Every finding on record at Green Acres Health and Rehabilitation

Based on observations, staff interviews, resident interviews, and record reviews, the facility failed to ensure two of three residents (R) (R55 and R69) sampled for Activity of Daily Living (ADLs) care, out of a total sample of 38, received care and services for ADLs. Specifically, the facility failed to ensure the removal of facial hair for R69 and baths and showers for R55. The deficient practice had the potential to place R55 and R69 at increased risk for unmet needs and a diminished quality of life. Findings include: 1. Review of the electronic medical record (EMR) for R69 revealed diagnoses including, but not limited to, muscle weakness, difficulty in walking, unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety Review of the Quarterly Minimum Data Set (MDS) assessment for R69, dated 7/8/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 5 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that R69 required substantial to maximal assistance with ADLs. Review of the care plan for R69 revealed a Focus area of Resident requires assistance with ADLs related to muscle weaknesses. Interventions included, but were not limited to, the resident needing assistance with ADLs as needed, bathing/showering as needed or as required, and requiring substantial to maximal assistance for personal hygiene and care. Observation on 8/12/2025 at 12:10 pm revealed R69 had a reasonable amount of thick white and black facial hair visible under her chin. Observation on 8/13/2025 at 9:14 am revealed R69 continued to have a reasonable amount of thick white and black facial hair visible under her chin. Observation on 8/14/2025 at 1:00 pm revealed R69 was sitting in a wheelchair in her room watching television, and continued to have a reasonable amount of thick white and black facial hair visible under her chin. In an interview on 8/12/2025 at 3:10 pm, a family member stated she visited R69 often. She stated she noticed R69 had facial hair, and she was sure the resident would want it removed if she was cognitively aware. In an interview on 8/14/2025 at 1:23 pm, Certified Medical Aide (CMA) EE stated staff was required to shave residents on their scheduled shower days unless they saw a need to do it immediately. In an interview on 8/14/2025 at 1:31 pm, Certified Nursing Assistant (CNA) FF revealed that she was responsible for the care of R69 more, and she had just received a bath on 8/13/2025. CNA FF confirmed that R69’s ADLs, including facial hair removal, should be done on her scheduled shower days. In an interview on 8/14/2025 at 1:50 pm, Licensed Practical Nurse (LPN) GG revealed that R69's scheduled shower days were Monday, Wednesday, and Friday on the day shift. LPN GG verified that R69 had visible facial hair on her chin and stated it needed to be removed and should have been done during her scheduled shower days. In an interview on 8/14/2025 at 2:30 pm, the Director of Nursing (DON) stated the facility did not have an ADL policy. She confirmed that R69 had visible facial hair on her chin. She revealed her expectation was for staff to provide ADL care and showers to residents as scheduled. 2. Review of the EMR for R55 revealed he was admitted to the facility with diagnoses to include Alzheimer's disease with early onset, unspecified disorientation, cognitive communication deficit, and major depressive disorder. Review of the Quarterly Minimum Data Set assessment, dated 5/10/2025, for R55 revealed Section C (Cognitive Patterns) documented a BIMS score of 4 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented the resident was dependent on staff for oral hygiene, toileting hygiene, showers/bathing, and personal hygiene. Review of the care plan for R55 revealed a “Care Area/Problem” related to self-care deficit, last reviewed and continued on 8/12/2025. The goal was for R55 to accept assistance with ADLs, and needs will be met during the next review period, last reviewed and continued on 8/12/2025. Interventions included assistance with ADLs as needed, reviewed, and continued on 8/12/2025. Review of the EMR revealed R55 resided in room [ROOM NUMBER]. Review of the “Bath Schedule” revealed room [ROOM NUMBER] (R55) was scheduled for showers on Tuesdays, Thursdays, and Saturdays. Review of the “Point of Care” data sheets, dated 7/14/2025 through 8/14/2025, revealed that out of 14 shower opportunities, R55 received six showers on 7/19/2025, 7/26/2025, 7/31/2025, 8/2/2025, 8/9/2025, and 8/14/2025. There was no documentation to indicate that R55 refused his scheduled showers during the specified time period. In an interview on 8/14/2025 at 3:30 pm, CNA AA confirmed that R55 had 14 opportunities for showers from 7/14/2025 through 8/14/2025, but only six showers were documented. CNA AA stated that if the shower was not documented, the shower did not happen. In an interview on 8/14/2025 at 3:45 pm, CNA BB stated he was not sure why showers for R55 were not documented. In an interview on 8/14/2025 at 4:20 pm, the DON stated she expected showers to be completed as scheduled or as needed, and should include nail care and grooming needs. She stated the documentation of ADL care needed to be consistent and reflect the care and services provided. She stated she was unable to determine if the showers were given during the identified period and confirmed that, without documentation, she would assume they were not.

Based on staff interviews, record review, and review of the facility's policy titled Medication Administration-General, the facility failed to ensure medications were administered as ordered by the physician to one of nine residents (R) (R20) observed for medication administration. This deficient practice had the potential to place R20 at an increased risk of adverse effects from the medication and a diminished quality of life. Findings include:Review of the facility's policy titled Medication Administration-General, review date 4/15/2025, revealed the Intent section stated, To facilitate that medications are administered as prescribed, in accordance with good nursing principles. The Guidelines section included, . Prior to medication administration, the Nurse or Certified Medication Aide (CMA): . Reads the administration directions on the MAR [medication administration record] and verifies correct medication, dose, and directions for use.Review of the Face Sheet for R20 revealed admission on [DATE]. Diagnoses included, but were not limited to, spastic diplegic cerebral palsy, anxiety disorder, essential hypertension, and muscle weakness.Review of the physician's orders for R20 revealed an order dated 5/9/2025 for amlodipine 5 milligrams (mg) tablet [a medication used to treat high blood pressure], one tablet by mouth one time per day. Hold if blood pressure (BP) is less than 110/60. Hold if systolic BP less than 110. Hold if diastolic BP less than 60. Review of the MedAid (medication aide) MAR dated 8/1/2025 to 8/14/2025 for R20 revealed amlodipine 5 mg tablet was administered on 8/3/2025, and the BP was documented as 90/67, and on 8/13/2025, and the BP was documented as 88/77.In an interview on 8/14/2025 at 4:09 pm, the Director of Nursing (DON) confirmed that the MedAid MAR for R20 documented that amlodipine 5 mg oral tablet was administered when the resident's BP was below the ordered parameters for holding the medication on 8/3/2025 and 8/13/2025. The DON stated the charge nurse should have been notified, and a follow-up should have been completed. In an interview on 8/14/2025 at 4:19 pm, Licensed Practical Nurse (LPN) CC verified that the MedAid MAR for R20 documented that amlodipine 5 mg oral tablet was administered when the resident's BP was below the ordered parameters for holding the medication on 8/3/2025 and 8/13/2025. She stated that the CMA should have notified her, she would have notified the physician, and the resident would have been monitored for changes.

Based on observation, record review and staff interview, the facility failed to provide right hand splint to prevent further contractures as recommended by the Occupational Therapist (OT) for one resident (R) (R#49). The sample was 28 residents. Findings include: Record review revealed that R#49 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed that R#49 was severely cognitively impaired, required total assistance of staff for activities of daily living (ADLs) and had limitations in range of motion (ROM) on one side of his upper and lower extremities. Review of the OT Discharge Summary dated 4/12/22 revealed that the resident had received OT services from 2/17/22 to 4/8/22 for contracture management. Continued review revealed that the resident was discharged on [DATE] to the Restorative Nursing Program/ Functional Maintenance Program for Passive Range of Motion (PROM) and application of right-hand splint and that nursing staff had received education on the application, wear schedule and precautions related to the hand splints. However, there was no indication in the medical record that R#49 received consistent restorative services or a functional maintenance program for splint application. Observations on 10/14/22 at 10:01 a.m., 10/15/22 at 8:51 a.m. and 1:44 p.m. and 10/16/22 at 10:01a.m. R#49 was lying in the bed. The resident had bilateral hand contractures but, there were no devices in place to prevent further contractures. Observation on 10/16/22 at 10:28 a.m., revealed that staff had placed rolled washcloths in the resident's left hand. The Occupational Therapist was not available an interview during this survey. Observation and interview on 4/27/18 at 12:10 p.m., revealed that the Director of Rehab Services (DRS) assessed the resident's bilateral hands and was able to extend his fingers slightly. She stated that the resident's ROM in his hands had not declined significantly since she last assessed him in January 2018 but, that he needed to be evaluated by therapy again for any needed interventions. Interview with Restorative Assistant (RA) GG on 4/27/18 at 12:26 p.m. revealed that R#22 had never received Restorative Services. Interview with Certified Nursing Assistant (CNA) HH on 4/27/18 at 12:34 p.m. revealed that she provided ROM exercises for the resident during care but, she did not apply hand splints. An interview with the Director of Nursing (DON) on 4/27/18 at 12:45 p.m. revealed that she did not know that the resident was supposed to wear bilateral hand splints. Continued interview revealed that the facility had identified a problem with the previous Director of Rehabilitation Services who failed to communicate discharge recommendations to nursing staff. During an interview on 10/16/22 at 10:01 a.m. Licensed Practical Nurse (LPN) BB stated that the facility does not have restorative aides and the CNAs on the floor are responsible for the ADL and restorative plan of care. During an interview on 10/16/22 at 10:34 a.m., CNA AA stated that she is a restorative aide and has worked in restorative for the last year. CNA AA stated that she usually puts R# 49's splint on daily, but she has not been able to locate his hand splint after his room was changed. CNA AA further stated that she tried to put a washcloth in R#49s right hand, but he would not allow her to. CNA AA told surveyor that she has not informed anyone that residents hand splint was missing. CNA AA further stated that she does not always document the restorative care provided. During an interview on 10/16/22 at 11:03 a.m. with DON revealed she was not aware that R#49 resists care or that his right-hand splint was missing. She further stated that she will make sure the resident gets a new splint. DON stated that it is her expectation that residents received the restorative plan of care as outlined by the therapist. During an interview 10/16/22 at 11:24 a.m. with Administrator revealed that it is her expectation that the restorative aides apply the splints and to performs the restorative plan of care as provided by the team.

Based on observations, record review, and staff interview, the facility failed to ensure all employees wore the required personal protective equipment (PPE) and performed hand hygiene when working in one (1) of four (4) sampled rooms for residents on contact precautions (Resident #3). The findings include: Based on observations, record review, and staff interview, the facility failed to ensure all employees wore the required personal protective equipment (PPE) when working in a room of one of four residents (Resident #3) sampled for contact precautions. This failure had the potential to affect 73 of 73 residents in the facility. The findings include: Review of Resident #3's Annual Minimum Data Set ((MDS) dated [DATE], revealed he had a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].>An observation on 09/03/20 at 9:30 AM, revealed a contact precautions sign posted outside of Resident #3's door. The sign instructed the staff they must clean their hands before entering and after leaving the room, and to put on gloves and a gown before entering the room. The resident was observed in his room in bed and Housekeeper (HK) #4 was observed in the room carrying a tray of dirty dishes with her bare hands. She was not wearing a gown or gloves. Without washing her hands, HK #4 put the tray down in the resident's room, went into the hallway, and obtained a gown from a cart. While putting on the gown, the ties dragged on the floor which she touched to tie the gown. HK #4 went back in Resident #3's room without washing her hands and/or putting on gloves, picked up a towel and clothes off the floor. The DON prompted her to leave the clothes and the food tray in the room and leave the room. HK #4 removed the gown, left the room and walked down the hall without performing hand hygiene. The Director of Nursing (DON) was present at the time of the observation and instructed HK #4 to put on a gown and gloves. The DON stated the employee should have had on a gown and gloves. Review of the facility's undated Pandemic Response Plan revealed that staff would be educated on PPE and hand hygiene. Review of the facility's in-service records revealed education on PPE and hand hygiene had been provided to the staff.

Based on record review, review of the 6/27/19 Performance Improvement Plan (PIP), staff interviews and review of the Administrator's Job Description, the facility failed to ensure that the Administrator provided oversight and monitoring of safety concerns with transfers to ensure there were no sharp objects on the beds, side rails/assist rails/rail bar to ensure the safe transfer for 59 of 81 residents that are dependent and assessed as needing assistance either by one or two staff or totally dependent for transfer and failed to ensure that all staff were educated to prevent further injury. A standard survey was conducted at Green Acres Health and Rehabilitation from 9/30/19 through 10/5/19. In addition, Complaint Intake Number GA 485, GA 878, and GA 318 were investigated in conjunction with this standard survey. The standard survey revealed that the facility was not in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B-Requirements for Long Care Facilities. The following deficiencies resulted from the facility's noncompliance related to the standard survey. In addition, the complaint investigation found GA 485 partially substantiated with deficiencies; GA 878, and GA 318 were unsubstantiated. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility 's census on 9/30/19 was 81 residents. On 10/5/19, a determination was made that a situation in which the facility 's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility 's Administrator, Interim Director of Nursing (DON), Nurse Consultant, Regional Vice President (VP) and the Company Safety and Engineering Manager for this region were informed of the immediate jeopardy on 10/5/19 at 5:07 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 6/24/19. The immediate jeopardy is outlined as follows: The facility failed to ensure safe transfer, from wheelchair to bed and failed to ensure no further hazards existing for all resident beds and failed to provide safe Activities of Daily Living (ADL) care, while in bed, by two persons, as assessed. Review of the Form CMS-672 dated 9/27/19 revealed there were 59 residents assessed as needing assistance either by one or two staff or totally dependent for transfer of 81 residents. 1. On 6/24/19, R#36 who was non-weight bearing and assessed on the 5/1/19 Quarterly Minimum Data Set (MDS) assessment as total dependence upon staff and extensive assist for transfer by two people. R#36 was being transferred from wheelchair to bed by two Certified Nursing Assistants (CNA) using stand and pivot. The resident's right leg came in contact with the assist bar which resulted in the resident receiving an avulsion laceration measuring 8 centimeters (cm) requiring both internal and external sutures to repair. The resident was also receiving [MEDICATION NAME] therapy at the time. The assist bar was removed from the resident's bed. There was no evidence that a thorough investigation as to how this accident occurred was conducted nor was there evidence that other beds and assist bars were audited to ensure that potential rough areas did not exist that could cause injury to other residents. 2. On 8/13/19, R#36 was receiving incontinent care, in bed, by one CNA, who turned the resident on her side and the resident fell out of bed. The resident was assessed on the 7/12/19 Significant Change MDS as total dependence for bed mobility by two persons and was receiving [MEDICATION NAME] therapy. The resident sustained [REDACTED]. The resident was admitted to the ICU then transferred to a larger hospital for more acute care. The resident was discharged back to the facility on [DATE]. The Immediate Jeopardy was identified on 10/5/19 and was determined to exist on 6/24/19 in the areas of 483.21(b)(iii) Care Plan Timing and Revision, F657, 42 C.F.R. 483.25(d)(2) Free of Accidents/Hazards and Supervision, F689; 42 C.F.R. 483.70 Administration, F835; §483.75(a) Quality Assurance and Performance Improvement (QAPI) activities, F867. F657 and F689 were at a Scope and Severity of J, and F835 and F867 were at a Scope and Severity of K. Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(d)(2) Free of Accidents/Hazards and Supervision, F689. At the time of exit on (MONTH) 5, 2019 an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remains ongoing. Findings include: A review of the facility Administrator Job Description revealed a summary that documented that the Administrator would direct the day-to-day functions of the Nursing Center in accordance with current Federal, State, and local regulations that govern long-term care and as may be directed by the Regional Vice-President, to provide appropriate care for the patients at the facility that included developing and maintaining written policies and guidelines that govern the operation of the center, assuming responsibility for maintenance of building, grounds and equipment and providing direction so that associates, patients, visitors, etc. follow established safety regulations to include fire protection/prevention, smoking regulations, infection control, etc. Line of Authority: The Administrator would report to the Regional Vice President of Operations. Supervisory Responsibility: Manages the Nursing facility, supervises all department supervisors and administrative staff. A review of the Quality Assurance Improvement Program Plan (QAPI) dated 6/27/19 revealed that Falls management was put into QAPI but the objective simply stated that it was completed timely. An interview on 10/4/19 at 3:56 p.m. with the Administrator, Interim Director of Nursing (DON), and Nurse Consultant GG, the Interim DON responded that the Minimum Data Set (MDS) Coordinator completed the MDS, reviewed and updated the care plan for each resident. The Interim DON revealed that the ADL care is entered into the handheld devices (used by the CNAs) are entered manually and that any nurse can update that information. The Interim DON revealed that there is not a designated person to ensure that the information in the handheld devices is up to date or correct. She confirmed that all nursing staff were responsible for entering information not a designated person. The Nurse Consultant GG confirmed that there was no policy for care plan development and revisions. She says they follow the regulations and the Resident Assessment Instrument (RAI) guidelines. The Nurse Consultant GG confirmed that there was no written process for updating the ADL handheld device system or for assessing residents for transferring. The interview revealed that currently the Assistant Director of Nursing (ADON) signed off on care plans with the MDS Coordinator. During the interview they were informed that R#36 has had three MDS assessments since non-weight bearing status was entered in documentation but the handheld device reflected that she was still able to transfer by stand and pivot maneuver. The Administrator revealed that the facility has unit managers with the title of Resident Care Coordinator (RCC) who are responsible for ensuring that care was provided to the residents on those units, rounding with the Physicians, and any follow-ups such as Physician/family follow-up. The Administrator stated that Registered Nurse (RN) KK was temporarily placed in the RCC position and they have a new RCC starting next week. She also stated that they have a new MDS nurse starting next week. The Administrator and Nurse Consultant GG were unsure as to the detail for RCCs on the electronic medical record or the handheld device used by the CNAs. Nurse Consultant GG stated that the job description for RCC was not going to be specific to include updating P[NAME] information as part of the RCC duties. They revealed that the Administrator would need to have conversation with the Therapy Department as to their role in assisting how to safely transfer residents. The Administrator revealed, at this time, that she was new to the building and was not employed when the incident occurred with R#36 traumatic injury while transferring. She was not able to provide evidence that an investigation was conducted as to how the accident occurred and that there is no evidence that the beds were checked throughout the facility until the survey team brought this to her attention nor was she able to provide evidence that CNAs were in-serviced to use two persons if a resident is assessed for extensive or total assist by two persons. The facility additionally could not provide evidence of how residents were assessed for the safest type of transfer. The current Administrator provided an email from the previous Administrator dated 10/3/19 at 9:33 a.m. which revealed that he was aware that the resident obtained a skin tear on 6/24/19 while the CNAs were transferring the resident from the wheelchair to the bed. The email further revealed that he had gone to R#36's room with the CNAs to re-enact the incident. He had the assist rail removed from the bed and educated the two CNAs on transferring residents. He felt this was an unfortunate and rare accident which was unlikely to occur again. The former Administrator revealed, in the email, that he was unable to provide any written documentation from the incident.

Based on review of Quality Assurance (QA) information the facility failed to have a Quality Assessment and Assurance (QAA) committee that effectively identified, developed, implemented, and monitored corrective action plans after R#36 received a traumatic injury, by either the bed or the assist bar, while being transferred from the wheelchair to the bed which could put 59 of 81 residents, who are dependent upon staff for transfers, at risk and after two ( R #22 and R #36), had falls from bed during Activities of Daily Living (ADL) care, by one person, resulting in injury. A standard survey was conducted at Green Acres Health and Rehabilitation from 9/30/19 through 10/5/19. In addition, Complaint Intake Number GA 485, GA 878, and GA 318 were investigated in conjunction with this standard survey. The standard survey revealed that the facility was not in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B-Requirements for Long Care Facilities. The following deficiencies resulted from the facility's noncompliance related to the standard survey. In addition, the complaint investigation found GA 485 partially substantiated with deficiencies; GA 878, and GA 318 were unsubstantiated. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility 's census on 9/30/19 was 81 residents. On 10/5/19, a determination was made that a situation in which the facility 's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility 's Administrator, Interim Director of Nursing (DON), Nurse Consultant, Regional Vice President (VP) and the Company Safety and Engineering Manager for this region were informed of the immediate jeopardy on 10/5/19 at 5:07 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 6/24/19. The immediate jeopardy is outlined as follows: The facility failed to ensure safe transfer, from wheelchair to bed and failed to ensure no further hazards existing for all resident beds and failed to provide safe Activities of Daily Living (ADL) care, while in bed, by two persons, as assessed. 1. On 6/24/19, R#36 who was non-weight bearing and assessed on the 5/1/19 Quarterly Minimum Data Set (MDS) assessment as total dependence upon staff and extensive assist for transfer by two people. R#36 was being transferred from wheelchair to bed by two Certified Nursing Assistants (CNA) using stand and pivot. The resident's right leg came in contact with the assist bar which resulted in the resident receiving an avulsion laceration measuring 8 centimeters (cm) requiring both internal and external sutures to repair. The resident was also receiving [MEDICATION NAME] therapy at the time. The assist bar was removed from the resident's bed. There was no evidence that a thorough investigation as to how this accident occurred was conducted nor was there evidence that other beds and assist bars were audited to ensure that potential rough areas did not exist that could cause injury to other residents. 2. On 8/13/19, R#36 was receiving incontinent care, in bed, by one CNA, who turned the resident on her side and the resident fell out of bed. The resident was assessed on the 7/12/19 Significant Change MDS as total dependence for bed mobility by two persons and was receiving [MEDICATION NAME] therapy. The resident sustained [REDACTED]. The resident was admitted to the ICU then transferred to a larger hospital for more acute care. The resident was discharged back to the facility on [DATE]. The Immediate Jeopardy was identified on 10/5/19 and was determined to exist on 6/24/19 in the areas of 483.21(b)(iii) Care Plan Timing and Revision, F657, 42 C.F.R. 483.25(d)(2) Free of Accidents/Hazards and Supervision, F689; 42 C.F.R. 483.70 Administration, F835; §483.75(a) Quality Assurance and Performance Improvement (QAPI) activities, F867. F657 and F689 were at a Scope and Severity of J, and F835 and F867 were at a Scope and Severity of [MI] Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(d)(2) Free of Accidents/Hazards and Supervision, F689. At the time of exit on (MONTH) 5, 2019 an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remains ongoing. Findings include: Record review of the Quality Assurance Improvement Program Plan (QAPI) dated 6/27/19 revealed that Falls management was put into QAPI but the objective simply indicated that it was completed timely. There were no goals indicated during this record review. The QAPI did not identify problems with education to staff related to falls and ADL care to residents. QAPI also did not develop a plan to identify and correct environmental concerns regarding the incident involving R#36 on 6/24/19. QAPI did not identify, develop a plan and educate staff related to fall prevention during ADL care nor that the fall lacked policies and procedures for care plans, transfers or ADL care or for assessing the residents for safe transfers. An interview on 10/4/19 at 4:30 p.m. with the Administrator and Interim DON revealed that they have been working on many things including falls. The Administrator provided a copy of the Performance Improvement Projects (PIP) list that included Falls Management but couldn't provide any written documentation as to what was being done on an ongoing basis. The Administrator further stated that she had other fires that needed to be addressed such as staffing replacements for the Resident Care Coordinator (RCC), Social Service Director (SSD) and an additional MDS staff person that was starting work on Monday, 10/7/19. The Administrator revealed she was aware there were issues with care plans but not to the extent that was brought forward by the survey team. The Administrator could not provide any forms and/or Policies and Procedures related to the Fall Management program. The Administrator confirmed that bed safety was not placed into QAPI after R#36 received a traumatic injury during transfer from wheelchair to bed. The Administrator further confirmed that a thorough investigation into the cause of the traumatic injury to R#36 during transfer was not conducted, which occurred prior to her employment at the facility. The Administrator provided an email from the previous Administrator dated 10/3/19 at 9:33 a.m. which revealed that he was aware that the resident obtained a skin tear on 6/24/19 while the CNAs were transferring the resident from the wheelchair to the bed. The email further revealed that he had gone to R#36's room with the CNAs to re-enact the incident. He had the assist rail removed from the bed and educated the two CNAs on transferring residents. He felt this was an unfortunate and rare accident which was unlikely to occur again. The former Administrator revealed, in the email, that he was unable to provide any written documentation from the incident. An interview on 10/4/19 at 6:35 p.m. with the Maintenance Supervisor revealed there was no documentation of audits being done immediately of beds in the facility after the incident with R#36 on 6/24/19 to identify rough edges. Although a record review of the PIP list revealed Fall Management in place as of 6/27/19, CNA education was not provided until 8/19/19 after R#22 and R#36 had already been injured from falls, from the bed, during ADL care. The PIP reflects that the RCC and DON are responsible for Fall Management.

Based on record review and staff interviews the facility failed to revise the comprehensive care plans for two residents (R) (R#36 and R#22) according to their Minimum Data Set (MDS) assessments of 36 sampled residents. Both R#36 and R#22 were assessed as needing two persons assist with Activities of Daily Living (ADL). Both residents were provided Activities of Daily Living (ADL) care related to toileting by one Certified Nursing Assistant (CNA) resulting in injuries. R#36 fell out of the bed suffering a [MEDICAL CONDITION] that required sutures and a broken left tibia. R#22 fell out of bed suffering a laceration across the bridge of his nose which required no sutures. A standard survey was conducted at Green Acres Health and Rehabilitation from 9/30/19 through 10/5/19. In addition, Complaint Intake Number GA 485, GA 878, and GA 318 were investigated in conjunction with this standard survey. The standard survey revealed that the facility was not in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B-Requirements for Long Care Facilities. The following deficiencies resulted from the facility's noncompliance related to the standard survey. In addition, the complaint investigation found GA 485 partially substantiated with deficiencies; GA 878, and GA 318 were unsubstantiated. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility 's census on 9/30/19 was 81 residents. On 10/5/19, a determination was made that a situation in which the facility 's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility 's Administrator, Interim Director of Nursing (DON), Nurse Consultant, Regional Vice President (VP) and the Company Safety and Engineering Manager for this region were informed of the immediate jeopardy on 10/5/19 at 5:07 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 6/24/19. The immediate jeopardy is outlined as follows: The facility failed to ensure safe transfer, from wheelchair to bed and failed to ensure no further hazards existing for all resident beds and failed to provide safe Activities of Daily Living (ADL) care, while in bed, by two persons, as assessed. Review of the Form CMS-672 dated 9/27/19 revealed there were 59 residents assessed as needing assistance either by one or two staff or totally dependent for transfer of 81 residents. 1. On 6/24/19, R#36 who was non-weight bearing and assessed on the 5/1/19 Quarterly Minimum Data Set (MDS) assessment as total dependence upon staff and extensive assist for transfer by two people. R#36 was being transferred from wheelchair to bed by two Certified Nursing Assistants (CNA) using stand and pivot. The resident's right leg came in contact with the assist bar which resulted in the resident receiving an avulsion laceration measuring 8 centimeters (cm) requiring both internal and external sutures to repair. The resident was also receiving [MEDICATION NAME] therapy at the time. The assist bar was removed from the resident's bed. There was no evidence that a thorough investigation as to how this accident occurred was conducted nor was there evidence that other beds and assist bars were audited to ensure that potential rough areas did not exist that could cause injury to other residents. 2. On 8/13/19, R#36 was receiving incontinent care, in bed, by one CNA, who turned the resident on her side and the resident fell out of bed. The resident was assessed on the 7/12/19 Significant Change MDS as total dependence for bed mobility by two persons and was receiving [MEDICATION NAME] therapy. The resident sustained [REDACTED]. The resident was admitted to the ICU then transferred to a larger hospital for more acute care. The resident was discharged back to the facility on [DATE]. The Immediate Jeopardy was identified on 10/5/19 and was determined to exist on 6/24/19 in the areas of 483.21(b)(iii) Care Plan Timing and Revision, F657, 42 C.F.R. 483.25(d)(2) Free of Accidents/Hazards and Supervision, F689; 42 C.F.R. 483.70 Administration, F835; §483.75(a) Quality Assurance and Performance Improvement (QAPI) activities, F867. F657 and F689 were at a Scope and Severity of J, and F835 and F867 were at a Scope and Severity of K. Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(d)(2) Free of Accidents/Hazards and Supervision, F689. At the time of exit on (MONTH) 5, 2019 an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remains ongoing. Findings include: 1. Record review revealed that R#36 was admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed for Functional Status, the resident was assessed for extensive assistance by two persons for bed mobility, transfer, and toilet use. Review of the Significant Change MDS assessment dated [DATE] revealed for Functional Status the resident was totally dependent, with two person assist, for bed mobility, transfer, dressing, toilet use and personal hygiene. Review of the Quarterly MDS assessment dated [DATE] revealed the resident was incontinent and totally dependent, requiring the assistance of two persons for ADL care including toileting, bed mobility, and personal hygiene. The resident is currently under Hospice care. Review of the resident's care plan related to ADL care: Dependent for ADL care related to impaired cognition, impaired mobility, and [MEDICAL CONDITION]. History of left femur fracture and impaired Range of Motion (ROM)-Unable to perform ADL's related to weakness/decreased endurance, impaired mental status. Which was updated on 8/13/19. Interventions: Assist with ADLs as needed, updated 2/1/18, assist devices as needed, updated 2/1/18, educate caregiver how to provide assistance with ADL needs, updated 7/3/18. Fall risk, Non-weight bearing updated 3/11/19. Interventions: Assist resident with ADLs as needed, updated 9/12/18, Non-skid strips to floor beside bed, updated 3/16/19, Non-skid socks, updated 2/1/18, wheelchair, updated 3/16/18. Range of Motion: Limited joint mobility interferes with bed mobility, dressing, hygiene, walking, and transferring updated 3/11/19. Interventions: Assist with ADLs as needed, updated 12/11/18, Turn and reposition frequently to maintain proper body alignment, updated 12/11/18. Care plan for at risk for complications related to irregular heart rate ([MEDICAL CONDITION] (AFib): Obtain PT ([MEDICATION NAME]) and INR (international normalized ratio) (a test for blood clotting time) as ordered, updated 3/16/19. Care plan for Risk of abnormal bleeding due to anticoagulant therapy, updated 7/3/18. Record review of an Event-Initial Note revealed that on 6/24/19 at 2:30 p.m. the resident was being transferred to bed, from the wheelchair by two Certified Nursing Assistants (CNAs) when the resident hit right lower leg on bed rail during assist resulting in a traumatic injury to the right lateral leg. Pressure was applied to the injury and dressing was applied by the treatment nurse. Orders were obtained to send resident to hospital per the Nurse Practitioner for acute care. Review of the local hospital records dated 6/24/19 revealed the resident sustained [REDACTED]. Bleeding was controlled. The resident is currently on [MEDICATION NAME] for [MEDICAL CONDITION] Fibrillation. Description of the wound: painful right, lateral avulsion (a partial or complete tearing away of skin and tissue beneath) laceration of calf, 8 centimeters (cm) long, irregular, flap, stellate (laceration caused by [MEDICATION NAME] trauma). The wound required 19 sutures and five deep layer sutures to repair. Pressure dressing was applied. The resident was returned to the nursing home. An interview with CNA BB on 10/3/19 at 1:53 p.m. revealed that she was assisting CNA AA on 6/24/19 to put the resident to bed from the wheelchair. She revealed that the resident's leg got caught on rail; on something that looked like a push button locking pin sticking out of the handrail. An interview with CNA AA on 10/3/19 at 2:03 p.m. revealed on 6/24/19 she and CNA BB were putting the resident back to bed after lunch and the resident's leg hit something on the bed, the assist bar, which had a rough edge. CNA AA revealed that the resident could stand enough at that time to stand and pivot. They did not know the resident's leg was cut until sitting her on the side of the bed, and then noticed a large pool of blood on the floor. One CNA went to get the wound nurse and one stayed with the resident. CNA AA says the assist bar was immediately removed from the bed. CNA AA revealed that the handheld device used by the CNAs to determine ADL care for residents only said for a two person assist and did not specify if a mechanical lift should be used. An interview on 10/03/19 at 3:15 p.m. with the Administrator, revealed that she was new to the facility and was not the Administrator when the injury to R#36 occurred. She further revealed that nursing and therapy evaluate the residents for their ability to transfer. She stated that all new residents are evaluated for ability to transfer by therapy although thereafter therapy is not involved in assessing a resident's ability to transfer unless the resident is currently receiving therapy. She also revealed being aware that the care plans were not being updated as required. The Administrator revealed that the facility did not have a policy regarding care plans, transfers or an evaluation process for transfers. Further interview with the Administrator revealed that there is no written evidence of an investigation as to what had occurred or caused R#36 injury on the bed. The Administrator provided an email from the previous Administrator dated 10/3/19 at 9:33 a.m. which revealed that he was aware that the resident obtained a skin tear on 6/24/19 while the CNAs were transferring the resident from the wheelchair to the bed. The email further revealed that he had gone to R#36's room with the CNAs to re-enact the incident. He had the assist rail removed from the bed and educated the two CNAs on transferring residents. He felt this was an unfortunate and rare accident which was unlikely to occur again. The former Administrator revealed, in the email, that he was unable to provide any written documentation from the incident. During an interview on 10/04/19 at 2:18 p.m. with the Minimum Data Set (MDS) Coordinator she confirmed the care plan has not been correctly updated for R#36 for transfers or ADL care. The MDS Coordinator revealed further she doesn't always review the care plan and she doesn't look at the care plan when MDS assessments are due. She explained when coding the MDS section G (functional status of residents) she gets the information from the ADL Plan of Care (P[NAME] the CNA handheld device) during that look back period. 2. A record review of the statement dated 8/13/19 by CNA AA revealed while alone, she was providing incontinent care to R#36. She further revealed that she was holding on to the resident with her right hand when she reached for some wipes and the resident rolled off the bed. Review of the Significant Change MDS assessment dated [DATE] revealed for Functional Status the resident was totally dependent, with two person assist, for bed mobility, transfer, dressing, toilet use and personal hygiene. Review of the care plan revealed resident is dependent for ADL care related to impaired cognition, impaired mobility, and [MEDICAL CONDITION]. She has a history of left femur fracture and impaired range of motion (ROM)-Unable to perform ADL's related to (r/t) weakness/decreased endurance, impaired mental status. Interventions: Assist with ADLs as needed (updated 2/1/18). Review of the Falls care plan revealed an intervention for ADL care by two assist that was updated after the resident's fall from bed (updated on 8/19/19). Review of the local hospital Trauma History and Physical report dated 8/13/19 revealed that the resident, per a CT (computerized tomography) scan, had an acute IPH (intraparenchymal hemorrhage-bleeding inside the brain) in the right temporoparietal region measuring 3.6 by (X) 2.5 centimeters (cm), a right [MEDICAL CONDITION] of 4 cm required suture repair, right periorbital [MEDICAL CONDITION] with conjunctival hemorrhage and left knee/ankle bruising. Resident is transferred to another hospital for a higher level of care due to her head injury. Review of the larger hospital records dated 8/13/19 at 2112 (military time) (9:12 p.m.) revealed the resident was admitted to the Trauma ICU with the following Diagnoses: [REDACTED]. Neurosurgery following, [MEDICAL CONDITION], closed left tibial fracture, Camboot in place, dementia, and [MEDICAL CONDITION] stage II. Review of the CT head without contrast at 16:18 (4:18 p.m.) revealed impression: Acute IPH in right temporoparietal region measuring 3.6 X 2.5 cm. No subdural or [MEDICATION NAME] component noted. Review of left tibia x-ray results dated 8/13/19 at 10:18 p.m. revealed: The bones are diffusely osteopenic, non-displaced oblique or spiral fracture through the distal tibial diaphysis. Impression: suspicious for an acute non-displaced oblique or spiral fracture through the distal shaft of the tibia. Very mild associated soft tissue swelling. Review of the hospital discharge summary dated 8/17/19 revealed the resident was discharged back to the Nursing Home at 14:14 (2:14 p.m.) with the following [DIAGNOSES REDACTED]. Closed left tibial fracture, fracture boot in place, dementia, and [MEDICAL CONDITION] stage II. An interview on 10/03/19 at 2:06 p.m. with CNA AA revealed that on 8/13/19 she was by herself providing incontinent care to R#36. She described R#36 as facing the window on her left side while lying in bed. CNA AA further revealed, she just slid out of my hands when I reached to get the wipes. Cross reference to F689 3. R#22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] and the Quarterly MDS dated [DATE] revealed that R#22 was assessed for Functional Status to require extensive assistance with two-person physical assistance with activities of daily living (ADLs) to include bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the resident's fall care plan revealed the resident had a fall without injury on 3/14/19 with interventions to assist patient with ADLs as needed (updated 9/10/18). Care area: requires assistance with ADL's related to (r/t) impaired mobility/balance, medication regimen, history of motor vehicle accident (MVA) with multiple fractures (updated 10/5/19). Interventions: encourage patient to complete as much self-care as possible independently or with minimal assist. The care plan does not indicate a need for two person assist with ADL care. Review of an Event - Initial Note dated 8/8/19 at 4:30 p.m. revealed R#22 experienced a fall while receiving ADL care from one CN[NAME] The report documented that the resident was being checked and changed with one CNA at the bedside with the resident. It further documented that as second CNA approached the side of the bed, to assist the first CNA, R#22 reached over to grab the drawer of the nightstand and rolled over onto the floor. The result of this fall resulted in laceration to bridge of nose and cut above the left side of the lip. Review of a Nurse Note dated 8/8/19 revealed a laceration to the bridge of nosed which was cleaned with normal saline, silicone contact-based layer applied and covered with dry dressing. The Physician was notified, satisfied with dressing in place. An interview on 10/3/19 at 11:17 a.m. with the Director of Nursing (DON) revealed that her expectation is for ADLs to be provided as indicated on the MDS assessment. She further explained that what is indicated on the MDS assessment should match what is on the resident's plan of care (handheld device for the CNAs). During an interview on 10/4/19 at 2:24 p.m. with MDS Coordinator who confirmed that she has not been updating the care plans as she should. The MDS coordinator reported that ideally the best time to update care plans is when assessments are completed. She revealed that as the only MDS Coordinator she has not been able to update care plans. A post survey telephone interview on 10/5/19 at 7:17 p.m. with the Administrator and Nurse Consultant MM revealed that the Corporation did not feel that the MDS assessment and the care plan had to match since the MDS assessment is only for a 7 day look back period. Cross refer to F689

Based on record review and staff interview the facility failed to maintain the safety of and provide adequate supervision for two residents (R) (R#36 and R#22) during direct care for Activities of Daily Living (ADL) and to ensure safe transfer for R#36. R#36 suffered an eight-centimeter (cm) avulsion laceration to her right lower leg, requiring sutures, while being transferred to bed from her wheelchair on 6/24/19 and on 8/13/19 fell from the bed while being provided incontinent care by one Certified Nursing Assistant (CNA) and suffered a laceration above her eye brow requiring sutures and a fracture to the left tibia. R#22 fell from the bed during ADL care by one CNA suffering a laceration to the bridge of his nose which did not require emergency treatment. A standard survey was conducted at Green Acres Health and Rehabilitation from 9/30/19 through 10/5/19. In addition, Complaint Intake Number GA 485, GA 878, and GA 318 were investigated in conjunction with this standard survey. The standard survey revealed that the facility was not in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B-Requirements for Long Care Facilities. The following deficiencies resulted from the facility's noncompliance related to the standard survey. In addition, the complaint investigation found GA 485 partially substantiated with deficiencies; GA 878, and GA 318 were unsubstantiated. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility 's census on 9/30/19 was 81 residents. On 10/5/19, a determination was made that a situation in which the facility 's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility 's Administrator, Interim Director of Nursing (DON), Nurse Consultant, Regional Vice President (VP) and the Company Safety and Engineering Manager for this region were informed of the immediate jeopardy on 10/5/19 at 5:07 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 6/24/19. The immediate jeopardy is outlined as follows: The facility failed to ensure safe transfer, from wheelchair to bed and failed to ensure no further hazards existing for all resident beds and failed to provide safe Activities of Daily Living (ADL) care, while in bed, by two persons, as assessed. Review of the Form CMS-672 dated 9/27/19 revealed there were 59 residents assessed as needing assistance either by one or two staff or totally dependent for transfer of 81 residents. 1. On 6/24/19, R#36 who was non-weight bearing and assessed on the 5/1/19 Quarterly Minimum Data Set (MDS) assessment as total dependence upon staff and extensive assist for transfer by two people. R#36 was being transferred from wheelchair to bed by two Certified Nursing Assistants (CNA) using stand and pivot. The resident's right leg came in contact with the assist bar which resulted in the resident receiving an avulsion laceration measuring 8 centimeters (cm) requiring both internal and external sutures to repair. The resident was also receiving [MEDICATION NAME] therapy at the time. The assist bar was removed from the resident's bed. There was no evidence that a thorough investigation as to how this accident occurred was conducted nor was there evidence that other beds and assist bars were audited to ensure that potential rough areas did not exist that could cause injury to other residents. 2. On 8/13/19, R#36 was receiving incontinent care, in bed, by one CNA, who turned the resident on her side and the resident fell out of bed. The resident was assessed on the 7/12/19 Significant Change MDS as total dependence for bed mobility by two persons and was receiving [MEDICATION NAME] therapy. The resident sustained [REDACTED]. The resident was admitted to the ICU then transferred to a larger hospital for more acute care. The resident was discharged back to the facility on [DATE]. The Immediate Jeopardy was identified on 10/5/19 and was determined to exist on 6/24/19 in the areas of 483.21(b)(iii) Care Plan Timing and Revision, F657, 42 C.F.R. 483.25(d)(2) Free of Accidents/Hazards and Supervision, F689; 42 C.F.R. 483.70 Administration, F835; §483.75(a) Quality Assurance and Performance Improvement (QAPI) activities, F867. F657 and F689 were at a Scope and Severity of J, and F835 and F867 were at a Scope and Severity of K. Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(d)(2) Free of Accidents/Hazards and Supervision, F689. At the time of exit on (MONTH) 5, 2019 an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remains ongoing. Findings include: 1. Record reviews revealed R#36 was admitted to the facility on [DATE] and had the following Diagnosis: [REDACTED]. A review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) of 8, indicating she was moderately cognitively impaired, required a two person assist for transfers and toileting. A review of the care plan for R#36 revealed the following Care Area/Problem: At risk for falls related to impaired balance during transitions, impaired mobility, impaired vision and medication regimen, incontinence, poor judgmental skills. She has a history of falls. (9/12/18: Updated), Fall score of 7 - 18 = high risk (9/12/18: Onset), Weight bearing status: non-weight bearing (3/19/19: Onset) Record review of an Event-Initial Note revealed that on 6/24/19 at 2:30 p.m. the resident was being transferred to bed, from the wheelchair by the stand and pivot method by two Certified Nursing Assistants (CNAs). The resident's right leg was hit either by the side rail (assist bar) or the bed, causing a severe laceration. The wound nurse assessed the wound, contacted the Nurse Practitioner who ordered to send the resident to the hospital. A Nurses Note dated 6/24/19 at 2:58 p.m. revealed that LPN JJ (wound nurse) was called to the room by CN[NAME] Resident noted with traumatic injury to right lateral leg 10 cm length by 5 cm depth, 6 cm wound depth. Muscle and adipose tissue exposed. Large amount of blood loss noted from wound. Area cleaned with normal saline, moistened 4X4s gauze placed inside of wound, optilock dressing applied, stretch gauze and tape. On call Nurse Practitioner notified by charge nurse, orders given to send to name (local hospital) emergency room , Resident's family notified. Review of the local hospital records dated 6/24/19 revealed the resident sustained [REDACTED]. Bleeding was controlled. The resident is currently on [MEDICATION NAME] for [MEDICAL CONDITION]. Description of the wound: painful right, lateral avulsion (a partial or complete tearing away of skin and tissue beneath) laceration of calf, 8 centimeters (cm) long, irregular, flap, stellate (laceration caused by [MEDICATION NAME] trauma). The wound required 19 sutures and 5 deep layer sutures to repair. Pressure dressing was applied. Follow-up with facility provider. Suture removal in 10 - 14 days. Antibiotics as prescribed. The resident was returned to the nursing home. A facility nursing note dated 6/25/19 revealed the right leg was noted with sutures and a small amount of blood noted on bandage. Remove sutures in 14 days. A record review of the facilities Physicians Progress Note dated 6/27/19 revealed the following: 1. Chief Complaint/Nature of Presenting Problem: The patient is being seen following recent emergency room (ER) visit due to injury to right lateral leg. 2. History of Present Illness: Patient sustained injury to her right lateral leg requiring sutures. The patient was seen and evaluated in the ER and returned with [MEDICATION NAME] Keflex (antibiotic) 500 milligrams (mg) every six hours for seven days. Review of a Nurses Note dated 7/1/19 at 7:50 a.m. by the Assistant Director of Nursing (ADON) revealed the black plastic piece that was on the right side of resident's bed on which her right leg was accidentally bumped causing a traumatic injury was removed. This was part of the intervention to prevent further injury, family aware. Review of In-Service Attendance Sign in sheet dated 4/5/19 through 4/9/19: Topic: Transfer training, Goal: For all CNA's to be able to provide safe patient transfer using the appropriate lift. This is to prevent falls; and maintain patient safety. Review our policy and procedures, with 17 CNA signatures. Attached was how to use a sit to stand lift. A telephone interview with the Responsible Party of R#36 on 10/2/19 from 3:57 p.m. revealed that he was told his mother was hurt while being transferred from her wheelchair to the bed. He was informed that the wheelchair caused the traumatic laceration to her leg. Continued interview revealed that he had been told in the emergency room that the traumatic laceration had been caused by a sharp object on the wheelchair. He had left the hospital and went straight to the nursing home to get more information on how this major laceration had occurred. He personally inspected the wheelchair and found no sharp objects which could have caused the laceration. The room had been completely cleaned and no blood could be found in the room, wheelchair or the bed. He was told later that the laceration had been caused by a sharp object on the bed and that the sharp object had been removed from her bed. The facility could not explain how or why the laceration had happened. He further revealed that the facility informed him that R#36 fell from bed on 8/14/19 when a CNA was providing care from the bed. He revealed that at this time the resident was declining and required total care, including eating, but that the care plan had not been updated to reflect her needs. An interview with CNA BB on 10/3/19 at 1:53 p.m. revealed that she was assisting CNA AA on 6/24/19 to put the resident to bed from the wheelchair. She revealed that the resident's leg got caught on the rail; on something that looked like a push button locking pin sticking out of the handrail. An interview with CNA AA on 10/3/19 at 2:03 p.m. revealed that on 6/24/19 she and CNA BB were putting the resident back to bed after lunch and the resident's leg hit something on the bed, the assist bar, which had a rough edge. CNA AA revealed that the resident could stand enough at that time to stand and pivot. They did not know the resident's leg was cut until sitting her on the side of the bed, and then noticed a large pool of blood on the floor. One CNA went to get the wound nurse and one stayed with the resident. CNA AA says the assist bar was immediately removed from the bed. CNA AA revealed that the handheld device used by the CNAs to determine ADL care for residents only said for a two person assist and did not specify if a mechanical lift should be used. An interview on 10/03/19 at 3:15 p.m. with the Administrator, revealed that she was new to the facility and was not the Administrator when the injury to R#36 occurred. She further revealed that nursing and therapy evaluate the residents for their ability to transfer. She stated that all new residents are evaluated for ability to transfer by therapy although thereafter therapy is not involved in assessing a resident's ability to transfer unless the resident is currently receiving therapy. She also revealed being aware that the care plans were not being updated as required. The Administrator revealed that the facility did not have a policy regarding care plans, transfers or ADL care. The Administrator confirmed that she could find no evidence that the cause of R#36 traumatic laceration on 6/24/19 was investigated and could not confirm exactly what part of the bed or rail caused the laceration. The Administrator provided an email from the previous Administrator dated 10/3/19 at 9:33 a.m. which revealed that he was aware that the resident obtained a skin tear on 6/24/19 while the CNAs were transferring the resident from the wheelchair to the bed. The email further revealed that he had gone to R#36's room with the CNAs to re-enact the incident. He had the assist rail removed from the bed and educated the two CNAs on transferring residents. He felt this was an unfortunate and rare accident which was unlikely to occur again. The former Administrator revealed, in the email, that he was unable to provide any written documentation from the incident. An interview on 10/03/19 at 3:17 p.m. with the Interim Director of Nursing (DON) revealed that if nursing identifies a change of condition in a resident that affects their ability to transfer, therapy is then consulted, and they evaluate the resident. The interim DON revealed that the facility does not have a policy for transferring residents. An interview on 10/03/19 at 4:17 p.m. with the Maintenance Supervisor revealed that the facility utilizes an Equipment Lifecycle System (TELS) has a checklist of things that are to be inspected for electric beds and manual beds. Review of the check list, that was provided, revealed that the checklist was last completed on 6/21/19 although the checklist does not list specific rooms that were checked. The Maintenance Supervisors revealed that specifics for the bed of R#36 were not available. He further revealed that he was on vacation when the incident with R#36 occurred. The Maintenance Supervisor revealed that he was not aware of what happened to assist rail and bar once it was removed. He revealed that he could not find it in the building. During an interview on 10/04/19 at 2:18 p.m. with the MDS Coordinator she revealed that the floor nurses perform the assessments therefore she was unaware of R#36's weight bearing status. She further stated that when she has three or four full MDS assessments due she doesn't have time to review the care plans. She explained when coding the MDS section G (functional status of residents) she gets the information from the ADL Plan of Care (CNA handheld device) during that look back period. An interview on 10/4/19 at 6:35 p.m. the Maintenance Supervisor confirmed that there was no documentation of audits being done of all beds in the facility to identify rough and/or jagged edges after the incident on 6/24/19 with R#36. Although the CNA's stated that R#36 was assisted by them both to stand and maneuver to the bed she had been assessed and care plan interventions had been added that R#36 was non-weight bearing status. Furthermore, the 6/24/19 incident revealed that R#36 hit her leg on a hand assist bar with a rough edge that was immediately removed from her bed, the facility failed to assess other beds at that time to prevent any additional traumatic injuries. 2. A record review of the statement dated 8/13/19 by CNA AA revealed while alone, she was providing incontinent care to R#36. She further revealed that she was holding on to the resident with her right hand when she reached for some wipes and the resident rolled off the bed. Review of the Significant Change MDS assessment dated [DATE] revealed for Functional Status the resident was totally dependent, with two person assist, for bed mobility, transfer, dressing, toilet use and personal hygiene. Review of the care plan revealed resident is dependent for ADL care related to impaired cognition, impaired mobility, and [MEDICAL CONDITION]. She has a history of left femur fracture and impaired range of motion (ROM)-Unable to perform ADL's related to (r/t) weakness/decreased endurance, impaired mental status. Interventions: Assist with ADLs as needed (updated 2/1/18). Review of the Falls care plan revealed an intervention for ADL care by two assist that was updated after the resident's fall from bed (updated on 8/19/19). Review of the local hospital Trauma History and Physical report dated 8/13/19 revealed that the resident, per a CT (computerized tomography) scan, had an acute IPH (intraparenchymal hemorrhage-bleeding inside the brain) in the right temporoparietal region measuring 3.6 by (X) 2.5 centimeters (cm), a right [MEDICAL CONDITION] of 4 cm required suture repair, right periorbital [MEDICAL CONDITION] with conjunctival hemorrhage and left knee/ankle bruising. Resident is transferred to another hospital for a higher level of care due to her head injury. Review of the larger hospital records dated 8/13/19 at 2112 (military time) (9:12 pm) revealed the resident was admitted to the Trauma ICU with the following Diagnoses: [REDACTED]. neurosurgery following, [MEDICAL CONDITION], closed left tibial fracture, Camboot in place, dementia, and [MEDICAL CONDITION] stage II. Review of the CT head without contrast at 16:18 (4:18 p.m.) revealed impression: Acute IPH in right temporoparietal region measuring 3.6 X 2.5 cm. No subdural or [MEDICATION NAME] component noted. Review of left tibia x-ray results dated 8/13/19 at 10:18 p.m. revealed: The bones are diffusely osteopenic, non-displaced oblique or spiral fracture through the distal tibial diaphysis. Impression: suspicious for an acute non-displaced oblique or spiral fracture through the distal shaft of the tibia. Very mild associated soft tissue swelling. Review of the hospital discharge summary dated 8/17/19 revealed the resident was discharged back to the Nursing Home at 14:14 (2:14 p.m.) with the following [DIAGNOSES REDACTED]. Closed left tibial fracture, fracture boot in place, dementia, and [MEDICAL CONDITION] stage II. An interview on 10/03/19 at 2:06 p.m. with CNA AA revealed that on 8/13/19 she was by herself providing incontinent care to R#36. She described R#36 as facing the window on her left side while lying in bed. CNA AA further revealed, she just slid out of my hands when I reached to get the wipes. 3. Record review revealed that R# 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed the resident was not assessed with [REDACTED]. The resident was identified to require extensive assistance with two-person physical assistance with activities of daily living (ADLs) to include bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of an Event - Initial Note dated 8/8/19 at 4:30 p.m. revealed R#22 experienced a fall while receiving ADL care from one Certified Nursing Assistant (CNA). The report documented that the resident was being checked and changed with one CNA at the bedside. It further documented that as the second CNA, entered the room, approached the side of the bed as the resident grabbed the drawer of the nightstand and rolled over onto the floor. The fall resulted in a laceration to bridge of nose and cut above the left side of the lip which did not require emergency services. The intervention that was added after the fall included educating CNA staff on positioning resident in middle of the bed and using two-person assist when providing care. Review of nurse noted dated 8/8/19 revealed laceration to bridge of nosed cleaned with normal saline, silicone contact-based layer applied and covered with dry dressing. The Physician was notified, satisfied with dressing in place. Interview was conducted on 10/5/19 at 10:05 a.m. with the Director of Nursing (DON) who reported that she has not been able to find evidence of an investigation after Resident # 22 fell from bed while receiving care. An interview on 10/5/19 at 10:25 a.m. with Nurse Consultant GG who provided a copy of an in-service dated 8/16/19 on how to provide care to residents which included that all staff should have residents' personal items within staff's reach while providing care. Direct care staff should carry with them small trash bags that should be placed on residents' (sic) bed to put in soiled/dirty linen and personal clothing while providing care. No briefs or clothing items should be thrown on the floor during care. She also reported the nurse on duty, at the time of the fall, provided verbal education to the CNAs involved not to begin care until two staff members were on each side of the bed. The facility could not provide policies or procedures for transfers or ADL care. A telephone interview was conducted on 10/05/19 at 10:49 a.m. with CNA SS who confirmed that she was present when R#22 fell on [DATE]. CNA SS further revealed that CNA TT was already in the room with R#22 and had him turned on his side when she entered the room. CNA SS reported that R#22 had fallen out of the bed by the time she made it to the foot of the bed. CNA SS reported that they always use two-person assistance when changing R#22. CNA SS reported that the she and CNA TT received education from the nurse to use two persons when assisting R#22 and to always assure that he is positioned in the center of the bed. A telephone interview was conducted on 10/5/19 at 11:03 a.m. with CNA TT who confirmed being in the room with R#22 at time of fall on 8/8/19. CNA TT reported that R#22 was lying in bed on his side and he began reaching for something that was on the floor. CNA TT reported that when CNA SS walked into the room R#22 began falling to the floor before CNA SS could get to the side of the bed. CNA TT acknowledged that R#22 requires two-person physical assistance and she began providing care before another CNA came into the room to aid with the care. CNA TT reported that after the incident the nurse on duty explained that care should not take place until CNAs are on both sides of the bed and resident should be positioned in the center of the bed. CNA TT denies that she has received any other in-service or education related to the specific care of R#22 but has received in-services on how to care for residents. A telephone interview was conducted on 10/5/19 at 5:49 p.m. with Licensed Practical Nurse (LPN) UU who revealed that CNA TT reported that R#22 was being changed when he rolled out of bed. LPN UU reported that she believes that both CNAs were in the room at the time of the fall, but CNA SS had just entered the room. LPN UU reported that she talked to both CNAs after the fall about positioning resident in center of bed and to make sure that two-person care was done with him. She reported that R#22 received a cut to the bridge of his nose that was treated, in the facility, after the fall.

Based on record review and staff interviews the facility failed to provide the Ombudsman with notification of transfer to the hospital for two residents of three residents (R) #47 and #72. Findings include: 1. Review of the Resident Census History for R#47 revealed hospital transfers on 7/20/19, 9/8/19, and 9/15/19. Review of the medical record revealed there was no evidence that the Ombudsman was not notified of resident's discharge to the hospital. 2. Review of the Resident Census History for R#72 revealed hospital transfers on 5/26/19 and 8/17/19. Review of the medical record revealed there was no evidence that the Ombudsman was not notified of resident's discharge to the hospital. An interview was conducted on 10/3/19 at 1:57 p.m. with the Social Services Director (SSD) who reported that she was not aware of who was responsible for notifying the Ombudsman when residents discharge. SSD confirmed that she has not notified the Ombudsman of any discharges since she began working on 8/27/19. An interview conducted on 10/3/19 at 3:10 p.m. with the Admissions Director revealed that she was not aware of the requirement to notify the Ombudsman of transfers or discharges. She reported that it was her understanding that the Ombudsman was only to be notified if there was a discharge against medical advice (AMA) or a facility-initiated discharge. An interview on 10/3/19 at 4:20 p.m. with the facility Administrator, revealed that the facility has not notified the Ombudsman of discharges as their understanding was notification was only needed for those leaving AMA and facility-initiated discharges.

Based on record review, resident and staff interviews, and review of the facility Policy titled, Bed Hold Policy the facility failed to ensure that two of three residents, residents (R) (R#47, R#72) were made aware of the facility's bed-hold policy before and upon transfer to a hospital. Findings include: 1. Review of medical record for R#47 revealed the resident was transferred from the facility to the hospital on the following days 7/20/19, 9/8/19, and 9/15/19. Review of the medical record for these hospitalization s did not revealed that a bed hold notice was provided to R#47. An interview with Resident #47, with a Brief Interview for Mental Status of 15 on the Admission Minimum Data Set ((MDS) dated [DATE], on 10/3/19 at 1:00 p.m. the resident denied receiving any type of notification or information related to bed hold during transfers to the hospital. During interview on 10/3/19 at 3:07 p.m. with Licensed Practical Nurse (LPN) II and Resident Care Coordinator (RCC) VV it was reported that a bed hold notice is sent with residents when going to the hospital. In addition to that a copy is scanned in the electronic medical record and another copy is mailed to the family. 2. Review of the medical record for R#72 revealed resident was transferred from the facility to the hospital on the following days 5/26/19 and 8/17/19 and there was no evidence, in the electronic medical record, that a bed hold notice was provided to R#72. An interview on 10/3/19 at 3:15 p.m. with LPN WW reported that when a bed hold letter is sent with the resident at the time of transfer to the hospital, a copy is then sent to medical records for entry into the electronic medical record. An interview was conducted on 10/3/19 at 4:20 p.m. with the Administrator who reported that the facility does provide bed hold notices to residents when transferring to the hospital but acknowledged that they have not been able to find the bed hold notifications for R#47 and R#72. A record review of the facility Policy titled, Bed Hold Policy dated (reviewed and updated) (MONTH) (YEAR) revealed the policy does not address the residents right to have a bed hold notice provided to them or their responsible party when they are on a therapeutic leave of absence.

Based on resident and staff interviews, record review, the review of policies and procedures entitled Grievances (Abuse Prohibition; Reporting and Investigating Abuse) copyrighted 2004-2017 for the parent corporation, the facility failed to report to the State Survey Agency (SSA) an allegation of physical abuse for one resident (R) #89. The sample size was 31. Findings include: In an interview on 7/9/18 at 3:23 p.m. regarding the quality of care at the facility, R #89 stated she was hit over the head by R #15 approximately three weeks ago. She further stated the staff came and took R #15 away to another facility but they brought her back in a few hours. She stated she was not physically injured but she avoids contact with R #15 as much as she can. Review of the Nurse's Notes for R #89, dated 6/23/18 at 18:43 (6:43 p.m.), revealed documentation that another resident hit R #89. R #89 suffered no visible injuries and her family was notified. Review of the Nurse's Notes for R #15, dated 6/23/18 at 18:27 (6:27 p.m.), revealed documentation that R #15 punched the other resident (R #89) on the right side of the face multiple times with no reason. The writer notified the family, the attending nurse practitioner (NP), the consulting psychiatric NP and the police. R #15 was transported by police out of the facility for further evaluation. The Administrator provided, upon request, a list of facility reported incidents (FRIs) for the last six months which did not include an incident dated 6/23/18. In an interview on 7/12/18 at 2:34 p.m. with the Administrator regarding the abuse allegation of 6/23/18, she stated she spoke with a corporate official, her Regional Vice President (RVP) who advised her not to report the abuse allegation to the SSA. She stated she did investigate the allegation and send the offender out for an evaluation. In an interview on 7/12/18 at 3:05 p.m. with the with the clinical nurse consultant regarding the reporting of abuse allegations, she stated she was not the official who advised the Administrator on that particular case. She stated the corporate protocol is for the Administrator to discuss any incidents with their consultants or corporate officials but ultimately, they must all follow state and federal regulations. In a telephone interview on 7/12/18 at 4:57 p.m. with the RVP regarding the reporting of abuse allegations to the SSA, he stated he did tell the Administrator not to report the abuse allegation of 6/23/18 to the SSA because his understanding was if the incident was witnessed, the other residents were safe and the offending resident was removed from the facility, the incident did not need to be reported. He stated he simply misunderstood the new regulations.

Based on observation, record review, review of Centers for Disease Control and Prevention (CDC) guidelines on processing of laundry, and staff interview, the facility failed to use personal protective equipment (gown) when sorting soiled laundry, and failed to cover clean laundry during transport. The facility census was 89 residents, and the sample size was 30 residents. Findings include: On 8/10/17 at 10:40 a.m., laundry employee DD was observed sorting soiled laundry that was inside a large cart in the laundry room. Further observation revealed that she put on gloves, but no gown or other protective garment, to ensure that the soiled laundry did not touch her clothing. Continued observation revealed that she had to reach over and down into the cart to obtain the soiled items, and she separated the dark laundry from the whites. She was then observed to reach down into the cart to pull the soiled white laundry out, and then put them into the washing machine. Continued observations revealed that after loading the washing machine, laundry employee DD removed her gloves and washed her hands. She was then observed to remove washed and dried laundry from a dryer, and the clean laundry was noted to touch her clothing with each armful she removed. During interview with laundry employee DD at this time, she verified that she did not wear a gown to cover her clothing when sorting the soiled laundry, and only did this if the laundry she was sorting was from a resident on isolation precautions. During further interview, she verified that the cart she used to bring clean laundry back into the resident rooms and clean linen storage areas was not covered during transport. She further stated that clean laundry had been transported this way for years, and she had never been told to cover them. During observation from the exit door on the clean side of the laundry to the door leading back into the facility on the 400-hall revealed that it was an approximate 30-foot distance, and the laundry cart had to be taken outside on a covered walkway between the two buildings. Review of the facility's Laundry Services policy and procedure with a release date of September 2015 noted: Standard precautions will be used by clinical and laundry staff handling the linen. In the laundry, hand hygiene facilities and protective barriers (e.g., fluid resistant gowns or aprons, gloves, and masks/face protection) shall be made available to personnel who sort laundry. Laundry personnel should wash their hands and remove protective barriers before going into the clean linen area. Review of a CDC website for Guidelines for Environmental Infection Control in Health-Care Facilities for Laundry and Bedding (https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/laundry.html) noted the following: Laundry workers should wear appropriate personal protective equipment (e.g., gloves and protective garments) while sorting soiled fabrics and textiles. After washing, cleaned and dried textiles, fabrics, and clothing are pressed, folded, and packaged for transport, distribution, and storage by methods that ensure their cleanliness until use. During interview with Laundry Tech DD on 8/9/17 at 1:37 p.m., she stated that it was the responsibility of the floor Certified Nursing Assistants (CNA) to bring the soiled linen carts out to the laundry, which was located outside the building at the end of the 400-Hall (Dogwood hall). She further stated that she sorted the soiled linens into whites and colors, as they were washed separately. During continued interview, she stated that once the clothes were washed and dried, she put them in a wheeled cart with a horizontal hanging rod connected to two vertical poles. She further stated that when the clothes were delivered to the floors and resident rooms, she put the items in the basket on the cart (socks, underwear, et cetera) and hung the clothing on the rod. She stated that she left the laundry through the exit door, and delivered the cleaned laundry to the respective rooms. She verified that she delivered the washed laundry and clothing in the cart without using any type of protective covering. She further stated that was the way that she had always done it, and couldn't recall whether there had ever been a cover used. Observation was made on 8/10/17 at 10:34 a.m., with(NAME)Tech DD sorting soiled linens wearing gloves but no other type of personal protective equipment (PPE) was used at this time. It was not noted that the soiled linens touched her body or clothing. During further observation of Laundry Tech DD folding the clean laundry, the clothing and linens did touch her body and her clothing over her abdominal area linens to the folding room. She was observed folding sheets, and sheets were observed to touch the clothing over her abdominal area during the folding process. Further observation revealed that the distance from the laundry room to outside entrance of the Dogwood hall in the facility was approximately 30 feet. Interview on 8/10/17 at 10:44 a.m. with Laundry Tech DD stated that she received two days training from the previous laundry tech. She stated that she wore PPE when handling linens for residents who were on isolation precautions, and that isolation laundry was washed separately. Interview on 8/10/17 at 11:22 a.m. with the Infection Control Coordinator, stated the laundry personnel received the same Infection Control educational inservices as all other staff members. She stated she was not aware of any other types of training they received or were required for working in the laundry. She stated that her expectation was for laundry personnel to be cautious about cross-contamination of clean linens, but was not aware of a policy requiring staff to wear PPE when sorting soiled laundry. She further stated that she was not aware whether or not the clean linens were required to be covered when transporting.

Based on record review and staff interviews, the facility failed to follow the Registered Dietician (RD) recommendations for vitamins, protein supplement, and larger entree portion sizes for one resident (R) #137. In addition, the facility failed to follow the PAR (Patient at Risk) committee recommendation for vitamins for wound healing for R #137. The sample size was 30 residents. Findings include: Review of R #137's clinical record revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Treatment Record-Wound assessment dated [DATE] revealed that R #137 was admitted to the facility with a Stage 2 pressure ulcer to the sacrum, as well as a deep tissue injury to the right heel. Review of the resident's Admission Minimum Data Set ((MDS) dated [DATE] revealed that nutritional status triggered as an area of concern. Review of his risk for alteration in nutrition due to multiple health complications and nutritional compromise, weight loss and dehydration care plan dated 8/1/17 revealed interventions for an RD consult PRN (as needed), with any recommendations to the MD (Medical Doctor) for review and consideration. Review of an [MEDICATION NAME] laboratory result dated 7/16/17 revealed a level of 2.2 (normal level 3.5 to 5.7). Review of an RD Consultant note dated 7/20/17 revealed that R #137 had increased nutrient needs related to chronic protein losses via [MEDICAL TREATMENT]. Further review of the RD's note revealed recommendations for added protein and nutrition, Renal MVI (multivitamins) daily, Prostat AWC (Advanced Wound Care) (a liquid protein supplement) 30 mL (milliliters) twice daily for 30 days, and large entree/meat portions at all meals for 30 days. Review of a PAR note dated 7/21/17 revealed that R #137 was a new admission with a left BKA ([MEDICAL CONDITION]), Stage 2 sacral ulcer, and UDTI (unstageable deep tissue injury) to the right heel. Further review of this PAR note revealed that a multivitamin with minerals and Vitamin C were added for wound healing. Review of the July 2017 and August 2017 physician's orders [REDACTED]. recommendations. During interview with Resident Care Coordinator (RCC) CC on 8/9/17 at 2:52 p.m., she stated that when the RD made a recommendation, she was the one responsible for forwarding the recommendation to the physician for approval. She further stated that she was unaware of the recommendations that the RD had made for R #137 on 7/20/17. During interview with the RD on 8/10/17 at 12:05 p.m., she verified that she had made nutritional recommendations for R #137 on 7/20/17, as it was standard protocol to add supplements for residents with wounds. She further stated that when she made a recommendation, she gave a verbal report to the Director of Nursing (DON) and to the RCC, and that her expectation was for her recommendations to be forwarded to the physician for consideration. During interview with the Wound Treatment Nurse on 8/10/17 at 2:48 p.m., she verified that she was the one who wrote that vitamins would be added for wound healing for R #137 in the PAR note on 7/21/17, and stated that it was her responsibility to follow through with this and get physician approval. She verified during further interview that there was no evidence that the recommended supplements were being provided for R #137.

Based on record review and staff interview, the facility failed to follow the care plan related to forwarding the Registered Dietician's (RD) recommendations to the physician for one resident (R) #137. The sample size was 30 residents. Findings include: Review of R #137's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of his Admission Minimum Data Set ((MDS) dated [DATE] revealed that Nutritional Status triggered as an area of concern, with the decision to care plan. Review of a risk for alteration in nutrition due to multiple health complications including nutritional compromise, weight loss and dehydration care plan dated 8/1/17 revealed an intervention to consult the Registered Dietician (RD) PRN (as needed), with any recommendations to the MD (Medical Doctor) for review and consideration. Review of his risk for pressure ulcer care plan dated 8/1/17 revealed an intervention to refer to the RD for assessment and dietary needs. Review of the RD Consultant note dated 7/20/17 revealed that R#137 had chronic protein losses through [MEDICAL TREATMENT], and her recommendations included a multivitamin, Prostat AWC (Advanced Wound Care) (a protein supplement), and large entree and meat portions at all meals for 30 days. During an interview with the Resident Care Coordinator (RCC) CC on 8/9/17 at 2:52 p.m., revealed that the RD's recommendations for R #137 were never implemented. During an interview with the Wound Treatment Nurse on 8/10/17 at 2:48 p.m., revealed that there was no evidence that the physician was ever notified of the RD's nutritional recommendations, and that the recommendations had never been implemented. Cross-refer to F 325

Based on observation record review and interview the facility failed to treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Findings include: Observation on August 9, 2017 at 3:30 p.m. with Licensed Practical (LPN) EE at nursing station standing in front of medication cart resident R # 11 asked LPN EE for his medication LPN EE stood around for several minutes resident started to leave nursing station mumbling. Then, LPN EE took out his medication, put medication on top of the cart said to R#11, here is your medication (nasal spray in box) and stated I do not have time to be bothered by you today. Resident took his medication out of the box used the nasal spray and then returned the medication to the cart. Resident was mumbling something that could not be understood. LPN EE told R#11 that she was not going to be messed with today. R#11 left and went down the hall mumbling. Interview with Resident # 11 on August 9, 2017 at 3:45 p.m. revealed that he was not afraid of the employee however he felt that LPN EE did not treat him with respect. Review of the medical record revealed that resident was not assessed for, care planned for or have physician order [REDACTED]. Interview with the Director of Nursing on August 9, 2017 at 4:00 p.m. revealed that her expectation for the residents to be treated with respect and with dignity and this type of communication with residents is not acceptable and will not be tolerated. Further interview revealed that LPN EE was a nursing agency employee. Interview with Nurse Consultant, Director of Nursing, and Administrator on August 9, 2017 at 4:00 p.m. revealed that R#11 had not been assessed to self-administer medication no order exits for resident to self-administer medication or is his care plan. Nurse Consultant revealed that it is the facility expectation that all resident to be treated with respect and dignity. Interview with Human Resources on August 9, 2017 at 4:30 p.m. revealed that all employees go through an initial orientation which includes agency employee.

Based on record review and staff interview, it was determined that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) for four (4) of six (6) residents reviewed (# 35, #108, #113 and #118) who were discharged from Medicare Part A Skilled Services and remained in the facility. Findings include: 1. Record review for Resident #35 revealed a Notice of Medicare Non-Coverage (Form CMS -NOMNC) dated [DATE], which indicated the effective date the coverage of Skilled Services would end was [DATE]. However, further record review revealed that even though Resident #35 remained in the facility after being discharged from Skilled Services on ,[DATE]//2014 and did not use up the 100 days of Medicare eligibility, there was no evidence to indicate that the resident/representative received a Skilled Nursing Facility Advance Beneficiary Notice or Denial Letter, CMS - , as required. 2. Record review for Resident #118 revealed a Notice of Medicare Non-Coverage form dated [DATE], which indicated the effective date the coverage of Skilled Services would end was [DATE]. However, further record review revealed that even though Resident #118 remained in the facility until his/her discharge from the facility on [DATE] and did not use up the 100 days of Medicare eligibility, there was no evidence to indicate that the resident/representative received a Skilled Nursing Facility Advance Beneficiary Notice or Denial Letter, as required. 3. Record review for Resident #113 revealed a Notice of Medicare Non-Coverage form dated [DATE], which indicated the effective date the coverage of Skilled Services would end was [DATE]. However, further record review revealed that even though Resident #113 remained in the facility after being discharged from Skilled Services on [DATE] and did not use up the 100 days of Medicare eligibility, there was no evidence to indicate that the resident/representative received a Skilled Nursing Facility Advance Beneficiary Notice or Denial Letter, as required. 4. Record review for Resident #108 revealed a Notice of Medicare Non-Coverage form dated [DATE], which indicated the effective date the coverage of Skilled Services would end was [DATE]. However, further record review revealed that even though Resident #110 remained in the facility until his/her death on [DATE] and did not use up the 100 days of Medicare eligibility, there was no evidence to indicate that the resident/representative received a Skilled Nursing Facility Advance Beneficiary Notice or Denial Letter, as required. Interview with the Financial Controller on [DATE] at 12:25 p.m. revealed that the Notice of Medicare Non-Coverage, provided to Residents #35, #118, #113 and #108, was the only form provided for any residents discharged from Skilled Medicare Part A Services. Further interview revealed that he did not know that the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) was suppose to be provided to residents who remained in the facility after discharge from Skilled Services. Continued interview with the Financial Controller revealed that there were eighteen (18) residents who were discharged from Medicare Part A services in the last six months of which twelve (12) residents remained in the facility.

Based on observations, record and care plan review, it was determined that the facility failed to apply protective coverings as care planned to the arms of one resident (#96) at risk for skin tears and bruising from a sample of twenty-five (25) residents. Findings include: Resident #96 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident received [MEDICATION NAME] and Aspirin (blood thinners) daily. Review of the resident's care plan dated 9/5/14 revealed that the resident was at risk for skin tears and bruising due to his/her fragile, elderly skin and medications ([MEDICATION NAME] and Aspirin) with an intervention for staff to apply protective coverings to his/her arms as indicated. Observations conducted 11/10/14 at 2:30 p.m. and on 11/12/14 at 7:30 a.m., 1:00 p.m. and 3:55 p.m., revealed the resident was not wearing long sleeves and staff had failed to apply protective coverings on his/her arms. Cross -Refer to F309

Based on observations, record review and staff interview, it was determined that the facility failed to apply protective coverings to the arms of one resident (#96) to prevent skin tears from a sample of twenty-five (25) residents. Findings include: Resident #96 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident received [MEDICATION NAME] and Aspirin (blood thinners) daily. Review of the resident's care plan dated 9/5/14 revealed that the resident was at risk for skin tears and bruising due to his/her fragile, elderly skin and medications with an intervention for staff to apply protective coverings to his/her arms as indicated. On 11/10/14 at 2:30 p.m., the resident was observed with purple discolorations on his/her right forearm, top of right middle and index fingers and top of left ring finger. The resident was not wearing long sleeves and staff had failed to apply protective coverings on his/her arms at that time. Observations on 11/12/14 at 7:30 a.m., 1:00 p.m. and 3:55 p.m., revealed the resident was not wearing long sleeves and staff had failed to apply protective coverings on his/her arms at those times. Review of the Nurses' Note dated 10/9/14 revealed that the resident had sustained a skin tear on his/her right hand during a transfer. Review of the Nurses' Note dated 10/10/14 revealed that gerisleeves (protective covering) were placed on the resident's arms. Review of the 11/12/14 Nurses' Note revealed that the resident sustained [REDACTED]. Interview with Licensed Practical Nurse (LPN) "A" on 11/13/14 at 12:40 p.m., revealed that the certified nursing assistants (CNAs) were responsible for applying gerisleeves (protective coverings) on residents who required them and that the nurses were responsible for ensuring that the residents were wearing the protective coverings. Interview with the Director of Nursing (DON) on 11/13/14 at 12:50 p.m., revealed that she expected CNA staff to apply gerisleeves to the resident's arms when the resident was out of bed.

Based on observation, record review, and staff interview, the facility failed to ensure that one (1) resident with a pressure sore (#1), from a survey sample of five (5) residents, received the necessary care and services to promote pressure sore healing. Findings include: Observation of Resident #1 on 12/04/2012 at 10:30 a.m., with Nurse "CC" in attendance, revealed a Stage II wound on the sacrum measuring approximately four (4) centimeters (cms) in length by 1.8 cms in width by 0.1 cm in depth. The wound bed was red and raw, and there was not any form of dressing on the wound. review of the resident's medical record revealed [REDACTED]. However, further record review for Resident #1 did reveal an order, originally dating from 09/24/2012, specifying to apply [MEDICATION NAME] ([MEDICATION NAME]) dressing to the sacrum, and to change every third day and as needed. During interview with Nurse "BB" and Nurse "EE" on 12/04/2012 at 2:35 p.m., they stated that the treatment order for the sacral [MEDICATION NAME] dressing had not been brought forward to the current physician's orders [REDACTED]. The resident's Treatment Record for November 2012 documented that a [MEDICATION NAME] dressing was to be applied to the sacrum every third day, and that a sacral [MEDICATION NAME] dressing had been changed/applied on 11/29/2012. However, further record review, to include review of the December 2012 Treatment Record, revealed no evidence to indicate that the [MEDICATION NAME] dressing was changed on 12/02/2012, the date it would have next been due for routine changing, or that the sacral dressing had been changed at all since the documented dressing change of 11/29/2012. Thus, there was no evidence to indicate that the sacral wound dressing change had been done for a period of five (5) days, as of the survey date of 12/04/2012. Additionally, review of the Wound Summary dated 11/29/2012 which was submitted did not include a reference to a wound to the sacral area for Resident #1. During the 12/04/2012, 2:35 p.m. interview with Nurse "BB" and Nurse "EE" referenced above, they acknowledged the above findings.

Based on observation, record review, and staff interview, the facility failed to update and revise the Plan of Care to reflect the presence of, and treatment for, a sacral pressure sore for one (1) resident (#1) from a survey sample of five (5) residents. Findings include: Please refer to F314 for more information regarding Resident #1. Record review for Resident #1 revealed an order, originally dating from 09/24/2012, specifying to apply [MEDICATION NAME] ([MEDICATION NAME]) dressing to the sacrum, to be changed every third day and as needed, and observation of the resident on 12/04/2012 at 10:30 a.m. revealed a Stage II wound on the resident's sacrum. Review of the current Plan of Care in the medical record for Resident #1 revealed that the Plan of Care referenced a 04/19/2012 entry, last updated on 09/20/2012, indicating that the resident was at a high risk for pressure ulcer development. However, the Plan of Care had not been updated/revised to reflect the actual development of the Stage II pressure sore, or the treatment for [REDACTED]. During interview with the Administrator, the Director of Nursing, and Administrative Nurse "FF" conducted on 12/04/2012 at 3:40 p.m., they acknowledged the above and stated that it was probably not there because they were in the interim review period. They further indicated that the facility policy was to develop an Acute Care Plan in between the review period. However, further record review failed to reveal the presence of an Acute Care Plan in the medical record, and during the interview referenced above, these facility staff acknowledged that there was not an Acute Care Plan developed for this problem/need based on review of the record.