Every finding on record at Gosnell Health and Rehab

Based on record review, interview, and facility policy review, the facility failed to ensure safety straps were placed and secured to all four wheels of a resident's wheelchair before being transported in the facility van which resulted in the resident falling backwards from the wheelchair for one (Resident #65) of four residents reviewed for accidents. The findings include: A review of Resident #65's Physician's Orders dated 12/31/2024, revealed an order to admit to long-term care on 09/18/2024. Resident #65's Physician's Orders also revealed diagnoses which included hemiplegia (complete or near-complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) which affected the right dominant side, and an acquired absence of left leg below the knee. Resident #65's Physician's Orders further revealed a medication for pain was ordered on 09/18/2024, to be given as needed every six hours. A review of Resident #65's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 12/19/2024, revealed a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. Resident #65's MDS also revealed the resident had functional limitation in range of motion in the lower extremity on both sides and used a wheelchair for mobility. A review of Resident #65's Care Plan revealed an activity of daily living self-care performance deficit, with interventions which included limited assistance by one staff for transfers between surfaces as necessary, revised 11/06/2024. Resident #65's Care Plan also revealed the resident had an actual fall on 12/06/2024, with interventions which included staff education on how to properly transport in the van, initiated on 12/10/2024. A review of Resident #65's reportable revealed the following: - The date and time of the Incident & Accident (I&A) was 12/06/2024 at 3:45 PM, and the alleged perpetrator was a facility employee. - The Summary of Incident revealed Resident #65 was being transported in the facility van by the facility transporter [Certified Nursing Assistant (CNA) #3], when the driver noticed a dip in the road. As the driver navigated the areas in the road, Resident #65 indicated they were falling. Resident #65 was assisted to an upright position in the wheelchair and refused transport to the emergency room for evaluation and denied pain or discomfort at the time of the fall. - The Findings and Actions taken revealed CNA #3 was interviewed by the Administrator (Admin) #2 and she revealed to Admin #2 she did not use the correct number of straps to secure [Resident #65's] wheelchair in the van. The straps were used in the larger van the prior night for a resident outing. Admin #2's interview indicated the Maintenance Director removed the strap from the van to use in the larger van and did not replace the strap in the van it originated from. Admin #2's interview revealed the van driver was to make a pre-trip inspection to ensure all equipment was present and in working condition. A review of a CNA #3's OLTC [Office of Long-Term Care] Witness Statement Form, dated 12/06/2024, revealed CNA #3 placed the two back floor locks and one front floor lock to Resident #65's wheelchair, but did not indicate which front lock was not placed on Resident #65's wheelchair. During the drive, CNA #3 approached a deep hump in the road, and as she hit the brakes, Resident #65's wheelchair tilted backwards and Resident #65 stated, I'm falling back. After stopping the van, CNA #3 stated she found Resident #65 lying flat on their back with the wheelchair on the floor of the van. A review of a Professional Van and Mobility Service Invoice dated 12/10/2024, for the van used to transport Resident #65 on 12/06/2024, revealed four retractors in working order, one shoulder belt, and one lap belt (male and female). A review of a Termination of Employment/Leave of Absence form indicated CNA #3's last day worked was 12/06/2024, and the infraction was violation of policies/procedures. A review of Resident #65's Progress Notes revealed a nursing I&A note dated 12/06/2024 at 5:30 PM, which indicated Resident #65 was being transported by a facility transport aide, and ended up falling backwards in the van as the wheelchair tumbled backwards. A review of Resident #65's Progress Notes revealed a neurologic focused evaluation dated 12/06/2024 at 6:31 PM, which indicated Resident #65 had a fall in the facility van and the resident voiced complaints of pain in the base on back of the skull. Resident #65 had a nodule on the back of the head and declined to go to the emergency room for evaluation. A review of two Inservice on Transportation Vans, dated as completed on 09/11/2024 and on 11/20/2024, revealed CNA #3 was shown how to properly secure the resident in the van 2. A review of two Transportation Program-Best Practice Recommendations for Van Safety forms revealed the resident being transported in a wheelchair will have the wheelchair securely attached to the body of the van and will maintain a center position in the van during transport. The forms included CNA #3's name and were dated 09/11/2024 and 11/20/2024. During an attempted telephone interview on 03/24/2026 at 7:35 PM, this surveyor called CNA #3's documented number, and an automated operator intercepted the call indicating the person called did not have a voicemail set-up yet and the call ended. During an attempted telephone interview on 03/24/2026 at 7:38 PM, this surveyor called Resident #65's documented number, and an automated operator intercepted the call indicating the destination voicemail box was full and the call was abruptly ended. During a telephone interview on 03/24/2026 at 8:00 PM, Admin #2 stated she did not recall much regarding the incident of Resident #65 falling out their wheelchair, while being transported in the facility van. She stated the Maintenance Director did some training with CNA #3 on how to properly secure a resident in a wheelchair in the van straps. She stated CNA #3 had performed skills checkoffs for securing residents in the van properly before being allowed to transport residents. Admin #2 stated CNA #3 was immediately suspended after the incident of Resident #65's falling out of the wheelchair and did not recall the events surrounding CNA #3's termination. During a concurrent observation and interview on 03/25/2026 at 8:31 AM, CNA #4 and CNA #5 used an empty wheelchair and demonstrated how to secure a wheelchair to the floor in the smaller van, using the safety straps and seat belt. After all the straps and the seat belt were locked, CNA #4 shook the wheelchair, and the wheelchair did not move. CNA #5 stated if either of the front locks were not secured and loose, this could cause the wheelchair to move. CNA #5 loosened the locks on both front wheels and when she shook the wheelchair, the front wheels did move. On 03/25/2026 at 9:30 AM, Admin #1 voiced intent to provide the manufacture's guidance on the safety straps for both vans. Admin #1 provided a copy of van checkoffs for CNA #4 and CNA #5. During an interview on 03/25/2026 at 4:14 PM, Maintenance stated a hold down device that hooked up to the back of the wheelchair, to keep the wheelchair from moving, was missing from the van in which Resident #65 was transported in on 12/06/2024. He stated the big van had a shortage of one of the straps because the big van was being used to take residents to a parade. He stated CNA #3 did not get the tie down (safety strap), which he clarified was to hold the wheelchair down, and left without putting the tie down back in the van the strap was removed from. He stated the tie downs were interchangeable, and he was unaware if CNA #3 did not hook a tie down in the front or the back of the wheelchair. He stated there has been no other van incidents since December 2024. During an interview on 03/25/2026 at 5:30 PM, Admin #1 revealed she became the Administrator at the facility on 01/29/2025. She stated to decrease the likelihood of the incident, which happened to Resident #65 on 12/06/2024, from happening again, the following tasks had been put in place: - the new van driver will complete a skills check off and ride with a seasoned van driver before driving residents. - the new van driver will have a seasoned van driver with them when they drive for first time. - the new van driver will perform a return demonstration in front of the seasoned van driver. - van drivers will complete a quarterly training. - a professional van service will watch all van drivers load and unload a wheelchair and inspect the facility vans yearly. - all van drivers must ensure there are no frays in any restraints before driving the van. Admin #1 verified that not securing a wheelchair properly in the transport van could cause injury, death, or mental anguish, such as a resident being scared of the van. She stated her expectations regarding van drivers operating the vans and securing the resident's wheelchairs properly for transport included safety being forefront, and van drivers must do everything correctly, to ensure every step occurred. As of 03/25/2026 at 6:00 PM, Admin #1 had not provided the manufacture's guidance on the safety straps for either van the facility used. A review of a Safety and Supervision of Residents policy, dated as revised July 2017, indicated the facility strives to make the environment as free from accident hazards as possible. The policy indicated employees should be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. A review of facility documents including in-services and inspections of the van being used to transport residents revealed the facility had identified and addressed concerns by 12/10/2024, resulting in these findings being cited at past non-compliance.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for one (Resident #5) of five residents reviewed for the resident's comprehensive assessment. Specifically, the facility failed to ensure Resident #5's comprehensive care plan included information that would require staff to provide care and monitor for resident safety. The findings include: A review of Resident #5's admission Record indicated the facility admitted the resident on 01/16/2026, with diagnoses which included nerve damage, muscle weakness, limitation of activities, type 2 diabetes mellitus, difficulty walking, inflammation of the spine, urinary tract infections, constipation, adjustment disorder, anemia, thyroid disorder, high cholesterol, sleep apnea, high blood pressure, irregular heartbeat, arthritis, chronic kidney disease, shortness of breath, fatigue, and stomach paralysis. A review of Resident #5's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/2025, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #5's MDS also revealed the resident was independent for daily decision making. The MDS indicated Resident #5 utilized a wheelchair and had impairment to both legs. Resident #5 was dependent on care for personal hygiene, toileting hygiene, showering, upper and lower dressing, and putting on and taking off shoes. Resident #5 was completely dependent of staff on mobility for rolling left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair-bed transfers, toileting transfers, and tub/shower transfers. A review of Resident #5's Physician's Orders revealed Resident #5 had orders for occupational, physical and speech therapy to evaluate and treat, resident and or family have been informed of medical conditions/diagnosis and plan of care, resident may participate in activity as tolerated, do not resuscitate orders, foley catheter care, occupational therapy for skilled interventions 3-5 times per week for the next 8 weeks, and enhanced barrier precaution. A review of Resident #5's Medication Administration Record for March of 2026, revealed Resident #5 was given oral medications for insomnia, three oral medications for diabetes, two injections to assist in controlling the diagnosis of diabetes, medication that promoted wound healing, antibiotic for a urinary tract infection, blood thinner medication, medications that assisted in controlling heart rate and rhythm, stomach acid medication, medication for nerve pain, monitoring of urinary output from a foley catheter, and pain medication. A review of Resident #5's Treatment Administration Record for March of 2026 indicated Resident #5 received an ointment applied every shift to promote wound healing to the buttocks, orders on how to cleanse, dry and cover a pressure ulcer to Resident #5's right buttocks, and for foley catheter care at bedtime. A review of Resident #5's Care Plan on 03/24/2026 at 11:07 AM, with an earliest initiation date of 01/19/2026, revealed the following care areas/interventions were not addressed: -The care plan did not address the resident's dependence on staff related to self-care performance deficits; there were no interventions listed to inform staff of the level of care required. -The care plan did not address the resident's impaired mobility related to impaired function in both legs; there were no interventions addressing the resident's need for mobility devices (wheelchair) or the prevention of falls. -The care plan did not address the resident's prescribed medications; there were no interventions listed to inform staff how to monitor for signs/symptoms of complications related to the resident's prescribed medications, which included an anticoagulant, antidepressant, an opioid pain medication, and medications for managing diabetes mellitus. There were no black-box warnings for Resident #5's prescription of an antidepressant medication which posed a risk for suicidal thoughts and ideations. There were no black-box warnings for Resident #5's prescription of an opioid pain medication, or guidance for staff to follow in responding to the resident's pain. -The care plan did not address the resident's impaired skin integrity; there were no interventions to guide staff in addressing current wounds, or the prevention of additional wounds. During an interview on 03/26/2026 at 10:06 AM, Certified Nursing Assistant (CNA) #6 indicated she did not access the kiosk to look at the care plan for any residents. She indicated she utilized the closet care plan. CNA #6 reported she only knew how to care for Resident #5 from their closet care plan. During an interview on 03/26/2026 at 10:30 AM, CNA #7 indicated the only way she knew how to care for Resident #5 was by the closet care plan as well. A review of Resident #5's Closet Care Plan, printed date 03/16/2026, revealed assistive devices, functional mobility, and pressure reducing devices were referenced, but no guidance referencing medications, wound care, or monitoring related to the resident's diagnoses or medications was present. During an interview on 03/26/2026 at 11:15 AM, the MDS Nurse indicated that care plans were updated quarterly, every three months. The MDS Nurse revealed information that should be included on a care plan consisted of medications, new antibiotics, advanced directives, any black box warning for medications, falls, skin assessments, and treatments. She stated the care plan identified how to care for the residents. No interventions were documented on the closet care plans. The MDS Nurse indicated that Resident #5's initial care plan was completed on 01/16/2026, and that comprehensive care plans should be completed within seven days and no later than 21 days after admission or change. She verified Resident #5's care plan was not comprehensive, and without a comprehensive care plan with interventions, one would not know how to care for their resident. The MDS Nurse stated she was the one who created and updated the care plans. During an interview on 03/26/2026 at 11:58 AM, the Director of Nursing (DON) indicated the facility had seven days after admission to complete a comprehensive care plan. She indicated the care plans included all the information needed to properly care for a resident, such as social activities, nutrition, levels of care, falls, black box warnings for medications, foley catheter care, pain medications, diagnoses, and interventions. The DON stated, If a care plan was not complete, then you will not know how to care for a resident. The DON continued to state, The CNAs cannot see the care plan and the Kardex does not include care interventions. During an interview on 03/26/2026 at 1:04 PM, the Administrator indicated that a care plan was to be completed within the first seven days of being at the facility. She then indicated that a base line care plan was completed first and then a comprehensive care plan. The Administrator stated, If a care plan is not completed then the facility would not know how to care for the resident, the care plan is how we know how to take care of our resident and what interventions have been put into place. The Administrator indicated the closet care plans were generic and she did not think they listed any interventions. A review of the policy titled Resident Rights with a revision date of 02/2021 states, Residents are, to be informed of, and participate in, his or her care planning and treatment. A review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised on March of 2022, indicated, The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant change in Status), and no more than 21 days after admission. The comprehensive, person-centered care plan includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment, any specialized services to be provided as a result of PASARR recommendations; and which professional services are responsible for each element of care, includes the resident's stated goals upon admission and desired outcomes, builds on the resident's strengths and reflects currently recognized standards of practice for problem areas and conditions. And reviews and updates are made to the care plan are significant changes in the resident condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay and at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interviews, record review, observations, and document review, the facility failed to prevent an accident that caused serious injury during a van with lift transfer due to not following the manufacturer's guidelines for the lift and training for 1 (Resident #199) of 1 resident reviewed for accidents. This deficient practice resulted in Resident #199 sustaining a left ankle fracture on 09/10/2024, and a suspected fracture to the sacrum. The findings are: On 09/17/24 at 11:09 AM, during an interview with [NAME] President of Operations regarding incident he confirmed Certified Nurse Aide #1 (CNA #1) assisted with unloading Resident #199. CNA #1 failed to confirm the lift gate was up and ready for the transfer which caused the fall. CNA #1 was suspended until the end of the facility investigation, then terminated. On 09/17/24 at 11:11 AM, Director of Nursing (DON) interviewed regarding the incident on 09/10/2024 involving Resident #199. When asked what her immediate action was following the incident, she confirmed she assessed Resident #199 then sent the resident to the nearest emergency department for an evaluation and treatment. She confirmed provider and family were notified. On 09/17/24 at 11:31 AM, Resident #199 was interviewed regarding incident. Resident stated, I was just sitting there in the van waiting to be taken back in and all of a sudden I was falling backwards. It happened very quick. My body was all catawampus, and was like a V, my legs came up to my body. Resident confirmed pain level was controlled with current treatment. On 09/17/24 at 02:04 PM, Maintenance Director was interviewed regarding mechanical actions/demonstration of lift on the 2018 van. Staff demonstrated the process of loading and unloading residents in wheelchairs. He demonstrated the warning threshold plate working properly (safety mechanism to warn the gate is not up). During an interview on 09/17/24 at 2:30 PM, CNA #7 stated she returned from assisting the first resident into the building and came back to assist CNA #1 with the last resident (Resident #199). The lift gate was down from the first transfer, and stated as she approached the van, she saw Resident #199 fall from the van in the wheelchair, and then CNA #1 fell out of the van soon after. CNA #7 confirmed she completed re-training on about 09/12/2024. On 09/17/24 at 2:40 PM, the Maintenance Director was interviewed regarding the van transport wheelchair training 01/16/2024. He confirmed CNA #1 was present for the class. Maintenance Director confirmed he attended the re-training for van transfers on 09/12/2024. On 09/17/24 at 02:44 PM, the Administrator was interviewed regarding the incident involving Resident #199. The Administrator confirmed CNA #1 did not follow the manufacturer's guidelines or the training, which CNA #1 last completed on January 16, 2024. On 09/17/24 at 03:27 PM, CNA #1 was interviewed regarding the incident on 9/10/2024. She stated, I assisted [CNA #7] in undoing the floor strap for the other resident. CNA #7 took the other resident inside the building, and I was in the process of undoing the floor strap for Resident #199 and preparing to transfer the resident. I said okay, and then I heard CNA #7 say okay, so I thought that meant she was ready and the lift was up, so I proceeded to push the resident to the edge, then both of us fell and that's when I knew the gate was not up. When asked if she looked to see if the gate was lifted, she stated, I am too short to see over the resident in the wheelchair. When asked about safety mechanism to alert gate is not up, CNA #1 stated, Are you talking about the beeping? It always beeps regardless of if it's up or down. CNA #1 stated, My last transfer training was at least two years ago. When asked if CNA #1 had worked as a transporter before her other roles, she stated, Yes, I used to be a transporter, then I switched to HR [Human Resources] about 6 years ago, but I was filling in doing transports. On 09/17/24 at 12:17 PM, the surveyor reviewed video footage of the incident that happened on 09/10/2024 at approximately 12:30 PM. The video shows the return of the transport van with two residents, CNA #1 and CNA #7. One resident was unloaded from the transport van without incident by CNA #7 and taken inside the facility. The gate remained lowered. CNA #1 was seen holding the wheelchair, facing the resident, both are located at the rear exit. As CNA #7 walked out of the front door, she walked toward the back of the van and noticed CNA #1 was struggling to hold the wheelchair/resident inside the back of the van. CNA #7 approached the van to assist but was unable to prevent the resident from falling out of the van. Resident #199 fell approximately 24 (measured from floor of van to base of the lift lowered). Resident #199's legs spread outward in opposite directions. The resident remained seated inside the wheelchair. CNA #1 also fell out of the back of the van, and partially landed on the left portion of the wheelchair, struck Resident #199's left leg/foot, pressing the resident's foot against the left foot pedal of the wheelchair. This action potentially caused the fracture to the left ankle. Resident #199 also sustained a suspected fracture to the sacrum (low back area). Reviewed the undated, Operator's Manual for the facility's wheelchair lift. Under the section labeled operation notes, vehicle loading and unloading, it read, The platform must be fully raised (at floor level) and the inner roll stop (bridge plate) must be properly positioned when loading or unloading passengers in or out of vehicle. It is the responsibility of the lift attendant to ensure the platform, and the inner roll stop are properly positioned at floor level when loading and unloading passengers. Review of training provided to CNA #1 on van transfers including the most recent dated 01/16/2024. The training acknowledgement was signed, and the signature matches other signatures in CNA #1 employment file. Other attendees of the van transfer training on 01/16/2024 confirmed CNA #1 was present for that training. A requirement for training included each of the transport staff to demonstrate proper loading and unloading techniques with a focus on understanding all safety measures. Transport staff were required to demonstrate proper operation of the transport van equipment to the instructor. Reviewed facility undated policy titled Accidents and Incidents - Investigating and Reporting Policy and the Facility Van/Vehicle Usage, undated policy which was consistent with the facility's actions following the incident on 09/10/2024. The facility completed an in-service for all staff on Abuse/Neglect dated 09/10/2024. On 09/18/24 at 10:49 AM, interviewed [named] Van and Mobility Mechanic that inspected the transport vans following the incident. He confirmed the safety mechanism on the threshold warning plate would not beep when the gate is fully up and engaged. [Named] Van and Mobility Mechanic also confirmed no repairs were needed on the lift or any other portion of the vans at time of inspection (09/16/2024). During an interview on 09/19/24 at 11:10 AM, CNA #6 confirmed the last training regarding van transport was on 09/13/2024, and attendees were required to demonstrate the skills of loading and unloading residents from the transport van via wheelchair, and safety measures. The facility implemented corrective actions which were completed prior to the State Agency's completion of its survey; thus, it was determined to be a Past Noncompliance citation. The facility has implemented the following plan of correction to correct the deficient practice effective 09/11/2024. Facility Plan of Correction: Step #1 Corrective Plan: On 9/10/2024 upon notification of deficient practice, the Administrator/designee immediately disabled the transport van from this incident from all further transports until investigation and review was completed. The transportation aide was not permitted to perform any further transports or transfers until corrective measures were completed and she was suspended from employment pending investigation process. Step #2 Identification of others with the potential of being affected: On 9/10/2024 the DON/Designee determined, through medical record review and transportation data for the last two weeks, that five residents had to potential to be affected and assessed all residents identified to ensure no injuries related to transportation had occurred. Step #3 To ensure deficient practice does not reoccur: On 9/10/2024, the Administrator made alternate arrangements for all resident transports until completion of transportation aide in-services with return demonstration could be completed. The maintenance director assisted in ensuring this staff education was completed. Both facility vans were placed in no transport mode until a thorough van/equipment inspection could be completed. Step #4 Monitoring: Administrator/designee will monitor loading and unloading of residents to facility vans for transport 3 times a week times 4 weeks minimally or until compliance is achieved. Findings will be documented on a monitoring log. Any negative findings will be corrected immediately, and Administrator/Designee notified. Step #5 QA Administrator/designee will present all findings to the monthly QA committee for further review and recommendations. The facility alleged compliance on 09/13/2024 The facility has implemented their Quality Assurance and Performance Improvement plan, and all steps have been completed, or if ongoing, has been initiated. The following are the goals listed with progress: 1. All staff members who will be driving the van will have a valid driver's license and approved driving record. Completed 09/11/2024 2. All staff members who will be driving the van or assisting during transport will be trained per manufacturer's guidelines/operator training videos and facility checklist. This will include instruction on lift operation and use of a sure-lock restraint system. Completed on 09/13/2024 3-service will be initiated when an incident occurs that involves the van. 4. The van must be taken out of service until deemed safe to use by [named] Van & Mobility of named city. All incidents/accidents involving the van will immediately be reported to the administrator/DON or designee. Incidents/accidents involving the van will be investigated and an incident report completed. Completed: 09/16/2024 and ongoing for continued monitoring. 5. Transports from facility will be monitored by a trained staff member 3 x weekly for 4 weeks, or until compliance is achieved. The above plan will be presented to the QAA committee, and any negative findings will be corrected immediately and reported to the QAA committee. Completed: This plan was starting immediately, but the facility chose to make alternative transport arrangements for all residents and halt all van transfers until they received the documentation from the van inspection which was 9/16/24, and the plan is ongoing. 6. Maintenance Inspection: Regional maintenance consultant will review van maintenance plan with maintenance director immediately and quarterly thereafter. Completed: 09/12/2024 and ongoing. 7. The van driver will perform a pre-transport documented inspection daily, prior to the first transport. 09/11/2024 and ongoing. 8. The facility will maintain a current list of employees who have been trained to drive the van and assist with transportation along with supporting documentation regarding training. Completed:09/13/2024 and ongoing. 9. Any transport driver found not following the appropriate transport policies will be immediately taken off transportation duty and disciplined up to and including termination. The staff member involved in the incident on 09/10/2024 was terminated after the facility's completed investigation. Completed: 09/11/2024 and ongoing. The facility implemented a plan for retraining all transport staff which was completed on several different dates, but the final transport staff member completed the training on 09/13/2024. The staff watched the manufacturer training video linked below: https://youtube.com/watch?v=vDLdUXcotEc&si=LgpoAUyOrtwuHRJV The transport staff completed training along with demonstration of the skills of loading and unloading a resident in a wheelchair. Training also included safety measures for safe transportation of residents. This training will be ongoing.

Based on observation, record review, and interview, the facility failed to ensure residents who required assistance with foot care were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure toenails were kept clean and trimmed for one resident of one sampled resident. (Resident #24). These are the findings: Review of an Order Summary Report revealed that Resident #24 had diagnoses of dementia, diabetes, chronic kidney disease, congestive heart failure, and need for assistance with personal care. There was no order for diabetic nail care for the nursing staff. Review of a Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/23/2024 revealed that Resident #24 scored a 4 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of a Care Plan initiated on 03/26/2024 revealed that Resident #24 had an activity of daily living (ADL) deficit that stated to check nail length, trim, and clean on bath day and as necessary. Report any changes to the nurse. On 09/16/2024 at 11:16 AM, Surveyor observed Resident #24 sitting in a recliner with uncovered feet propped up, toenails were long, jagged, and thick, the right greater toenail was jagged and missing the middle part of the toenail. Resident #24 stated my toenails are long and that one missing part of the toenail is worrying me; I would like to have them trimmed. On 09/17/2024 at 9:30 AM, Surveyor observed that toenail care had not been done. On 09/18/2024 at 3:00 PM, Surveyor observed that toenail care had not been done. On 09/18/2024 at 4:00 PM, during an interview Certified Nursing Assistant #3 (CNA) stated that the nails had not been reported as Hospice usually gives Resident #24 a bath. CNA #3 then stated Resident #24 usually does not need much help either. CNA #3 then described the nails as long, thick, jagged especially that one big toe and that they needed trimmed. CNA #3 stated the nurse does nail care as the resident is diabetic, otherwise a CNA does it as needed. CNA #3 then stated the toenails in the current condition could set up an infection or sores as they could snag on the resident's shoes or socks ripping the nail. On 09/18/2024 at 4:14 PM, during an interview Licensed Practical Nurse #5 (LPN #5) stated Resident #24's toenails had not been reported to them, and that they look terrible and need to be taken care of. LPN #5 then stated the resident was a diabetic and nail care was important as they can be ripped off by snagging on shoes, socks or blankets. LPN #5 continued it could set up sore or infection. LPN #5 confirmed they did not have a current order for diabetic nail care for Resident #24. On 09/19/2024 at 10:15 AM, during an interview the Director of Nursing (DON) stated that having orders for diabetic nail care was important so the staff could actually perform and chart on nail care. The DON then stated nailcare was for skin protection, not cutting themselves, and overall health for diabetics to not cause sores or infection. Review of a facility policy Fingernails/Toenails, Care of revealed, General Guidelines 1 . Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 5. Watch for and report any changes in the color of the skin around the nail bed. blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc. 6. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease.

Based on observation, record review, and interview the facility failed to accurately code a Minimum Data Set (MDS) for a contracture under Section GG for one out of one sampled residents (Resident #3). These are the findings: A review of the Order Summary revealed Resident #3 had a diagnosis of stroke with left sided weakness/paralysis. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/05/2024 reveals that Resident #3 scored a 12 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). A review of Section GG in the MDS reveals that for upper limited mobility was marked no impairment. On 09/16/2024 at 11:36 AM, the surveyor observed Resident #3 in bed with left hand contracture with no intervention in place. Surveyor observed that Resident #3 could not stretch the hand out, and they stated, that they have had the contracture for a while. On 09/16/2024 at 3:00 PM Surveyor observed Resident #3 up in wheelchair with left hand contracture and no interventions. On 09/19/2024 at 9:25 AM, during an interview Certified Nursing Assistant #4 (CNA) stated that resident has had a contracture since admission, and they were not aware of any interventions for contracture. On 09/19/2024 at 9:45 AM, during an interview Licensed Practical Nurse (LPN) #5 stated that Resident #3 has had a contracture since admission and I believe we do range of motion for the contracture. On 09/19/2024 at 9:29 AM, during an interview the MDS Coordinator confirmed that limited mobility is not marked on Section GG for Resident #3's contracture. The MDS Coordinator stated an accurate assessment is important because that is what care is being provided to the resident and gives an accurate description of the resident. MDS Coordinator continued Resident #3 without an accurate assessment does not help capture what is needed for interventions to prevent it from worsening. On 09/19/2024 at 10:15 AM, during an interview the Director of Nursing (DON) stated that an accurate assessment populates the care plan with interventions for how we take care of the resident. The DON then stated that for a contracture an accurate assessment is needed to maintain and treat the contracture, and to be able to add interventions in the care plan. On 09/19/2024 at 10:25 AM, the MDS Consultant stated that the facility follows the RAI Manual for MDS and there are no separate policies.

Based on observation and interview, the facility failed to ensure foods stored in the refrigerator and freezer were covered and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 56 residents who received meals from the kitchen (Total Census: 57), as documented on a list provided by the Dietary Supervisor on 09/26/23 at 3:01 PM. The findings are: 1.On 09/25/23 at 11:01 AM, the following observations were made on a shelf in the freezer: a. An opened box of polish sausage. The box was not covered or sealed. b. An opened box of sausage links. The box was not covered or sealed. c. An opened box of diced chicken. The box was not covered or sealed. d. An opened box of fish. The box was not covered or sealed. e. An opened box of briskets. The box was covered or sealed. 2. On 09/25/23 at 11:15 AM, two boxes of breadcrumbs were on a rack in the storage room with an expiration date of 7/20/23. 3. On 09/25/23 at 11:28 AM, Dietary Employee (DE) #1 was wearing gloves on her hands when she touched the recipe book. She used a knife to cut open a bag of shredded carrots and a bag of red cabbage. She emptied them on top of the shredded lettuce in a pan. At 11:29 AM, she removed fresh tomatoes from their original carton on a shelf in the refrigerator and placed them on the cutting board. Without changing gloves and washing her hands, she sliced the tomatoes without rinsing them and placed them on top of the shredded lettuce in a pan on the counter to be served to the residents for the lunch meal. 4. On 09/25/23 at 11:43 AM, DE #2 was wearing gloves on her hands when she turned on the food preparation sink and rinsed a bowl. She then turned off the faucet, contaminating her hands. Without changing gloves and washing her hands, she used her contaminated gloved hand to push tuna into a pan to be used in preparation of tuna casserole. 5. On 09/25/23 at 12:11 PM, during the noon meal service DE #4 was assisting on the tray line and picked up butter tubs and cartons of beverages and placed them on the trays, contaminating her gloves. Without changing gloves and washing her hands, she picked up beverage glasses by their rims and placed them on the trays to be served to the residents for lunch. On 09/26/23 at 11:18 AM, the Surveyor asked DE #4 what should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 6. On 09/25/23 at 3:35 PM, DE #2 picked up the water hose with his bare hand, used it to spray leftover food from inside of the dishes, contaminating her hands. She then placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, she moved to the clean side of the dishwasher area and picked up clean dishes and placed them on the clean rack to be used in serving the noon meal to the residents. The Surveyor immediately asked what should you have done after touching dirty objects or before handling clean equipment? He stated, I should have washed my hands. 7. On 09/25/23 at 3:42 PM, DE #2 picked up the water hose with her bare hand, used it to spray leftover food from inside of the dishes, contaminating her hands. She then placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, she moved to the clean side of the dishwasher area and picked up clean dishes and placed them on the clean rack to be used in serving the noon meal to the residents. The Surveyor immediately asked what should you have done after touching dirty objects or before handling clean Equipment? She stated, I should have washed my hands. 8. On 09/26/23 at 11:11 AM, DE #3 picked up a glove box and placed it on the counter. She removed gloves from the box and placed them on her hands, contaminating the gloves. Without changing gloves and washing her hands, she removed slices of bread from the bag and placed them in individual bags. At 11:13 AM, the Surveyor asked DE #4 what should you have done after touching dirty objects and before handling food items or clean equipment? She stated, I should have washed my hands. 9. A facility policy titled, Employee Cleanliness and Handwashing Technique, provided by the Dietary Supervisor on 09/26/23 at 3:01 PM documented, .Dietary department employees are required to wash their hands on the occasions listed below: a. before starting shift b. after breaks . g. after handling dirty dishes . j. any other time deemed necessary .

Based on observation, record review and interview, the facility failed to ensure portable oxygen was used when transporting a resident who required continuous oxygen for 1 (Resident #10) and oxygen tanks were checked to ensure the resident was receiving oxygen as ordered by the Physician for 1 (Resident #18) of 2 (Residents #10 and #18) sampled resident who received oxygen. The findings are: 1. Resident #10 had diagnoses of Chronic Respiratory Failure, Unspecified whether with Hypoxia or Hypercapnia. a. On 09/27/23 at 2:05 pm, Resident #10 was seated in a wheelchair being pushed by staff down the hall from the therapy room. Resident #10 had her nasal cannula in her nose, but the nasal cannula tubing was not connected to an oxygen cylinder and a portable oxygen cylinder was not on the back of the wheelchair. The Surveyor followed the resident down the hall and into her room. The Occupational Therapist connected Resident #10's oxygen tubing to a stationary oxygen tank at the bedside. Resident #10 stated, I'm a little short of breath. The Surveyor asked the Occupational Therapist if Resident #10 had been in therapy. The Occupational Therapist stated, Yes. The Surveyor asked if Resident #10 usually uses oxygen while in therapy. The Occupational Therapist stated, Yes. We have a tank in therapy that the residents use. The Surveyor asked why Resident #10 didn't have a portable tank on the back of her wheelchair. The Occupational Therapist stated, [Resident #10] had one before but says that it hurts her back to have the tank on the back of her chair. Licensed Practical Nurse (LPN) #1 came into the room and checked Resident #10's oxygen saturation, which was 83. LPN #1 turned up Resident #10's oxygen to 4 liters per minute. The Surveyor asked LPN #1 if the resident had an order to increase the liters. LPN #1 stated, We have standing physician orders. The Surveyor asked if Resident #10 usually uses portable tanks when outside of room. LPN #1 stated, Yes. There was a sling to hold the tank, but it hasn't been on the chair for a while now. I'm not sure what happened to it. b. A Physician Order dated 08/30/23 noted Resident #10 was to receive humidified oxygen at 2 liters per minute every shift for shortness of breath. c. A Physician Order dated 05/04/23 noted Standing Orders may be used. d. The Care Plan with revision date of 08/30/23 noted Resident #10 received oxygen at 2 liters per minute via nasal cannula as needed. e. The Standing Physician Orders provided by the Administrator on 09/29/23 at 9:57 am noted an order for oxygen at 2 to 4 liters per minute via nasal cannula as needed for shortness of breath and/or pulse oximeter less than 90%. 44852 2. Resident #18 had diagnoses of Acute and Chronic (Congestive) Heart Failure and Emphysema. a. On 09/26/23 at 8:49 AM Resident #18 was in her room sitting in her wheelchair. Observed a portable oxygen tank in the room, the gauge was on zero. The Surveyor accompanied LPN #1 to Resident #18's room and asked LPN #1 to check the oxygen. She stated, It's empty. The Surveyor asked if the resident was to receive oxygen continuously. LPN #1 stated, Yes. The Surveyor asked when the portable tanks are checked and changed. She stated, The night shift got her up and they should have put on a new tank. The Director of Nursing (DON) stated, During my rounds this morning I checked her oxygen, and she had some. b. The Physicians Orders dated 05/21/23 noted Resident #18 may have oxygen at 4 liters per minute via nasal cannula every shift. c. The Comprehensive Care Plan with an initiated date of 05/21/23 noted Resident #18 had oxygen at 4 liters per minute via nasal Cannula. 3. A facility policy titled, Oxygen Administration, with a revision date of October 2010, provided by the Administrator on 09/28/23 at 11:28 am documented, .The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure . Equipment and Supplies .

Based on observation, interview and record review, the facility failed to ensure the resident's living space (9 of 37 rooms, the hallways (1 of 4), shower rooms (2 of 2) and equipment were clean and well maintained. The failed practice had the ability to affect all residents who live in the facility, who utilize the common areas and shower rooms according to the census and condition which was provided by the administrator on 9/25/23 at 1:30 PM. The findings are: Resident room [ROOM NUMBER] B: a. On 09/25/23 at 11:58 AM, observed a medication cup sitting on the windowsill. The cup was approximately 1/2 full of a white granulated substance. The Surveyor asked the resident if he was aware of what was in the cup. The resident stated, That started out as cream for my butt, but it's been there while. Three tiny spiders were in the area surrounding the cup and dead bugs extending down the length of the windowsill from side to side. b. On 09/26/23 at 9:30 AM, observed holes in the left wall. The dead insects and the medication cup 1/2 full of a white granulated substance continued to be on the windowsill. 2. Resident room [ROOM NUMBER] A: a. On 09/25/23 at 1:30 PM, observed in the bathroom a full trash can and discarded paper towels on the floor. The toilet seat had multiple, permanent discolored areas on top. In two places the top layer of porcelain was broken and chipped away. The toilet contained a yellow liquid, and 4 gnats were flying around the area of the toilet. Next to the resident ' s bed the floor was sticky. b. On 09/26/23 at 9:08 AM, the bathroom continued to have trash in the floor, gnats flying around, and the toilet seat remained discolored, broken, and chipped. 3. Shower room [ROOM NUMBER]: a. On 09/26/23 at 8:40 AM, the wall immediately to the left upon entry had missing plaster just above the baseline. The area was covered in a black substance. The floor around the wall by the toilet contained caked dirt and debris against the baseline. The white pad on top of a shower gurney on the right side of the room was cracked exposing the padding and allowing water to enter and exit the pad creating a risk of cross contamination. Under the pad was an additional crack the length of the pad. The blue mesh the pad rests on had areas where water had pooled and dried. The area was dark grey and black with white flecks. 4. Shower room [ROOM NUMBER]: a. On 09/26/23 at 8:45 AM, observed in Shower room [ROOM NUMBER] two bath gurneys. The white pad on top of one of the bath gurneys had multiple cracks allowing water to enter and exit creating the risk of cross contamination. The blue mesh had areas where water had pooled and dried. The area was discolored and contained flecks of debris in various colors extending down the length of the gurney. A shower chair was sitting in the front shower area. The joints where the legs and frame intersect were discolored with a buildup of dirt, soap scum and other debris. All 4 wheels casings contained a black/dark gray substance. 5. Resident room [ROOM NUMBER] B: a. On 09/27/23 at 2:05 PM, the walls in Resident room [ROOM NUMBER]B had multiple scraps and areas in need of paint. 6. Resident room [ROOM NUMBER]: a. On 09/27/23 at 2:20 PM, the floor of the bathroom in Resident room [ROOM NUMBER] was sticky and the bathroom had a strong smell of urine. 7. Resident room [ROOM NUMBER]: a. On 09/27/23 at 2:32 PM, the floor of the bathroom of Resident room [ROOM NUMBER] was sticky. 8. Resident room [ROOM NUMBER]: a. On 09/27/23 at 2:35 PM, in Resident room [ROOM NUMBER], food was spilled on the floor in the middle of the room, on the top sheet and extended down the side of the bed and onto the floor. On top of the overbed table was 2 cups of liquid, a water pitcher, and a discarded napkin. The surface of the table was covered with a white powdery substance. 9. Resident room [ROOM NUMBER]: a. On 09/27/23 at 2:40 PM, in Resident room [ROOM NUMBER], the 2 walls surrounding the resident's bed were scraped with paint missing. In the bathroom sink there was a washcloth with 8 small flying insects on it. 10. Resident room [ROOM NUMBER]: a. On 09/27/23 at 2:45 PM, in Resident room [ROOM NUMBER], there was a dried dark substance stuck to the floor. The substance was close to the bed and had been tracked to the middle of the room. 11. 300 Hall: a. On 09/27/23 at 2:50 PM, observed scrapes with missing paint on the walls on the 300 Hall. Toward the end of the hall, on the left side was a gouge approximately 8 inches long right above the base board. 12. On 09/29/23 at 8:55 AM, the Surveyor asked Housekeeper #1 what the process was for cleaning a room. Housekeeper #1 stated, First we wipe down all the furniture and the beds. We strip off the linen. The floors are swept, sometimes three times a day. The Surveyor asked if the windowsills were normally part of the cleanup. She stated, Yes.

Based on observation and record review, the facility failed to ensure insulin vials were dated when opened, and expired medications were removed from the narcotic box. This failed practice had the potential to affect 8 residents who received insulin off the medication cart for the 100 and 200 Halls, and (1) resident with an expired narcotic card. The findings are: 1. On 9/27/23 at 2:07 PM, the following observations were made in the Medication Room: a. The Medication Cart had one opened vial of Novolog Insulin with no open date on it. b. The Medication Cart had one card of Trazadone with an expiration date of 9/14/23 in the locked narcotic box. c. On 9/27/23 at 2:28 PM, the Surveyor asked Licensed Practical Nurse (LPN) #3 how often do you check your medication cart for expired medications. LPN #3 stated, When I can. d. On 9/29/23 at 9:34 AM, the Surveyor asked the Director of Nursing (DON) how often do you check the carts for expired medications? The DON stated, Assistant Director of Nursing [ADON], and myself check it monthly. The night shift nurses check it randomly and the Pharmacy Consultant checks it monthly. The Surveyor asked when do you date a bottle of insulin? The DON stated, When you open it. e. A facility policy titled, Storage of Medications, provided by the Administrator on 9/29/23 at 9:57 AM documented, .2. The nursing staff shall be responsible for maintaining storage . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals . 9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room .

Based on record review and interview, the facility failed to ensure the resident's representative or Power of Attorney (POA) was notified after a resident choked and the Heimlich Maneuver was performed for 1 (Resident #32) of 1 sampled resident. The findings are: 1. On 09/26/23 at 11:09 am, during Resident Council Meeting a resident stated, I just wanted to give kudos to [Name], the Activity Director, for helping the man [Resident #32] seated across the table from me in Bingo, who choked on the [Name] candy. She did the Heimlich and saved him. 2. On 09/27/23 at 1:49 pm, the Surveyor asked the Activity Director/Certified Nursing Assistant (CNA) #1, Can you tell me about an incident that happened during an activity this week? Activity Director/CNA #1 stated, Oh yes. On Monday afternoon after Bingo, I was passing out snacks when a resident at the table with Resident #32 reported to me that the resident seated beside him was choking. I told the transport driver to go get the nurse, but I didn't feel she came quick enough, so I did the Heimlich on him. The Surveyor asked, Who came to assist you? CNA #1 stated, The Director of Nursing (DON) was the first person to get there, but I had already gotten the [Candy] up. Then a second nurse came. The Surveyor asked, What did they do then? CNA #1 stated, They asked me if anything came up and I told them yes a [Candy], and then they took him away to his room. 3. On 09/28/23 at 10:12 am, the Surveyor asked the DON Who was notified of the incident? The DON stated, I know the provider was notified to see if he wanted to do anything. The Surveyor asked, Who else should be notified? The DON stated, The [Family Member], [Charge Nurse] should have documented it in the progress note. 4. Resident #32's Progress Notes from 09/01/23 to 09/28/23 did not address the choking incident or that anyone was notified of the incident.

Based on record review and interview, the facility failed to ensure Medicaid recipient residents and/or their responsible parties were notified when the amount in their Trust Fund account was within $200 of the maximum Medicaid recipient cash assets for 3 (Residents #9, #18 and #30) of 12 (Residents #1, #8, #9, #18, #23, #24, #25, #26, #30, #32, #36 and #41) sampled residents who had Medicaid coverage and had Trust Funds managed by the facility. The findings are: 1. On 09/27/23 at 1:00 PM, the Surveyor received the resident Trust Fund balances from the Business Office Manager (BOM) and noted Resident #9 had a balance of $1877.93, Resident #18 had a balance of $1867.97, and Resident #30 had a balance of $1892.90. 2. On 09/27/23 at 2:48 PM, the Surveyor asked the BOM for the documentation regarding the Medicaid notification letters for Resident #9, Resident #18, and Resident #30. The BOM stated she had not sent out the notification letters. The Surveyor asked how do you let resident/family know that they are approaching the maximum amount allowed by Medicaid. The BOM stated, I send out a letter, but I just overlooked them for this month. 3. On 09/27/23 at 4:55 PM, The Administrator stated, We do not have a Personal Fund Policy.

Based on observation, record review and interview, the facility failed to ensure fall prevention interventions were promptly and consistently implemented to minimize the potential for fall related injuries and failed to ensure new interventions were developed after a fall for 1 (Resident #45) of 2 (Residents #32 and #45) sampled residents who had falls in the last 30 days. This failed practice had the potential to affect 20 residents who were at high risk for falls according to a list provided by the Nurse Consultant on 6/22/22. The findings are: Resident #45 had diagnoses of Urinary Tract Infection, Dementia, Muscle Wasting and Atrophy and Heart Failure. The Admission Minimum Data Set with Assessment Reference Date of 5/12/22 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status and required extensive physical assistance of two plus persons for bed mobility, dressing, toileting, personal hygiene, and was totally dependent for transfers. a. The Nursing Admit/Readmit Assessment Care Plan completed upon admission on 5/5/22 documented the resident scored a 75 on the Morse Fall Scale (45 and higher indicates at high risk for falls), had a previous fall, and was care planned as high risk for falls. b. The Closet Care Plan dated 5/5/22 in the resident's room did not address fall risk. c. The Incident/Accident Report dated 5/31/22 documented, .CNA [Certified Nursing Assistant] reported resident [Resident #45] fell out of bed. Received lying on left side with arm under him . [Resident #45] states, 'I was reaching out of bed trying to grab something other night and just wanted to do it again. I reached too far this time and slipped .' .notified DON [Director of Nursing], family member, and on call APRN. [Advanced Practice Registered Nurse] ordered x-ray to L [left] shoulder . d. On 06/22/22 at 8:20 AM, Resident #45 was sitting in bed in his room. Bed was raised to a waist high level and at 45 degrees. e. On 06/22/22 at 8:23 AM, CNA #1 was asked How long have you worked at this facility? CNA #1 replied Six years. CNA #1 was asked, Are you familiar with [Resident #45's] care? CNA #1 replied, Yes. CNA #1 was asked, Is he at risk at for falls? CNA #1 replied, No. We do everything for him. CNA #1 was asked, How do you know what care he needs? CNA #1 replied, It's on his closet care plan. CNA #1 was asked, Has the resident had a fall? CNA #1 replied, Not since I've been here. f. On 06/22/22 at 8:30 AM, Licensed Practical Nurse (LPN) #1 was asked, Are you familiar with [Resident #45's] care? LPN #1 replied I know him some. LPN #1 was asked, Is he at risk for falls? LPN #1 replied, Yes. LPN #1 was asked, What interventions are in place? LPN #1 replied, Keep his call light within reach, bed lowered, and take to the dining room for meals so he can be supervised. g. On 06/22/22 at 8:35 AM, the Care Plan Coordinator was asked, Are you responsible for care plans? She replied, Yes. She was asked, Who completes the nursing admission/readmit assessment and care plans? She replied, ''Technically the floor nurse, but I also do them. Basically, we put stuff on paper so it can be in the closet care for the CNAs, so they know how to take care of the resident. She was asked, Are you familiar with the [Resident #45's] care? She replied, For the most part yes. She was asked, Was a fall risk assessment completed upon admission for the resident? She replied, How it works, there are a few assessments that will generate for what you can take care of them. So, it's under Morse Fall Scale. She was asked, What was the score of the assessment? She replied, 75. She was asked, What does a score of 75 indicate? She replied, It says 45 or higher is high risk for falls. She was asked, What was done since the resident was at high risk for falls? She replied, It was care planned [on the 48-hour care plan] so aids knew he didn't know his limits and to bring awareness that he is at risk. She was asked, What interventions were put in place? She replied, Other than standard of making sure he needs are met, round every 2 hours, I can't answer off the top of my head. She was asked, Were the intervention put on the comprehensive care plan, and closet care plan? She replied, They should have been. She was asked, Should this information carry over to the closet care plan? She replied, Yes. She was asked, Did [Resident 45] have a fall? She replied, I think he has not, but recently, they did discuss it in a meeting yesterday. She was asked, What was the fall date discussed in the meeting? She replied, 5/31/22. She was asked, What interventions were implemented after the fall? She replied, I did do it yesterday, the 21st. I updated the comprehensive care plan. She was asked, What were the interventions? She replied, Monitor prn [as needed] for 72 hours for signs and symptoms of pain, bruising, change in mental status for any new onset of confusion, or agitation. She was asked, How quickly should interventions be implemented after a fall? She replied, Immediately. She was asked, Has the closet care plan been updated? She replied, No, I've not put a new one down there.

Based on observation, record review and interview, the facility failed to ensure licensed nursing staff observed complete consumption of medications during medication administration to assure appropriate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failed practice had the potential to affect 52 residents who received medications as documented on a list of Alphabetical Residents provided by the Administrator on 04/18/2022 at 11:00 am. The findings are: 1. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission assessment dated [DATE] documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. On 04/18/22 at 11:38 am, Resident #3 was sitting in bed. There was a medicine cup containing an oblong, white tablet on the bedside table. She was asked if that was her medication in the cup. She stated, Yes, I need to take that. and she took the pill. 2. Resident 4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 03/18/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS. a. The April 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date 10/26/20 . [MEDICATION(S)] Tablet 75 MG Give 1 tablet by mouth one time a day . Order Date 11/05/20 . [MEDICATION(S)] Tablet 5 MG ([MEDICATION(S)] HCl) Give 1 tablet by mouth four times a day for GERD [Gastroesophageal reflux disease]. Order Date 05/10/21 . [MEDICATION(S)] Tablet 5 MG, Give 1 tablet by mouth one time a day . Order Date 09/17/21 . [MEDICATION(S)] Tablet 20 MG Give 1 tablet by mouth one time a day for decreased appetite. Order Date 11/18/21 . b. On 04/19/22 at 11:47 am, Resident #4 was lying in bed. There was a medicine cup with approximately 4 to 5 pills in it on the bedside table. He was asked if that was his medication in the cup. He stated, Yes. He was asked if the nurses usually leave his medicine on his bedside table. He stated, Not usually. They handed it to me, but I was feeling short of breath, so I didn't take them right away. I guess I can take them now. 3. On 04/19/22 at 1:49 pm, Licensed Practical Nurse (LPN) #1 was asked, Should nurses watch residents take their medications? She stated, Yes. She was asked, Should medicine be left on the bedside table? She stated, No. She was asked, What are some negative outcomes that could happen from leaving medicine on the bedside table? She stated, A resident could only take half of it or spill it, wandering residents could take it. 4. On 04/19/22 at 1:54 pm, LPN# 2 was asked, Should nurses watch residents take their medications? She stated, Yes. She was asked, Should medicine be left on the bedside table? She stated, No. She was asked, What are some negative outcomes that could happen from leaving medicine on the bedside table? She stated, Residents with Dementia could wander into another's room and take it, or any other resident could take it. If resident takes medicine at the wrong time, it may worsen their condition. 5. On 04/19/22 at 2:00 pm, Registered Nurse (RN) #1, Interim/Acting Director of Nursing (DON) was asked, Should nurses watch residents take their medications? She stated, Yes. She was asked, Should medicine be left on the bedside table? She stated, No. She was asked, What are some negative outcomes that could happen from leaving medicine on bedside table? She stated, The resident could spill it or just not take it. Another resident could wander into the room and thinking it was theirs, take it. 6. A facility policy titled Administering Oral Medications provided by the Administrator on 04/19/22 at 1:59 pm documented, .Steps in the Procedure .21. Remain with the resident until all medications have been taken .

Based on record review and interview, the facility failed to ensure a comprehensive, person centered care plan was completed to meet the residents' needs for 1 of 1 (Resident #1) who care plan was reviewed. The findings are: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/22 documented the resident was significantly impaired per a staff assessment for mental status, was totally dependent for all Activities of Daily Living (ADLs) and nutrition and hydration via a gastrostomy tube. a. The Care Plan with an initiation date of 01/25/2022 documented a focus .The resident has dehydration or potential fluid deficit r/t [related to] left blank with an intervention of . administer medications as ordered. Monitor/document effectiveness . The Care Plan with an initiation date of 01/19/2022 documented a focus .the resident has (SPECIFY acute/chronic) [CONDITION(S)] r/t: left blank. There were no goals or interventions documented. The Care Plan with an initiation date of 01/25/2022 documented a focus .The resident has a potential/actual impairment to skin integrity of the (SPECIFY location) r/t: left blank with goal documented .The resident will be free from injury (SPECIFY) to (SPECIFY location through the review date . and there were no interventions documented. There was no care plan documented for the resident's gastrostomy tube or nutritional needs. b. On 03/25/2022 at 10:47 AM, the MDS Coordinator was asked, When did you begin the MDS position? MDS Coordinator stated, I've been In this building August 2021. She was asked, How long have you been doing MDS? She stated, Since 2014 I believe. Can you describe the purpose of the CAA's? She stated, So you make sure you get stuff care planned that needs care planned that was triggered on MDS. She was asked , Do you ever have a circumstance where you would care plan more? She stated, Yes. She was asked, Do you care plan enteral feeds, gastrostomy tubes on your residents? She stated, We should. She was asked, Why would it be important to care plan enteral feeding? She stated, So you know how the feeding is supposed to happen and if something goes wrong what to do. She was asked, Would you care plan monitoring of nutrition and hydration for a resident, particularly if receiving all nutrition through enteral feeds? She stated, Yes, or dietary should. Dietary does the nutritional on G [gastrostomy] tube. She was asked, What is an appropriate intervention for a resident with dehydration or potential fluid deficit? She stated, To push fluids. We would need to push fluids, check lung sounds, check for [CONDITION(S)]. She was asked, Is the administration of medications and monitoring the medication side effects a sufficient intervention for monitoring a resident at high risk for dehydration? She stated No. She was asked, Who verifies and checks on appropriate care planning? She stated It should be the MDS coordinator. She was asked, Does your interdisciplinary team meeting discuss any of these things? She stated, They should. She was asked, Should [Resident #1] have been care planned for gastrostomy tube needs? She stated, Yes, if she had it on admission or when she got it. She was asked, Was [Resident #1] a hospice resident? She stated, No. She was asked, Do you know why she was care planned as hospice? She stated, No. She was asked, Why is it important to have accurate care planning? The MDS Coordinator did not answer. The Surveyor stated, [Resident #1] is cared planned for has/had acute/[CONDITION(S)]. What are appropriate care plan goals and interventions? MDS Coordinator did not answer. The Surveyor stated, [Resident #1] has potential/actual impairment to skin. What would be an appropriate goal for that potential problem? She stated, Not to have a breakdown through the review date. She was asked, What would be appropriate interventions? She stated, Weekly skin audits, turning and repositioning.

Based on observation, record review and interview, the facility failed to ensure the urinary catheter tubing was properly secured and stabilized to prevent accidental dislodgement, pain or trauma to the meatus and promote maximal comfort for 2 (Residents #43 and #32) of 5 (Residents #43, #32, #12, #204 and #2) sample residents who had indwelling urinary catheters. This failed practice had the potential to affect 7 residents who had indwelling urinary catheters according to a list provided by the Nurse Consultant on 04/08/2021. The findings are: 1. Resident #43 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/09/2021 documented the resident scored a 13 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS) and required extensive assistance of one person physical assist for Activities of Daily Living (ADLS) and had an indwelling urinary catheter. a. The Care Plan documented, The resident has (foley) Catheter: [CONDITION(S)] Atonal bladder, the resident will be/remain free from catheter-related trauma through review date. Date Initiated: 06/30/2020 . b. The April 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] & [and] TUBING BELOW LEVEL OF BLADDER AT ALL TIMES every shift related to OTHER NEUROMUSCULAR DYSFUNCTION OF BLADDER Order Date 06/24/2019 c. On 04/06/2021 at 8:25 A.M., Resident #43's urinary catheter bag was hanging on the bed in a privacy bag. Certified Nursing Assistant, (CNA) #2 assisted Resident #43 to the side of her bed and then assisted her to pivot to the wheelchair. Resident #43 was then assisted to the bathroom in her wheelchair. CNA #2 pulled Resident #43's pants down and assisted her to the toilet. There was no Stat lock or other device on the resident's catheter to secure it to her leg to prevent the catheter tubing from pulling and tugging on the bladder. d. On 04/06/2021 at 8:40 A.M., CNA#1 was asked, Should the resident have a leg band to secure her catheter tubing? She stated, Yes, she should have one. e. On 04/07/2021 at 1:15 P.M., Resident #43 was lying in bed, the urinary catheter bag was hanging on the side of bed in a privacy bag. Resident #43 states, I don't have any kind of leg band or clamp on my catheter and I don't remember ever having one. f. On 04/08/2021 at 2:20 P.M., CNA #1 was asked, How should a Foley Catheter be secured to keep it from pulling or tugging on a resident's bladder? She stated, It should be strapped to their leg so it don't pull. She was asked, Does [Resident #43] have a secure device on her catheter tubing? She stated, No she don't. She was asked, Do you know why she does not have one? She stated, No, I don't unless it just came off. g. On 04/08/2021 at 3:59 P.M., the Nurse Consultant was asked, How should a Foley Catheter be secured to keep it from pulling or tugging on a resident's bladder? She stated, They should have a leg band or stat-loc on the tubing to secure it. She was asked, Should [Resident #43] have a leg band on? She stated, Yes she should, and I will get that done right away. 2. Resident #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change MDS with an ARD of 02/22/2021 documented the resident scored 15 (13-15 indicates cognitively intact) per a BIMS and required extensive assistance of two plus persons physical assist with toilet use and personal hygiene and had an indwelling urinary catheter. a. The Comprehensive Care Plan documented, .The resident has a foley catheter due to [CONDITION(S)] bladder Date Initiated: 11/06/2020 The resident will be/remain free from catheter-related trauma through review date. Date Initiated: 11/06/2020 . b. The April 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 04/06/2021 at 9:30 A.M., Resident #32 was turned and repositioned multiple times during wound care and the urinary catheter tubing was not secured to prevent pulling, tugging, or dislodgement. There was no Stat lock or other device on the resident's catheter to secure it to the leg to prevent the catheter tubing from pulling and tugging on the bladder. 3. On 04/08/2021 at 2:00 P.M., Licensed Practical Nurse (LPN) #1 was asked, How do you prevent tugging on Foley catheter tubing during transfers, peri-care, and repositioning? She replied, Usually we have stat-locks in place to secure the catheter. LPN #1 was asked, How is it monitored for its presence? She replied, We have catheter care on our MAR [Medication Administration Record] every shift. LPN #1 was asked, What can happen if a Foley catheter is not secured? She replied, It can be pulled out, bulb and all and cause urethral problems. 4. On 04/08/2021 at 2:30 P.M., the Director of Nursing (DON) was asked, How do you prevent tugging on Foley catheter tubing during transfers, peri-care, and repositioning? She replied, We use stat-locks. The DON was asked, How is it monitored that it is present? She replied, We have catheter care on our MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ? She replied, It can be displaced. 5. A Catheter Care, Urinary policy provided by the Nurse Consultant on 04/08/2021 documented, .2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) .

Based on observation, record review, and interview, the facility failed to ensure residents' fingernails were trimmed for 1 (Resident #49) and oral care was performed to promote good personal hygiene for 1 Residents (Residents #4) of 35 (#52, #44, #18, #12, #204, #35, #41, #25, #10, #36, #154, #14, #38, #16, #27, #43, #40, #24, #32, #4, #5, #46, #49, #29, #20, #6, #50, #42, #3, #34, #19, #23, #11, #39, and #7) sample residents who were dependent for nail care and 8 (Residents #18, #12, #41, #25, #36, #32, #50, #23) sampled residents who were dependent on oral care. This failed practice had the potential to affect 49 residents who were dependent for nail care according to the list provided by the Director of Nursing (DON) on 04/08/2021 and 10 residents who were dependent for oral care as documented on a list provided by the DON on 04/09/2021. The findings are: 1. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Comprehensive Care Plan initiated on 12/22/2017 documented, .The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] dementia . PERSONAL HYGIENE: The resident requires (limited assistance) by (1) staff with personal hygiene and oral care .The resident has a communication problem r/t cognition r/t Alzheimer's . Anticipate and meet needs . b. On 04/07/2021 at 8:18 A.M., Resident #4's natural teeth had a white substance built up on them and her gums were red. Resident #4 stated that no one assisted her with oral care. (Photo taken.) c. On 04/08/2021 at 1:55 p.m., Licensed Practical Nurse (LPN) #1 was asked, When is oral care performed on residents? She replied, Usually in the mornings when the CNA's [Certified Nursing Assistant] are getting residents up. Some residents can do their own. d. On 04/08/2021 at 2:20 p.m., the Director of Nursing (DON) was asked, Who is responsible for oral care? and When is oral care performed on residents? She replied, The CNA's are responsible. The usually do it in the mornings when they are getting residents up. The residents that can do their own, do. e. A Mouth Care policy provided by the Nurse Consultant on 04/08/2021 at 2:24 p.m., documented, .The purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent oral infection. Preparation 1. Review the resident's care plan to assess for any special needs of the resident . 2. Resident #49 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with ARD of 03/21/2021 documented the resident scored 12 (13-15 indicates moderately impaired) per a BIMS required limited assistance of 1 person physical assistance personal hygiene. a. c. The Comprehensive Care Plan initiated on 03/17/2021 documented, .The resident has an ADL self-care performance deficit r/t weakness . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short . b. On 04/05/2021 at 10:41 a.m., Resident #49's fingernails were approximately 1/4 inch long. The fingernails on his right hand were thick and brittle. Resident # 49 was asked, Are you a diabetic? He replied, Yes. (Photo taken.) c. On 04/07/2021 at 8:37 a.m., Resident #49's fingernails were approximately 1/4 inch long. The fingernails on his right hand were thick and brittle. Resident # 49 was asked, Do you like your fingernails that long? He replied, Before I got sick, I liked them short but when I got sick, I got to where I couldn't clip them. (Photo taken.) d. On 04/08/2021 at 1:55 p.m., LPN #1 was asked, Who is responsible for nailcare on the residents and how is it scheduled and monitored? She replied, The CNA's do nailcare on the non-diabetics, the nurses do the diabetics. There is a treatment on the TAR [Treatment Administration Record] for diabetic nailcare. e. On 04/08/2021 at 2:20 p.m., the DON was asked, Who is responsible for nailcare on the residents and how is it scheduled and monitored? She replied, The CNA's do nailcare during their showers unless the resident is a Diabetic. If the resident is a Diabetic, the nurses do it on Mondays, it is on the TAR. f. A Fingernails/Toenails, Care of policy provided by the DON on 04/08/2021 at 1:15 p.m., documented, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming . Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .

Based on observation, record review, and interview, the facility failed to ensure humidity bottles were changed and dated and oxygen was consistently administered at the flow rate ordered by the physician to minimize the potential for [CONDITION(S)] or other respiratory complications for 1 (Resident #41) of 6 (Residents #52, #44, #41, #5, #6 and #11) who had orders for oxygen. These failed practices had the potential to affect 10 residents who had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident #41 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set with Assessment Reference Date of 03/06/2021 documented the resident scored 10 (8-12 indicates moderately impaired) per a Brief Interview of Mental Status and received oxygen therapy while not a resident and while a resident. a. The Comprehensive Care Plan initiated on 03/03/2021 documented .The resident has altered cardiovascular status r/t [related to] [CONDITION(S)] [CONDITION(S)]. OXYGEN SETTINGS: O2 via nasal prongs @ 5LPM PRN [as needed] . b. The April 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] @ [at] 5L [Liters] per NC [Nasal Cannula] SOB [Shortness of Breath] Order Status Active Order Date: 03/04/2021 . c. On 04/05/2021 at 10:33 A.M., Resident #41 was receiving oxygen per nasal canula at 4 liters per minute. The water bottle was dry and dated 3/22/21 on the top of the bottle and another date on the front dated 4-2-21. (Photo taken.) d. On 04/06/2021 at 8:47 A.M., Resident #41 was receiving oxygen per NC at 4 LPM, the water bottle was dry and dated 3/22/21 on the top of the bottle. (Photo taken.) e. On 04/06/2021 at 12:50 P.M., Resident #41 was receiving oxygen per NC at 4 LPM, the water bottle was dry and dated 3/22/21 on the top of the bottle. (Photo taken.) f. On 04/08/2021 at 1:50 P.M., Licensed Practical Nurse (LPN) #1 was asked, How often are the oxygen tubing, humidity, and storage bags changed? She replied, Weekly on Friday night and prn [as needed]. LPN #1 was asked, Is there something that prompts the nurses to change it? She replied, Yes, it is on the MAR [Medication Administration Record] for night shift. LPN #1 was asked, What could happen if it isn't changed? She replied, It could dry out the nasal membranes and if they have congestion it could dry on the tubing and block the oxygen from going through. g. On 04/08/2021 at 2:05 P.M., the DON was asked, How often are the oxygen tubing, humidity, and storage bags changed? She replied, Weekly on Friday nights. The DON was asked, How do the nurses know when to change it? She replied, It is on the MAR. The DON was asked, What could happen if it doesn't get changed like it should? She replied, The nose can get dry and have nosebleeds. h. An Oxygen Administration policy provided by the DON on 04/08/2021 at 1:15 P.M. documented, .Review the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Be sure that there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through .Periodically re-check water level in humidifying jar .

Based on observation, interview and record review, the facility failed to ensure the environment was free of accidents and hazards by leaving medications at the bedside for self-administration for 1 (Resident #17) sample resident. This failed practice had the potential to affect 21 residents who were mobile according to a list provided by the Director of Nursing (DON) on 04/08/2021 at 1:15 P.M. The findings are: 1. Resident #17 had diagnosis of Human Immunodeficiency Virus Disease (HIV), Candidiasis of Skin and Nail and Dermatophytosis. The Quarterly Minimum Data Set with Assessment Reference Date of 02/08/2021 documented the resident scored 15 (13-15 indicates cognitively intact) per a Brief Interview of Mental Status and required supervision with bed mobility, transfers, toilet use, personal hygiene, and bathing. a. The April 2021 Physician Orders documented, .[MEDICATION(S)] Cream 5 % [percent] Apply to warts topically at bedtime every Mon [Monday], Wed [Wednesday], Fri [Friday] related to DERMATOPHYTOSIS, UNSPECIFIED . until 05/28/2021 23:59 [11:59 P.M.] Wear gloves upon application and ONLY apply cream to the wart area, not surrounding tissue Order Date 02/22/2021 . b. On 04/05/2021 at 10:47 A.M., a medicine cup approximately half full of pills was sitting on the bedside table. Resident #17 was asked, Does the staff leave your medications at your bedside for you to take yourself? He replied, Yes. (Photo taken.) c. On 04/05/2021 at 12:45 P.M., Resident #17 was asked if he had any concerns he would like to discuss with the Surveyor. Resident #17 replied, Sometimes a female resident will wander into my room and I don't like that. d. On 04/06/2021 at 8:57 A.M., Resident #17 reached into his bedside drawer and got out a cream. He stated, I put this on my groin area three times a week. (Photo taken.) e. On 04/08/2021 at 2:04 P.M., LPN #1 was asked, Have any of the residents been assessed for self-administration of medications? She replied, Not that I know of. LPN #1 was asked, What could happen if medications are left at the bedside for self-administration? She replied, Another resident could walk over and take the cup and swallow them. LPN #1 was asked, Do you have any residents that wander in other residents' rooms? She replied, We do have residents that are confused and wander into other residents' rooms. f. On 04/08/2021 at 2:35 P.M., the DON was asked, Have any of the residents been assessed for self-administration of medications? She replied, No resident has been assessed or ok'd for medication self-administration. The DON was asked, What could happen if medications are left at the bedside for self-administration? She replied, Someone else could get it or the resident could hold them and then take more all at once. They could also choke. The DON was asked, Do you have any residents that wander in other residents' rooms? She replied, Yes, we do have wanderers. g. An Administering Medications policy provided by the DON on 04/08/2021 at 1:15 P.M. documented, .Medications shall be administered in a safe and timely manner and as prescribed .1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so .3. Medications must be administered in accordance with the orders .24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely .

Complaint # (AR 448) was substantiated, all or in part, with these findings: Based on observation, record review, and interview the facility failed to ensure the physician and family received notification of a change in the resident's skin condition for 1 (Resident (R) #1) of 3 sampled residents who had Pressure Ulcers. The failed practice had the potential to affect 4 residents who had Pressure Ulcers according to a list provided by the Director of Nursing (DON) on 09/25/2020 at 10:25 AM. The findings are: 1. Resident #1 was admitted on [DATE] and was discharged on [DATE] to the hospital and did not return to the facility. She had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident was severely impaired in cognitive skills for daily decision making and was totally dependent on staff for transfers, toileting and bathing. a. A physician order [REDACTED].Clean Shear to Coccyx With Wound Clenaser, Pat Dry With Gauze, Apply Hydro cellular Sacral Dressing Qod (Every Other Day) And Prn (as needed) every day shift every other day . b. A physician order [REDACTED].Assess Dressing To Coccyx For Intactness Assess Peri Wound For S/Sx (Signs And Symptoms) Infection Assess For Pain everyday shift . c. The Comprehensive Care Plan with a revision date of 07/16/2020 documented, .Focus: The resident is at risk for skin breakdown related to limited mobility and incontinence .Interventions/Tasks: Monitor/document location, size and treatment of [REDACTED]. (etcetera) to MD (Medical Doctor) . Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Date Initiated: 06/18/2019 . d. Nsg (Nursing) Weekly Assessment/Skin Audits of the sacral (coccyx) wound for R #1 provided by the Treatment Nurse on 9/23/2020 at 11:18 AM documented, .7/9/2020 09:03 .Site: Coccyx .Type: Shearing .Length X Width X Depth (1.5 X 1.1 X 0.1) . Current Skin assessment summary: (no skin assessment summary documented.) .(7/16/2020 No Weekly Assessment/Skin Audit Form found) .7/23/2020 08:40 (8:40 a.m.) . Site: Coccyx .Type: Shear . Length X Width X Depth (1.5 X 1.5 X 0.1) . Current Skin assessment summary: (no skin assessment summary documented) .7/30/2020 18:40 (6:40 p.m.) .Site: Coccyx .Type: Shear .(No measurements documented) .(no skin assessment summary of the coccyx wound documented) .8/6/2020 16:40 (4:40 p.m.) .Coccyx .Shear .Length X Width X Depth (2.5 X 2.0 X 0.1) . (no skin assessment summary of the coccyx wound documented) .8/13/2020 16:40 (4:40 p.m.) .Coccyx .Shearing .(No measurements documented) .(no skin assessment summary of the coccyx wound documented) . On 08/16/2020 the resident was sent to the hospital. e. The hospital Medical Records documented, .Physician Documentation .Medical Center .Arrival Date: 08/16/2020 .Time: 06:07 (6:07 a.m.) .Diagnosis: [REDACTED]. Nurses' Notes .Medical Center .Presentation: Triage assessment: 06:23 (6:23 a.m.) .Appears unkempt .Assessment: 09:19 (9:19 a.m.) Derm (Dermatology): Decubitis (Decub) located on sacrum approximately 7.6 cm (centimeters) to 20 cm .bed has eschar present .unable to be staged .is draining small amount malodorous, dark color .family reports no knowledge of decub on sacrum. Contacted Nursing home to find out info about patient's decub and was told that the treatment nurse was taking care of the decub . f. The hospital Medical Records documented, .8/16/2020 21:10 (9:10 p.m.) .room [ROOM NUMBER]/1 .Daily Physical Assessment-Evaluation Flowsheet .Buttock Detail: Coccyx .Comment: unstageable .Amount and Type of Drainage: brown . g. A Lab Report of a Culture and Sensitivity of R #1's sacral wound documented, Collected: 8/16/20 10:42(a.m.) .Reported: 8/19/2020 10:12(a.m,) .Procedure Culture, Exudate .Specimen Source: pressure ulcer to coccyx .Organisms Identified .Streptococcus anginosus .Staphylococcus aureus . h. On 09/22/2020 at 9:33 AM, R #1's daughter was interviewed by telephone and was asked, Did the facility notify you that the resident had a coccyx or sacral wound? She stated, No. We didn't know about it until she was in the emergency room (ER). i. On 09/23/2020 at 10:39 AM, the Treatment Nurse was asked, Did you provide care for R #1 when she was a resident? She stated, Yes. The Treatment Nurse was asked, Did you treat a wound on her sacral area? She stated, Yes. She had a shearing that was about 2 cm. The Treatment Nurse was asked, Was the family and the physician notified? She stated, Yes. Was there ever a change in condition of the wound? She stated, No. It stayed the same. There was never a major decline. It would actually look like it was about to close up at times, then get a little worse. Should the family and physician be notified if there is a change in condition? She stated, Yes. When did you last provide care for the wound? She stated, On 8/13/2020 and she went out on 8/16/2020. The Treatment Nurse was asked, Would you say there's a difference in a shearing and a pressure ulcer? She stated, Yes, but a shearing can turn into a pressure ulcer within 24 hours. I saw that documented somewhere. I will find it . j. On 09/25/2020 at 9:28 AM, the DON was asked, The DON was asked, Are nurses trained to report any change in condition of the resident to the family and physician? She stated, Yes. The DON was asked, She was shown the picture of R #1's sacral wound taken in theER on [DATE] and asked, Is this a shearing or a pressure ulcer? She stated, That looks bad. It's a pressure ulcer, it's got black in it .is this her (R#1)? To be honest, I never saw it. If the APN (Advanced Practical Nurse) would have known she would have done something. k. On 09/25/2020 at 9:53 AM, the APN was shown the pictures of R #1 taken in theER on [DATE] and asked, Were you notified that R #1's wound had a smell and was draining? She stated, No. I can see it has eschar. I never heard anything about it getting worse. As far as I knew she had a small shearing that was being treated and doing well. I always tell them to let me know if it gets worse. I would have changed the treatment. I could have cultured it and put her on antibiotics. Even though with her age, advancing Dementia, her not eating and drinking she probably wasn't going to get any better, but still . l. A Policy on Notification in Change of Condition provided by the DON on 9/25/2020 at 10:15 a.m. documented, .The responsible party is notified any time there is a change in a patient's condition .

Complaint # (AR 542) and Complaint # (AR 448) was substantiated, all or in part, with these findings: Based on observation, record review, and interview the facility failed to ensure wound measurements and wound descriptions were consistently conducted and documented, and the physician was notified when the wound became worse so treatment could be promptly provided to aid in healing and prevent further deterioration for 1 (Resident #1) of 3 sampled residents (Residents #1, #2, and #3) who had Pressure Ulcers. The failed practice had the potential to affect 4 residents who had Pressure Ulcers according to a list provided by the Director of Nursing (DON) on 09/25/2020 at 10:25 AM. The findings are: Resident #1 was admitted on [DATE] and was discharged on [DATE] to the hospital and did not return to the facility. She had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident was severely impaired in cognitive skills for daily decision making and was totally dependent on staff for transfers, toileting and bathing. a. A physician order [REDACTED].Clean Shear to Coccyx With Wound Clenaser, Pat Dry With Gauze, Apply Hydro cellular Sacral Dressing Qod (Every Other Day) And Prn (as needed) every day shift every other day . b. A physician order [REDACTED].Assess Dressing To Coccyx For Intactness Assess Peri Wound For S/Sx (Signs And Symptoms) Infection Assess For Pain everyday shift . c. The Comprehensive Care Plan with a revision date of 07/16/2020 documented, .Focus: The resident is at risk for skin breakdown related to limited mobility and incontinence .Interventions/Tasks: Monitor/document location, size and treatment of [REDACTED]. (etcetera) to MD (Medical Doctor) . Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Date Initiated: 06/18/2019 . d. Nsg (Nursing) Weekly Assessment/Skin Audits of the sacral (coccyx) wound for R #1 provided by the Treatment Nurse on 9/23/2020 at 11:18 AM documented, .7/9/2020 09:03 .Site: Coccyx .Type: Shearing .Length X Width X Depth (1.5 X 1.1 X 0.1) . Current Skin assessment summary: (no skin assessment summary documented.) .(7/16/2020 No Weekly Assessment/Skin Audit Form found) .7/23/2020 08:40 (8:40 a.m.) . Site: Coccyx .Type: Shear . Length X Width X Depth (1.5 X 1.5 X 0.1) . Current Skin assessment summary: (no skin assessment summary documented) .7/30/2020 18:40 (6:40 p.m.) .Site: Coccyx .Type: Shear .(No measurements documented) .(no skin assessment summary of the coccyx wound documented) .8/6/2020 16:40 (4:40 p.m.) .Coccyx .Shear .Length X Width X Depth (2.5 X 2.0 X 0.1) . (no skin assessment summary of the coccyx wound documented) .8/13/2020 16:40 (4:40 p.m.) .Coccyx .Shearing .(No measurements documented) .(no skin assessment summary of the coccyx wound documented) . On 08/16/2020 the resident was sent to hospital. e. The hospital Medical Records documented, .Physician Documentation .Medical Center .Arrival Date: 08/16/2020 .Time: 06:07 (6:07 a.m.) .Diagnosis: [REDACTED]. Nurses' Notes .Medical Center .Presentation: Triage assessment: 06:23 (6:23 a.m.) .Appears unkempt .Assessment: 09:19 (9:19 a.m.) Derm (Dermatology): Decubitis (Decub) located on sacrum approximately 7.6 cm (centimeters) to 20 cm .bed has eschar present .unable to be staged .is draining small amount malodorous, dark color .family reports no knowledge of decub on sacrum. Contacted Nursing home to find out info about patient's decub and was told that the treatment nurse was taking care of the decub . f. The hospital Medical Records documented, .8/16/2020 21:10 (9:10 p.m.) .room [ROOM NUMBER]/1 .Daily Physical Assessment-Evaluation Flowsheet .Buttock Detail: Coccyx .Comment: unstageable .Amount and Type of Drainage: brown . g. A Lab Report of a Culture and Sensitivity of R #1's sacral wound documented, Collected: 8/16/20 10:42(a.m.) .Reported: 8/19/2020 10:12(a.m,) .Procedure Culture, Exudate .Specimen Source: pressure ulcer to coccyx .Organisms Identified .Streptococcus anginosus .Staphylococcus aureus . h. On 09/22/2020 at 9:33 AM, R #1's daughter was interviewed by telephone and was asked, Did the facility notify you that the resident had a coccyx or sacral wound? She stated, No. We didn't know about it until she was in the emergency room (ER). It was a huge bedsore. I didn't get really close to it because it smelled bad, but it looked about 4 inches in diameter. I was surprised because they were pretty good about calling whenever she got a skin tear, she got them all the time. I don't recall them telling me about a sore on her back side . R #1's granddaughter was also present and stated, I called to ask her about it and the wound care nurse told us the last time she saw it, it was a 2 cm (centimeters) cut. She stated she had checked it a few days before she was sent out The daughter stated, She called it a shear and I don't know, I'm not going to say they did or didn't say something about a shear a while back, but what I saw in the ER was not a shear it was a huge sore. The Nurse at the hospital said it was impacted with poop and had no bandage on it, said this was a lawsuit waiting to happen. They said they were going to report it, but I don't know if they did or not. We're not thinking about a lawsuit, we just want something done so something like this doesn't happen to anyone else. I was always praising them because the nursing care was good and the staff was wonderful, but somebody wasn't doing their job . The granddaughter stated, She (Treatment Nurse) said wounds can grow really fast if they have an underlying condition, but I don't think it turned into something like that within a week after she saw it, it had black in it . She was asked, Did you speak with the DON or Administrator? She stated, No. When we called to speak to whoever was in charge and told them what it was about, they got the wound care nurse on the phone . i. On 09/23/2020 at 10:39 AM, the Treatment Nurse was asked, Did you provide care for R #1 when she was a resident? She stated, Yes. The Treatment Nurse was asked, Did you treat a wound on her sacral area? She stated, Yes. She had a shearing that was about 2 cm. The Treatment Nurse was asked, Can you describe a shearing? She stated, It's like when you rub the top layer of skin off. Her skin was very fragile and when the aides slide her on the sheet to reposition her, her skin was so fragile it would tear, or the top layer of her skin would rub off. The Treatment Nurse was asked, When was the shear first discovered? She checked the computer and stated, 7/9/2020. The Treatment Nurse was asked, Was the family and the physician notified? She stated, Yes. Was there ever a change in condition of the wound? She stated, No. It stayed the same. There was never a major decline. It would actually look like it was about to close up at times, then get a little worse. The Treatment Nurse was asked, How often did you provide care for the wound? She stated, Twice a week, every other day. The Treatment Nurse was asked, Did you ever see black in the wound (eschar) or did it ever develop and odor? She stated, No. It did not smell and there was no odor. Of course, it's hard to smell sometimes with these masks on. The Treatment Nurse was asked, How often should wound assessments and measurements be done? She stated, Normally we do it weekly, but I missed 8/6/2020 because it was so busy. I think we were doing COVID testing that week. Should the family and physician be notified if there is a change in condition? She stated, Yes. When did you last provide care for the wound? She stated, On 8/13/2020 and she went out on 8/16/2020. The Treatment Nurse was asked, Would you say there's a difference in a shearing and a pressure ulcer? She stated, Yes, but a shearing can turn into a pressure ulcer within 24 hours. I saw that documented somewhere. I will find it . j. On 9/23/2020 at 12:07 PM, Licensed Practical Nurse (LPN) (Licensed Practical Nurse) #1 was asked, Were you the charge nurse when R #1 sent out on 8/16/2020? She stated, Yes. LPN #1 was asked, Did you check to make sure the dressing to her sacral wound was intact before she left? She stated, I didn't check, I was passing meds. LPN #1 was asked, Do you know if she had been provided incontinent care or bathed if needed? The aides told me they had just changed her brief and the aide I was working with is very reliable. I took her word. k. On 09/23/2020 at 3:42 PM, Certified Nursing Assistant (CNA) #1 was asked, Were you providing care for R #1 the morning she was sent out? She stated, Yes. CNA #1 was CNA #1 was asked, Did you bathe her? She stated, Yes. Me and the other aide. She stated, Was there a bandage on her sacral (back side) wound? She stated, No. We cleaned her up and put cream and a brief on her. CNA #1 was CNA #1 was asked, Did the wound have an odor? She stated, Yes. It smelled and was oozing . j. On 09/25/2020 at 9:28 AM, the DON was asked, Are CNA's trained to report a change in condition or a dressing that has come off to the nurses? She stated, Yes. The DON was asked, Are nurses trained to report any change in condition of the resident to the family and physician? She stated, Yes. The DON was asked, How often are wound assessments and measurements done? She stated, Weekly. The DON was asked, Is there a difference in a shearing and a pressure ulcer? She stated, Yes. The DON was asked, She was shown the picture of R #1's sacral wound taken in theER on [DATE] and asked, Is this a shearing or a pressure ulcer? She stated, That looks bad. It's a pressure ulcer, it's got black in it .is this her (R#1)? To be honest, I never saw it. If the APN (Advanced Practical Nurse) would have known she would have done something. The DON was asked, Do you think this could have gone from a shearing to a Stage 4 Pressure Ulcer in 2 or 3 days? She stated, Absolutely not. I promise you something will be done about this . k. On 09/25/2020 at 9:53 AM, the APN was shown the pictures of R #1 taken in theER on [DATE] and asked, Were you notified that R #1's wound had a smell and was draining? She stated, No. I can see it has eschar. I never heard anything about it getting worse. As far as I knew she had a small shearing that was being treated and doing well. I always tell them to let me know if it gets worse. I would have changed the treatment. I could have cultured it and put her on antibiotics. Even though with her age, advancing Dementia, her not eating and drinking she probably wasn't going to get any better, but still . l. A Policy on Notification in Change of Condition provided by the DON on 9/25/2020 at 10:15 a.m. documented, .The responsible party is notified any time there is a change in a patient's condition .

Complaint # was substantiated, (all or in part) with these findings. Based on observation, record review and interview the facility failed to ensure a newly hired, non-certified nursing assistant's competency with transfers and dealing with combative residents was verified prior to allowing him to independently provide a 1-person manual transfer to 1 (Resident #4) of 2 (Residents #1 and #4) case mix residents who were severely cognitive impaired and required one person assistance with transfers. The failed practice resulted in actual harm to Resident #4, who fell during a transfer and sustained nasal bone fractures, and was likely to affect 2 severely cognitively impaired residents who required one-person assistance with transfers and received care from non-certified nursing assistants, according to a list received from the Director of Nursing on 2/2/12 at 2:00 p.m. The findings are: Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of 12/2/11 documented the resident had severe impairment in cognitive skills for daily decision-making per a staff assessment of mental status, verbal and physical behaviors, required assistance of one person for transfers and had no recent falls. a. A Lift/Transfer Assessment form dated 1/18/12 documented, "Requires minimum of 1 man lift/transfer." b. An Incident/Accident Report dated 1/20/12 at 5:10 a.m. documented, " ...Called to (resident's) room per C.N.A. (Certified Nursing Assistant (this was actually non-certified Nurse Aide (NA) #1 according to Witness Statements below). Found C.N.A. (N.A. #1) at bedside supporting (resident) in sitting position on side of bed coughing up blood and nose bleeding. Bridge of nose swollen ...to (Hospital emergency room ) by (Emergency Medical Services) ..." c. A Computed Tomography (CT) Scan of the maxillofacial area dated 1/20/12 documented, " ...Impression Comminuted displaced fractures of the bilateral nasal bones. Possible minimally displaced [MEDICAL CONDITION] nasal septum. Air fluid levels within the sinuses may represent blood or due to sinusitis ..." d. The emergency room Physician's Clinical Impression dated 1/20/12 documented, " ...Contusion bridge of nose and upper lip, laceration less than 0.5 cm (centimeters) bridge of nose and fracture of nasal bones." e. Nurse's Notes dated 1/20/12 (not timed) and signed by N.A. #1 included a handwritten entry, "Initial Statements" at the top of the note and documented, "I, (N.A. #1), came into (Resident #4 room) to get her dress and up for the morning. When I change her bed I commence to getting her up to put her gown on. When I put the gown on I laid her back in bed with rail up. When I bend down to get the spoil linen she cough up blood and was gurgling. I then got the CN (Charge Nurse) to witness her spitting blood." f. A typed interview dated 1/20/12 and signed by the Director of Nursing and with a witness signature by Registered Nurse (RN) #1documented, "At approximately 9:15 a.m., Employee (N.A. #1) was interviewed (regarding) an incident involving (Resident #4). (N.A. #1) was asked if he noted any bleeding from (Resident #4's) nose, mouth on initial entry into the room. He answered "No". He was asked if there was any other indication of anything abnormal (regarding) the same area. He stated "No". He was then asked about assisting her with putting on her gown. He was asked if he had made any contact with her nose/mouth in the process of this assistance. He stated "No". He was asked about the Resident's behavior during the dressing assistance. He stated that she was combative. He was asked how he dealt with her combativeness. He stated that he had placed her hands together and placed them under his arm and finished in putting on her gown. He was asked if at any time during her combativeness did he notice or have any suspicion that the resident had any self injury. He stated "No". He was asked if at any time did he have her turned in a manner that would have placed her facial area next to or near the side rail of the bed. He stated "No". He was asked if after he finished in assisting her getting dressed and laid her back in the bed, was there bleeding or any indication of injury observed. He stated "No". His statement says that when he bent over to collect the dirty linen; he heard a sound, looked and noted bleeding. He noted blood on top of the side rail. He was asked if it was present when he initially entered the room. He stated "No". He also stated that he noted blood on the sleeve of his shirt. He was asked if the resident fell . He stated "No". He was asked so the resident did not fall and you did not put her back in the bed. He stated, "No" ...He was informed that an investigation had begun and that per policy, he would be suspended from work pending the outcome of the investigation..." g. A Witness Statement dated 1/20/12 and signed by C.N.A. #2 (Lead C.N.A.) documented, "At 3:45 p.m., I received a phone call from (N.A. #1) stating that he wanted to call me and tell the truth about what happen this morning. He goes on to say he was getting (Resident #4) up. He put her gown on the hold while she was being very combative with him. So he sit on the side of the bed and went to pull her wheelchair closer and somehow he lost hold of her. She fell sidewards and her whole face went into the nightstand. He said (C.N.A. #2) I didn't tell the truth because I was scared ..." h. A second Witness Statement signed by C.N.A. #2 (Lead C.N.A.) and dated 1/31/12 documented, "Clarification of statement giving on 1/20/12. On or about 3:45 p.m. (N.A. #1) call my cell phone and stated he was 'ready to tell me the truth about what happened this morning'. He said 'O.K. you know (Resident #4) was combative, fighting me. So I had got her up, put her gown on her and I pulled her to the side of the bed. When she kept trying to fight at me so I put her hands together and put them under my arm and I went to get her wheelchair closer she fell to the side. I mean her whole face went into the night stand. (C.N.A. #2) I seen all that blood. I was scared is the reason I lied. I'm so sorry (C.N.A. #2) but that's what really happened' ..." i. A second Witness Statement dated 1/20/12 (not timed) and signed by N.A. #1 documented, "I, (N.A. #1), was doing my last round for tonight. I entered (Resident #4's) room at 5:35 a.m. to change her and her bed. She was combative through the whole process until I held her hand and put on her gown. I grab her wheelchair, pull it close to her as possible and lock it. When I check to secure the wheelchair, I then grab (Resident #4) by her elbows and arms to place her in the chair. While during the process she was still combative. I then lost control of her arms and she fell on the right side of the bed. Her whole head went into the dresser that was on that side. I then ASAP (as soon as possible) went and got the Charge Nurse and told her she was bleeding. She went and got (Charge Nurse) the other CN and they immediately came to the room to aid her and comfort her until more help arrive..." j. On 1/30/12 at 3:11 p.m. and 4:10 p.m. and on 1/31/12 at 8:40 a.m., 10:41 a.m. and 3:33 p.m., the resident was observed with bruising of the nose and under bilateral eyes. k. On 2/1/12 at 9:00 a.m., N.A. #1 was asked to describe the incident with (Resident #4) and NA #1 stated, "On 1/20/12 I worked the third shift, 10:00 p.m. until 6:00 a.m. I came to work on 1/19/12 (at 10:00 p.m.). (Resident #4) was one of my residents. I started two and one half or three weeks ago (Hire Date-12/30/11). This was my first job as a nursing assistant. I am not certified. (Resident #4) was combative. Her behavior included swinging and smacks, hit and punched with her hands. The incident occurred about 5:45 a.m. on 1/20/12. I was attempting to get her up to take her to the dayroom. I had her dressed already. Then I laid her back down. I put the rail up. I reached and got the wheelchair. I put it on the left side of the bed at the head of the bed and moved it to the foot of the bed. I let her side rail down on the left. I got her feet first and pivoted her to a sitting position. She was combative with her hands. I placed my hands on her elbows. I did not apply a gait belt. I got her under her arms, picked her up and pivoted her. She freaked out. She startled me. She went 'no'. She threw her arms up in the air. I turned loose. I panicked and she fell forward into the bedside table. Her whole face went into the front of the bedside table. I picked her up from the floor, placed her back in bed and went and got the charge nurse." NA #1 was asked about the training he had received for transferring a resident and stated, "I was taught in C.N.A. training to use a gait belt or to have help when transferring a combative resident. I was not told to use a gait belt with each resident transfer at this facility. The (closet) care plan says transfer assist times one. It does not say to use the gait belt. I knew where the care plans are, but I had never looked at one. I did not use a gait belt because I wasn't given one. I was not given a skills check list. I didn't tell the truth the first time because I was scared. I saw all the blood and it scared me. I just picked her up and laid her on her back and went and got the charge nurse. I was not given a form to sign that I received a gait belt." A certificate dated 12/21/11 documented NA #1 completed a 90-hour Nursing Assistant Training course on 12/21/11. The facility's personnel file for NA #1 documented the NA was hired by the facility on 12/31/11. l. On 2/1/12 at 9:50 a.m., C.N.A. #2 stated, "I did not have him sign any piece of paper for the gait belt I gave him." m. On 2/1/12 at 10:03 a.m., the Administrator stated and presented a written statement which documented, "When new C.N.A.'s are given their gait belts by the lead C.N.A. they are required to sign a form showing they received it." As of 2/2/12 at 11:54 a.m., the facility could not present a signed statement from N.A. #1, demonstrating his receipt of a gait belt. n. On 2/2/12 at 11:55a.m., the Director of Nursing stated, "I have no documentation of skills checks on (N.A. #1). He should have completed a skills check list prior to leaving orientation. I do not know how he dealt with combative residents. I do not know if he knew to report the accident as soon as it happened. (N.A. #1) had three days of orientation on the evening shift before being assigned to nights. He was not working with a buddy system that night. I do not know about his transfer skills." The Director of Nursing was asked about inservices regarding transfers or care of the combative resident since the incident. The Director of Nursing stated, "There has not been any inservices related to transfers or caring for combative residents since the incident except for the inservice on 1/20/12 regarding the combative resident. It was presented to 20 members of our nursing staff." The inservice documentation dated 1/20/12 documented signatures by less than one half of the nursing employees of the facility.

Complaint # was substantiated, (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure adequate supervision was provided to a newly hired, non-certified nursing aide, as evidenced by failure to ensure the aide was trained in handling combative residents and failure to verify (check off) that the aide was competent with transfers prior to allowing him to independently conduct a 1-person manual transfer for 1 (Resident #4) of 2 (Resident #1 and #4) case mix residents who were severely cognitive impaired and required one-person assistance with transfers. The failed practice resulted in actual harm to Resident #4, who fell during a transfer and sustained nasal bone fractures, and was likely to affect 2 severely cognitively impaired residents who required one-person assistance with transfers and were provided care by non-certified nursing assistants, according to a list received from the Director of Nursing on 2/2/12 at 2:00 p.m. The findings are: Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of 12/2/11 documented severe impairment in cognitive skills for daily decision-making per a staff assessment of mental status, verbal and physical behaviors, assistance of one person for transfers and no recent falls. a. A Lift/Transfer Assessment form dated 1/18/12 documented, "Requires minimum of 1 man lift/transfer." An Admission Care Plan dated 1/18/12 documented, "ADL (activities of daily living) Function/Rehab (rehabilitation) Potential ... Ambulation/Transfer Assist: X (times) 1 ..." b. An Incident/Accident Report dated 1/20/12 at 5:10 a.m. documented, " ...Called to (resident's) room per C.N.A. (Certified Nursing Assistant (this was actually non-certified Nurse Aide (NA) #1 according to Witness Statements below). Found C.N.A. (N.A. #1) at bedside supporting (resident) in sitting position on side of bed coughing up blood and nose bleeding. Bridge of nose swollen ...to (Hospital emergency room ) by (Emergency Medical Services) ..." c. A Computed Tomography (CT) Scan of the maxillofacial area dated 1/20/12 documented, " ...Impression Comminuted displaced fractures of the bilateral nasal bones. Possible minimally displaced fracture of the bony nasal septum. Air fluid levels within the sinuses may represent blood or due to sinusitis ..." d. The emergency room Physician's Clinical Impression dated 1/20/12 documented, " ...Contusion bridge of nose and upper lip, laceration less than 0.5 cm (centimeters) bridge of nose and fracture of nasal bones." e. Nurse's Notes dated 1/20/12 (not timed) and signed by N.A. #1 included a handwritten entry, "Initial Statements" at the top of the note and documented, "I, (N.A. #1), came into (Resident #4 room) to get her dress and up for the morning. When I change her bed I commence to getting her up to put her gown on. When I put the gown on I laid her back in bed with rail up. When I bend down to get the spoil linen she cough up blood and was gurgling. I then got the CN (Charge Nurse) to witness her spitting blood." f. A typed interview dated 1/20/12 and signed by the Director of Nursing and with a witness signature by Registered Nurse (RN) #1documented, "At approximately 9:15 a.m., Employee (N.A. #1) was interviewed (regarding) an incident involving (Resident #4). (N.A. #1) was asked if he noted any bleeding from (Resident #4's) nose, mouth on initial entry into the room. He answered "No". He was asked if there was any other indication of anything abnormal (regarding) the same area. He stated "No". He was then asked about assisting her with putting on her gown. He was asked if he had made any contact with her nose/mouth in the process of this assistance. He stated "No". He was asked about the Resident's behavior during the dressing assistance. He stated that she was combative. He was asked how he dealt with her combativeness. He stated that he had placed her hands together and placed them under his arm and finished in putting on her gown. He was asked if at any time during her combativeness did he notice or have any suspicion that the resident had any self injury. He stated "No". He was asked if at any time did he have her turned in a manner that would have placed her facial area next to or near the side rail of the bed. He stated "No". He was asked if after he finished in assisting her getting dressed and laid her back in the bed, was there bleeding or any indication of injury observed. He stated "No". His statement says that when he bent over to collect the dirty linen; he heard a sound, looked and noted bleeding. He noted blood on top of the side rail. He was asked if it was present when he initially entered the room. He stated "No". He also stated that he noted blood on the sleeve of his shirt. He was asked if the resident fell . He stated "No". He was asked so the resident did not fall and you did not put her back in the bed. He stated "No" ...He was informed that an investigation had begun and that per policy, he would be suspended from work pending the outcome of the investigation..." g. A Witness Statement dated 1/20/12 and signed by C.N.A. #2 (Lead C.N.A.) documented, "At 3:45 p.m., I received a phone call from (N.A. #1) stating that he wanted to call me and tell the truth about what happen this morning. He goes on to say he was getting (Resident #4) up. He put her gown on the hold while she was being very combative with him. So he sit on the side of the bed and went to pull her wheelchair closer and somehow he lost hold of her. She fell sidewards and her whole face went into the nightstand. He said (C.N.A. #2) I didn't tell the truth because I was scared ..." h. A second Witness Statement signed by C.N.A. #2 (Lead C.N.A.) and dated 1/31/12 documented, "Clarification of statement giving on 1/20/12. On or about 3:45 p.m. (N.A. #1) call my cell phone and stated he was 'ready to tell me the truth about what happened this morning'. He said 'O.K. you know (Resident #4) was combative, fighting me. So I had got her up, put her gown on her and I pulled her to the side of the bed. When she kept trying to fight at me so I put her hands together and put them under my arm and I went to get her wheelchair closer she fell to the side. I mean her whole face went into the night stand. (C.N.A. #2) I seen all that blood. I was scared is the reason I lied. I'm so sorry (C.N.A. #2) but that's what really happened' ..." i. A second Witness Statement dated 1/20/12 (not timed) and signed by N.A. #1 documented, "I, (N.A. #1), was doing my last round for tonight. I entered (Resident #4's) room at 5:35 a.m. to change her and her bed. She was combative through the whole process until I held her hand and put on her gown. I grab her wheelchair, pull it close to her as possible and lock it. When I check to secure the wheelchair, I then grab (Resident #4) by her elbows and arms to place her in the chair. While during the process she was still combative. I then lost control of her arms and she fell on the right side of the bed. Her whole head went into the dresser that was on that side. I then ASAP (as soon as possible) went and got the Charge Nurse and told her she was bleeding. She went and got (Charge Nurse) the other CN and they immediately came to the room to aid her and comfort her until more help arrive..." j. On 1/30/12 at 3:11 p.m. and 4:10 p.m. and on 1/31/12 at 8:40 a.m., 10:41 a.m. and 3:33 p.m., the resident was observed with bruising of the nose and under bilateral eyes. k. On 2/1/12 at 9:00 a.m., N.A. #1 was asked to describe the incident with (Resident #4) and NA #1 stated, "On 1/20/12 I worked the third shift, 10:00 p.m. until 6:00 a.m. I came to work on 1/19/12 (at 10:00 p.m.). (Resident #4) was one of my residents. I started two and one half or three weeks ago (Hire Date-12/30/11). This was my first job as a nursing assistant. I am not certified. (Resident #4) was combative. Her behavior included swinging and smacks, hit and punched with her hands. The incident occurred about 5:45 a.m. on 1/20/12. I was attempting to get her up to take her to the dayroom. I had her dressed already. Then I laid her back down. I put the rail up. I reached and got the wheelchair. I put it on the left side of the bed at the head of the bed and moved it to the foot of the bed. I let her side rail down on the left. I got her feet first and pivoted her to a sitting position. She was combative with her hands. I placed my hands on her elbows. I did not apply a gait belt. I got her under her arms, picked her up and pivoted her. She freaked out. She startled me. She went 'no'. She threw her arms up in the air. I turned loose. I panicked and she fell forward into the bedside table. Her whole face went into the front of the bedside table. I picked her up from the floor, placed her back in bed and went and got the charge nurse." NA #1 was asked about the training he received for transferring a resident and stated, "I was taught in C.N.A. training to use a gait belt or to have help when transferring a combative resident. I was not told to use a gait belt with each resident transfer at this facility. The (closet) plan of care says transfer assist times one. It does not say to use the gait belt. I knew where the care plans are but I had never looked at one. I did not use a gait belt because I wasn't given one. I was not given a skills check list. I didn't tell the truth the first time because I was scared. I saw all the blood and it scared me. I just picked her up and laid her on her back and went and got the charge nurse. I was not given a form to sign that I received a gait belt." A certificate dated 12/21/11 documented NA #1 completed a 90-hour Nursing Assistant Training course on 12/21/11. The facility's personnel file for NA #1 documented the NA was hired by the facility on 12/31/11. l. On 2/1/12 at 9:50 a.m., C.N.A. #2 stated, "I did not have him sign any piece of paper for the gait belt I gave him." m. On 2/1/12 at 10:03 a.m., the Administrator stated and presented a written statement which documented, "When new C.N.A.'s are given their gait belts by the lead C.N.A. they are required to sign a form showing they received it." As of 2/2/12 at 11:54 a.m., the facility could not present a signed statement from N.A. #1, demonstrating receipt of a gait belt. n. On 2/2/12 at 11:55a.m., the Director of Nursing stated, "I have no documentation of skills checks on (N.A. #1). He should have completed a skills check list prior to leaving orientation. I do not know how he dealt with combative residents. I do not know if he knew to report the accident as soon as it happened. (N.A. #1) had three days of orientation on the evening shift before being assigned to nights. He was not working with a buddy system that night. I do not know about his transfer skills." The Director of Nursing was asked about inservices regarding transfers or care of the combative resident since the incident. The Director of Nursing stated, "There have not been any inservices related to transfers or caring for combative residents since the incident except for the inservice on 1/20/12 regarding the combative resident. It was presented to 20 members of our nursing staff." The inservice documentation dated 1/20/12 documented signatures by less than one half of the nursing employees of the facility.