting hand splint. The MDS Nurse stated she and Medical Records shared the responsibility of developing and updating the nursing care plans and Medical Records may have been the one responsible for Resident #1's care plan entry. An interview, on 11/4/21 at 08:45 AM, with Medical Records, revealed she was not responsible for developing or updating care plans for any of the residents. Medical Records stated she did change Resident #1's Activities of Daily Living (ADL) Care Plan in the Electronic Health Record (EHR), for the resting hand splint, on 11/3/21. An interview with Rehabilitation Services Director, revealed she requested an (OT) evaluation for Resident #1, to be completed on 11/4/21, for assessment of the contracture, to the right wrist, for decline in range of motion, due to staff possibly not using the resting hand splint as ordered. An interview, on 11/4/21 at 09:02 AM, with CNA #3, revealed the nurses are the only ones responsible for taking splints off residents. CNA #3 stated she always asked the nurse to remove any kind of splint or brace from a resident. CNA #3 stated she had not been in-serviced in the past week by the therapy department regarding application of the resting hand splint for Resident #1. An interview, on 11/4/21 at 09:02 AM, with CNA #4 revealed CNAs are in-serviced by the therapy department to apply and remove splints and braces from facility residents and there is a sign off sheet showing understanding of the training. CNA #4 stated she had not been in-serviced in the past week by the therapy department regarding placement of the resting hand splint for Resident #1. CNA #4 stated CNAs are responsible for charting on splints and braces, if it comes up on the tasks on their Kiosk. CNA #4 stated she had seen the task, on the Kiosk, for Resident #1, for the resting hand splint. During an interview, on 11/4/21 at 09:15 AM with the DON, she revealed that the resident could have worsening contractures with the right-hand splint not being worn. An interview, on 11/4/21 at 11:00 AM, with the OT revealed Resident #1 had noted a decline in her contracted right wrist. An interview, on 11/4/21 at 11:10 AM, with LPN #2, revealed she could not say the resting hand splint was applied to Resident #1's right wrist every day. LPN #2 revealed Resident #1 removed the hand splint at times and she did not reapply the resting hand splint, because Resident #1 would not want it back on. LPN #2 confirmed that she did not document this. Record review of Resident #1's Face Sheet revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident #1 had an order, dated 3/15/21 and a reorder dated 4/16/21, which stated, Patient to wear resting hand splint on the right forearm/wrist/hand six (6) hours each day in order to prevent contracture. Record Review of the OT's form titled Functional Maintenance Program, dated 3/15/21 revealed a recommendation for Resident #1 that stated, Right resting hand splint should be worn for four (4) to six (6) hours daily. Record Review of ADL Assigned Tasks List from the facility Kiosk for CNA documentation revealed Patient is to wear resting hand splint on patient's right forearm/wrist/hand for 6 hours each day in order to prevent contractures. Remove resting hand splint on patient's right forearm/wrist/hand and monitor skin integrity. The Assigned Tasks List revealed the tasks were assigned to the CNAs to complete, every day, starting at 08:00 AM and ending at 02:00 PM. Record review with LPN #2 revealed the Electronic Treatment Authorization Record (ETAR) showed Resident #1 with documentation for the resting hand splint to be applied to Resident #1's right forearm/wrist/hand at 08:00 AM and was to be removed at 02:00 PM each day. Record review of nurse's notes revealed no documentation from any discipline that Resident #1 refused to wear the resting hand splint or removed the resting hand splint from her own wrist. Record review, of the ETAR, revealed documentation that stated, Patient is to wear resting hand splint on patient's right forearm/wrist/hand 6 hours each day in order to prevent contractures. Remove resting hand splint on patient's right forearm/wrist/hand and monitor skin integrity. The TAR revealed Resident #1 had documentation for the resting hand splint as follows: 10/23/21 - An entry of N at 08:00 AM that indicated the resting hand splint was not administered, but a green check mark at 02:00 PM that indicated the resting hand splint was removed at 02:00 PM. 10/11/21 - An entry of N documented that stood for the resting hand splint was not administered. 10/9/21 - No entry showed the resting hand splint was applied on this date. 10/3/21 - No entry showed the resting hand splint was applied at 08:00 AM, but was removed at 02:00 PM 10/2/21 - No entry showed the resting hand splint was applied on this date. 09/26/21 - No entry showed the resting hand splint was applied on the date. 09/25/21 - An entry of N at 08:00 AM that stood for the resting hand splint was not administered. Record review, of a Minimum Data Set, (MDS), Annual Assessment, with an Assessment Reference Date of 5/6/21, revealed a Brief Interview for Mental Status, (BIMS), score of 99, indicating severely impaired cognitive skills.

Based on observation, staff interview, record review and facility policy review the facility failed to follow the care plan for Activities of Daily Living related to Shaving residents for two (2) of five (5) residents reviewed and Position and Mobility related to placement of a splint for one (1) of three (3) residents reviewed with splints. Resident #1, Resident #15, and Resident #402. Findings Include: Review of facility policy titled, Comprehensive Care Plans, with a revision date of 11/2017 stated, It is the policy of [NAME] to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. An observation, during initial tour, on 11/01/21 at 11:55 AM, revealed Resident #1, had a resting hand splint on her bedside table. Resident #1 had a contracture of the right wrist. An observation, on 11/2/21 at 01:30 PM, revealed Resident #1 was not wearing the resting hand splint on her right wrist. The resting hand splint was not observed visible on any surface in the room. An observation, on 11/3/21 at 09:16 AM, revealed Resident #1 did not have her resting hand splint on the right wrist. Resident #1 did respond to the request to pull her covers back and allow her right wrist to be observed for resting hand splint placement. The resting hand splint was observed across Resident #1's room in a chair. An observation, on 11/3/21 at 03:06 PM, revealed Resident #1 had the resting hand splint on her right wrist and appeared to be resting comfortably with the resting hand splint on. She did not show any visible signs of discomfort. An initial tour observation, on 11/01/21 at 11:30 AM, revealed Resident #15, had facial hair that appeared to be from several days of growth. Resident #15 appeared to need a shave. When asked if he wanted to shave, Resident #15 answered, Yes. An observation, on 11/2/21 at 09:39 AM, revealed Resident #15 continues to have facial hair and has not been shaved. An observation, on 11/3/21 at 09:12 AM, revealed Resident #15 continues to have facial hair and has not been shaved. An observation, on 11/4/21 at 08:40 AM, revealed Resident #15 continues to have facial hair and has not been shaved. Resident #15's facial hair was observed to be approximately one (1) inch long on today. An initial tour observation, on 11/1/21 at 11:30 AM, revealed Resident #402 was not shaved. Resident had facial hair that appears to be a result from several days growth. An observation, on 11/02/21 at 09:10 AM, revealed Resident #402 continues to have facial hair and has not been shaved. An observation, on 11/3/21 at 09:12 AM, revealed Resident #402 continues to have facial hair and has not been shaved. An observation, on 11/4/21 at 08:40 AM, revealed Resident #402 continues to have facial hair and has not been shaved. Resident's facial hair was observed to be approximately one-half inch long. An interview, on 11/3/21 at 03:11 PM, with Certified Nursing Aide (CNA) #2, revealed she had been assigned to Resident #1 on second shift for the past two (2) weeks. CNA #2 stated she had noticed Resident #1 had not been wearing the resting hand splint much in the past two (2) weeks. CNA #2 stated she saw Resident #1 did not have the resting hand splint on yesterday, 11/2/21. CNA #2 stated that she did not put the resting hand splint on Resident #1 on 11/2/21, because she could not find it in Resident #1's room. CNA #2 stated Resident #1 was supposed to wear the resting hand splint every day, for a certain number of hours, and it needed to be taken off to let Resident #1's hand rest. CNA #2 also stated the splint had to be removed to clean Resident #1's hand. CNA #2 stated she did not know why the resting hand splint was not being used on Resident #1's wrist. An interview, on 11/3/21 at 03:20 PM, with Licensed Practical Nurse, (LPN) #1 revealed she was not aware Resident #1 had a discrepancy with the order and care plan documentation regarding the resting hand splint. LPN #1 stated she did not remember how many times Resident #1 had not worn the resting hand splint for the past 3 days this week. An interview, on 11/3/21 at 04:10 PM, with the Director of Nursing (DON), revealed she had no knowledge the resting hand splint was not being adequately applied on Resident #1 according to the order and care plan. She stated she was not aware the documentation of the order and the documentation on the care plan, for the resting hand splint, did not match, regarding the use of the resting hand splint for Resident #1. The DON stated she was aware some of the facility care plans needed corrections. The DON stated all resident orders should match their care plans to ensure all care is being given to all residents. An interview, on 11/3/21 at 04:10 PM, with the Administrator, revealed she had no knowledge the resting hand splint was not applied on Resident #1 according to the order and care plan. She stated she was not aware the documentation on the order and the documentation on the care plan, for the resting hand splint, did not match, regarding the use of the resting hand splint for Resident #1. Administrator stated all resident orders should match their care plans. She stated she was aware some of the facility care plans needed corrections. An interview, on 11/4/21 at 08:36 AM, with the Minimum Data Set (MDS) Nurse, revealed she was not aware of the care plan, for Resident #1, not matching information on the orders for the resting hand splint. The MDS Nurse stated she and Medical Records shared the responsibility of developing and updating the nursing care plans. The MDS Nurse stated Medical Records may have been the one responsible for Resident #1's care plan entry. An interview, on 11/4/21 at 08:45 AM, with Medical Records, revealed she was not responsible for developing or updating care plans for any of the residents. Medical Records stated she did change Resident #1's Activities of Daily Living (ADL) Care Plan in the Electronic Health Record (EHR), for the resting hand splint, last evening, 11/3/21, per administrator's request. An interview, on 11/4/21 at 08:45 AM, with the Administrator, revealed the MDS Nurse was assigned the task of developing and updating nursing care plans. Administrator stated the incorrect entry on the care plan, related to use of the resting hand splint, for Resident #1 was entered by the MDS nurse. Administrator stated she did request Medical Records to correct Resident #1's Care Plan to match the order for the resting hand splint on last evening, 11/3/21. An interview, on 11/3/21 at 09:45 AM, with CNA #4 revealed the ADL care for Resident #15 was complete for 11/3/21. CNA #4 revealed she observed there was hair on Resident #15's face. CNA #4 stated the shaving ADL task fires in the Kiosk for the second shift CNAs, but did see the ADL task had not been completed by the second shift CNA. CNA #4 stated she saw Resident #15 had facial hair when she was assigned to him on Monday. CNA #4 stated that she should have shaved him and reported the task was not done on 2nd shift. An interview, on 11/4/21 at 09:35 AM, with the DON, revealed Resident #15 and Resident #402 should have been shaved before today and was not aware Resident #15 and Resident #402 needed to be shaved all week. The DON stated Resident #15 and Resident #402 did not receive adequate assistance with all ADLs as Care Planned. The DON stated all ADL tasks for residents should be completed every day, the CNA's are responsible for completing all ADL tasks, for all residents, every day and the Lead CNA has the responsibility to round in each resident's room, daily, to ensure all ADL tasks, for every resident, had been completed. An interview, on 11/4/21 at 09:41 AM, with the Lead CNA #5, revealed all CNAs were aware of the ADL Care Plans and all ADLs are to be completed for every resident, every day. CNA #5 stated she has the responsibility, of making rounds, in every resident's room to assess residents, behind the other CNA's, to ensure all ADL care was completed for all residents. CNA #5 stated she was not aware Resident #15 and Resident #402 had received a shave all week. CNA #5 recognized Resident #15 and needed to be shaved from today's observation. An interview, on 11/1/21 at 12:00, with Resident #402, revealed he wanted to be shaved. He stated that this is very important. An interview, on 11/3/21 at 09:45 AM, with CNA #4 revealed ADL care for Resident #402 was complete for 11/3/21. CNA #4 revealed she observed there was hair on Resident #402's face. CNA #4 stated the shaving ADL task fires in the Kiosk for the second shift CNAs, but did see the ADL task had not been completed by the second shift CNA. CNA #4 stated she saw Resident #402 had facial hair when she was assigned to him on Monday. CNA #4 stated she should have shaved him and reported the task not being done by 2nd shift. Record review revealed Resident #1 had a Care Plan developed with an approach that revealed the Patient is to wear resting hand splint at all times, only to be removed for bathing, hand hygiene, and monitor skin integrity. Record review, of Resident #1's orders, with LPN #1, revealed an order stating, Patient to wear resting hand splint on the right forearm/wrist/hand six (6) hours each day in order to prevent contracture. Record review, of the ADL Care Plan for Resident #15 revealed the problem I require assistance with my ADLs. and an approach that directed staff to Assist elder with ADLs, as needed, to maintain current function and improve independence with ADLs. Record review, of ADL Care Plan for Resident #402, revealed the problem I require assistance with my ADLs. and the approach that directed staff to Assist elder with ADLs, as needed, to maintain current function and improve independence with ADLs. Record review, of an annual MDS, for Resident #1, with an Assessment Reference Date (ARD) of 5/6/21, revealed a Brief Interview for Mental Status, (BIMS), score of 99, indicating severely impaired cognitive skills. Record review of an Annual MDS with an ARD of 5/6/21 for Resident #402 revealed a BIMS, score of eight (8), indicating moderately impaired cognitive skills. Record review of a Quarterly MDS with an ARD date of 8/9/21 for Resident #15 revealed a BIMS score of 5, indicating severely impaired cognitive skills.

Based on observation, interview of residents and staff, and record review the facility failed to shave residents who were dependent for Activities of Daily Living (ADL) for two (2) of five (5) residents observed. Resident #15 and #402. Findings include: Review of facility policy titled, Grooming a Resident's Facial Hair, dated 11/1/2016, revealed, It is the practice of this facility to assist residents with grooming facial hair to meet their preference. Initial tour observation of Resident #402, on 11/01/21 at 12:00 PM, revealed Resident #402 was not shaved. He had facial hair that appeared to be a result from several days growth. Resident #402 stated he would like to be shaved. He stated that this is very important. Initial tour observation revealed Resident #15, had facial hair that appeared to be from several days of growth. Resident #15 appeared to need a shave. When asked if he wanted a shave, Resident #15 answered, Yes. An observation, on 11/2/21 at 09:39 AM, revealed Resident #15 continues to have facial hair and has not been shaved. An observation, on 11/3/21 at 09:12 AM, revealed Resident #15 continues to have facial hair and has not been shaved. An observation, on 11/4/21 at 08:40 AM, revealed Resident #15 continues to have facial hair and has not been shaved. Resident # 15's facial hair was observed to be approximately one (1) inch long on today. An observation, on 11/02/21 at 09:10 AM, revealed Resident #402 continued to have facial hair and had not been shaved. An observation, on 11/3/21 at 09:12 AM, revealed Resident #402 continued to have facial hair and had not been shaved. An observation, on 11/4/21 at 08:40 AM, revealed Resident #402 continued to have facial hair and has not been shaved. Resident's facial hair was observed to be approximately one-half inch long. An observation and interview, on 11/4/21 at 09:35 AM, with the Director of Nursing (DON), revealed she recognized Resident #402 needed to be shaved. The DON asked Resident #402 if he wanted to be shaved today and Resident #402 answered Yes. The DON revealed Resident #402 should have been shaved before today and was not aware Resident #402 needed to be shaved all week. The DON stated she was aware Resident #402 did not normally wear facial hair and liked his face to stay clean shaved. The DON asked Resident #15 if he wanted to be shaved today. Resident #15 answered Yes to wanting to be shaved today. The DON stated Resident #15 should have been shaved before today and was not aware Resident #15 needed to be shaved all week. The DON stated she was aware Resident #15 did not normally wear facial hair and liked his face to stay clean shaven. She stated the CNA's are responsible for completing all ADL tasks, for all residents, every day. The DON stated the Lead CNA has the responsibility to round in each resident's room, daily, to ensure all ADL tasks, for every resident, had been completed. The DON stated Resident #15, and Resident #402 should not have gone all week without being shaved. She stated Resident #15 and #402 did not receive adequate assistance with all ADLs. An interview, on 11/3/21 at 09:45 AM, with CNA #4 revealed the morning ADL care for Resident #402 had been completed. CNA # 4 revealed she observed there was hair on Resident #402's face, the shaving task fires in the Kiosk for the second shift CNAs, and male residents are to be shaved every other day. CNA #4 revealed she was not at work yesterday but saw Resident #402 had facial hair when she was assigned to him on Monday. CNA #4 stated she should have shaved Resident #402 on Monday and reported the task not being done, by the second shift CNA, to her supervisor. An interview, on 11/4/21 at 09:41 AM, with the Lead CNA #5, revealed all CNAs were aware that all male residents were to be shaved every day. CNA #5 stated she has the responsibility of making rounds, in every resident's room, to assess residents, behind the other CNA's, to ensure all ADL care was completed for all residents. CNA #5 stated she was not aware Resident #15 and Resident #402 had not received a shave all week. CNA #5 stated she has been at work all week this week. CNA #5 stated she has been tied up, all week, weighing every resident in the facility, and did not observe Resident#15 and Resident #402 needed a shave when he was weighed. CNA #5 stated Resident #15, and Resident #402 should have received a shave every day this week. CNA #5 stated Resident #15, and Resident #402 liked to stay clean shaved. An interview, on 11/3/21 at 09:45 AM, with CNA #4 revealed she had completed Resident #15's ADL care for 11/3/21. CNA # 4 revealed she observed there was hair on Resident #15's face, the shaving task fires in the Kiosk for the second shift CNAs, and male residents are to be shaved every other day. CNA # 4 revealed she was not at work yesterday but saw Resident #15 had facial hair when she was assigned to Resident #15 on Monday. CNA #4 stated she should have shaved Resident #15 on Monday and reported the task not being done, by the second shift CNA, to her supervisor. Record review of the form, Assigned Tasks List from the Kiosk for CNAs, revealed Resident #15 did not have a task listed for shaving to be completed by the CNAs. Record review of the form, Assigned Tasks List, from the Kiosk for CNAs, revealed documentation for Resident #402 stating, Daily shave on two to ten (2-10) shift. Use an electric razor to shave me. Record review of an Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/6/21 for Resident #402 revealed a Brief Interview for Mental Status, (BIMS), score of eight (8), indicating moderately impaired cognitive skills. Record review of a Quarterly MDS with an ARD date of 8/9/21 for Resident #15 revealed a BIMS, score of 5, indicating severely impaired cognitive skills.

Based on record review, facility policy review and staff interview the facility failed to obtain a lab value (Hemoglobin A1C) as ordered by the Physician for Resident # 7, one (1) of 13 sampled residents reviewed for obtaining lab work as ordered. Findings include: A review of the facility's policy entitled Laboratory Services, dated 06/12/14, documented the following: The facility will provide or obtain laboratory services to meet the needs of it's elder's. The facility will promote practices to ensure the quality and timeliness of laboratory services. Laboratory services may only be provided or obtained when ordered by the elder's physician. During the monthly check of newly printed Medication and Treatment Administration Records (MARS) and TARs (Treatment Administration Record), the designated nurse will schedule lab work to be drawn within the ordered time frame. The Medical Record Nurse and/or Director of Nursing Services (DONS) will maintain and update a log of all regularly scheduled laboratory tests. A review of the information on the lab test Hemoglobin A1C (HgbA1c), provided by the facility, documented the following information: The A1C test also called a Hemoglobin A1c test is a common blood test to gauge your average blood sugar level over the past two to three months. A review of Resident #7's medical record revealed the last HgbA1c was dated 1/31/17. There was no HgbA1c for the month of April 2017. A review of Resident # 7's physician's orders [REDACTED]. A review of the physician's orders [REDACTED].# 7 was listed with a handwritten note A1c due. During an interview on 06/13/17 at 11:10 AM, the Registered Nurse Supervisor (RN # 1) said the Director of Nursing prints off the list of labs due and is responsible for checking labs. The RN acknowledged the HgbA1c lab test was not done for April 2017, as ordered by the physician for Resident # 7. During an interview on 06/13/17 at 11:20 AM, the DON confirmed that she was responsible for obtaining routine lab work and the HgbA1c lab request for Resident #7 was on her list for April 2017. The DON said the lab just got overlooked. The DON also acknowledged the lab test was to measure the resident's blood sugar levels for the past three (3) months and it is in the best interest of the elder to follow physician's orders [REDACTED]. The facility readmitted Resident #7 on 12/18/12, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), with an Assessment Reference Date of 09/27/16, identified the resident with a BIMS (Brief Interview for Mental Status) of 12, which indicated moderate cognitive impairment.

Based on staff interview, facility policy review and record review the facility failed to follow the comprehensive care plan related to Foley catheter care for one (1) of thirteen (13) resident care plans reviewed; (Resident #8). Findings include: Review of the facility's policy, Care Plans - Comprehensive, dated October 2010, revealed, Each resident's comprehensive care plan is designed to: e. Reflect treatment goals, timetables and objectives in measurable outcomes. F. Identify the professional services that are responsible for each element of care. Observation on 4/26/16 at 11:40 AM with Certified Nursing Assistant (CNA) #1 revealed CNA #1 performed Foley catheter care on Resident #8 and failed to clean the Foley catheter tubing properly. CNA #1 held the catheter at the insertion point and cleaned downward toward the urethra, instead of away from the urethra. Review of CNA care task for 04/27/16 revealed urinary catheter care as a task to be performed. Interview on 04/27/16 at 10:10 AM with the Director of Nursing confirmed the Foley catheter care was not performed properly and failed to follow the care plan for Foley catheter care. The facility's face sheet revealed the facility admitted Resident #8 on 03/24/16 with a [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/04/16, revealed a Brief Interview of Mental Status (BIMS) score of 00, which indicated Resident #8 had severe cognitive impairment.

Based on observation, staff interview and facility policy review, the facility failed to provide Foley catheter care in a manner to prevent possible infection for one (1) of one (1) residents with a Foley catheter; (Resident #8). Review of the facility's policy, Urinary Catheter Care, with an effective date, 06/12/14, revealed, b. clean the area where the catheter is inserted by wiping away from the insertion site, to prevent germs from being moved from the anus to the urethra. D. Wash the catheter to remove any blood or other materials from the catheter, wiping downwards from the urethra. Observation on 4-26-16 at 11:40 AM with Certified Nursing Assistant (CNA) #1 revealed CNA #1 performed Foley catheter care on Resident #8 and failed to clean the Foley catheter tubing properly. CNA #1 held the catheter at the insertion point and cleaned downward toward the urethra three (3) times. During an interview on 04/27/16 at 9:20 AM, Certified Nursing Assistant (CNA) #1 stated she realized she had cleaned the catheter tubing in the wrong direction yesterday. CNA #1 stated she had received training at the facility on performing catheter care and was instructed to wipe away from the body to prevent germs from entering the bladder. Record review revealed CNA #1 received skills performance training on incontinent care and catheter care on 03/16/16. Interview on 04/27/16 at 9:50 AM with the Director of Nursing (DON) revealed she is responsible for checking the CNA's off on catheter care along with the Lead CNA's. Interview on 04/27/16 at 10:00 AM with CNA #2 revealed she checked CNA #1 off on catheter care last month. CNA #2 stated employees are instructed to hold the catheter at the urinary meatus and wipe away from the body. Interview on 04/27/16 at 10:10 AM with the DON revealed CNA #1 failed to perform catheter care as instructed. Review of the facility's face sheet revealed the facility admitted Resident #8 on 03/24/16 with a [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/04/16, revealed a Brief Interview of Mental Status (BIMS) score of 00, which indicated Resident #8 had severe cognitive impairment.

Based on staff interview, record review and facility policy review, the facility failed to obtain a lab as ordered by the physician for Resident #4 for one (1) of 12 labs reviewed. Findings Include: Review of facility policy dated 06/12/14 and titled, Laboratory Services, stated, The facility will promote practices to ensure the quality and timeliness of laboratory services. The Director of Nursing (DON) and or medical records nurse will complete lab audits periodically to ensure proper compliance. Record review on 04/26/16 revealed a physician's orders [REDACTED]. Further record review revealed that the results of the February 2016 monthly PT/INR lab results were missing from the resident's medical record. Interview with the DON on 04/26/16 at 2:45 PM confirmed that the lab test was missed for February 2016 and she stated that a lab audit had occurred and the facility was made aware that we had missed it. We had a person that was drawing our labs previously and then we started drawing them ourselves. We have a nurse on the night shift now that draws labs and she just forgot to draw it. We talked to her and counseled her. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) was conducted on 03/02/16 and the resident scored a 99, indicating she was too cognitively impaired to finish the assessment.

Based on observation, staff interview and the facility policy review the facility failed to maintain equipment in a clean and sanitary manner, and failed to properly store and label food according to manufacturer's recommendation for two (2) of three (3) dietary tours. Review of the facility's policy entitled, Cleaning of Food and Nonfood Contact , dated 1/14, revealed Nonfood contact surfaces of equipment cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris. The cavities and door seals of microwave ovens cleaned at least once a day. The Director assigns daily cleaning responsibilities in each position workflow. The cleaning schedule revealed, daily organize and sanitize pantry, check for food labels, out of date products. Review of the facility's policy entitled, Food and Supply Storage Procedures, dated 1/14, revealed the use by date is the last date that a food can by consumed; do not sell products in retail areas or place on patients trays/resident plates past the date on the product. Foods past the use by date discarded. Date and rotate items. Discard food past the use by or expiration date. Containers in the refrigerator storage are to have labels and date. Expiration dates printed by the manufacturer apply until the product opened. Once opened, use these time limits, open date counts as day 1. Spices discarded within one (1) year of opening. Observation on 05/13/15 at 9:40 AM with Dietary #1 revealed seven loaves of honey wheat bread with a used by date of 4/17 and one loaf of honey wheat bread with a used by date of 4/3 in the dietary prep area. A clear container with a red top, containing sausage and gravy, was in the reach in cooler without a prep date. A plastic container of what appeared to be oatmeal was on shelving in the dietary prep area with an expiration date of 2/6/14. A container of grits in the dietary prep area had an expiration date of 2/27/15. A container of vanilla with no open date, lemon pepper with no open date, sage no open date, and thyme expiration date of 7/14 were in the dietary prep area. There were containers of black pepper in the dietary prep area with no open date, white pepper with an expiration date of 4/18/15, cinnamon with an open date of 11/10/14 and no expiration date and baking soda with an open date of 3/31/15 and no expiration date. The microwave in the dietary prep area noted to have dried brown/yellow splatters on the inside top and on the inside of the door. Interview on 05/13/15 at 9:40 AM with Dietary #1 revealed, It (microwave) is dirty. Interview on 05/14/15 at 9:20 AM with Dietary #2 revealed, We have a daily and weekly cleaning schedule. No, they don't initial it, it depends on your station (work area) at the time. When the food (spices) comes in, I put the date on a label. When the cook opens it, they should write the date and the expiration date on the label. I called (name of bread service) about the wheat bread because we don't use it often. Interview on 05/14/15 at 9:30 AM with Dietary #2 revealed, No, we don't check the dates (bread), he does a night drop and it's here the next morning. Observation on 05/14/15 at 11:30 AM with Dietary #1 revealed, the microwave in the dietary prep area have brown/yellowish splatter on the inside. Interview on 05/14/15 at 11:30 AM with Dietary #1 revealed, I had them take it (microwave) to the dish room to scrub it yesterday. No, I don't think they did a good job.

Based on observation, record review, interview, and policy review, the facility failed to provide privacy for Resident #13 during medication pass (medpass) observation on 06/19/14 for one (1) of seven (7) residents observed during medication administration. Findings include: A review of the facility's information booklet entitled "A Matter of Rights," copyright 2011, documented, on page 12, under "Privacy, Confidentiality and HIPAA (Health Insurance Portability and Accountability Act.) Your right to privacy and confidentiality is as important to you as it is to any other person. You have the right to have other people respect your personal privacy as you receive care; confidentiality for your personal and health information." During an observation of medication administration on 06/19/14 at 7:00 AM Resident #13 was observed to be in the rotunda (open area between the two wings) of the facility with staff and other residents. LPN (Licensed Practical Nurse) #2 prepared Resident #13's medication from the cart in the rotunda area. The LPN approached Resident #13 and attempted to administer the resident's medication. The resident said "No, get away." The LPN spoke in a loud voice informing the resident "This is your medicine." Again the resident refused the medication. The LPN said in a loud voice "This is your medicine; it is for the pain in your shoulder." After LPN #2 explained again in a loud voice the resident took the medication. Other staff, including the Administrator and Director of Nurses were present in the area with residents. During an interview on 06/19/14 at 10:30 AM the Administrator affirmed that LPN #2 did not provide privacy for medication administration for Resident #13. She said the nurse should not have discussed Resident #13's pain medication in front of other residents. During an interview on 06/19/14 at 1:25 PM with LPN #2, she acknowledged that she administered Resident #13's medication in the rotunda area in view and in hearing range of other residents. LPN #2 said she talked loud because she was nervous and the resident was very hard of hearing. During an interview on 06/20/14 at 2:40 PM, the Director of Nursing (DON) acknowledged other residents were present and within hearing range during the medpass observation on 06/19/14 for Resident #13. She said, "I thought it was about privacy" because the nurse talked loud and said the medication was for the resident's pain. The DON said LPN #2 should have given the medication in the resident's room or waited a while and tried again. During an interview on 06/20/14 at 1:45 PM, the Social Services Designee said residents with Dementia can get in a crowd and become over stimulated. She said to ensure privacy during medpass, staff should gain permission from the resident if possible, pull curtains, take the resident to their room or private, or try again later to give the medication (if initially refused). The facility admitted Resident #13 on 09/28/10. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 06/09/14, identified the resident with a BIMS (Brief Interview for Mental Status) of 0 (zero) or cognitively impaired.. The MDS identified the resident with moderate difficulty in hearing. The speaker had to increase volume, speak distinctly. Resident #13 sometimes understood.

Complaint Investigation (CI) MS # Based on observation, interview, record review, and policy review the facility failed to ensure that avoidable accidents did not occur during transportation in the facility van for two (2) of seven (7) residents reviewed, who had been transported in the van. This is for Resident #1 and Resident #3. These Resident's were not secured properly in the van. On [DATE], Resident #1 was being transported per wheelchair in the facility van. The van made a turn and Resident #1's wheelchair was not secured properly, and the wheelchair rolled into another Resident's wheelchair. On [DATE], Resident #1's wheelchair turned over in the van. Resident #1 was taken to the emergency room for evaluation. Resident #1 did not receive an injury. The facility did not have a return demonstration by staff of the proper way to secure Resident's in wheelchairs after the incident occurred with Resident #1 on [DATE]. These actions put all Resident's being transported by wheelchair in the facility van at risk for serious harm, impairment or death. There are 28 of 56 residents who use a wheelchair during transportation on the van residing in the facility. The facility's failure to ensure that Resident #1 and Resident #3's wheelchairs were secured, prior to transport in the facility van, was deemed an Immediate Jeopardy (IJ) on [DATE] at 1:50 p.m. The IJ began on [DATE] and was determined to be removed on [DATE]. The Administrator was notified of the IJ on [DATE] at 1:55 p.m. The facility provided a credible Allegation of Compliance (AoC) on [DATE]. Based on the facility's implementation of corrective actions and an acceptable AoC, the Immediate Jeopardy was removed as of [DATE] and lowered to a "D" level which constitutes no actual harm with potential for more than minimal harm. Findings included: Resident #1 Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of "8". A score of ",[DATE]" indicates mild cognitive impairment. Review of the most recent MDS with an ARD of [DATE] revealed that Resident #1 was now scored at a "5" indicating severely cognitive impairment. Both MDS's revealed that Resident #1 required extensive to total assistance with Activities of Daily Living (ADSL's). Observation and interview on [DATE] at 10:30 a.m. revealed that Resident #1 was alert and oriented to person and place, but not time. Resident #1 was seated in a wheelchair. A lift sling was in place. Resident #1 recalled that she had fallen over in the wheelchair, while in the van, going to the doctor. Resident #1 stated that she did not have any problems with the incident and had no complaints of pain or discomfort. Resident #1 stated that she did have straps across her when the chair fell over in the van. Resident #1 had no bruising noted to exposed skin. Review of a written report from the facility dated [DATE], revealed that Resident #1 went out on pass to a Physician's appointment on [DATE] per the facility van, accompanied by two (2) staff members, who were identified as the Activity Assistant (AA) #1 and CNA/Van Driver #1. Resident #2 was also present. Per report," both residents were secured correctly on the van and during a turn, (Name of Resident #1) slumped over in the wheelchair and bumped her upper body on the wheelchair of the other Resident (Resident #2). Resident #1 denied being hurt...". upon return to the facility, Resident #1 was assessed with [REDACTED]. "On the morning of [DATE], (2012), (Name Resident #1) had some bruising noticed by the shower aides. They notified the (Name of RN Supervisor), who found greenish/yellow bruising to (Name of Resident #1's) upper chest. She denied any discomfort but the RN went ahead and asked the MD for a x-ray. He was reluctant but did agree on ,[DATE] (2012) for a x-ray to be performed. (Name of Resident #1) had complained of tenderness to the area once over this time period. The x-ray was performed on ,[DATE] (2012) and results received with Impression: nondisplaced probably acute fracture to the distal clavicle."(Name of Resident) has osteoarthritis and generalized pain." "Her responsible party and physician were kept up to date throughout the entire process and when made aware of the clavicle fracture opted to treat with pain medication as needed. Her pain is well controlled; she has only requested prn (as needed) pain medication on one occasion since learning of the fracture. MD did not order a clavicle splint. Plan of care was updated as needed." Review of Nurse's Notes dated [DATE] at 10:32 a.m. revealed: "Resident out on pass with staff to (name of Physician's office) for follow up eye appointment. No distress noted upon departure." The Nurse's Notes on [DATE] at 1:00 p.m. revealed: "Called from facility van per (Name of CNA) stated that while driving van resident w/c (wheelchair) leaned up against (Name of another Resident) w/c. No injuries noted. Did not fall our of chair or on floor." The Nurse's Notes on [DATE] at 4:47 p.m. revealed: "Returned from OOP (out on pass) with facility van. Assessed resident r/t bump on van. Alert and responsive up in wheelchair. No bruising noted ROM (range of motion) done able to move extremities without facial grimaces. No c/o pain or discomfort. Will continue to observe. RP present and aware." The Nurse's Notes on [DATE] at 8:58 a.m. revealed: "Summoned to shower room per CNA. When entered notice some greenish/yellow bruising to upper rt arm/chest area. Resident had a previous bump on van earlier in week while van was turning into MD office. When this nurse asked resident if rt arm shoulder was hurting upon return from appt stated< "no". No apparent injury noted upon return from appt. Bruising noted this am (morning) to RT (right) upper chest. No other injury noted. when asked resident if area was sore stated, no. RP/MD made aware of bruising and incident." Nurse's Notes dated [DATE] at 1:43 p.m. revealed a new order for x-ray related to right shoulder pain and results of x-ray received [DATE] at 6:48 p.m. right shoulder two views: "there is a probably acute vertical oblique fracture noted through the distal clavicle, and believe it extends into the acromioclavicular joint. The glenohumeral joint is normal, and the proximal humerus is intact with no humeral fracture identified. There is no shoulder dislocation or soft-tissue calcification. Impression: non-displaced probably acute fracture distal clavicle. (Resident was monitored every shift with documented nurse's notes with no complaints of pain and participated in usual activities)." Review of a physician's orders [REDACTED].#1 due to a fall on the van on [DATE] and now complains of pain in the right shoulder. Review of a Radiology Report dated [DATE], revealed that Resident #1 had a non-displaced probably acute fracture of the distal clavicle. Review of Resident #1's Electronic Medication Administration Record (EMAR) for [DATE] revealed that no pain medication was administered from [DATE] - [DATE] for complaint of shoulder/arm pain. Resident #1 did receive Lortab ,[DATE] milligrams (mg) on [DATE] and [DATE] for complaints of foot pain ([DIAGNOSES REDACTED]. Resident #1 routinely receiving Tylenol Arthritis one (1) tablet twice daily for Osteoarthrosis. Interview with Resident #2 on [DATE] at 10:00 a.m. revealed that he was alert and oriented to person, place and time. Resident #2 stated that he was in the van coming back from a physician's appointment when the bus kind of hit a bump during a turn and he saw (Resident #1) coming toward him in her wheelchair. Resident #2 stated that he had tried to catch and hold Resident #1 up; and hollered for the girl who was with them (could not recall her name). Resident #2 stated that (Resident #1) didn't complain of any pain or injury. Resident #2 stated that the wheelchair had been strapped in the back, but, wasn't sure about the front, that it all happened too fast. Resident #2 stated that his chair never moved (motorized). Resident #2 stated that he had been transported a lot in the van without incident. Review of Resident #2's most recent MDS with an ARD of [DATE] revealed that his BIMS score was 13, therefore he was cognitively intact. Interview with AA #1 on [DATE] at 9:35 a.m. revealed that she was on the van with Resident #1 and Resident #2 ([DATE]) along with Van Driver #1. AA #1 stated that during a turn, Resident #1's wheelchair tilted toward Resident #2 and hit against him. AA #1 stated that she had tried to catch Resident #1 and that the Resident didn't fall. AA #1 stated that she had eased Resident #1 down and the Resident didn't fall. AA #1 stated that Resident #1 was still in the wheelchair with the straps still around her. AA #1 stated that Resident #1 did not complain of pain and had no injury. AA #1 stated that Van Driver #1 came to the back of the van and they called the facility. They let the Nurse know what had happened and that Resident #1 was okay with no complaints and no injury. AA #1 stated that Resident #1 was assessed by the Nurse upon return to the facility. AA #1 stated that later in the week, Resident #1 complained of some soreness to her right arm. AA #1 stated that she had strapped Resident #1 in with the floor belts and shoulder strap prior to transport and didn't know why the chair had tipped over. Van Driver #1 was not available for interview and attempts to reach her by phone on [DATE] at 11:10 a.m. were unsuccessful. Interview with RN #1 on [DATE] at 11:15 a.m. revealed that she was notified by staff on the van when the van had made a turn and Resident #1 tilted over toward the other resident. The incident occurred on [DATE]. RN #1 stated that AA #1 told her that Resident #1 had not fallen, that she'd caught her, and set her back up, with the Van Driver's assistance. RN #1 stated that she was told by the van staff that Resident #1 had been properly secured. RN #1 stated that she assessed Resident #1 upon return to the facility and found no injury or complaint from the resident. RN #1 stated that later in the week, there was a small area of yellowish/green bruising around right arm/upper chest area, RN #1 asked the Physician for an X-ray. RN #1 stated that Resident #1 was dark skinned and the bruises may not have shown up until they started turning colors. RN #1 stated that Resident #1 had no reports of any other incidents or falls. RN #1 stated that she did not fill out an incident report until the bruising was noted, because, there had been no reported fall. RN #1 stated that she did not ask for a demonstration of how the resident had been strapped in the wheelchair. RN #1 assumed that the staff knew how to secure the Resident. RN #1 stated that Resident #1 never complained of any pain, only some soreness with movement at times. Interview with Certified Nurse's Assistant (CNA) #1 on [DATE] at 3:05 p.m. revealed that she had showered Resident #1 on Mondays, Wednesdays, and Fridays. On Monday, ([DATE]), there were no signs of bruising. On Wednesday, ([DATE]), she saw small amount of greenish/yellow bruising around Resident #1's shoulder area and reported it to the Nurse. CNA #1 stated that Resident #1 had not complained of any pain. CNA #1 stated that Resident #1 was dark skinned and that the bruises may not have shown up until then. Resident #3 Observation and interview on [DATE] at 9:32 a.m. revealed that Resident #3 was in a wheelchair with a half lap tray to the right side. Resident #3 was alert and oriented to himself and confused to place and time. Resident #3 could not recall an incident or fall while in the van. There was no bruising noted to exposed skin. Record review revealed that Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's most recent MDS with an ARD of [DATE] revealed that his BIMS score was a "5" indicating severe cognitive impairment. Review of an incident report dated [DATE] at 4:00 p.m. revealed that the Van Driver #2 called the facility and stated that on the way to the facility from the physician's office the van turned right and Resident #3's wheelchair turned and tipped over on the floor. Resident's Responsible Party (RP) was present. Resident #3 was taken to the emergency room (ER) to be assessed for injury before return to facility. No injury reported from fall. Review of Nurse's Notes for Resident #3 dated [DATE] at 4:49 p.m. revealed: "(Name of Van Driver) called stated "That resident tipped over on the van". This nurse told her to take reisdent (resident) to the ER r/t stated that reisdent (resident) was moaning. RP is present on van." Review of the Nurse's Notes [DATE] at 7:42 p.m. revealed: "Call per facility van driver while on the way to the facility from dr. office. 2 CNAs needed on van ride. Rp (Responsible Party) present and MD aware...". Review of an ER report dated [DATE] revealed an ER [DIAGNOSES REDACTED].#3 with no complaint of pain and no rib fractures seen. Review of Resident #3's EMAR for [DATE] revealed that there was no increase in pain medication after the incident in the van on [DATE]. Interview with Resident #3's RP on [DATE] at 10:35 a.m. revealed that she had been on the van ([DATE]) with Resident #3, when the driver turned the van around, and Resident #3's wheelchair turned completely over on the side. Resident #3's RP stated that the shoulder straps were around him and she thought that the hooks were still on the wheelchair. Resident #3's RP stated that when the van turned, she heard a thump and saw Resident #3 on the floor still in his wheelchair. Resident #3's RP stated that Resident #3 was not hurt and did not holler out. They (staff) took him on to the ER to be evaluated. Resident #3's RP stated that nothing was broken and he had no visible bruising or injury from the incident. Interview with Van Driver #2 on [DATE] at 10:45 a.m. revealed that she transported Residents in the facility van for a couple of months now. Van Driver #2 stated that she was transporting Resident #3 back to facility ([DATE]), when she realized she's made a wrong turn. As she was turning the van around, she heard Resident #3's wife yell. Van Driver #2 stated that she looked to the back and saw Resident #3's wheelchair tipping over with him in it. Van Driver #2 stated that she had anchored the wheelchair down using three (3) anchors, two (2) on the back wheels, and one (1) on the front wheel. Van Driver #2 stated that the seat belt was across the Resident. Van Driver #2 stated that when she stopped the van and checked on the resident, he was on the floor on his right side with the strap still across him. Van Driver #2 stated that Resident #3 didn't really complain of any pain. Van Driver #2 stated that she called the facility and talked to the nurse (RN #1) and told her of the incident. RN #1 told her to take the Resident to the ER for evaluation. Van Driver #2 stated that the anchors were still in place on the wheelchair. Van Driver #2 stated that the anchors had stretched out. She said the Resident back up and re-tightened the straps. Van Driver #2 stated that there was no visible injury to Resident #3 and he had no complaints of pain. Van Driver #2 stated that the ER Nurse said that there was no injury. Van Driver #2 stated that Resident #3 was brought back to the facility, and was assessed by the Nurse. Van Driver #2 stated that she did not know of any other incidents of falls or injury, while assisting to transport residents in the van. Van Driver #2 stated that she was shown previously how to secure them (residents') in the van in the wheelchairs. Interview with RN #1 on [DATE] at 11:15 a.m. revealed that Van Driver #2 called the facility and reported that Resident #3's wheelchair had tipped/turned completely over ([DATE]) when she was turning the van around. RN #1 stated that she advised Van Driver #2 to take Resident #3 directly to the ER before returning to the facility. RN #1 stated that Resident #3's wife was with them on the transport van. RN #3 stated that the X-rays were negative and they (ER) had found no injury. RN #1 stated that upon return to the facility she had assessed Resident #3 and found no bruising or injury. RN #1 stated that Resident #3 had some scratches, but, that the Resident was prone to scratching himself. because ok Observation on [DATE] at 11:00 a.m. on the facility van revealed seven (7) anchor straps with a ratchet device present on the straps. The van had seven (7) anchor tracks and two (2) shoulder strap/seat belts. Van Driver #2, AA #1, and Maintenance Director were present on the van. The Activity Director, Quality Assurance Nurse, and the Administrator were called to the van for demonstrations from staff of how to secure residents in a wheelchair for transport. Observation on [DATE] at 11:05 a.m. revealed that Van Driver #2 was providing a demonstration as to how she had secured Resident #3's wheelchair to the van prior to transport on [DATE]. Van Driver #2 used three (3) of the straps and wrapped a strap to both back wheels of the wheelchair; secured the hook to the metal ring on the straps; wrapped a strap to the front right wheel of the wheelchair; and secured the hook to the metal ring. Van driver #2 did not use the ratchet to tighten the straps. The shoulder strap was placed across the wheelchair and buckled. The wheelchair was locked. Van Driver #2 used force to pull the wheelchair to the side and the wheelchair tipped completely over onto it's side with all straps in place. Observation on [DATE] at 11:10 a.m. revealed that AA #1 was demonstrating how she had secured Resident #1's wheelchair in the van prior to transport on [DATE]. AA #1 used two (2) straps and wrapped one (1) strap around the back right wheel of the wheelchair several times; hooked the metal ring on the strap; used another strap and wrapped around the right front wheel of the wheelchair; and secured the hook to the metal ring on the strap. AA #1 did not use the ratchet to tighten them the straps. AA #1 buckled the shoulder strap across the wheelchair. The wheelchair was locked. AA #1 used force to pull the wheelchair to the side and the wheelchair tipped completely over onto it's side with all straps in place. AA #1 stated that the Activity Director (AD) had originally shown her how to secure the wheelchair straps in the van. AA #1 stated that she had been transporting residents for about five (5) years without residents turning over. Interview with the QA Nurse on [DATE] at 11:15 a.m. revealed that she had only in-serviced and shown staff how to secure/anchor a geri-chair to the van, and not wheelchairs. Observation of the AD on [DATE] at 11:20 a.m.: The AD was asked to demonstrate how she had trained staff to secure wheelchairs on the van prior to transport. The AD used four (4) straps and wrapped a strap to both back wheels and both front wheels, wrapping the strap several times around each wheel and attached the hook to the metal ratchet. The AD did not ratchet the straps to tighten them. Force was used to try to pull the wheelchair to the side. The wheelchair tipped slightly but was more stable and did not turn over. The AD stated that she had not used the ratchet to tighten the straps. Interview with the Maintenance Director on [DATE] at 11:25 a.m. revealed that the procedures for Van Driver #2, AA #1 and the AD for securing the wheelchair in the van were incorrect. The Maintenance Director stated that the straps had to be tightened with the ratchet to secure the wheelchair in place properly. The Maintenance Director stated that he had checked the straps and ratchet after the incidents with Resident #1 and Resident #3 for proper functioning. He found them in good working order. The Maintenance Director stated that he had not asked for staff to demonstrate how the residents had been secured prior to transport. Interview with the Administrator on [DATE] at 11:30 a.m. revealed that she had not asked for demonstrations. The Administrator did not go to the van after the incidents. Interview with the Administrator on [DATE] at 12:00 p.m. revealed that there had been no particular policy and procedure for check-offs on the van transportation prior to [DATE]. The Administrator stated that the AD had shown staff how to secure residents for transport in the van. The Administrator stated that she had been there five (5) years and was not aware that the AD wasn't teaching the proper procedure for securing a wheelchair in the van. Interview with the Director of Nurse's (DON) on [DATE] at 12:25 p.m. revealed that the AD and AA#1 had been transporting Resident's in the van for a long time. The DON stated that CNA #3 had also been transporting Resident's. The DON stated that when Van Driver #2 was placed in the position as the "Main Transporter", that she had was shown how to secure the wheelchairs for transport. The DON stated that she had assumed that the AD, AA#1 and CNA #2 knew the proper way to secure a wheelchair in the van since they had done it for years. The DON stated that she did not go out and look, or did she get AA #1 to demonstrate how Resident #1 had been secured in the van. The DON stated that Resident #1's incident had occurred on [DATE] and bruising did not show up until [DATE]. The DON stated that she pretty much knew that the fracture for Resident #1 had occurred during the incident on the van on [DATE], because there had been no other incident or fall for Resident #1. The DON stated that after Resident #3 had the incident of turning over in the wheelchair in the van, that she had the QA Nurse to do an in-service to make sure the straps were anchored correctly to secure the wheelchair during van transport. The DON stated that she had not asked for a demonstration of how Resident #3 was secured after the incident ([DATE]). Interview on [DATE] at 4:10 p.m. with CNA #2 revealed that she had been on some van transports before, but that it had been awhile. CNA #2 stated that CNA #3 had shown her how to secure residents for transport and to make sure that the straps were secure and the resident was locked in. CNA #2 stated that she made sure that the straps were wrapped tightly but had not used the ratchet to tighten the straps, but had secured the straps with the metal hook. Interview with CNA #3 on [DATE] at 10:12 a.m. revealed that she had transported residents in the van before, but that it had been awhile. CNA #3 stated that Van Driver #2 was the designated Transporter" with assistance from the Activity Director and Activity Assistant #1. CNA #3 stated that sometimes, when making a turn, a wheelchair might slide some. CNA #3 stated that the procedure to secure the wheelchair to the van was to lock the wheelchair; put anchors on the wheels; and shoulder strap across the resident/chair. CNA #3 stated that the straps were wrapped tightly around the wheels and hooked to the metal piece on the strap. CNA #3 stated that she was trained on how to strap residents for transport. "This is to serve as the facility's credible Allegation of Compliance." "On [DATE], Resident #1 went out on pass at 10:32 a.m. to a physician's appointment on the facility van. Resident #1 went by wheelchair; Resident #2 was transported during the same trip by electric wheelchair. Two staff members accompanied them, Activity Assistant #1 and Van Driver #1. During a turn, Resident #1 slumped over bumping her upper body on the wheelchair of Resident #2. Activity Assistant #1 and Van Driver #1 asked Resident #1 if she was hurt and she said no. Van Driver #1 called facility at approximately 1:00 p.m. and informed RN Supervisor #1 of what had happened. Activity Assistant #1 and Van Driver #1 informed RN Supervisor #1 that Resident #1 had been properly secured when the incident occurred. Upon returning to the facility at 4:46 p.m. on [DATE], Resident #1 was assessed by RN Supervisor #1 and no injury was noted and no complaints of pain or discomfort were voiced. On the morning of [DATE], Resident #1 had some bruising noticed by CNA #1. RN Supervisor #1 was notified and found greenish/yellow bruising to right upper chest of Resident #1 during her shower. An x-ray was performed on [DATE], and results received with "impression: non-displaced, probably acute fracture to distal clavicle." No treatment was ordered for the probable fracture. Resident #1 has had no complaint or complications. On [DATE], Resident #3 was transported by facility van at 9:32 a.m. for a physician's appointment; he was accompanied on the van by his wife. Van Driver #2 secured Resident #3 and left the facility. The chair of Resident #3 over turned when the van made a right turn. Van Driver #2 stopped and pulled over, then went to the back of the van. Resident #3 voiced that he was not hurt. Van Driver #2 sat the chair up and called RN Supervisor #1. The decision was made by RN Supervisor #1 to take Resident #3 to the local hospital and have him evaluated; no injuries were found during their examination and x-rays were negative. After both incidents, the Director of Maintenance checked the van and straps for mechanical problems. None were found. The Director of Maintenance checked the van for the first time on [DATE] (2012) and next on [DATE] (2012). The facility failed to check for human error to ensure Resident #1 and Resident #3 had been secured properly. On [DATE], at approximately 11:45 a.m., the Administrator and Director of Maintenance observed that Van Driver #2, Activity Assistant #1 and Activity Director were unable to demonstrate how to properly secure the wheelchair for transport by failure to use the ratchet to tighten the straps securely. On [DATE], Quality Assurance Nurse conducted review and found that the facility has 28 of 56 residents who use a wheelchair during transportation on the van. On [DATE], beginning at 11:45 a.m., Director of Maintenance began performing demonstrations throughout the day showing 25 staff members how to properly secure a resident in a wheelchair for transport in the van. Return demonstrations were required to ensure that each staff member could properly secure a resident in a wheelchair. At 9:45 p.m. on [DATE], Administrator posted instructional sheets on the back wall of the van as a reminder of how to properly secure a wheelchair. These sheets are also in the van's log book. No staff member will be able to drive or assist on the van until they have demonstrated the ability to properly secure a resident in a wheelchair for transport in the van. On [DATE], a "Resident Safety" section was added by Administrator to the "Inspection Log" that is filled out by the van driver with each transport on the van. This Section documents the steps to ensure the resident is positioned securely prior to transporting. Twenty one staff members were in-serviced by Administrator as to how to fill out the log and what specifics must be in place before a resident can be transported. No staff member will be able to drive or assist on the van until they have attended this in-service. On [DATE], at 2:30 p.m. an emergency Quality Assurance Meeting was held by phone with the Medical Director, Director of Nursing, Quality Assurance Nurse, and Administrator. Administrator informed Medical Director of the following: "Two incidents have occurred with wheel chairs tipping on the van. The residents involved in these incidents were Resident #1 on [DATE] and Resident #3 on [DATE]. Resident #1 had a probable clavicle fracture and Resident #3 had no injuries. Following the incident the Director of Maintenance checked the van and the ratchet straps to be sure there was not a maintenance issue causing the falls. No issue was found. On [DATE], it was discovered that the staff who have been driving the van did not know how to properly secure the chairs. In-servicing has begun with staff and any who are on the van will be trained before leaving with a resident on how to use the straps and properly secure the chair." Medical Director voiced his agreement that any staff going on van trips should be trained on properly securing the wheelchair. He had no further input. On [DATE], a "Transportation Policy" was enacted by Administrator and Director of Nursing after consulting with the Medical Director. The policy details that each person assisting or driving the van will be able to properly secure a wheelchair. On [DATE], the "Incidents-Surveillance Of" policy was updated by Administrator and Director of Nursing to reflect that each incident will be studied and investigated. Previously, this had read that trends would be studied and investigated. On [DATE], Director of Nursing in-serviced nurses on the importance of incident reports and thorough investigation which should begin at the time the incident is reported. The investigation must include written witness statements for all incidents. No licensed nurse will be allowed to work until he/she has been in-serviced. On [DATE], Director of Nursing implemented an "Incident Check Off Log" that will be used for all incidents from [DATE] forward. The log consists of 15 check points including witness statements, investigation initiated at time of incident, and return demonstration for proper procedures for those involved. The Incident Check Off Log will be conducted by the Director of Nursing or designee following any incident." Verification of the AoC: Review of in-services dated [DATE] and [DATE] revealed that staff had been trained and return demonstrations performed for securing a resident in a wheelchair prior to transport in the facility van, using the ratchet straps to anchor the wheelchair. Observation of the facility van on [DATE] revealed detailed instructions on how to secure residents in a wheelchair prior to transport on the van posted at the back of the van and in the log book. Review of the Transportation Policy dated [DATE] revealed that each resident in a wheelchair will be properly secured with ratchet straps by a trained individual. Random interviews with staff on [DATE] revealed that they were trained and had performed return demonstrations on how to secure a resident in a wheelchair, in the van prior to transport, and the procedures for the safety checklist. Observation on [DATE], of staff who routinely drive and/or assist with van transport, revealed correct demonstration of securing a resident in a wheelchair with the use of ratchet straps and the review of the safety checklist. Review of in-services dated [DATE] revealed that staff were trained on properly filling out incident reports to include witness statements and investigation at the time of the occurrence. Review of a policy updated [DATE] for "Incidents-Surveillance Of" revealed that there would be a study and investigation of each incident. Random interviews on [DATE] with licensed nurses revealed that they were trained on the correct way to fill out an incident report and to start an immediate investigation with documented witness statements and possible causes for the incident with any re-education that was needed. Review of a Quality Assurance (QA) meeting minutes dated [DATE] revealed that the Medical Director was informed of the actions that the facility had taken in regards to the safety of residents during transport in the facility van. Based on verification of the facility's implementation of corrective actions and an acceptable Credible Allegation of Compliance (AoC), the Immediate Jeopardy (IJ) was removed on [DATE] and the scope and severity was lowered to a "D" level which constitutes no actual harm with potential for more than minimal harm, to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.